How the State of Oregon Kidnapped Our Son

Unexplained Injury

On November 8th, 2011 we noticed my son was feeling some pain and was running a low grade fever (100.2° F). I was concerned so I called an advice nurse that my wife's insurance provided. The nurse on the line was very polite and recommended that we go to the ER because my son was only five weeks old. Her concern was that at that age a fever could mean something was seriously wrong and we needed to have it examined.

The First Hospital 

We went to the local hospital in our home town to see a doctor there. Upon arrival the triage nurse performed her introductory evaluation, noting that there were "no bruises, swelling, or any external abnormalities" while also noting that "all four extremities are moving strongly and equally." 

We were brought to a room in the ER where a doctor performed a number of tests. This included a hip flexing check and saw that the legs were pulled up tightly towards the abdomen. He explained that sometimes when babies have abdominal pain they'll pull their legs in tightly. While the doctor manipulated my son's legs he let out a very loud scream, quite unlike we had heard before. This was very different than the experience with the triage nurse just minutes before.

The doctor ordered an x-ray to view my son's abdomen and hips. The doctor's belief was that their could possible be an obstruction in my son's intestines causing the pain. 

The X-Ray Technician

My wife needed to return home at this point. In our haste to get to the ER we had forgotten to bring a change of clothes and diapers, and while there our son soiled his outfit. I stayed and the x-ray technician came in to take a number of images. At one point while we were moving my son the x-ray technician looked at me in a confused way and asked if the doctor had mentioned anything about my son's left leg. I replied that he hadn't other than a possible abdominal issue. 

The technician left after taking his initial x-rays, and came back half an hour later. He was told to take specific pictures of the leg. He then came in again one more time after another half an hour to take a clearer picture of the leg. My wife had returned at this point and the Doctor came in and told us that our son had a spiral femur fracture (We later learned that it was actually an oblique fracture and not a spiral). The doctor informed us that as protocol he had to notify the authorities and an investigation would take place. (It was also noted that he had gaseous distention from the x-rays)

The First Police Office

We spoke to the police officer that came to see us and explained that there hadn't been anything traumatic that happened. Nobody dropped him, no one fell with him, nothing happened. While we spoke to the police officer we mentioned we came in because our son was having abdominal pain, thought to be bad gas, and a low grade fever. We mentioned that he had no bruises (which was confirmed by a nurse that was in the room at the time) and we told him we had no idea there was a fracture. Our son hadn't screamed in pain as he did until the doctor manipulated his leg.

My son was only mildly more fussy than normal prior to our visit, and as young parents we thought that as long as he was eating he was okay. The night before we also noticed a fever and we went to the store so he could have baby Tylenol and Gripe Water (Natural medicine to reduce gas). This seemed to work as it lowered his temp and calmed him down.

The Children's Hospital

The Children's Hospital was notified. Their EMT crew and a pediatrician arrived and wrapped up my son's leg. My son was transferred to the Children's Hospital in an ambulance with my wife. I had to run home and pick up some things for my son, and then I drove out there myself. 

While in the ambulance, my wife was able to hear a pediatrician and an EMT discuss that they thought this was clearly abuse and that it was only protocol to bring a parent. When they arrived at the Children's Hospital a complete trauma workup was performed on my son. It was noted again that there were no bruises, swelling, lesions, abrasions, and that my son was content beyond his leg. It was noted that my son had extra cartilage on his skull but it was not trauma related, and I remember wondering what that meant. My son showed no symptoms of being in any pain or distress, though he did have a low grade fever. 

My wife had been advised to ask the ER doctor what could cause such injuries in an infant. She was rudely told that "It was either child abuse or you're lying (about there being no accident)." 

My son was sent to have a head CT done immediately. His results came back perfectly normal. There was no bleeding on the brain, no hemorrhaging, no skull fractures, or signs of trauma. My wife requested that a new doctor be placed with our son after the encounter with the previous doctor, and was given an advanced resident to look over our son. A full blood workup was run, including a spinal tap, to check for infection because of his low grade fever. My son, minus the blood drawing, remained content, fed well, and soothed easily. It was very hard for the doctors to draw blood from our son, and it took quite a lot of time for them to finally get anything, causing my son great pain in the process. On the spinal tap, one of the residents missed the spinal fluid and hit a vein, causing blood to become mixed in with the spinal fluid. They also took new x-rays while in the Children's Hospital ER. Even after taking the blood, a number of tests were lost or not valid. 

The Inpatient Room

We were eventually moved to an inpatient room. They tried to draw more blood during the night, but they didn't tell us what the blood was being drawn for. We were also informed not to feed our son throughout the night so they could reset the bone, and he cried through the night in hunger pains. We followed the directions we were given. Despite all this, he wasn't given any medication because he was still soothing himself. The room was very cold at night, yet my son maintained a high temperature and was even sweating. None of the nurses adjusted the temperature at night, nor did they tell us how. 

In the morning a new nurse came in and said my wife could feed our son. They took a full skeletal survey in the morning where they noted a number of fractures. These inculded:

• An acute left femoral diaphysis angulated oblique fracture, 
• Age-indeterminate bilateral distal femoral, 
• Probable left and right proximal tibia metaphyseal corner fractures, 
• Probable age-indeterminate left proximal humeral metaphyseal corner fracture, 
• Probable partially healed proximal right tibia and fibula fracture, 
• And healing bilateral rib fractures (Probably three). 

Note, the only fully confirmed fracture has been the left femur fracture and an age-indeterminate posterior rib fracture. This is also the point where they say it was on oblique fracture and not a spiral. A doctor came in to look at my son's eyes. She saw no retinal hemorrhaging, but noticed a mild discoloration in his eyes. She called in a superior who also noted that there was nothing wrong with his eyes, but that he did have mild discoloration. Again, My son was only 5 weeks old at the time. 

My son had seen many different doctors in this time, all noting that he look healthy an happy. My son had been in for a 1 week check, 2 week check, at about 3 1/2 weeks he was circumcised, he had visited the hospital twice because he was jaundice, and my wife's midwife had also seen him during one of her post birth visits the day before we went to the hospital.

They attempted to draw more blood, and continued to be unsuccessful, taking a full second day to gather the blood needed to send out for the Osteogenesis Imperfecta (OI) test and a few other tests regarding bone health. He was still on no medication until they decided to put an IV in his head where they used morphine. They took an abdominal CT because my son had high liver enzymes, but his CT came back perfectly normal. He was put into a Pavlik harness to help heal his femur fracture. 

The State Intervenes

A Child Protective Services (CPS) worker, a detective, and a police captain interviewed me, my wife, and my wife's parents. They agreed that everything we have said had been consistent. There hasn't been any trauma, and certainly no outward signs abuse. The police never filed criminal charges.

We had to appear in court for an emergency hearing as requested by CPS. I had already obtained a lawyer but my wife hadn't had time yet. During the hearing the judge seemed to want to give us both of our children back. But CPS boldly lied and said there was liver damage and stated that all fractures were fact, rather than possibilities. The judge reluctantly had our son put into a "Medical" foster home, while allowing us to keep our daughter (As long as we were in sight and sound of Linda's parents with our daughter).

At 3 Months

CPS continued to hold our son, and was attacking our parenting skills and the well being of both of our children. We had 3 1-hour visits a week with our son, and during that last month we discovered that our son now had an umbilical hernia (which may have been developing while he was still with us). We asked CPS to take our son to see a doctor, but they informed us they had another appointment set up for his two month check and will have it looked at than. 

We have since discovered that our son does have low calcium, low vitamin D, high alkaline phosphatase. We have looked into many different possibilities, including OI, Rickets, Temporary Brittle Bone Disease (TBBD), and other diseases that could have caused this. The OI test came back negative, but there are other options, but at this time it was very difficult to have our son tested. 

Back in the Womb

My wife had a rough pregnancy because of his size. We discovered that she has a retroverted uterus. This made our son's birth even tougher. He was born at 41 5/7 weeks by induction with pitocin. My son had severe shoulder dystocia during birth, and had an initial APGAR score of 3, taking a full minute to even breath. During the later stages of pregnancy my son was unable to move much, but certainly was noticeable due to his large size. My son only moved at night when my wife was able to lay flat, especially during the third trimester. His birth weight was 9lbs 7oz and 21 1/2 inches. 

The Judicial Hearing

We started the Judicial Hearing Process on January 5th, 2011. The hearings were held on the 5th, 6th, 9th, 10th, 11th, and 18th. One of the worst problems with this process is that it is held in the Juvenile Courts, and rather than using "Beyond a reasonable doubt" they use "Preponderance of Evidence" which refers to balancing the evidence (50/50), and whichever side is over the 50% mark wins the case. 

We clearly should have had more than enough evidence to prove that we had not abused our son. Firstly, it was made clear that the hospital had lost blood tests, including a very important vitamin D, phosphorus, ionized calcium, and the PTH tests, all vital for diagnosing Rickets. They also noted elevated liver enzymes related to bone breaks which were elevated even higher after our son was in foster care, after declining to a normal level at the hospital. 

The Expert and the Villain

We had hired Dr. David Ayoub to testify about what he saw from the x-ray and CT images. He testified that he could see from the radiological evidence that our son had neonatal rickets. Dr. Ayoub even had images taken directly from My son's X-rays and CT scans to show these signs. 

The state provided numerous medical witnesses, and each of these witnesses, except Dr. Villain (A Child abuse Expert who has been certified by American Board of Pediatrics, Child Abuse Pediatrics since 2009), had admitted that if our son had a medical condition of bone fragility that it could explain his fractures. It was also noted that our son had no bleeding on the brain, no subdural bleeding, no retinal hemorrhaging, no bruising, no swelling, no internal organ damage, no brain damage, no cuts or lesions, and no tissue damage. The only thing noted were the unexplained bone fractures without local tissue trauma. 

It was even noted in court that there was very likely a new rib fracture after our son was placed in foster care. There was even a physician's assistant who noted that if our son did have bone fragility he himself could have accidentally broken our son's ribs during a routine well baby check. 

The ER doctor who saw our son when we brought him to the hospital still can't give a clear answer about whether or not he broke our son's femur, and when asked on the stand said "I don't believe I did." rather than a simple yes or no. The pediatrician who is currently seeing our son was even confused why they were calling this abuse when there clearly were other things that needed to be looked at first, and recommended that our son see and endocrinologist and geneticist. 

There were two doctors who testified that the obvious fact that all of the normal signs of abuse were missing meant it was unlikely to be abuse when evaluating the differential diagnosis. 

The State recalled two of their medical witnesses to discredit Dr. Ayoub's work simply because his current study hadn't been published in a peer reviewed journal yet. Dr. Villain (who had never actually seen our son, nor viewed his full medical history) claimed that he didn't care if our son had a medical condition. He (in a very belligerent attitude)believed that this was abuse anyways, and would not be convinced otherwise.

The Judge's Ruling

So the Judge erred on the side of caution and adjudicated my wife and I of abusing our son. We we able to keep our daughter home with us, because she was in perfect health. He even stated that we should bring new medical evidence to him should we have any.

We tried to have CPS take our son to specialist to evaluate him, and the judge even order them to do it. This never happened. We fought for our innocence, and after 17 month we got our son back. The verdict hadn't changed, but the judge had decided that we were trustworthy enough to have our son back.

The new evidence

In 2013 we finally had the opportunity to have our son evaluated by a endocrinologist at the very same children's hospital. They thought the situation was very odd. While they found no endocrine problems, they suggest that our son be evaluated for Ehlers-Danlos with a geneticist.

We finally were able to see the very busy geneticist in 2014, and they said that our son clearly has Ehlers-Danlos type-III (Hypermobility). We were told that his was very likely the reason our son was injured without a traumatic accident. We thought that it was great to finally know what we as a family were dealing with. The syndrome isn't life threatening for our son, but it isn't a simple disorder either. He deals with fatigue and soreness frequently.

We haven't been able to return to court, because it is very difficult to find an attorney who wants to reopen finished cases.

We didn't abuse our son, and they shouldn't be able to take our son like this without reasonable cause. 

Our story has been passed on, and we hope people continue to share it. So please repost and spread the word about this huge injustice to all your friends and family. This isn't about just our family anymore. This scenario is happening over and over again all across the country and internationally. So please share this story, it may help a family be saved.

Fractured Leg, Fractured Family: A Misdiagnosis Leads to Allegations of Child Abuse

Reposted from: http://jjie.org/fractured-leg-fractured-family-misdiagnosis-leads-allegations-of-abuse/43001

Written by: Ryan Schill on Oct 3, 2011

Anthony Richards, Jr.

When Anthony Richards, Jr., was born on an early Sunday morning in June, the only complications involved his family getting the cameras in focus to capture his arrival into the world. He was a healthy baby and his parents, Queenyona Boyd and Anthony Richards, Sr., couldn’t have been happier. Yet, only four days later Anthony was put in foster care after doctors discovered an unexplained broken femur, his distraught parents the suspects of child abuse.

A Protective Father’s Discovery

After the hospital discharged Boyd and her baby boy, Richards took the two straight home later that Sunday. The following day, Boyd slipped out to pick up her prescriptions at a pharmacy only a short drive away. She wasn’t gone long when she received a phone call from her husband. Something was wrong with Anthony.

Although Boyd had a daughter already, Richards was a first-time dad. And like many first-time dads he was protective to a fault and he worried, maybe a little too much. So when he found a lump on Anthony’s leg while changing a diaper, he grew concerned.

“Did you notice his leg has some swelling?” he asked Boyd.

“Is it where he got the hepatitis B vaccine?” she asked. Richards said it was. Boyd wasn’t worried. Swelling around inoculations is normal, she thought. But she came home just in case.

Queenyana Boyd

Her husband wasn’t convinced the swelling was from the vaccine so he called his sister, a nurse. She told them to put warm compresses on the leg and massage the swollen area. Baby Anthony never cried while his parents followed the nurse’s advice. He even fell asleep.

Anthony was due for his three-day check-up with the pediatrician on Wednesday, but his parents moved it up to Tuesday as a precaution. The swelling was still present despite their efforts.

At the check-up, the pediatrician gave Anthony a clean bill of health. The only problem he saw was the swelling on the baby’s leg. He referred them to the emergency room at Children’s Health Care of Atlanta’s (CHOA) Egleston hospital in metro Atlanta. (A spokesperson for CHOA declined to comment for this story citing patient privacy concerns.)

In the ER, the doctor looked Anthony over and said that he thought the swelling could be a result of the hepatitis B injection missing the muscle. Swelling like Anthony had is not uncommon if the injection is mistakenly delivered subcutaneously. The doctor ordered X-rays and an ultrasound to be sure. Through it all, Anthony didn’t cry except when they were changing his diaper and Boyd suspected this was because Anthony had been circumcised Sunday.

First, they X-rayed Anthony’s leg. While the images were developing they took Anthony for the ultrasound, but just before they were to begin, the X-ray technician rushed into the room.

“Stop the ultrasound,” she said. “There’s a break.”

That’s when everything changed for Anthony’s parents.

The Science of Misdiagnosis of Child Abuse

In a recent report, the federal Administration on Children, Youth and Families estimated that 702,000 children were victims of maltreatment in 2009. That’s the equivalent of nine abused children for every 1000 in the population. But the report also says that only one in five investigations of abuse are substantiated. The rest, 80 percent, are cases in which the children are “found to be non-victims of maltreatment.”

What is not counted in the study is the number of investigations leading to deprivation (the state taking the child from the parents and placing them in foster care) before the parents are ultimately cleared of abuse. No one knows how many incidences of misdiagnosis occur each year. But one Child Welfare Law Specialist from Atlanta, Diana Rugh Johnson (who would eventually represent Boyd and Anthony) says she has brought six cases of misdiagnosis to trial in the last two years.

“Once a child abuse expert says there has been child abuse, that’s not the end of the investigation,” she said. “It’s the beginning.”

Experts must determine whether an injury is the result of trauma or was accidental or natural. But once a child abuse expert makes a determination of abuse, says Dr. Julie Mack, professor of radiology at Hershey Medical Center in Pennsylvania, it becomes very difficult to change the tenor of the conversation.

“The problem,” Mack wrote in an email, “is with the assumption of trauma — it becomes the default diagnosis, the one that is assumed as most likely. This is a dangerous assumption for the patient (who may have an underlying medical disease) and for the parents (who will appropriately deny trauma if none existent).”

In her cases, Johnson has found the same thing. She relies on out-of-state medical experts because she often cannot find a doctor locally who would publicly disagree with CHOA’s child abuse expert.

“Once [the child abuse expert] says it’s child abuse, everyone else shuts up,” she wrote.

But in infants especially, Mack wrote, “it is not appropriate to assume trauma is the most likely diagnosis, particularly in the absence of outward evidence of trauma.” Although, she adds, no physician she knows believes child abuse is not a reality. “Children are abused by their parents,” she wrote. Because of that, it is important to work hard to find the correct diagnosis.

“Fractures in the absence of history of significant trauma,” she wrote, “are also a characteristic feature of fractures caused by bone diseases such as osteogenesis imperfecta, bone disease of prematurity, and bone disease associated with vitamin deficiencies (rickets).”

Often cited as a contributing factor is rickets, a disorder that causes weak or soft bones.  Rickets is often caused by a deficiency of vitamin D and in many cases a vitamin D deficiency in the mother will lead to the same deficiency in their newborn. But vitamin D deficiency may be hard to diagnose.

In a commentary in the journal Pediatrics, Dr. Colin Patterson of the University of Dundee, Scotland, writes that one difficulty in the diagnosis of vitamin D deficiency, “is that the radiologic signs may be absent or unimpressive in cases of children with biochemically severe deficiency, which is particularly true of infants younger than one year.”

The conundrum, Mack says, occurs in an infant with fractures. “If a child presents with multiple fractures, but no clinical history or signs of trauma, ‘hidden’ (abusive) forceful trauma is often assumed,” she said. “The logic used is ‘abuse is present because the parents have failed to explain the fractures.’”

Queenyana Boyd struggled with a vitamin D deficiency throughout her pregnancy with Anthony.

“Are you here to take my child away?”

Boyd and Richards were in shock. How could Anthony’s leg be broken? You must have the wrong family, they told the X-ray tech. They had brought the newborn to the hospital because of complications from a vaccination. But the tech confirmed their details. It was true; Anthony had a broken leg.

When Boyd and her husband returned to their room in the ER, the doctor and a social worker met them. The doctor spoke first.

X-ray of Anthony Boyd's fractured leg.

“I’m sorry,” he said. “I should have asked you if you could have dropped Anthony or if he could have fallen.”

Absolutely not, Boyd and Richards told him. The social worker spoke up wanting to know what happened, so Boyd told them both the story, from the moment her husband discovered the swelling to when they arrived at the ER.

Richards’ eyes were tearing up. “Are you here to take my child away?” he asked the social worker. Boyd refused to believe that. They’d done nothing wrong.

“Well,” the social worker said, “we’re going to have to admit him to the hospital and do further tests.”

No one took their son that day. In fact, Boyd and Richards were allowed to stay in the hospital with Anthony, often alone in their room with the door closed, while Anthony was breastfed.

A caseworker from Georgia’s Child Protective Services (CPS) arrived later that day and began interviewing Anthony’s family. He spoke with Boyd and Richards, Boyd’s 7-year-old daughter Anya, Boyd’s sister and Richards’ mother, who had flown in after the birth. He also interviewed the nurses who had treated Anthony in the hospital. No one had a negative thing to say. The caseworker even told Boyd that her Anya was very happy and showed no signs of abuse. (Repeated calls to CPS were not returned.)

Boyd then asked the caseworker to contact Anthony’s pediatrician. She was told he would get to that later. He then explained to Boyd and Richards they needed to meet with a representative from the hospital’s child protection division. In the meantime, doctors continued to run tests on baby Anthony.

The next morning, the couple arrived for the interview with the child protection division. Once again they told the story of finding the swollen leg and how they had wound up in an interview with protective services. The representative said that she saw no indications of abuse; the break looked like “one of those things that happens.” Boyd agreed. She was also struggling to pinpoint when or how the leg could have broken.

Following the interview, a doctor from the child protection division spent a few minutes examining Anthony. He told the parents that Anthony appeared to be completely healthy, save for the broken leg.
Boyd and Richards were beginning to feel a little relief. They felt that if the hospital or CPS truly suspected abuse they would have contacted the police by now. At this point, it had been more than a day since the break was discovered. Boyd and Richards had been left alone with Anthony on multiple occasions. No one involved in the case had indicated seeing any signs of abuse. But as the day wore on, the couple began to worry. Although it was true no one had said their case looked like abuse, no one had told them they were cleared either. The pair repeatedly called the CPS caseworker asking for information but they never received any.
That evening, the CPS caseworker walked into their hospital room with a security officer. “I’m sorry,” he said, “but I have to take your son into custody.”
With those words Boyd felt the air go out of her. “Why?” she managed to ask. “Why are you taking our son?”
The caseworker explained that the report from the child protection division doctor who had examined Anthony concluded the break was non-accidental and to investigate possible child abuse.
“There’s nothing we can do,” he told her.
Boyd pleaded with the caseworker, asking if her sister could take Anthony rather than placing him in foster care. She was told that was impossible. He had no choice but to put Anthony in foster care. As CPS took her son away, Boyd felt like Anthony was being kidnapped. She had no idea where her son was — CPS wouldn’t tell her — and she had no way of continuing to breastfeed him. Boyd wouldn’t learn where her child was for five more days.

How Big a Problem?

Misdiagnosis of child abuse occurs, especially in infants. It is the word of the parents against the medical opinion of the doctor who examines the child. But is it a growing problem?
“I think it has been a problem since the 1990s or maybe a little earlier -– we just didn’t know it,” Seattle attorney Heather Kirkwood said. “In the past decade, it has begun to spiral, I think . . . one of those pendulums that swings too far and is due for correction. [The same thing] happened in antitrust, too, just not with such disastrous consequences. Here, I suspect that we are looking at hundreds to thousands of destroyed families and falsely imprisoned parents and caretakers.”
Kirkwood has handled a number of high profile cases of misdiagnosed child abuse. Her cases have been written about in The New York Times and The Chicago Tribune. Others were featured on the PBS documentary series, Frontline, as well as on NPR and ProPublica.
According to Kirkwood, many misdiagnoses originate “simply because we don’t know (or in some cases have forgotten) how to diagnose vitamin D deficiency (rickets), vitamin C deficiency (scurvy), etc.”
“Often the key to the diagnosis,” she said, “is that the child has no bruises, no pain and the ‘fractures’ are self-curing — with good nutrition, the bones will develop normally without any other intervention.  Not, in short, your typical fracture picture.”
The first step for Kirkwood when investigating is to do a retrospective diagnosis.
“In that stage,” she said, “I work with experts and read the literature to see how the medical findings fit together, both within the disciplines and with the clinical history. Sometimes it takes quite a few tries before we begin to put the entire picture together.”
Over time, in what is an evolving process, she has learned what to look for.
“When I first began to review cases,” she said, “I assumed that one fracture might be accidental but that multiple fractures without a major accident must be abusive.”
As she examined more cases, however, she began to conclude “that in cases in which the baby has no bruises or signs of abuse and otherwise seems well cared for, the opposite is true: the more fractures there are, the more likely it is that we are looking at some type of metabolic bone disease.”
And rickets often leads to fractures. Patterson, in his commentary in Pediatrics, writes, “In a recent retrospective study, fractures were found in seven of 40 children younger than 24 months with overt radiologic evidence of rickets.”

A Mother’s anguish

It was Wednesday evening. Boyd’s son had been placed in foster care earlier in the day. She was distraught and couldn’t understand why CPS wouldn’t let Anthony go with a family member. She called her aunt who had been in the delivery room when Anthony was born.
She was feeling hysterical and needed to talk to someone she trusted who would calm her down. While on the phone, her aunt began flipping through the pictures she’d taken at the delivery. And that’s when — in the middle of the conversation — Boyd’s aunt made a startling discovery that would further alter the course of events.
“I’m going to send you a picture,” her aunt said. “Did you see your son’s leg?”
Boyd’s aunt immediately emailed the camera phone picture to her. Boyd looked at the photograph, taken moments after delivery before the umbilical cord was cut; Anthony’s leg was already swollen in the photo. Boyd searched her own pictures for a higher resolution picture and found another that showed Anthony’s leg was swollen at birth. She discovered a picture on her camera taken at nearly the same moment as her aunt’s picture. It two appeared to show swelling on Anthony’s leg.
If the leg was broken before Boyd had even held her baby — and the swollen leg in the photos would seem to indicate that — CPS had no case. This was all the evidence she needed, Boyd thought. She emailed the photos to CPS the same night and asked that they be shown to the doctor at the child protective division at CHOA hospital. She never heard back.
Outraged at CPS for not communicating with her and impatient for the first hearing Monday (delayed until after the weekend because of a state furlough day on Friday), Boyd enlisted the help of Johnson. When shown the photos from the delivery, Johnson was astonished.

Photo from just after Anthony Boyd was born showing his swollen right leg.

“The leg looked completely messed up,” she said later.
A mandatory “72-hour” hearing was held Monday to determine if further foster care was necessary for Anthony. The judge granted Boyd and Richards’ daily visitation rights with their son. They could spend three hours a day with him, but they weren’t allowed to bring him home yet. The judge scheduled an ad judicatory hearing for nearly three weeks later.
Adjudication is similar to a trial, but the judge makes the final ruling without a jury’s involvement. In this case, the judge would decide if the allegations of child abuse were true. The hearing lasted five hours. The prosecutor argued that Anthony must have been abused, as there was no other explanation for the broken femur. Both the CHOA hospital child protective division doctor and the obstetrician from Anthony’s delivery testified that the kind of break that Anthony had could not have happened at delivery. They were too rare.
Johnson brought in Dr. Julie Mack, a medical expert from Lancaster, Pa., who countered that claim. Mack had research that showed numerous similar cases. In nearly every one, the break wasn’t diagnosed until days later, even if the baby never left the hospital. She also compared the photos from the delivery with Anthony’s X-rays, showing that the swollen area in the picture was where the break was in the X-ray.
The judge ruled for Boyd and Richards. Anthony could finally come home with his parents.
While she is overjoyed to have her son back, the experience has left Boyd scared and upset. She worries every time she has to take Anthony to the pediatrician. She’d done nothing wrong when she took Anthony in with the swollen leg. In fact, she did everything right. But CPS took her child anyway. Boyd felt as if she were guilty until proven innocent. Until CPS said otherwise, she was an abusive parent.
Anthony was later diagnosed with a vitamin D deficiency, likely inherited from his mother. However, he was never tested during the abuse investigation and has not, to date, been diagnosed with rickets.

SBS: EVERTHING IS BROKEN

Shaken Baby Syndrome Myth

* SBS began as an unproven theory and medical opinions, now discredited by biomechanical engineering studies
* No DIFFERENTIAL DIAGNOSIS done to eliminate other causes, abuse assumed without evidence
* Shaken Baby diagnostic symptoms not caused by shaking
* Child protective agencies snatch children, destroy families based on medical accusations without proof of wrong-doing
*Poor or deceptive police investigations, falsified reports, perjured testimony threaten legal rights, due process
* Prosecutors seek "victory", over justice; defense attorneys guilty of ineffective counsel, ignorance, lack of effort
* Care-takers threatened, manipulated, in order to force plea bargains, false confessions
* A fractured criminal justice system--a big piece for the rich, a small piece for the poor, and none for alleged SBS cases. Read More Here

Adoption halted as court told baby milk led to 'innocent' couple being accuse of abuse

Vitamin supplements in baby milk may have led an innocent couple being condemned for battering their newborn son, a top family judge has heard

Adoption halted as court told baby milk led to 'innocent' couple being accuse of abuse Photo: ALAMY

By John Bingham, Social Affairs Editor

11:58AM BST 20 Sep 2012

The boy, who cannot be named, was taken away from his parents and was poised to be adopted after multiple broken bones were put down to child abuse.

But Lord Justice McFarlane halted the process yesterday after hearing how an extraordinary combination of medical events could have led to a case of congenital rickets being overlooked.

The parents, who have fought a three-year custody battle, have been given a final chance to get their son back.

It came after lawyers had what they described as a "light bulb moment" and understood the full significance of the child's medical records.

Michael Shrimpton, for the family, who are from the north of England, told the Court of Appeal in London that there is evidence that the boy was born with a Vitamin D deficiency, inherited from his mother, leading to "soft bones" and rickets.

It suggests that the broken bones could have occurred during his difficult forceps birth, or even in the womb.

Blood tests to check for signs of vitamin deficiency, when the boy was four weeks old were normal.

But the court heard hat it is possible that it was "masked" by the formula milk given to him by his mother – which contained Vitamin D supplements.

He added that there was "striking" evidence of severe abnormalities in the functioning of the baby boy's liver, an organ instrumental in processing Vitamin D.

The judge temporarily halted the adoption process and ordered urgent medical reports.

Having a child taken away is an “exceptionally awful” ordeal, he remarked, adding that it was essential to examine whether the Vitamin D deficiency explanation for the boy's injuries was "more than an intellectual possibility".

He also noted that there was no evidence of emotional difficulties, domestic violence, alcohol or drug abuse, or any signs of dysfunction within the family, to indicate a risk of child abuse.

Mr Shrimpton said that one of the country's top endocrinologists, Professor Stephen Nussey, who has carried out pioneering work on the causes and effects of Vitamin D deficiency, will be instructed to carry out that task if he is available at short notice.

Observing that medical knowledge on the causes of infant injuries is in a state of constant movement, the barrister added: "This is an important case. It is starting to take on the appearance of a leading test case".

After hearing expert evidence in June last year, a judge at Sheffield High Court ruled that one or other of the parents must have been responsible for the baby's injuries. The same judge refused to change her mind earlier this year and freed the boy for adoption.

However, Lord Justice McFarlane observed: "Medical knowledge of how some children may have bones that are more susceptible to injury than normal children has moved on".

Emphasising the extreme urgency of the case in light of plans for the boy's imminent adoption, the judge gave the parents 28 days to obtain a report from Professor Nussey, or another expert, in support of their case.

The local authority involved in the case had informed the Appeal Court that suitable adoptive parents have already been found for the boy but no further steps in the process would be taken prior to the court ruling on the case.

The case will return to the Appeal Court once the expert medical report has been obtained.

Charges dropped in toddler assault case

By Nicole Montesano
Of the News-Register 

Charges against a McMinnville man accused of fracturing a toddler's skull were dropped on Thursday, after a grand jury declined to indict him.

Nicholas Ryan Bates, 25, had been charged in May with third-degree assault and first-degree criminal mistreatment, after his girlfriend's 2-year-old son was found to have suffered a fractured skull and collarbone.

Grand jury proceedings are secret by law; not even the defendant is allowed to be present. During the proceedings, the jury receives evidence favorable to the prosecution; no defense is presented. It then determines whether it believes that the evidence, if unexplained or contradicted at trial, would support a conviction. If so, it determines which charges are supported.

Defendants are informed of the outcome at a court hearing, when they are either formally advised of the charges against them, or the charges are officially dismissed.

Prosecutor May Chou said, that "at this point, I do not expect to" file any additional charges in the case. She declined further comment.

The case came to light in mid-May, when the toddler's mother, 22-year-old Felicia Megan Manley, took him to the hospital emergency room.

According to the Yamhill County Sheriff's Office, she told investigators that she and the child had been at Bates' home when she stepped outside to smoke a cigarette, and returned inside, to find the child had a small amount of blood on his mouth, as if he had bitten his tongue. The next day, the toddler was unresponsive and acted as if his arm hurt, so she took him to the hospital, where doctors discovered the injuries, and notified police. She told investigators she did not know how the toddler had been injured.

Bates said that he is no longer with Manley.

He said he does not know how or when the child was injured.

"We were not being good parents, that's all I can say. ... We were just having a bonfire, everyone was drinking, no one was paying attention."

The situation continues to be a painful one, he said, because he feels his reputation has been permanently damaged.

"I wish there was any way to fix that, but the damage has already been done. I don't know if anybody is ever going to believe me," he said. "I'm not a child beater. ... I'm just pretty upset about the whole situation."

http://newsregister.com/article?articleTitle=charges-dropped-in-toddler-assault-case--1339857429--3759--news

What is Hypophosphatasia (HPP)?

Hypophosphatasia is an inherited metabolic (chemical) bone disease that results from low levels of an enzyme called alkaline phosphatase (ALP). Enzymes are proteins that act in the body's chemical reactions by breaking down other chemicals. ALP is normally present in large amounts in bone and liver. In hypophosphatasia, abnormalities in the gene that makes ALP lead to production of inactive ALP. Subsequently, several chemicals - including phosphoethanolamine, pyridoxal 5'-phosphate (a form of vitamin B6) and inorganic pyrophosphate - accumulate in the body and are found in large amounts in the blood and urine of people with Hypophosphatasia. It appears that the accumulation of inorganic pyrophosphate is the cause of the characteristic defective calcification of bones in infants and children (rickets) and in adults (osteomalacia).

Nevertheless, the severity of hypophosphatasia is remarkably variable from patient-to-patient. The most severely affected fail to form a skeleton in the womb and are stillborn. The most mildly affected patients may show only low levels of ALP in the blood, yet never suffer bony problems.

In general, patients are categorized as having "perinatal", "childhood" or "adult" hypophosphatasia depending on the severity of the disease, which in turn is reflected by the age at which bony manifestations are first detected. Odontohypophosphatasia refers to children and adults who have only dental, but not skeletal, problems (premature loss of teeth).

The x-ray changes are quite distinct to the trained eye. Similarly, the diagnosis of hypophosphatasia is largely substantiated by measuring ALP in the blood (a routine test) that is low in hypophosphatasia. However, it is important that the doctors use appropriate age ranges for normals when interpreting an ALP level.

Prevalence

It has been estimated that severe forms of hypophosphatasia occur in approximately one per 100,000 live births. The more mild childhood and adult forms are probably somewhat more common. About one out of every 200 individuals in the United States may be a carrier for hypophosphatasia

Prognosis

The outcome following a diagnosis of hypophosphatasia is very variable. In general, the earlier the diagnosis is made the more severe the skeletal manifestations. Cases with severe, not mild, deformity at birth almost always have a lethal outcome within days or weeks. When the diagnosis is made before six months of age, some infants have a downhill and fatal course, others survive and may even do well. When diagnosed during childhood, there can by presence or absence of skeletal deformity from underlying rickets, but premature loss of teeth (less than five years of age) is the most common manifestation. Adults may be troubled by recurrent fractures in their feet and painful, partial fractures in their thigh bones.

Symptoms

Depending on the severity of the skeletal disease, there may be deformity of the limbs and chest. Pneumonia can result if chest distortion is severe. Recurrent fractures can occur. Teeth may be lost prematurely, have wide pulp (inside) chambers, and thereby be predisposed to cavities.

Inheritance Factors

The severe perinatal and infantile forms of hypophosphatasia are inherited as autosomal recessive conditions. The patient receives one defective gene from each parent. Some more mild (childhood or adult) hypophosphatasia cases are also inherited this way. Other mild adult and odonto hypophosphatasia cases seem to be inherited in an autosomal dominant pattern (the patient gets just one defective gene, not two, transmitted from one of his/her parents). In this form, mild hypophosphatasia can occur from generation-to-generation. The perinatal form of hypophosphatasia can often be detected during pregnancy by ultrasound and by measuring ALP activity in chorionic villus samples from amniocentesis.

Individuals with hypophosphatasia and parents of children with hypophosphatasia are encouraged to seek genetic counseling to explain the likelihood and severity of hypophosphatasia recurring in their families.

Treatments

As yet, there is no cure for hypophosphatasia and no proven medical therapy. Some medications are being evaluated. Treatment is generally directed towards preventing or correcting the symptoms or complications.

Expert dental care and physical therapy are recommended. An orthopaedic procedure called "rodding" may be especially helpful for adults with painful partial fractures in their thigh bones. Severely affected infants may manifest increased levels of calcium in their blood that may be treated with calcitonin and certain diuretics. Doctors should avoid the temptation to give calcium supplements or vitamin D unless there is clear-cut deficiency.

Contributing Medical Specialist
Michael P. Whyte. M.D.
Medical Director
Center for Metabolic Bone Disease and Molecular Research
Shriners Hospital
St. Louis, Missouri

Here are a few links to Review our case:

Urgent Plea: Child Stolen

Couple denies abusing son as they battle state for custody

Linda and Daniel Dossey: couple accused of shaking child battles State for custody. Specialist found neonatal rickets. Presumption of guilt? KATU.

Couple denies abusing son as they battle state for custody

Causes: Bring Babies Home

Linfield alumna fights for child custody in rickets case

Wronglyaccusedperson.org.uk

Rickets an Epidemic

CPS doesn't know a good family from a bad one

Read "Vitamin Deficiency Rises"

Sometimes Secrecy isn't Best for the Children

AFR Front Page News

Brigham Young University Law Review

Parents Against Injustice

Tweetbuzz: Hottest stories from [forum.wronglyaccusedperson.org.uk] on Twitter

Our Story

COMMON PEDIATRIC BONE DISEASES-APPROACH TO PATHOLOGICAL FRACTURES

COMMON PEDIATRIC BONE DISEASES-APPROACH TO PATHOLOGICAL FRACTURES

Click for pdf:  Common pediatric bone diseases

General Presentation

Background: It is not uncommon for children to present with fractures after experiencing trauma. However, children may also present with pathological fractures, which are fractures that occur in abnormal bones and typically occur during routine activity or after minor trauma. It is important to be able to distinguish between traumatic fractures and pathological fractures as the prognosis and treatment can vary quite considerably. One also MUST consider non-accidental injury in the child that presents with multiple unexplained fractures. Non-accidental injuries are discussed in a separate article on this site.

These fractures will generally present as localized pain and tenderness over the involved bone. Refusal to weight bear in the younger, non-verbal child is also very common.

Pathophysiology: Although there are many potential etiologies for weakened bone manifesting as pathological fractures, it is simple to divide it into three categories with common etiologies:

1)    Metabolic bone disease- eg. Rickets

2)    Bone tumours – eg. Benign tumours (non-ossifying fibroma and osteochondroma) and malignant tumours (osteosarcoma and Ewing’s sarcoma)

3)    Connective tissue bone disease- eg. Osteogenesis imperfecta

Metabolic Bone Disease: Normal bone growth and mineralization requires adequate calcium and phosphate. There are numerous etiologies of rickets, including nutritional deficiencies (calcium, phosphate and vitamin D), drug induced, renal pathology, and tumours. The end result and clinical manifestations of rickets are secondary to the failure of calcification of the growth plate cartilage because of a deficiency of either calcium or phosphate. Rickets is defined as deficient mineralization at the bone’s growth plate whereas osteomalacia refers to impaired mineralization of the bone matrix. Rickets is relatively common in children, especially those who have poor dietary intake, poor absorption, increased excretion of calcium, phosphate, or vitamin D, premature infants or breast-fed infants who are not supplemented with vitamin D. Regardless of whether it is calcium or phosphate deficient rickets, the typical clinical findings associated with Rickets include:

• Skeletal Findings(see Figure 1):
  • Delayed closure of the fontanelle
  • Parietal and frontal bossing
  • Craniotabes (soft skull bones)
  • Rachitic rosary (enlargement of the costochondral junction such that there is beading across the anterolateral aspects of the chest)
  • Widening of the wrists; bowing the distal radius and ulna
  • Progressive bowing of the femur and tibia
• Extraskeletal Findings(vary depending on the primary mineral deficiency):
  • Calcipenic rickets – hypoplasia of dental enamel, decreased muscle tone, delayed achievement of motor milestones, hypocalcemic seizures, increased sweating
  • Phosphopenic rickets – dental abscesses

Bone Tumors: Tumours, regardless of whether they are benign or malignant, can cause pathological fractures by growing and replacing the normal tissue of bone. This results in an abnormal, weakened bone more prone to fractures. In children, benign bone tumours are fairly common, but are often asymptomatic and discovered incidentally during evaluation for trauma or another condition, and thus, the true incidence is unknown. If they are symptomatic, they may present with localized pain, swelling, deformity or a pathological fracture. Most benign tumours generally present during the second decade. Two examples of common benign tumours which can present as pathological fractures include non-ossifying fibroma, and osteoid osteomas.

Malignant bone tumours account for 5% of all pediatric malignancies, with the peak occurrence between the ages of 10-24. The two most common malignant bone tumours in children are Ewing’s sarcoma and osteosarcoma which collectively make up 90% of the pediatric bone tumours. Ewing’s sarcoma is more common within the first 10 years, and then osteosarcoma becomes more common. The cancers often arise in the pelvis, femur, tibia and humerus. These can commonly present with symptoms of pain and swelling, which may be worse with exercise or at night, and sometimes the first signs may be due to a pathological fracture.

Connective Tissue Disease: Osteogenesis imperfecta (OI) is an inherited connective tissue disorder commonly known as “brittle bone disease” which can manifest in a wide spectrum, from mild to lethal forms. It is usually due to a deficiency of normal Type I collagen, which is an organic component necessary for proper bone formation.  Although its incidence is estimated to approximately 0.005%, it is important to include this disease in the differential diagnosis because it can present early in children as numerous and recurrent pathological fractures. The common clinical manifestations of OI include:

• Multiple and/or atypical fractures
• Short stature
• Scoliosis
• Basilar skull deformities
• Wormian bones (irregular, small bones along the cranial sutures)
• Blue sclera
• Hearing loss
• Opalescent teeth that wear quickly
• Increased laxity of ligaments and skin
• Easy bruising
• Accelerated osteoporosis

Questions to Ask

• How did the fracture occur – How, when, where? – to determine if it was pathological or traumatic fracture
• Has the child had any previous fractures or any other concurrent fractures? If so, can you describe them? – to help determine pathological versus traumatic fracture
• What is the child’s diet like? To determine if nutritional deficiency Rickets may be the cause
• Did the child have any previous bone pain?  If so, can you describe what makes it better or worse? Also, does it get worse at night? To check for potential bone tumors
• Does the child have a fever? To rule out any potential infectious causes or malignancies (constitutional symptoms – fevers, weight loss, drenching night sweats)
• Does the child have any other medical history? To rule out a secondary cause of the bone disease
• Do you suspect that the child may have been abused? Who is the primary caretaker of the child?
• Is the child taking any other medications?

Differential Diagnosis for Pathological Fracture

• Rickets from Vitamin D deficiency
• Osteogenesis Imperfecta
• Renal Osteodystrophy
• Osteomyelitis
• Child abuse
• Preterm birth resulting in osteopenia – neonates
• Fibrous dysplasia
• Osteomalacia
• Copper deficiency – infants: first 6 months
• Bone tumours and cancers
• Chronic Vitamin A toxicity
• Metabolic diseases – leading to calcium wasting and demineralization
• Prolonged administration of prostaglandins, glucocorticoids, or methotrexate
• Congenital syphilitic periostitis
• Hypophospatasia
• Juvenile Osteoporosis

Investigations and Management

1)    Rickets:

Laboratory findings:

1. Elevated alkaline phosphatase – indication of impaired bone mineralizeation
2. Serum phosphorous concentrations – usually low in hypocalcemic and hypophosphatemic rickets
3. Serum calcium concentration – decreased only in hypocalcemic rickets
4. Parathyroid hormone – usually elevated in hypocalcemic rickets, but usually normal in hypophosphatemic rickets
5. 25-OH Vitamin D – low in vitamin D deficiency
6. GFR and Creatinine – to determine kidney function

Radiographic Findings:

1. Osteopenia
2. Metaphyseal cupping  and fraying (See Figure 2)
3. Physeal widening
4. Enlargement of costochondral junction
5. Bowing of long bones (See Figure 3)

Management:

1. Oral doses of 5,000-15,000 IU/day of Vitamin for 4 weeks for Vitamin deficient Rickets
2. Optimize calcium intake for hypocalcemic rickets
3. Treat underlying primary cause of Rickets

2)    Bone Tumors (benign and malignant)

Laboratory Findings:

1. If suspect malignancy: blood work including liver enzymes, CT chest, bone scan, bone biopsy, MRI of affected bone

Radiographic Findings:

1. Benign: single lesion generally, sharp area of delineation, overlying cortex intact, sclerotic margins, no or simple periosteal reaction (See Figure 4)
2. Malignant: multiple lesions often, poor delineation of lesion, loss of overlying cortex, extensive periosteal reaction, potential soft tissue involvement (See Figure 5)

Management:

1. Benign: follow up with radiographs 4-6 months later
2. Malignant: complete resection, chemotherapy, radiation

3)    Osteogenesis Imperfecta

Laboratory Findings:

1. Elevated levels of serum alkaline phosphatase
2. Hypercalciuria – magnitude reflects severity of disease
3. C-terminal peptide (marker of bone formation) and C-telopeptide (marker of bone resorption) –can be higher

Radiographic Findings:

1. Mild OI: Thin cortex and relatively few fractures with normal skull development
2. More severe OI: hyperplastic callus formation (from thickened periosteum), shortened long bones with multiple fractures (See see Figure 6)

Management:

1. Bisphosphonates

Conclusion

Children who present with pathological fractures always require a thorough evaluation. It is important to keep an open mind as to the various causes of pathologic fractures and to always rule out non-accidental injury.

References

1)        Beary J, Chines A. Clinical features and diagnosis of osteogenesis imperfecta. (Last Updated June 15, 2010) In: UpToDate, Tepas E (Ed), UpToDate, Wellesley, MA, 2010.

2)        Scheri S. Differential diagnosis of the orthopedic manifestations of child abuse. (Last Updated Dec. 3, 2008) In: UpToDate, Wiley E (Ed), UpToDate, Wellesley, MA, 2010.

3)        Rauch F. Overview of Rickets in Children. (Last Updated August 11, 2010). In: UpToDate, Hoppin A (Ed), UpToDate, Wellesley, MA, 2010.

4)        Tis J. Overview of benign bone tumors in children and adolescents. (Last Updated September 28, 2010) In: UpToDate, Torchia, M (Ed), UpToDate, Wellesley, MA, 2010.

5)        Kliegman R, Behrman, Jenson H, Stanton B. Nelson Textbook of Pediatrics, 18^th ed. Philadelphia: Saunders, 2007.

6)        Benson M, Fixsen J, Macnicol M. Children’s Orthopaedics and Fractures, 3^rd ed. New York: Springer, 2010.

7)        Kirpalani A, Babyn P. Imaging in Osteogenesis Imperfecta. eMedicine (Last Updated August 5, 2008). Available from http://emedicine.medscape.com/article/411919-print [Accessed on March 5, 2011]

8)        Rijn R, McHugh K. Rickets Imaging. eMedicine (Last Updated March 18, 2009). Available fromhttp://emedicine.medscape.com/article/412862-print [Accessed on March 5, 2011]

9)        Dugani S, and Lam D. Toronto Notes. Toronto Notes Medical Publishing Inc. 2009

10)     Jenny C. Evaluating Infants and Young Children with Multiple Fractures. Pediatrics. 2006; 118(3):1299-303.

11)      Adam A, Dixon A. Adam: Grainger & Allison’s Diagnostic Radiology, 5^th ed. Philadelphia: Churchill Livingstone, An Imprint of Elsevier, 2008.

Acknowledgements

Written by: Teresa Liang

Edited by: Anne Marie Jekyll, MD (Pediatric Resident)

Images

(Image from Rijn R, McHugh K. Rickets Imaging. eMedicine (Last Updated March 18, 2009). Available fromhttp://emedicine.medscape.com/article/412862-print [Accessed on March 5, 2011])

(Image from Rijn R, McHugh K. Rickets Imaging. eMedicine (Last Updated March 18, 2009). Available fromhttp://emedicine.medscape.com/article/412862-print [Accessed on March 5, 2011])

(Image from Rijn R, McHugh K. Rickets Imaging. eMedicine (Last Updated March 18, 2009). Available fromhttp://emedicine.medscape.com/article/412862-print [Accessed on March 5, 2011])

(Adapted from Adam A, Dixon A. Adam: Grainger & Allison’s Diagnostic Radiology, 5th ed. Philadelphia: Churchill Livingstone, An Imprint of Elsevier, 2008)

(Adapted from Adam A, Dixon A. Adam: Grainger & Allison’s Diagnostic Radiology, 5^th ed. Philadelphia: Churchill Livingstone, An Imprint of Elsevier, 2008)

(Image from Kirpalani A, Babyn P. Imaging in Osteogenesis Imperfecta. eMedicine (Last Updated August 5,2009). Available from http://emedicine.medscape.com/article/411919-print [Accessed on March 5, 2011])