Associated Press Writer
KANSAS CITY, Mo. - It appeared to be a clear-cut case of child abuse: An infant hospitalized with bleeding in his brain, his father behind bars suspected of shaking the baby.
Only after the boy died without his father at his bedside did doctors realize the bleeding was brought on by a vitamin K deficiency - not abuse.
Dr. Jim Anderst, who diagnosed the deficiency about 18 months ago while working at a San Antonio hospital, tells the story to doctors-in-training he teaches at Children's Mercy Hospital in Kansas City and says it underscores why the subspecialty of child abuse pediatrics is necessary.
The field involves not only treating suspected abuse victims but coordinating with police and welfare workers and testifying in court hearings. It will reach a milestone in November, when about 200 doctors sit for a board examination offered for the first time by the American Board of Pediatrics in Chapel Hill, N.C.
Its recognition as a subspecialty also is expected to lead to a formal system of accreditation for some of the roughly 25 child abuse pediatrics fellowship programs across the country for which there is currently no formal oversight.
Anderst, who leads one of the fellowship programs, said his findings sometimes force children from their homes. Other times, like with the boy who died after failing to receive a vitamin K shot typically given to newborns, they free parents from jail.
"It stuck with me because it made me realize the impact you can have if you try to go about it appropriately and find out what actually happened to these kids," said Anderst, who said that without the second look the boy's father would likely still be jailed today.
"Certainly, there are many cases where it is obvious. There can be multiple fractures and injuries. There are all sorts of things that can happen to kids that could be abuse but might not be, and we have to try to determine the truth."
Studies have repeatedly shown that many doctors lack the expertise to handle these difficult cases. Practitioners hope the changes result in more experts who can teach in medical schools, conduct research and serve as a resource for general pediatricians.
A survey released this year in Pediatrics, the journal of the American Academy of Pediatrics, found current levels of child abuse training are inadequate. Many residents reported concerns about handing sexual abuse cases and most had difficulty identifying certain genital parts. The report notes concern regarding the lack of knowledge of female genitalia among medical professionals is not new.
Desmond Runyan, professor of social medicine and pediatrics at the University of North Carolina at Chapel Hill, said the lack of training makes some doctors reluctant to handle child abuse cases.
"I've found in my own experience kids are still kids, and it's not unpleasant to deal with kids," he said. "It's sometimes difficult work and sometimes unpleasant, but I can't imagine that telling people they have cancer or some other fatal disease is any easier."
Practitioners also hope greater recognition of the subspecialty will lead to higher payments from insurance companies and government health care programs - a relief for hospitals that typically lose money on their child abuse teams because of the time involved in the cases.
Runyan said a clinic he helped found in Durham, N.C., had to stop providing medical examinations for suspected child abuse victims in 2006 because the effort was losing about $400,000 a year.
But others fear the subspecialty will make it more difficult for pediatricians who lack the board certification to testify in court. They note that general pediatricians will continue to handle most of the estimated 3.2 million cases of child abuse reported each year.
How many of those cases are misdiagnosed is unclear, although only 794,000 were substantiated in 2007, the latest year for which federal information is available.
Dr. Rachel P. Berger, a pediatrician in the Child Advocacy Center at Children's Hospital of Pittsburgh, said she worries the shift might lead to difficulties in areas with nobody certified if defense attorneys challenge the credentials of regular doctors.
"Who is going to testify on behalf of those children?" she asked. "Are you going to fly in a child abuse expert for every one of these cases? Clearly not. So I think we've created a big problem for being able to testify."
Other say the risk is worth it.
Dr. Robert W. Block, a professor at the University of Oklahoma of Community Medicine in Tulsa, led efforts to create the subspecialty. He said the designation is a critical development in a field that has evolved rapidly since a 1962 article in the Journal of the American Medical Association that urged doctors to consider the possibility of child abuse.
Gradually, doctors gravitated to the field and conducted research on broken bones, burns and sexual abuse.
"There are children, their siblings and families in great pain and stress," he said. "This is an area where you can do a whole lot of good."