A 2-month-old girl was brought to your office with a history of facial lesions shown which had become progressively worse over the day (Image 42). The infant was taking less formula from the bottle and was sleeping more than usual. No vomiting, diarrhoea or fever had been noted. https://s3-euw1-ap-pe-df-pch-content-public-u.s3.eu-west-1.amazonaws.com/9780429170423/236ca68c-f283-4df8-88b2-3b8ff49bccc9/content/fig42.jpg" xmlns:xlink="https://www.w3.org/1999/xlink"/>

What does the image show?

What tests are important to determine the aetiology for this patient’s presentation?

What important information about the social history will help child protective authorities provide for a safe environment for the infant?

The child had bruises over the upper lip. There may have been additional lesions over the cheek that are not well depicted. Child abuse is strongly suspected.

A complete physical examination should be done, including examination of the inside of the mouth to look for intraoral injuries such as torn frena, injuries to the palate or injuries to the inner cheeks or gums. A history of any bleeding, bruising or trauma should be asked. Weight, height and head circumference should be measured and information about the birth should also be sought, including whether the infant was given supplemental vitamin K at birth. No other skin findings were noted and there were no frena injuries. 1 Given the possibility of inflicted trauma in this presentation, head imaging and full imaging of the axial skeleton using a skeletal survey is indicated. Coagulation tests such as a complete blood count, prothrombin time and partial thromboplastin times are also indicated to determine if the child has an underlying coagulation disorder contributing to the bleeding. 2

A full psychosocial assessment was needed to determine the strengths and needs of the family to raise and protect this infant. It was important to review who had been caring for the infant and what findings, if any, there had been on well-baby medical visits since birth. It was critical to speak with the caretakers about the baby’s ability to feed from the bottle, whether the baby had been crying or fussy, and whether solids had been introduced, and whether they had attempted to force the bottle or other objects into the infant’s mouth to promote intake. Physical abuse, force feeding, facial trauma or underlying bleeding disorders are all possible explanations for these findings.