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Child Abuse Case 22


A 6-year-old girl, being evaluated for a well child appointment, is noted to have these marks on her back. She was born in Africa and her family now lives locally after emigrating as refugees. These lesions are non-painful and the family indicates that she developed them while being treated for an illness as an infant.


Case 22

Photo courtesy of Terri Morse, FNP, Upstate Golisano Children’s Hospital


What is the most likely cause of these healed scars?

  1. Cigarette burns
  2. Cupping
  3. Moxibustion
  4. Coining

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The answer is C.

When traumatic conditions leave scars that follow a pattern, it is a good rule of thumb to assume that the injuries were inflicted. In some cases, however, being inflicted does not necessarily mean that there was intent to do harm. Some forms of cultural practices and non-traditional medicine can leave cutaneous signs that may be mistaken for child abuse. Many folk remedies, including moxibustion, cupping and coining (skin scraping), have been reported to be mistaken for abuse. Moxibustion may be mistaken for burns, particularly cigarette burns. Other forms of therapeutic burning using heat sources other than moxa have been mistaken for intentional burns due to child abuse.

Moxibustion is part of a spectrum of therapies that may be offered as complementary alternative medicine treatments. It is a traditional Chinese medical procedure to treat pain, behavioral concerns, asthma, low blood pressure, enuresis and other symptoms. The method is also used by other cultures, especially those of Asian origin, including refugees in the United States. With moxibustion small pieces of the moxa herb, Crossostephium artemisioides, are burned on or above acupuncture points. The heat from the burning moxa is believed to stimulate acupuncture points, thereby increasing local blood circulation. A medium is sometimes used to separate the burning moxa from the skin. If it is not, second-degree burns, as shown above (healed), may occur.

Since moxibustion can leave permanent scarring, this cultural practice may not be considered acceptable to cultures that do not consider the treatment beneficial. However, for those who utilize this method, the unintended harmful outcome (scar) is a small risk compared to the intended outcome of relief of symptoms. Compared to cupping or coining (see below), moxibustion is the most likely to leave a permanent cutaneous finding. However, other than the cosmetic effect, there is no known long-term functional harm. As long as there is no functional harm, the spectrum of harm should be considered on a case-by-case basis and include the value placed on the treatment by the culture of origin and the beliefs of the parents.

Cupping is another cultural medicine practice that is used in Asia, the Middle East and parts of Europe to treat pain, fever and other symptoms. Treatment remedies for various conditions (cupping versus moxibustion, for example) vary based on practitioner. The patient in the photo below received cupping for successful alleviation of his shoulder pain. A heated glass or bamboo cup is held against the skin (either the painful area or an acupuncture site) until the trapped air cools and contracts. This forms a vacuum and the cup is left in place. Petechiae may develop in the shape of the cup. Dry cupping does not draw blood. The lesions are non-painful and temporary.

Cupping

Photo courtesy of Terri Morse, FNP, Upstate Golisano Children’s Hospital


Coining is also called coin rubbing, cheut sah (Chinese) and cao gio (Vietnamese). This procedure involves rubbing the edge of a coin against the skin until petechial bruising appears. Warm oil may be used to coat the skin or a balm may be used on the edge of the coin. These lesions may be seen as symmetrical purpuric stripes on large areas of the chest and/or back. They are temporary and cause minimal to moderate discomfort.


References

Hansen KK. Folk remedies and child abuse: A review with emphasis on caida de mollera and its relationship to shaken baby syndrome. Child Abuse and Neglect. 1997;22(2):117-127.

Kim JI, Lee MS, Lee DH, Boddy K, Ernst E. Cupping for treating pain: A systematic review. Evidence-Based Complementary and Alternative Medicine. 2009;2011, Article ID 467014, 7 pages.

Lee MS, Choi TY, Kang JW, Lee BJ, Ernst E. Moxibustion of treating pain: A systematic review. The American Journal of Chinese Medicine. 2010;38(5):829-838.

Look KM, Look RM. Skin scraping, cupping and moxibustion that may mimic physical abuse. Journal of Forensic Sciences. 1996;42(1):103-105.

MacReady N. AAP retracts statement on controversial procedure. Lancet. 2010;3:376(9734):15.

Rosenblat H. Coin rolling misdiagnosed as child abuse. CMAJ. 1989;140:417.


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