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Invited commentary: His life was lost but his heart still beats: In honor of children harmed by child abuse

Jonathan was a beautiful 6-month-old with bright eyes and a big smile whose parents described him as a happy and easy baby, content with life. There were no prior concerns about his growth and development by his parents or pediatrician. It was therefore completely unexpected when he presented to the hospital in full arrest with a history of choking during a feeding while at daycare. When the ambulance arrived at the daycare, the caregiver was performing cardiopulmonary resuscitation. At the hospital, it was noted that his pupils were fixed and dilated, and he had bruising of his face and neck, not reasonably explained by resuscitation. Subsequent medical evaluations included detailed history taking (history of present illness, past medical history, and family history), physical examinations, and premortem diagnostic testing. American Academy of Pediatrics and American College of Radiology guidelines (Christian, 2015; Wootton-Gorges et al., 2017) were followed. These guidelines are based on decades of the best available medical evidence, designed to appropriately diagnose and differentiate child abuse from other medical conditions. Jonathan died 3 days later despite the best efforts of physicians and nurses at a Level I Pediatric Trauma Center. At the hospital and ultimately upon autopsy, he had extensive bruising to his right forehead, left cheek, right jaw, left lateral neck, right posterior neck, and an upper frenula laceration. Radiographs and autopsy revealed a total of 23 fractures: bilateral rib fractures in different stages of healing (including a rare first rib fracture), a left clavicle fracture, an acute spiral fracture of the left femur, acute and healing buckle fractures of bilateral tibias and fibulas and left radius. There were also classic metaphyseal lesions of the left distal femur, left distal and proximal tibia, right distal femur and left proximal humerus. CT-scan revealed small bilateral subdural hemorrhages at the vertex extending along the superior aspect of the falx. There was suggestion of edema in the bilateral parietal, temporal, and occipital lobes. At autopsy, there were multifocal scalp hemorrhages as well as diffuse brain swelling with uncal and tonsillar herniation; in addition, there was a disrupted cervical spinal cord with acute parenchymal and peripheral nerve root damage. Child abuse is real and has a high prevalence. There are a nationally estimated 674,000 victims of child abuse and neglect per year. The victim rate is 9.1 child victims per 1,000 children (U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau, 2019). Nationally, more than one-quarter (28.5%) of victims are younger than 3 years old. Children in their first year of life have the highest rate of victimization at 25.3 per 1,000 children (U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau, 2019). The greatest percentages of children suffered from neglect (74.9%) and physical abuse (18.3%). In 2017, a national estimate of 1,720 children died from abuse and neglect at a rate of 2.32 per 100,000 children in the population (U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau, 2019). The United States Commission to Eliminate Child Abuse and Neglect Fatalities found that 4–8 children die in the United States from abuse or neglect/day (U.S. Commission to Eliminate Child Abuse and Neglect Fatalities, 2016). In the United States, 69% of victims are maltreated by a parent. Around 13% of victims are maltreated by a perpetrator who was not the child's parent. The largest categories in the nonparent perpetrator group are relative(s) (4.7%), partner of parent (2.9%), and “other” (2.7%), which includes nonrelated adult, nonrelated child, foster sibling, babysitter, household staff, clergy, and school personnel (U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau, 2019). These data inform efforts to prevent child maltreatment. They are not used to diagnose child abuse in an individual patient or to identify a perpetrator. In this case, Jonathan should have returned home from daycare to his loving parents, but they lost him, a loss from which they say they will never recover. In this case, the perpetrator was not a parent but rather a daycare provider. While the medical evaluation may contribute to a timeline that assists with the identification of the perpetrator, it is ultimately the job of child protective services, law enforcement, judges, and juries to determine the perpetrator. As medical professionals seek to not only heal, but also to prevent disease and recurrence of disease, the identification of the perpetrator bears medical relevance. It is thus the responsibility of medical providers to care for the child at the bedside and to share the best available evidence-based medical data with child protective services, law enforcement, and courts. After this infant's death, when his family returned home, it would have been ideal for them to have time to process and to grieve his death, but like many families of victims, their story did not end in the hospital. A criminal case was brought against the alleged perpetrator, a painful ordeal for a family of both the victim and the perpetrator to even fathom, let alone endure. During the proceedings, the defense tried to explain all the injuries with various flawed theories and unique Received: 3 July 2019 Accepted: 15 August 2019