by Sandeep K. Narang, M.D., J.D., FAAP
Child abuse cases are plagued with extraneous
theories and hypotheses for how injuries occurred.
;ese explanations, such as rare diseases and improbable mechanisms, often are accepted as more
likely etiologies than abuse.
Following are but a few examples. Unfortunately,
they are not uncommon.
In a suspected abusive head trauma case, a
4-month-old who died had subdural hemorrhages,
severe retinal hemorrhages with retinoschisis, di;use
swelling of the cervical spinal cord and rib fractures
in di;erent stages of healing. A pediatrician testified
for the defense that coughing and/or choking could
explain the child’s subdural and retinal hemorrhages.
;e pediatrician testified that “micro-aspirations of
formula” could result in “laryngospasm and bronchospasm,” which “could result in sudden death.”
;e pediatrician attributed the healing rib fracture
to an uncomplicated cesarean section delivery four
months prior and the fresh rib fractures to the CPR
preceding the child’s death. ;e defendant was convicted of serious bodily injury to a child, but the
jury deadlocked on the capital murder charge, and
a mistrial was declared on that charge.
In another suspected abusive head trauma case (a
child dependency hearing), a 4-month-old had acute
and chronic subdural hemorrhages, retinal hemorrhages, di;use cerebral edema and an unexplained
femur fracture at 1 month of age. A pediatric neu-roradiologist provided a sworn report to the court
that the acute/chronic subdural hemorrhages and
di;use cerebral edema were “post-vaccinal sequelae”
in the setting of “vitamin D or vitamin C deficiency.” He attributed the previous femur fracture to
that “nutritional deficiency” as well. Fortunately, the
court took protective custody of all children in the
In a suspected child physical abuse case of a
2-month-old with facial bruising, facial burns, a
healing femur fracture and healing rib fractures,
a pediatric orthopedic surgeon provided a sworn
report to the court that the healing fractures were
attributable to “accident.” ;e orthopedic surgeon
a;rmed that the father’s “stretching out” of the baby’s legs at 3 weeks of age was a plausible accidental
mechanism for the femur fracture, and the father’s
history of “grabbing the child and pulling her out
of the chair quickly/forcibly” was a plausible accidental mechanism for the rib fractures. Based on
these a;rmations, the prosecutor accepted a guilty
plea of “reckless conduct — great bodily harm” (a
Class 4 felony), and the father was sentenced to 30
We all understand the “why” and the “how” of
these happenings: emotional bias forged in rela-
tionships with caregivers,
philosophical denialism of
the entity of abuse, political
dissatisfaction and mistrust
of child welfare systems, and
plain old pecuniary interests.
;e di;culty for decades has
been the solution.
Although many solutions
for ensuring sound and ethical expert testimony have
been offered — from regulation by state medical licensing boards to individual
actions for malpractice —
the most e;ective course has
been when physicians resolve
to act at both the individual
and collective levels.
As U.S. Appellate Judge
Richard Posner once stated,
“It is no answer that judges
can be trusted to keep out such testimony. Judges
are not experts in any field except law. Much escapes
us … when a member of a prestigious professional
association makes representations not on their face
absurd … the judge may have no basis for question-
ing the belief.”
A growing number of professional societies have
implemented a variety of mechanisms for assuring
ethical expert testimony, including witness precerti-
fication programs, voluntary a;rmation statements
and disciplinary sanctions. Although these tools are
available, it is up to physicians to act. Pediatricians
should be mindful that the quality of testimony pro-
vided in child abuse cases not only can negatively
impact child protection, but it can tarnish the rep-
utation of all pediatricians.
;e Academy recently revised its policy statement
Expert Witness Participation in Civil and Criminal
Proceedings, http://bit.ly/2kLeMwh.;e following
are key provisions of that statement as they pertain
to child maltreatment cases:
• The member will take all necessary steps to
provide expert work that is relevant, reliable,
honest, unbiased and based on sound scientific
• ;e member will provide conclusions that are
objective, valid and well-supported by his/her
clinical experience and the best evidence-based
medical literature, regardless of whether it is to
be used by the plainti;/prosecutor or defendant.
• ;e member will testify to matters only within
his/her expertise and refrain from testifying to
matters outside his/her expertise.
• Members should testify in cases of abuse and
neglect, especially if they have special knowledge
and/or extensive experience in the field. General
pediatricians testifying in these cases may wish
to consult with subspecialists in child-abuse pe-
• ;e member will submit his or her testimony
to scrutiny, if requested, by professional organizations, hospitals, peer-review bodies and state
medical and/or licensing boards, as appropriate.
• ;e member will engage in contractual agreements for expert testimony/consultation that
are structured in a way that promotes fairness,
accuracy, completeness and objectivity.
Pediatricians acting as experts in child abuse cases
serve an important role when they provide scientifically sound and unbiased testimony.
Dr. Narang is a member of the AAP
Committee on Medical Liability and
Pediatricians can protect children by offering
ethical expert testimony in court
More professional societies are implementing mechanisms for assuring ethical
testimony, including witness precertification programs, voluntary affirmation
statements and disciplinary sanctions.
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