OBJECTIVE. The objective of this study was to identify the healing process and outcome of nonhymenal injuries in prepubertal and pubertal girls.
METHODS. This multicenter, retrospective project used photographs to document the healing process and outcome of nonhymenal genital injuries in 239 prepubertal and pubertal girls whose ages ranged from 4 months to 18 years.
RESULTS. The genital injuries sustained by the 113 prepubertal girls consisted of 21 accidental or noninflicted injuries, 73 injuries secondary to abuse, and 19 injuries of unknown cause. All 126 pubertal girls were sexual assault victims. These nonhymenal genital injuries healed at various rates depending on the type and severity. There was no statistical difference in the rate of healing between the 2 groups. Abrasions disappeared by the third day after injury. Edema was no longer present by the fifth day. Ecchymosis (bruising) resolved within 2 to 18 days depending on the severity. One prepubertal girl still had a labial hematoma at 2 weeks. Submucosal hemorrhages of the vestibule and fossa navicularis resolved between 2 days and 2 weeks. Petechiae and blood blisters proved useful for approximating the age of an injury. Petechiae were gone by 24 hours, whereas blood blisters were detected at 30 days in a prepubertal girl and 24 days in a pubertal girl. The depth of a laceration determined the time required for it to heal. Superficial vestibular lacerations seemed healed in 2 days, whereas deep perineal lacerations required up to 20 days. The appearance of new blood vessel formation was detected only in prepubertal girls, whereas scar tissue formation occurred only after a deep laceration in both groups.
CONCLUSIONS. The majority of these nonhymenal genital injuries healed with little or no evidence of previous trauma. The time required for resolution varied by type, location, and severity.
- accidental genital injuries
- adolescent sexual assault
- child abuse
- child sexual abuse
- forensic evidence
- genital injuries
- sexual abuse
- sexual assault
The evaluation of a female child or adolescent who is suspected of having been sexually abused requires a careful evaluation. It begins with a detailed history of the event(s) followed by a complete physical examination and, if appropriate, the collection of forensic material. Although the interpretation of the outcome of the findings has received a good deal of attention, there are still many unanswered questions.1–12
There is relatively little information about the healing process of a female's genital injury. Except for the report by Heppenstall-Heger et al,10 most studies have focused on the outcome of hymenal injuries in prepubertal girls.11, 12 Very little is known about the amount of time that it takes a genital injury to resolve. It is unclear whether the type of injury or its location or the developmental stage of the girl makes a difference. It is unknown whether there is a sequence or a time frame in this process that could be used to determine the age of a healing injury. It is also unknown whether there are specific findings that could help to identify the approximate age of an injury. This study, along with its companion report13 on the healing of hymenal injuries, was designed to help answer these questions.
The patients for this multicenter study were recruited from medical centers throughout the United States. The majority of these cases were obtained through the use of the Helfer Society's Listserv. The members of this honorary society are recognized for their expertise in the evaluation and treatment of abused and neglected children and adolescents. The participants were asked to provide pertinent medical information and photographs of any female child or adolescent who had sustained a genital injury from any cause. Patients from birth through 17 years of age were eligible. In addition to the photographic documentation of an injury, all patients were required to have at least 1 follow-up examination. Because this was a retrospective, convenience-sample study, the period between an injury and the follow-up examination was not uniform. Each center's institutional review board authorized its center's participation in the project.
The participants provided the authors with a summary of the portion of a patient's medical chart that pertained to the genital injury. The information requested included the individual's birth date and ethnicity, the examiner's opinion as to the cause of the injury, and the examination method used. The time and date of all examinations became part of a computer-generated database. The patient's computerized medical chart and photographs were assigned a number to protect the individual's identity.
Photographic documentation by the participating institutions was captured through the use of a variety of recording methods. The most common recording device was either a 35-mm camera with a macrolens or a camera that was mounted on a colposcope. Several centers provided images that had been captured through the use of digital still or video cameras. Prints of the images were provided by each center.
Analysis of the Photographs
The patients were examined by a variety of methods. These included the supine labial separation method, the supine labial traction technique, and the prone knee-chest position. When a patient had been examined by >1 method, we divided the photographs into separate envelopes on the basis of the method used. Each photograph was evaluated in the presence of all 3 medical authors. During the evaluation, the authors were blinded to the cause of the patient's injury and to the contributor's interpretation of the findings. An agreement by all 3 medical authors was required before the interpretation of a finding was recorded on a worksheet illustration and entered into the database.
Analysis of the Patients
We divided the patients into 2 groups on the basis of the hormonal effect on the hymen. The first group consisted of the girls whose hymen showed no estrogen effect. Their hymens tended to be thin, delicate membranes with relatively smooth edges. The few girls who were younger than 3 years and retained some visual evidence of endogenous estrogen were placed in the first group that is referred to as prepubertal girls. The second group consisted of the older girls whose hymen did show an estrogen effect. Their hymens tended to be thicker and more redundant and frequently had scalloped edges. This second group is referred to as pubertal girls.
Types of Nonhymenal Genital Injuries
We subdivided the nonhymenal injuries into abrasions, contusions, and lacerations (see Appendix). Evidence of a contusion included the presence of blood blisters, edema, hematomas, petechiae, and submucosal hemorrhages. The abrasions and contusions were classified further as to their size and color. The severity of each abrasion and contusion was categorized through the use of the term mild, moderate, or marked. Each of these characteristics was compared with those noted during the initial examination, and the time between examinations was recorded.
The depth of a nonhymenal genital laceration was based on its appearance. A laceration was recorded as superficial when it did not extend into the subcutaneous tissue, intermediate when subcutaneous tissue could be visualized, and deep when the injury penetrated into the underlying muscle. Completion of the healing process was defined by the disappearance of the signs of an acute injury and the cessation of changes in the depth and configuration of a laceration. An acute injury was defined as the presence of a fresh-cut surface and/or evidence of active bleeding. New blood vessel (neovascularity) and scar tissue formation along with the appearance of the finding at the time of the last evaluation was also documented.
Individually, we performed a blinded reexamination of a random sample of 10% (n = 25) of the cases to assess and measure the reliability of the original agreement on the interpretation of a finding. κ statistics were used to determine this interobserver reliability. The κ scores ranged from 0.46 to 1.0 (moderate to excellent). On the basis of the interpretation of κ results by Landis and Koch14 as well as Fleiss,15 the authors concluded that the results from this study are sufficiently reliable.
We entered all collected data into an Access (Microsoft, Redmond, WA) database. We documented the photographic findings on a worksheet and systematically entered it into the created database. These data were then transferred directly into SPSS (SPSS, Inc, Chicago, IL) for analysis. Descriptive statistics were used to show the results of each of the 3 examination methods. Data were analyzed by using t tests, χ2, Yates continuity correction or Fisher's exact tests, and Mann-Whitney U tests, when appropriate. Statistical significance was defined as P < .05.
The patients consisted of 239 female children and adolescents from 4 months to 18 years of age. There were 113 (47%) prepubertal girls and 126 (53%) pubertal girls. Of the 113 prepubertal children, 50% were white, 16% were black, 26% were Hispanic, 4% were Asian, and 4% were of a mixed race. Of the 126 pubertal girls, 48% were white, 28% were black, 14% were Hispanic, 4% were Asian, and 6% were of a mixed race.
Timing of Examinations and the Cause of Injuries
The period between an injury and the initial examination ranged from 1 hour to 3 days. A total of 164 (69%) of the 239 girls were seen within 24 hours of their injury, 208 (87%) were examined within 48 hours, and the other 31 (13%) were first evaluated between 48 and 72 hours after their injury. The mean time between an injury and the first examination was 24 hours. The longest a prepubertal girl was followed was 2.6 years. The average follow-up period was 9.9 months. For the 126 pubertal girls, the soonest reevaluation also occurred within 24 hours of the assault. The longest a pubertal girl was followed was 3.7 months. The average follow-up period was 61 days. The causes of the injuries in the 113 prepubertal girls, as determined by the contributors, included 21 (19%) accidental or noninflicted injuries, 73 (65%) injuries secondary to abuse, and 19 (17%) injuries of unknown cause. All 126 pubertal adolescents were said to be victims of a sexual assault.
Summary of the Findings
Because of the nature of this study, the timing of both the initial and the follow-up examinations varied as a result of the circumstances of each case. During the follow-up examination, the number of days since the injury and the status of each nonhymenal genital abrasion, contusion, or laceration were recorded.
“Last detected” identifies the day on which a finding was last documented in patients with a particular injury.
“Earliest disappearance” identifies the day on which a particular finding was no longer identified in any 1 patient.
“Gone” identifies the first examination day on which a finding was no longer seen in any of the patients with that finding.
“Never seen” represents a finding that was never identified during a follow-up examination in any of the patients with that type of injury. Unfortunately, in this case, there was no way of knowing when such an injury had actually disappeared.
For example, in Table 1, of the 21 (19%) prepubertal girls with a labial abrasion, (for whom there were a total of 31 follow-up examinations), the last time this finding was seen on a follow-up examination in any of the girls was on the fourth day after an injury. The earliest day on which a labial abrasion was not detected was on the third day in 1 of 9 patients with this finding. No labial abrasions were identified during any of the other follow-up examinations (20 of 20) beginning with the fifth day after injury. Eight other prepubertal girls with this type of injury were reexamined during the next 5 days, and none of them had evidence of an abrasion on the labia.
The abrasions in the pubertal girls as found in Table 1 are used as an example of the term “never seen.” Nineteen (15%) pubertal girls had what initially seemed to be a labial abrasion. Of the 19 follow-up evaluations, no abrasions were ever detected (“never seen”) during a follow-up evaluation (19 of 19). The soonest that any of these girls (1 of 1) were reexamined was on the third day after their assault. During the next 7 days, 11 more of the pubertal girls with this finding were reevaluated and none had signs of their previous injury.
Nonhymenal Genital Contusions
A thin blood-filled vesicle (blood blister) was found in the vestibule of 2 prepubertal and in 6 pubertal girls (Table 2). In both groups, the blood blisters were usually detected during a follow-up examination as the tissue swelling receded and the extravasation of blood resolved. The earliest identification occurred on the fifth day after injury in a prepubertal girl and on the sixth day after assault in a pubertal girl. Once formed, these 2- to 5-mm blood-filled vesicles shrank in size as they healed.
One of the 2 prepubertal girls with this finding still had a blood blister 30 days after her injury (see Table 2). It is unknown when this blister eventually disappeared. The blood blister in the other prepubertal girl was gone by the time she returned 48 days after her injury.
Blood blisters were present in 6 pubertal girls on their visits 6, 18, 22, and 24 days after assault. Blood blisters were gone in 2 pubertal girls by days 30 and 33. It is unknown when the other blood blisters eventually disappeared.
Flat hemorrhagic lesions (ecchymosis/bruise) were detected on the keratinized tissues of the labia, perineum, and posterior fourchette (Table 2). In the prepubertal girls, straddle-type injuries accounted for 37 (67%) of the labial injuries and 13 (38%) of the posterior fourchette injuries. The earliest disappearance of a bruise in the prepubertal girls ranged from 2 to 5 days. During the first week after injury, evidence of a bruise had disappeared in 21 of 30 prepubertal girls with this finding.
Very few bruises (ecchymosis) were identified on any part of the pubertal girls’ genitalia (Table 2). Evidence of a bruise was never seen during a follow-up examination in the majority of these girls (see Table 2).
No sign of edema was found during a follow-up examination in any of the 10 prepubertal girls with this finding (Table 2). Edema was last detected on the fifth day in 1 of the 4 adolescent girls with signs of swelling of the tissues.
The redness of tissues created by capillary congestion (erythema) constitutes a nonspecific finding; therefore, erythema is not included as a variable in this section because of its uncertain clinical significance.
Hematomas of the Labia
A well-defined, localized collection of blood (hematoma) was an uncommon finding in both groups of girls (Table 2). The labial hematoma in 1 prepubertal girl was gone by 10 days (see Table 2), whereas a hematoma in the other girl was still present at her 2-week follow-up examination.
Only 2 pubertal girls had hematomas on their labia. The hematomas in both girls were never seen at the time of their first reevaluation, which took place on their 10th day after assault (see Table 2).
Hematomas of the Vestibule and Fossa Navicularis
Only 1 prepubertal girl had what initially seemed to be a vestibular hematoma (Table 2). By the first follow-up examination on day 5, this well-defined, localized collection of blood (hematoma) had disseminated into the surrounding tissues. The “hematomas” of the fossa navicularis of 4 prepubertal girls evolved into submucosal hemorrhages by the second day after injury. No hematomas were found in the vestibule or the fossa navicularis of the pubertal girls.
Seventy-four (65%) of the 113 prepubertal girls had pinpoint, nonraised, perfectly round, purplish red spots (petechiae) on their nonhymenal genital tissues at the time of their initial examination (Table 2). No petechiae were detected beyond 24 hours (day 1) in any of the prepubertal girls (Figs 1–⇓3). Of the girls with this finding, 15 of the 97 follow-up examinations occurred between 48 and 72 hours after their injury. None had any sign of a petechial lesion.
Thirty-two (25%) of the 126 pubertal girls had petechiae on their nonhymenal genitalia at the time of their initial evaluation (Table 2). No petechiae were identified on a follow-up examination in any of the pubertal girls (see Table 2). Five of the girls were reexamined between 48 and 72 hours after their assault. None had any sign of a petechial lesion.
Submucosal hemorrhages were among the most common lesions found in the perihymenal region of the vestibule of the prepubertal girls (Table 2). In the prepubertal girls, evidence of bleeding into the areolar tissue beneath the mucosal membrane of the vestibule was found in 62 (55%) and in the fossa navicularis in 32 (28%). During the 80 follow-up examinations, the earliest disappearance of a mild vestibular submucosal hemorrhage occurred on day 2 (3 of 7). The last marked hemorrhage of the vestibule was detected on day 8 (1 of 32). One mild fossa navicularis submucosal hemorrhage had resolved (earliest disappearance) by day 3 (1 of 4). A marked submucosal hemorrhage in this same area was last detected on day 12 (1 of 20) in 1 prepubertal girl.
Fourteen (11%) of the pubertal girls were found to have submucosal hemorrhages of the perihymenal tissues in their vestibule, whereas 13 (10%) had this same type of injury in their fossa navicularis (Table 2). The earliest disappearance of a vestibular submucosal hemorrhage in a pubertal girl occurred on the seventh day after assault (1 of 2). The earliest recorded disappearance of a mild fossa navicularis hemorrhage was on day 2 (1 of 1). As the submucosal hemorrhages resolved, they became smaller in size and paler in color.
The lacerations were classified as superficial, intermediate, or deep (Table 3). The 157 nonhymenal lacerations identified in the 113 prepubertal girls were reevaluated 251 times. The number of the reevaluations varied according to the circumstances. Some girls were reexamined 1 time, whereas others were reexamined several times. One prepubertal girl who sustained a laceration was followed for 2.6 years. The 87 nonhymenal lacerations detected in the 126 pubertal girls were reexamined 94 times. The earliest reevaluation occurred on the third day after assault, whereas the last assessment took place 5 months after the adolescent's assault. Despite the relatively small numbers for any given type of laceration, there seemed to be a high correlation between our assessment of depth from a photograph and the time required for the resolution of a laceration.
Forty-seven (37%) prepubertal girls had lacerations of the labia minora or the labia majora (Table 3). Seventy-four percent of the labial tears were at the junction of these 2 structures. The deeper lacerations took on a shallower appearance as they healed. Depending on the depth, the time required for a laceration to resolve varied from 2 days to 14 days.
All 9 (7%) of the pubertal girls’ labial lacerations were superficial (Table 3). The soonest reevaluation of any of these girls occurred on the seventh day after assault (1 of 1). There was no sign of a laceration in any of these pubertal girls who were reexamined between the seventh and the 30th days after their assault.
Vestibular lacerations were documented in 10 (9%) prepubertal girls (Table 3). The earliest disappearance of a laceration occurred at 2 days in 1 of 2 girls. The last time a superficial laceration was detected was on the eighth day after injury (1 of 1). Depending on the depth, evidence of the other vestibular lacerations disappeared between 6 and 11 days. The deeper lacerations took on a more superficial appearance as they healed.
None of the 6 pubertal girls with a vestibular laceration had evidence of their injury at the time of their reexamination. The earliest reevaluations occurred on the third, fifth, and 10th days after assault.
Fossa Navicularis Lacerations
Forty-two (37%) prepubertal girls had lacerations of their fossa navicularis (Table 3). As with the other lacerations, the deeper tears evolved into shallower-appearing injuries as they healed. The time of resolution for the prepubertal girls’ fossa navicularis lacerations ranged from 2 days for a superficial laceration to 21 days for a deep tear (17 of 17). During the follow-up examinations, 6 of 19 fossa navicularis lacerations were noted to have resolved by 7 days and 14 of 42 by 14 days.
Fossa navicularis lacerations were detected in 38 (30%) pubertal girls (Table 3). The earliest disappearance of a superficial laceration occurred on day 4 (1 of 1), whereas a deep laceration was last detected on day 10 (1 of 3). By day 13, the remaining 6 deep lacerations had healed. Both the intermediate and deep lacerations evolved into shallower-appearing tears before healing completely. On the follow-up examinations, 6 of 9 fossa navicularis lacerations had resolved by 7 days and 18 of 23 by 14 days.
Posterior Fourchette Lacerations
Posterior fourchette lacerations were found in 34 (27%) prepubertal girls (Table 3). Depending on the depth, evidence of the prepubertal girls’ lacerations disappeared between 3 (1 and 1) and 20 days (19 of 19). On the follow-up examinations, 7 of 18 posterior fourchette lacerations had resolved by 7 days and 23 of 47 by 14 days.
Twenty-seven (21%) pubertal girls sustained posterior fourchette lacerations (Table 3). Although the earliest disappearance of a superficial laceration was documented on the third day after assault, none of the lacerations of this depth was ever seen again (14 of 14). The same result was found with the 9 intermediate depth lacerations. The earliest disappearance of this depth laceration was recorded on the sixth day after an assault. Of the 5 deep tears, the earliest disappearance occurred on day 7 (1 of 1) and the last 1 was detected on day 10 (1 of 1). On the follow-up examinations, 5 of 5 posterior fourchette lacerations had resolved by 7 days and 12 of 13 by 14 days.
Twenty-four (21%) prepubertal girls had perineal lacerations (Table 3). Evidence of both the superficial (6 of 6) and the intermediate (5 of 5) depth lacerations were no longer visible at the time of a follow-up evaluation. However, the earliest reevaluation of a girl with a superficial perineal laceration occurred on day 12 (1 of 1). The earliest reevaluation of a prepubertal girl with an intermediate depth laceration occurred on day 3 (1 of 1). Signs of a deep laceration were still present in 1 girl at 20 days (1 of 13). On the follow-up examinations, 3 of 8 of the deep perineal lacerations had resolved by 7 days and 7 of 16 by 14 days.
The pubertal girls had no sign of any of their perineal lacerations at the time of their reevaluations (Table 3). This included 1 of 1 reevaluation of a deep laceration on the seventh day after assault. On the follow-up examinations of the deep lacerations, 1 of 1 perineal laceration had resolved by 7 days and 4 of 4 by 14 days.
Neovascular and Scar Tissue Formation
New blood vessel formation (neovascular changes) and scar tissue formation (thickened pale white lines) were considered to be present only when they were detected ≥30 days after an injury. Neovascular formation was found only in the prepubertal girls and then relatively infrequently (Table 4). This new blood vessel formation occurred mainly on the mucosal surfaces of the vestibule (2 of 6) and the fossa navicularis (2 of 10).
Scar tissue formation was also an infrequent finding and then detected only in the girls who had sustained a deep laceration. Scars were found more commonly in the posterior fourchette (7 of 14) and on the perineum (6 of 8) of the prepubertal girls (Table 4).
This study reconfirmed that female genital injuries heal rapidly and usually leave little if any evidence of the previous trauma.6, 10–12, 16–22 There was no significant difference in the rate of healing or the final outcome of the nonhymenal genital injuries in these 2 groups of girls (Tables 1–4). The search for a “pattern” or a “time sequence” in the healing process that could determine the age of a wound did not materialize. The amount of time required for an injury to resolve depended on its severity. In both groups, signs of the less severe injuries disappeared in 2 to 3 days, whereas evidence of the more severe injuries took up to 2 weeks to resolve. New blood vessel formation and the appearance of scar tissue were rare in both groups of girls; however, 2 findings that provided the examiner with a method for approximating the age of an injury were identified. One was the presence of petechiae, and the other was the detection of a blood blister. The presence of petechiae was an indication that the injury had occurred within the past 24 hours. None of these pinhead-sized lesions was found on the nonhymenal genital tissue beyond 24 hours in any of these girls (Figs 1–3). Petechiae were also detected on the hymen in this study's companion report.13 Both studies used the same population of patients. In the companion report, petechiae were present on the hymen up to 48 hours in the prepubertal girls and up to 72 hours in the pubertal girls.
In both reports, there was a finding that initially seemed to be an exception to the time frame for the disappearance of a petechia. What originally were thought to be petechiae turned out to be small vascular anomalies. These lesions, which blanched with pressure, persisted for weeks.
The other finding was the blood blister (Fig 4). These blood-filled vesicles, which usually appeared for the first time during a follow-up examination, were associated with the more severe injuries. Their presence was an indication that an injury had occurred sometime in the past month. This finding was particularly helpful when all other signs of a recent injury had resolved.
The remarkable healing of the majority of these injuries was not unexpected. The healing process, as described by Kissane23 and Edwards and Dunphy,24 was similar to that found in this study. The less severe injuries, such as an abrasion or a superficial laceration, seemed to heal by regeneration in which all signs of the injury rapidly disappeared. The deeper lacerations most likely healed by repair. Only occasionally did any of these injuries leave behind new blood vessels (neovascular changes) or scar tissue formation (Table 4).
As a convenience-sample study, there are a number of limitations in this report. We did not have a predetermined protocol for the timing of the follow-up evaluations or specify the type of recording device to be used. Even the examination method was not mandated. In addition, not every injury was followed until complete healing had taken place. Although all of these factors were considered, we believed that to obtain a large enough sample size in a reasonable amount of time, we would need to obtain help from our colleagues throughout the United States. We decided to ask them to submit cases that they had previously evaluated.
The large number of cases submitted did provide us with an opportunity to evaluate both the healing processes and the outcome of most of these injures. Although not all of the injuries had completely healed by the time of the last reevaluation, the majority of the findings had either disappeared or had significantly changed when last examined. The photographs obtained by the various recording devices proved to be excellent. In addition, the fact that half of the girls were examined by 3 different methods proved to be an unexpected and valuable finding. This discovery provided us with an opportunity to compare the results obtained through the use of the supine labial separation method, the supine labial traction technique, and the prone knee-chest position. The results of this comparison are reported in a companion article.25
The results from this project should help medical examiners interpret the anatomic findings of a girl's nonacute genital injury. The presence of petechiae or a blood blister should provide valuable information to the investigator who is attempting to determine when an injury might have occurred. The rapid and complete healing of the majority of these injuries should also prove to be reassuring to both the girl and her family.
The results from this study corroborate previous observations that nonhymenal genital injuries in a young girl or an adolescent heal remarkably well and tend to leave little, if any, evidence of the previous trauma. The rapid resolution of the petechiae along with the persistence of blood blisters did provide findings that can be used for approximating the age of an injury. Similar to the other types of injuries, the time required for resolution and the final appearance of the nonhymenal lacerations did depend on their severity. The rapid resolution of these injuries makes it imperative that a child or an adolescent be examined as soon as possible when there is a suspicion of a possible sexual assault.
Abrasion: An area of body surface denuded of skin or mucous membrane by some unusual or abnormal mechanical process. Blood blister: A thin blood-filled vesicle. Contusion: A bruise; an injury of a part without a break in the skin. Types of injuries included as a contusion in the text: ecchymosis/bruise, hematoma, petechiae, and submucosal hemorrhage. Ecchymosis/bruise: A flat hemorrhagic lesion/a superficial injury produced by impact without laceration; a contusion. Edema: The presence of abnormally large amounts of fluid in the intercellular tissue spaces of the body. Erythema: Redness of the tissues created by capillary congestion. Hematoma: A well-defined, localized collection of blood. Petechiae: Pinpoint, nonraised, perfectly round, purplish red spots. Submucosal hemorrhage:Bleeding into the areolar tissue beneath a mucosal membrane. Laceration: A defect of the tissues caused by a ripping or pulling apart (rendering). The wound may contain bridging structures.26
This study was supported in part by the Lucile Packard Foundation; the Kenneth Jonsson Family Foundation; and the Children's Miracle Network through the Department of Pediatrics, University of California, Davis.
We gratefully acknowledge the participation of the following individuals in this multicenter, collaborative research project: David Kerns, MD (Valley Medical Center, San Jose, CA); Marilyn Kaufhold, MD (San Diego Children's Hospital); Mary Ritter, CHA (Valley Medical Center); Joan Voris, MD (University Hospital and Medical Center, Fresno, CA); Terrence Donald, MD (Women's and Children's Hospital, North Adelaide, Australia); Martin Finkel, DO (University of Medicine and Dentistry of New Jersey, Stratford, NJ); Lori Frasier, MD (University Physicians-Green Meadows, Columbia, MO); Wendy Gladstone, MD (Exeter Pediatric Associates, Exeter, NH); Penny Grant (Child Abuse Network, Tulsa, OK); Nancy Harper, MD (Naval Medical Center, Portsmouth, VA); Roberta Hibbard, MD (Indiana University School of Medicine, Indianapolis, IN); Ralph Hicks, MD (Wright State University, Dayton, OH); Margie Hogan, MD (Hennepin County Medical Center, Minneapolis, MN); Michael Jordan, MD (Medical Office Building, Newark, NY); Michael Knappman, PA-C (Redwood Children's Center, Santa Rosa, CA); Kathe Kraley, RN, MSN, CPNP (Children's Mercy Hospital, Kansas City, MO); Susan Murawski, MS, ARNP, CPNP (Southwest Florida Children's Fund, Fort Myers, FL); Vincent Palusci, MD (Michigan State University College of Human Medicine, Grand Rapids, MI); Andrew Sirotnak, MD (Children's Hospital, Denver, CO); Naomi Sugar, MD (HCSATS, Seattle, WA); Andi Taroli, MD (Children's Advocacy Center, Scranton, PA); Danny Waldrop, MD (Geisinger Medical Center, Danville, PA); and J.M. Whitworth, MD (Florida Children's Fund, Jacksonville, FL).
Special thanks go to Ana Ross, PA-C, for assistance with reviewing the medical charts of the University of California Davis Medical Center patients; to Stephen Boos, MD, formerly a Lieutenant Colonel, United States Air Force Medical Corps, for review of the manuscript; and to Lisa Stenhouse and Lieschen Trelford for assistance with the myriad of tasks connected to the preparation of this manuscript.
- Accepted May 21, 2007.
- Address correspondence to John McCann, MD, 10788 NE Bill Point Dr, Bainbridge Island, WA 98011. E-mail:
- Address reprint requests to Cathy Boyle, MSN, PNP, CAARE Diagnostic and Treatment Center, Department of Pediatrics, University of California Davis Children's Hospital, 3300 Stockton Blvd, Sacramento, CA 95820-1451. E-mail:
The authors have indicated they have no financial relationships relevant to this article to disclose.
Dr McCann is retired.
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- Copyright © 2007 by the American Academy of Pediatrics