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Journal of Pediatric Endocrinology and Metabolism

Editor-in-Chief: Kiess, Wieland

Ed. by Bereket, Abdullah / Darendeliler, Feyza / Dattani, Mehul / Gustafsson, Jan / Luo, Fei Hong / Mericq, Veronica / Toppari, Jorma

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Volume 32, Issue 10


Findings of metabolic bone disease in infants with unexplained fractures in contested child abuse investigations: a case series of 75 infants

Marvin Miller
  • Corresponding author
  • Dayton Children’s Hospital, Department of Medical Genetics, 1 Children’s Plaza, Dayton, OH 45404, USA
  • Department of Pediatrics, Ob/Gyn and Biomedical Engineering, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
  • Email
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Adrienne Stolfi
  • Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ David Ayoub
Published Online: 2019-10-10 | DOI: https://doi.org/10.1515/jpem-2019-0093



Infants who present with multiple unexplained fractures (MUF) are often diagnosed as victims of child abuse when parents deny wrongdoing and cannot provide a plausible alternative explanation. Herein we describe evidence of specific and commonly overlooked radiographic abnormalities and risk factors that suggest a medical explanation in such cases.


We evaluated such infants in which we reviewed the radiographs for signs of poor bone mineralization. We reviewed medical, pregnancy and family histories.


Seventy-five of 78 cases showed poor bone mineralization with findings of healing rickets indicating susceptibility to fragility fractures that could result from a wide variety of causes other than child abuse. We found risk factors that could explain the poor bone mineralization: maternal and infant vitamin D deficiency (VDD), decreased fetal bone loading, prematurity and others. Most infants had more than one risk factor indicating that this bone disorder is a multifactorial disorder that we term metabolic bone disease of infancy (MBDI). Maternal and infant VDD were common. When tested, 1,25-dihydroxyvitamin D levels were often elevated, indicating metabolic bone disease.


Child abuse is sometimes incorrectly diagnosed in infants with MUF. Appreciation of the radiographic signs of MBDI (healing rickets), risk factors for MBDI and appropriate laboratory testing will improve diagnostic accuracy in these cases.

Keywords: bone loading; child abuse; fractures in infancy; metabolic bone disease of infancy; Utah Paradigm; vitamin D deficiency


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About the article

Corresponding author: Marvin Miller, MD, Dayton Children’s Hospital, Department of Medical Genetics, 1 Children’s Plaza, Dayton, OH 45404, USA; and Department of Pediatrics, Ob/Gyn and Biomedical Engineering, Wright State University Boonshoft School of Medicine, Dayton, OH, USA, Phone: +(937) 641-5374, Fax: +(937) 641-5325

Received: 2019-02-18

Accepted: 2019-07-05

Published Online: 2019-10-10

Published in Print: 2019-10-25

Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

Research funding: None declared.

Employment or leadership: None declared.

Honorarium: None declared.

Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

Citation Information: Journal of Pediatric Endocrinology and Metabolism, Volume 32, Issue 10, Pages 1103–1120, ISSN (Online) 2191-0251, ISSN (Print) 0334-018X, DOI: https://doi.org/10.1515/jpem-2019-0093.

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