The death of temporary brittle bone disease is premature

In this issue of Acta Paediatrica is an article on temporary brittle bone disease (TBBD) by Paterson (1). Paterson will be forever linked to TBBD as he coined the term in the early 1990s to describe a group of infants who had multiple unexplained fractures (MUF) in the first year of life (most under 6 months of age). He thought TBBD was a transient, intrinsic bone disorder as the fractures were limited to the first year of life, and that it was highly unlikely that these infants were abused as there was no bruising (2,3). However, these infants had X-ray fracture characteristics that are thought to be pathognomonic of child abuse including: (i) metaphyseal fractures; (ii) posterior rib fractures and (iii) fractures at various stages of healing. Paediatric radiologists had long preached that these features indicated child abuse and paediatricians accepted this dogma without question. Paterson’s proffer of TBBD as a mimic of child abuse was a direct challenge and threat to the child advocacy establishment (CAE) who strongly disagreed with Paterson’s assertion that this was an intrinsic bone disorder, as Paterson could not provide evidence at that time of a specific bone disease or predisposing factor(s) that might explain TBBD. Paterson testified in the legal proceedings of infants with MUF in which he diagnosed TBBD, but the CAE diagnosed child abuse and the children were removed from their parents. In some of these cases, the infants were returned to their parents, because of Dr Paterson’s testimony that defended the concept of TBBD in the court room. Dr Paterson’s success in returning children to their parents, in the face of a diagnosis of child abuse by the CAE, angered the CAE (4). Because the CAE was having a difficult time prevailing in attacking his message in the court room, the CAE decided to attack the messenger, Dr Paterson, in the court room and brought successful proceedings of disbarment against him in 2004 by the GMC in England leading to Dr Paterson’s apparent premature retirement from medicine (5). By having Dr Paterson disbarred and publishing policy statements and reviews in publisher friendly journals which explicitly state that TBBD does not exist and is a ruse for child abuse, the CAE had hoped to forever bury TBBD (6,7). After all, accepting the existence of TBBD would be tantamount to the admission of the incorrect diagnosis of child abuse in thousands of cases of infants with MUF over the past 30 years. Much is at stake for both the families enmeshed in this issue and for the physicians who diagnose child abuse in these cases.