By Sarah Schulz
sarah.schulz@theindependent.com

Dr. Sheila Snyder, a pediatrician at Children's Hospital in Omaha, testified she examined Ingrid Aguirre's infant on June 21, 2007.

Aguirre, 21, is charged with felony child abuse resulting in serious bodily injury for incidents that occurred between May 16, 2007, when the child was born, and June 20, 2007. The baby is currently in foster care.

The baby was sent to Omaha from St. Francis Medical Center after three hospital stays and a number of clinic visits failed to yield any explanations for the girl's condition, which included periods when she quit breathing.

Snyder was concerned about the girl's blood tests, which showed elevated liver enzymes, potential indicators of child abuse. Further tests, including x-rays of the baby's chest and sides, were ordered.

Rib fractures along the baby's back were evident in the side x-rays so a full-skeletal survey, which involved multiple views of the same bones from head to toe, was done. Nineteen separate rib fractures, as well as fractures to both legs were found, she said. The rib fractures were in three stages of healing, she said.

"That was highly suggestive that this was an inflicted injury," she said.

A cat scan and three-dimensional reconstruction scan of the girl's skull were also done to rule out a skull fracture, she said.

After the survey, Snyder said she contacted Dr. Jeff DeMare, a physician at the hospital who works with the agency's child advocacy team, because she was concerned that the baby had suffered abuse.

Snyder said she observed the infant at the hospital with Aguirre. The baby appeared normal and Aguirre interacted with her in an appropriate manner. Snyder added that in her experience as a physician, she has never witnessed someone suspected of abuse harming the child while at the hospital.

DeMare reviewed the test results, lab findings and x-rays done at Children's Hospital but never examined the baby.

He said the injury to the baby's liver, which caused the elevation in enzymes, could have been related to direct trauma or the lack of oxygen.

According to testimony from the baby's local pediatrician, Dr. Douglas Boon, she had stopped breathing on two occasions and was hospitalized.

Boon also testified he had treated the child for a distended abdomen, which he believed could have been related to difficulties with feedings, and spoke to Aguirre about the baby being fussy. There were also occasions when Aguirre sought medical treatment because the baby's abdomen and extremities were discolored, he said.

He was concerned the child might have an infection and did blood tests. Chest x-rays were also ordered and Aguirre was sent home with an apnea monitor, which would sound alarms if the baby quit breathing.

"We thought we had done a rather extensive work up," Boon said.

After the baby's third trip to the emergency room at St. Francis, she was sent to Omaha, he said.

More tests and x-rays were done at Children's Hospital, including the side x-rays that revealed the fractures.

Snyder said the fractures could have been difficult to see from a straight on chest x-ray.

DeMare said rib fractures don't automatically mean abuse. However, in this case the fractures were near the spine and could only have been caused by squeezing hard with the fingers. Because of the size of an adult's hands, the fingertips can dig into the baby's back and cause fractures if the infant is squeezed, he said.

The injuries couldn't be caused by someone performing CPR because compressions are done from the front. Ribs could be fractured on the front or sides from CPR but not along the back, he said.

In his experience, people squeeze or shake babies to quiet them. While the actions do quiet a child temporarily, they can also cause serious physical trauma, he said.

DeMare testified that two of the fractures were "fresh," three occurred 10 to 14 days prior to the baby arriving at the hospital, four occurred about 14 days prior to her arrival and 10 of the fractures occurred on two separate occasions 14 to 21 days prior to the baby's arrival in Omaha.

"This is a severe injury," he said.

The types of fractures the baby had on her legs can occur when the legs "whiplash" back and forth when a baby is being shaken or when the legs are yanked down, he said.

"It requires an amazing amount of force," he said. "And by that I mean an objective person who saw these injuries being inflicted would be horrified."

He testified that the baby did have signs of brain injury, such as stopping breathing, irritability and color changes.

In his medical opinion, the injuries the baby suffered were the result of child abuse. He added that it isn't uncommon for the perpetrators of abuse to later seek medical treatment for the child.

The trial continues in Hall County District Court today.