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Help Me. I Can’t Speak.


 

Each week in the United States, child protective services and agencies receive reports of more than 50,000 suspected child abuse incidents. In 2002, 2.6 million incidents involving 4.5 million children were reported. Approximately four children die every day as a result of abuse or neglect.1 But numbers don’t tell the whole story. Behind every number is a child at risk.

“I can picture right now in my mind a young baby who was about six months of age with a belly that was protruded and distended,” says Erin R. Stucky, MD, a pediatric hospitalist at Children’s Hospital and Health Center San Diego, and an associate professor of pediatrics at the University of California San Diego. “[She had] no bowel sounds, and the arms and legs were so thin, had no fat whatsoever. The skin was rolling. The face looked dysmorphic, but it was simply because the eyes were so white, and there was no fat on the face at all. The baby had an irritated cry. The hair was thin. [She] had a look of anxiety, true anxiety [in her] eyes. It was impressive, as though this infant was saying, ‘Help me. I can’t speak.’ [She] was very socially engaged, but tired. If you had to qualify the look further, it would be something like, ‘I’m in pain. Protect me. Please don’t walk out the door.’

“The child had been admitted from the emergency department at an outside facility. They had been focused, appropriately to some extent, on the fact that the belly was distended and that the baby had no bowel sounds. They were focused on the fact that the parent’s history [of the child] was of vomiting during the day, but it clearly did not equate whatsoever with the way the child looked. It was immediately clear, simply looking at the baby while walking in the room, that something very bad was wrong and that the parents’ answers and explanations did not fit.”

Pediatric hospitalists are in a unique position to recognize child abuse and neglect, intervene appropriately, and help families avoid ultimate tragedy.

What It Is

Child abuse manifests in many forms, including physical abuse, sexual abuse, emotional abuse, and neglect, with a “child” typically defined as a person under 18. Legal definitions of the forms of child abuse vary, but, in general, they reflect societal views of actions deemed improper and unacceptable because they place a child at risk of physical or emotional harm.2 The federal Child Abuse Prevention and Treatment Act (CAPTA) defines child abuse and neglect as:

  • Any recent act or failure to act on the part of a parent or caretaker that results in death, serious physical or emotional harm, sexual abuse, or exploitation; or
  • An act or failure to act that presents an imminent risk of serious harm.3

States must include these minimum standards in their statutes in order to receive federal funds.

Neglect is the most common form of child abuse.2 Although definitions of neglect vary by state, they share characteristics. Minnesota defines neglect as inadequate food, shelter, clothing, or medical care. California includes both overt acts and omissions in the definition of neglect, defining general neglect as a lack of food, clothing, or medical care and severe neglect as malnutrition, failure to thrive, or willfully putting a child in danger. And Rhode Island’s neglect definition goes even further, including the above acts and omissions as well as the failure to provide a minimum degree of care or proper supervision or guardianship due to unwillingness, social problems, mental incompetency, or the use of a drug, drugs or alcohol, desertion, or abandonment. Rhode Island also includes the failure to take financial responsibility for a child.4

According to Georgia Berrenberg, esq., deputy district attorney, Second Judicial District of New Mexico, sexual abuse is the most common type that goes to trial. Berrenberg, who has been a prosecutor since 1984 and was in the child abuse division from 1996–2005, estimates that approximately 70% of cases involve sexual abuse compared with 30% that involve physical abuse.

However, pediatric hospitalists will most commonly see neglect, presenting as malnutrition or failure to thrive, in a child admitted to the hospital.4

Recognize Abuse and Neglect

Pediatric hospitalists are in a unique position to recognize child abuse and neglect, intervene appropriately, and help families avoid ultimate tragedy. They are trained to consider the entire child—no matter the presenting condition—to look at general issues and to think about development and nutrition every time they examine a child.

“When someone says, ‘This child has pneumonia,’ my job is to not think pneumonia; my job is to think, ‘What’s causing this child to breathe fast?’ to make sure I don’t miss anything,” says Dr. Stucky. “If the history doesn’t fit the examination and my first, second, [and] third thoughts are child abuse/neglect. It’s my job to work on that, but it’s also my job to push my own buttons to make sure that it’s not anything else medically going on. The child that never has a bruise or fracture is the odd one out. The key [to recognizing abuse] is history.”

Don’t jump to conclusions. Hospitalists need to consider the history reported by the parent in light of the physical exam of the child. For example, if the parent tells you that the child fell headfirst off a tricycle and landed on his face, note the pattern of the bruising. If the child has bruising around the eye then that could be consistent with the history, but if the child’s eyelid is cut or bruised and there’s no bruising around the eye, that’s another matter. The eyebrow and cheekbone will protect the eye when you fall and land on your face.

“Pay attention to what you hear and see in those first few minutes and hours with that family because stories are going to change,” says Berrenberg. “Be very, very clear about the initial things that are said.”

Dealing with the medical issues that led to the admission is paramount, and it’s important for the hospitalist to communicate effectively with the parent to ensure that the child receives the most appropriate treatment. Asking open-ended questions while you take the history can be revealing:

  • Can you tell me how long this has been happening?
  • What do you think might be contributing to this?
  • Can you tell me how you’ve been dealing with these issues at home?
  • Run me through a typical day at home with your baby.

In addition to the history, consider the parent/child interaction. “Most kids, even when they’re stressed and in pain are very attentive to where their parents are,” says Dr. Stucky. “They want to be with them no matter what. They may be angry and battling. They may respond to pain differently, but that relationship is very important. As you watch it you can really get a good sense [of whether] this child’s anger outburst is because they’re in pain, they’re confused, they have autism, or they are really angry with their parent and this is the way they’re protecting themselves.”

The hospitalist has to be up front with the parent about what the next step in their child’s treatment is going to be. “It’s a delicate discussion, but an honest one,” says Dr. Stucky. “It’s important to say to the parent, overtly, ‘I’m very concerned about your baby’s weight loss. I’m very concerned that this has happened over the past several months and that it has taken this long for your baby to be seen by a doctor. I’m very concerned, and I want you to understand that your baby has a critical condition right now. It’s so malnourished that the body’s organs aren’t working properly. ... Because of this concern, I’m going to call social workers. Because of this concern I’ll use [work with] a team of people to help me to take care of your baby. They’ll ask a lot of questions, and it’s very important that you answer honestly so we can do the best for your baby and make sure that the whole family can get whatever help is needed to take care of the problem.’ ”

Legal definitions of child abuse vary, but generally reflect societal views of actions deemed improper and unacceptable because they place a child at risk of physical or emotional harm.

Reporting Requirements

In most states healthcare workers not only have a moral responsibility to report suspected abuse, they are required by law to do so. In fact, New Mexico’s statute requires anyone who suspects child abuse to report it and makes failure to do so a misdemeanor. Hospitalists should know in advance to whom to report the suspected abuse.

Consider making a call to a social worker your first step. “Social workers are invaluable,” says Dr. Stucky. “They’re there for the families. They ask the harder questions that allow us to have that medical relationship and continue to care for the child’s needs. They can look up information that we can’t. They can look up child protection history, whether the parent has been incarcerated, things that support the possibility of abuse. They can file the CPS report, allowing the hospitalist to continue caring medically for the child.”

According to Berrenberg, the police should be your second call.

Dealing with child abuse and neglect is a team effort. In addition to the police and a social worker, you need to involve the nutritionist and the primary care pediatrician (if they have one). If you’re lucky, your hospital may have a child abuse specialist on staff. “Be ready to deal with a whole variety of people who may or may not know what else has already happened,” says Berrenberg.

After the Hospital Stay

Although child abuse is all too common, most pediatric hospitalists won’t often see the inside of a courtroom. Dr. Stucky says that cases with which she’s been involved have gone to trial twice during her 10 years as a pediatric hospitalist. And Berrenberg says, “Failure to thrive is not something we charge very often. That’s a difficult thing to prove.”

That said, prepare for the possibility of being called as a fact witness. According to Berrenberg, physicians may be asked to report on not just their observations of the child, but also on statements made in their presence.

“Statements made to physicians and to healthcare personnel are critical—be it by parents, caretakers, or the child themselves in the case of sexual abuse,” she says. “If statements are made in the course of diagnosis and treatment, then those statements can come in under hearsay exceptions. ... The doctor can testify about those statements.”

Remember it’s the doctor/patient relationship that’s important. Your patient’s parents have no doctor/patient relationship.

Berrenberg offers the following advice for physicians preparing to testify: “Be patient. Read everything you have on your case. Expect everything to change. When you’re told that you’re going to trial on Monday, expect that to change. If you’ve testified before and there are transcripts available, expect the defense to know about that previous testimony. If you’re basing your opinion on literature, expect the defense attorney to have found that literature and be familiar with it.

“Work with your prosecutor. Know what they want you for. They might only want you for a limited piece; they might want you for the whole gamut. They will tell you what they’re going to expect of you. Spend as much time as you can with them, with the photos, with the file. It’s always what you don’t expect to come up that comes up.”

Pediatric hospitalists should also be prepared for old cases to come back. “We’ll bring you from wherever you are—even if you’re out of the country,” says Berrenberg. “We’ll bring you back if we need you to testify. We’ll find you. If you’re the one who saw the child and were the initial responder, so to speak, no one else can say what you saw.”

Risk Factors for Neglect4

  • Poverty;
  • Maternal depression; and
  • Substance abuse.

Conclusion

What happened to the six-month-old baby Dr. Stucky remembers so clearly?

“I only know what happened during the hospital stay,” she says. “This family clearly needed help and guidance. There was an overwhelming, clear [indication] that the mother had significant, major depression. She wasn’t feeding the baby. She was completely ignoring the child, and she acknowledged that. ... The father was at work and thought that perhaps this baby was just ill or sickly. He was told that the baby was being taken to the doctor, and that wasn’t happening. He was naive and innocent in thinking that things were being dealt with and thinking that their baby was simply a baby who cried a lot and wasn’t gaining weight well.

“Once this was all [addressed], he jumped at the opportunity to have the mother in therapy and on medications. The mother herself was completely willing to give up the care. ... In this case, the paternal grandmother took over the care of this child. The father would drop off the baby at her house during the day and pick up the baby at night. On weekends they would share the duties. That was the plan at discharge. ... I can’t guarantee it, but it’s my sense that this worked very well.”

Keri Losavio is a medical journalist with more than 10 years’ experience.

References

  1. National Clearinghouse on Child Abuse and Neglect Information: http://nccanch.acf.hhs.gov/topics/prevention/index.cfm.
  2. “What Is Child Maltreatment?” From A Coordinated Response to Child Abuse and Neglect: The Foundation for Practice. National Clearinghouse on Child Abuse and Neglect Information: http://nccanch.acf.hhs.gov.
  3. Child Abuse Prevention and Treatment Act. Download the complete text from the Cornell University Legal Information Institute: www4.law.cornell.edu/uscode/42/ch67.html.
  4. “Monitoring Child Neglect.” Summary of discussions at a meeting co-sponsored by the Centers for Disease Control and Prevention (CDC) and Prevent Child Abuse America (PCA America), March 29, 2002.

PEDIATRIC SPECIAL SECTION

In the Literature

Optimizing Management of GERD: Medical therapy or surgical intervention?

Hassall E. Outcomes of fundoplication: causes for concern, newer options. Arch Dis Child. 2005;90:1047-1052.

Review by Ray Chan, MD

This narrative review provides a concise overview of gastroesophageal reflux disease (GERD) while specifically addressing surgical treatment. The author focuses on the potential complications of surgical treatment and cites several studies demonstrating a high rate of complications and patient dissatisfaction with their outcomes. In contrast, the review does cite several sources that concluded good outcomes; however, the article questions the conclusions of these studies due to study designs with poorly defined and subjective outcome measures.

In contrast to the discussion on fundoplication, the review offers a more favorable description of proton pump inhibitor therapy. In the concluding remarks Hassall argues that medical therapy options should be exhausted prior to surgical therapy. The author states that the risk of mortality and morbidity combined with less than desirable efficacy of fundoplication should caution clinicians from being too eager in recommending fundoplication.

Clinically significant GERD is a common inpatient problem. This article provides a good review of the pathophysiology of this disease and available treatment options. Unfortunately, this narrative review does not utilize a systematic method of identifying relevant studies nor does it include a systematic approach for critical appraisal of these studies. Nevertheless the caution it raises about fundoplication is a worthy one that should be explored further. It is interesting to note that prior to this review the author has received grant support and was a paid consultant for AstraZeneca and TAP Pharmaceutical Products Inc.

Support for Bag UA Screening During Evaluation for UTI

McGillivray D, Mok E, Mulrooney E, et al. A head-to-head comparison: “clean-void” bag versus catheter urinalysis in the diagnosis of urinary tract infection in young children. J Pediatr. 2005;147(4):451-456.

Review by Jenny Geheb, RN, CPNP

Early detection of urinary tract infection (UTI) can be especially important in children. This study uses a cross-sectional design to compare the validity of the urinalysis on clean-voided bag versus catheter urine specimens using the catheter culture as the “gold” standard. This study looked at 303 non-toilet-trained children under age three at risk for UTI who presented to a children’s hospital emergency department. Paired bag and catheter specimens were obtained from each child and sent for dipstick and microscopic urinalysis. Sensitivity and specificity were compared using McNemar’s [chi]2 test for paired specimens and the ordinary [chi]2 test for unpaired comparisons.

The study, which was conducted at the Montreal Children’s Hospital, found that the bag dipstick was more sensitive than the catheter dipstick for the entire study sample: 0.85 (95% confidence interval [CI] = 0.78 to 0.93) versus 0.71 (95% CI= 0.95 to 0.99), respectively. Both bag and catheter dipstick sensitivities were lower in infants <90 days old. Specificity was consistently lower for the bag specimens than for the catheter specimens.

A child at high risk for UTI (previous history of UTI, anatomic abnormalities, immunosuppressed, or presence of urinary symptoms) should be catheterized to obtain both a UA and culture; however, in children older than 90 days with fever without source and at low risk for UTI, a “selective catheterization” approach, as outlined in the American Academy of Pediatrics practice parameter, appears to be reasonable.

In low-risk children, serious consequences of infection are less likely, and the authors propose that the risks of missing a UTI are likely to be outweighed by the risks of catheterization, including pain, false-positive result, trauma, introduction of infection, test resistance by staff, and parental concern.

In summary, the provider may choose to use a bag urine screening strategy to reduce the number of unnecessary catheterizations in children who are considered low risk and over 90 days old. Further studies are needed to analyze the cost-benefit ratio of this approach as well as to confirm these findings with larger populations.

Resources

Short-Course Antibiotic Treatment for Streptococcal Pharyngitis

Casey JR, Pichichero ME. Meta-analysis of short course antibiotic treatment for group A streptococcal tonsillopharyngitis. Ped Infect Dis J. 2005;24(10):909-917.

Review by Jenny Geheb, RN, CPNP

Group A streptococcal (GAS) tonsillopharyngitis is a common cause for antibiotic treatment in children. Researchers at the University of Rochester Medical Center (N.Y.) performed a meta-analysis of current data to compare bacterial and clinical cure rates in patients with GAS tonsillopharyngitis treated with short course antibiotic treatment with oral [beta]-lactam or macrolide antibiotics for four to five days with standard 10-day treatment courses. Medline, Embase, reference lists, and abstract searches were all used to identify applicable publications. Trials were included if there was bacteriologic confirmation of GAS tonsillopharyngitis, random assignment to antibiotic therapy for a [beta]-lactam or macrolide antibiotic of shortened course versus a 10-day course, and assessment of bacteriologic outcome using a throat culture.

Twenty-two trials involving 7,470 patients were included in four separate analyses. Trials were grouped by a short course of cephalosporins (n=14), macrolides (other than azithromycin) (n=6), penicillin (n=2), and amoxicillin (n=2). Cephalosporin trials were further grouped by penicillin (n=12) or the same cephalosporin (n=3). Five trials were conducted in the United States with the remainder conducted in Europe.

Meta-analysis showed that short course cephalosporin treatment was superior for bacterial cure rate compared with 10 days of penicillin (OR 1.47; 95% CI, 1.06-2.03). Short-course penicillin therapy was inferior in achieving bacterial cure versus 10 days of penicillin. Clinical cure rate mirrored the bacterial cure rate results. Small sample size limited the statistical power and conclusions of the short course macrolide trials as well as trials of four or five days of cephalosporin therapy compared with 10 days of the same.

This meta-analysis shows that short-course treatment of GAS tonsillopharyngitis can be more effective when prescribing four or five days of cefdinir, cefpodoxime, or cefuroxime treatment than standard 10-day treatment of penicillin. In the United States cefdinir, cefpodoxime, and azithromycin are indicated for short-course treatment. As prescribing practitioners, it is important for us to consider the advantages of shortened antibiotic courses, including improved patient compliance, fewer adverse effects, and reduced impact on development of antibiotic resistance and nasopharyngeal colonization with resistant bacteria. However, the authors emphasize that caution must be used in interpretation of the results of this meta-analysis.

For example, the trials were grouped according to class of antibiotics so that the cephalosporin group included seven different cephalosporins (one first generation, two second generation, and four third generation). In addition, there was much variability in the quality and design of compared studies, which makes it difficult to make strong conclusions. Repeat studies are needed, especially in regard to short-course macrolide or amoxicillin treatment.

What is very helpful is camaraderie with other people who are doing the same work. We cry together, laugh together, and we talk about really awful things in a really coarse way in order to blow off steam, [and] other people looking on might not understand. But that camaraderie is invaluable.

—Georgia Berrenberg, Esq.

The Emotional Toll

Emotions run high when dealing with abused children. The key is remembering why you’re doing the job. “The hospitalist has the opportunity, sometimes, to be the one person to make a difference,” says Dr. Stucky.

“It’s very hard,” says Berrenberg. “I would ... discipline myself to look at it as evidence and to look at in a very cold way, but that only goes so far. A lot of what is very helpful is camaraderie with other people who are doing the same work. We cry together, laugh together, and we talk about really awful things in a really coarse way in order to blow off steam, [and] other people looking on might not understand. But that camaraderie is invaluable.

“Every once in a while, you make a difference, a little bit of a difference and that keeps you going,” she says. “But frequently it feels like spitting in the ocean, too.

“There’s a girl who I met in 1987. I wound up taking her case to court twice because there was a reversal. I see her on occasion. I’ve seen her grow up from a very angry teenager to a pretty OK young woman. I’ve been able to be her friend, and that’s been a big reward for me.”—KL

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