Cases series of child abuse needing pediatric intensive care: Hiding in plain sight?

INTRODUCTION

Child abuse or maltreatment is defined by the Indian Academy of Pediatrics as any form of “physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity, in the context of a relationship of responsibility, trust or power.”^[1] While there are national data on child abuse available from high-income countries, data from low and medium-income countries are mainly in the form of single-center case reports and case series.^[2-4]

CASE SERIES

We reviewed children with severe child maltreatment needing Pediatric Intensive Care admission between December 2016 and December 2024. There were nine children ranging in age from 6 weeks to 7 years of age. Three children suffered non-accidental poisoning, and six children suffered physical injury [Table 1]. Majority (6/9) were boys. All the children had normal development and no comorbidities. Five children died, and one survived with sequelae.

Case 4

A 6-year-old boy was brought with an alleged history of loss of consciousness following fall in the bathroom. The child was admitted with Glasgow Coma Scale 3 and needed measures to treat raised intra-cranial pressure (ICP). He was found to have multiple bruises, including bruises over his back, limbs, shoulder, chest, and forehead. He had cerebral edema, subdural hemorrhage, and skull fractures on computed tomography (CT) scan [Figure 1]. He had bilateral retinal hemorrhages as well as sub-hepatic hematoma. The child succumbed to his injuries.

Close

Figure 1:

A 6 year old boy with alleged unwitnessed fall in bathroom followed by loss of consciousness. (a-c) Bruises over anterior chest wall, forehead and right shoulder (blue arrows). (d) Computed tomography brain showing frontoparietal hypodensities and left subdural hemorrhage (blue arrow). (e) Occipital and frontal skull fractures (blue arrows).

Export to PPT

There was a changing and inconsistent history. It was subsequently found that the mother’s partner who brought the child to hospital along with mother was not the child’s biological father. The mother with her two children had migrated to the city with her new partner who worked as a construction worker.

Case 6

A 5-year-old boy was brought by his mother with posturing and loss of consciousness following a bath. On admission, the child was posturing and unable to maintain airway. He needed intubation and measures to control raised ICP.

Clinical examination showed multiple crescent abrasions around the neck (0.5–1 cm × 0.2–0.3 cm), abrasions over the right side abdomen and left leg, spindle-shaped thermal burn on the thigh, ulcer and healed scars around the anus, and multiple healed scars (left eyelid, back, and limbs). His CT head showed subdural hemorrhages of different ages, cerebral edema, and tonsillar herniation [Figure 2]. Chest X-rays showed bilateral clavicular fractures.

Close

Figure 2:

A 5 year old boy with alleged history of fall after bath with loss of consciousness. (a) Patterned thermal burn right thigh. (b and c) Bruises anterior and lateral aspect right thigh. (d) Fracture both clavicles.

Export to PPT

History revealed that the mother was verbally and physically abused by the child’s biological father when he was drunk. The mother had lodged a police complaint and they had separated 3 years earlier; the father and paternal grandmother returned to their village with the child. A few months ago, the villagers contacted the mother and asked her to take the child as he was being physically abused by the father who was an alcoholic. She then brought him to the city and during her working hours, she left him in the care of her current partner.

The child had a prolonged intensive care unit (ICU) course and needed tracheostomy. At discharge, he was unaware of his surroundings and dependent on caregivers.

Case 7

A 6-week-old boy was brought to hospital after being found unresponsive at home. Family consisted of parents, 1-year-old sibling and this infant who all lived in one room. The family denied any history of shaking, fall, or other trauma.

The mother had returned 2 weeks earlier, following delivery at her maternal home in another state. The family had no relatives living nearby.

The baby was admitted in altered sensorium, with poor respiratory effort needing intubation. Indirect ophthalmoscopy showed retinal hemorrhages. Complete blood count and coagulation profile were normal. CT brain showed subdural hemorrhage and cerebral edema.

MRI brain showed diffuse restricted diffusion involving both cerebral hemispheres and basal ganglia and thalami. There were multiple extra-axial and parenchymal hematomas with diffuse cerebral edema and trans-tentorial and tonsillar herniation [Figure 3]. X-rays did not reveal other fractures. Parents denied shaking or dropping the baby. The mother had small healed circular scars on her fore arms. The child was managed with mechanical ventilation and measures to treat raised intracranial pressure, but he did not improve and succumbed after 2 days.

Close

Figure 3:

A 6 week old boy found unresponsive. Magnetic resonance imaging brain showing restricted diffusion both cerebral hemispheres, basal ganglia and thalami.

Export to PPT

DISCUSSION

We present nine children who presented following maltreatment through physical trauma, burns, gunshot injury, and poisoning. Although there was a male preponderance (6/9), this may be due to admission bias. Studies have shown both sexes to be equally at risk of intentional harm. Out of nine children, five died and one survived with severe sequelae. In addition, a sibling and three mothers died.

History of family discord and/or domestic violence was obtained in six cases. Intimate partner violence or domestic violence has been shown to be associated with child abuse.^[5-7] History of migration for work was found in three cases. Studies have shown that while abuse may occur in any social or economic class, unemployment and lack of social or family support are known risk factors for abuse.^[8] Increasing migration for employment is leading to nuclear families with loss of the usual support structure of extended families and neighbors.

There were two sets of families where the mother fed her children the toxin and then consumed it herself. Filicide suicide is a type of homicide-suicide death that refers to cases where the parent kills the child and then commits suicide. It has been shown to be associated with mental health illness, domestic abuse, and substance abuse. In case of the child admitted with severe burns, it was not known if the perpetrator was the mother or someone else.

It is very important to identify non-accidental injury on the first presentation to medical care as failure to do so may lead to continued abuse as seen in case 6 and severe morbidity or death. A 5-year retrospective chart review of 173 children <3 years old with abusive head trauma found that nearly a third of children (54/173) were missed on initial presentation to hospital and 15 children were re-injured after the first hospital visit.^[9] Approximately a third of children diagnosed with child maltreatment in the emergency department may need intensive care admission.^[10] There is a dearth of knowledge on the burden of non-accidental injury presenting to emergency care in our country.

Small infants presenting as unexplained acute life-threatening event such as case 8 have been reported by others as well.^[11] It is important to do retinal examination and skeletal survey in such children.

An important red flag pointing to intentional harm includes circumstance or mechanism of injury not fitting with the developmental age or injury seen in the child [Table 2]. Other red flags include inconsistent or changing history and certain injuries that are highly specific for abuse; these include fractures such as metaphyseal or corner fracture of long bones, fracture of posterior medial ribs, vertebral and complex skull fractures, multiple fractures of different ages, and patterned injuries and injuries in unusual areas of the body and retinal hemorrhages. Severe multi-layered retinal hemorrhages extending to the periphery of the retina as well as retinoschisis are specific for abuse.^[12] Indirect ophthalmoscopy with dilated pupil is needed as there may be peripheral retinal hemorrhages which may otherwise be missed. Neuroimaging in abusive head trauma may reveal subdural, subarachnoid, or parenchymal hemorrhage and/or hypoxic injury.^[13] Shaken baby syndrome may present with a triad of encephalopathy, subdural hemorrhage, and retinal hemorrhage as seen in case 7 of our series. Some children may be seen in emergency room or only by other specialties such as general surgery, plastic surgery (scald or thermal burns), orthopedics (fractures), or neurosurgery.

While being vigilant not to miss cases of abuse, it is important not to wrongly label certain medical conditions as abuse. Subdural hemorrhage with trivial trauma can be caused by conditions such as glutaric aciduria and factor 13 deficiency. Fractures may be seen in children with osteogenesis imperfecta. Children with developmental delay and cerebral palsy are particularly challenging. They are at higher risk of accidental injury with fractures as they may have osteoporosis as well as Vitamin C and or D deficiency. They are also at high risk of non-accidental injury due to caregiver stress along with the inability to protect themselves or communicate with others.

In India, there is no way to ascertain the exact incidence of non-accidental trauma as they are hardly reported and there is no system in place for surveillance of the same. A study in 2007 which defined child abuse as “intended, unintended, and perceived maltreatment of the child” surveyed 12,247 children aged 5–18 years from 13 states in India and found 69% to have faced physical abuse.^[14]

A cross-sectional survey of 6957 school-going adolescents in Kerala showed a high (89.9%) prevalence of abuse with physical and emotional abuse being the most common.^[15]

In low and medium income countries (LMICs) such as ours, certain cultural practices and norms such as branding, corporal punishment, and preference for a male child as well as socioeconomic realities such as street children, child labor, and child trafficking increase the risk of adverse childhood experiences.^[16]

When child abuse is suspected, detailed assessment, documentation, reporting to the police and Child and Women cell, and ensuring safety of the child are paramount. Child helplines, police force, criminal justice system, and the community all have a role in ensuring safety of the victim.^[1,17]

This study has several limitations. This is a retrospective case series from a single-center pediatric ICU (PICU). There may be missing data. Cases of neglect may have been missed. The follow-up and outcome (forensic, legal) are not known.

CONCLUSION

This case series from PICU showed two thirds of cases having poor outcome with severe morbidity or mortality. Child maltreatment needs to be prevented or diagnosed early. Clinicians must be aware of such cases as they are usually caught off guard, and thus, the child may be discharged back to the same environment again resulting in harm. Let the eye of vigilance never be closed.