May 10, 2024 • 44 mins
Child Neglect: Signs, Symptoms and What to Do
Link for MOC Credit:
https://cmetracker.net/UTHSCSA/Publisher?page=pubOpen#/getCertificate/10095849
In this powerful episode, Pediatrics Now Host Holly Wayment brings us a grand rounds talk by the University of Texas Health Science Center's Dr. Mary Ann Alvarez-Griffis, a child abuse fellow. She sheds light on the critical issue of child neglect. Providing an in-depth analysis based on National Child Abuse and Neglect Data System (NCANDS) statistics, she challenges common misconceptions and highlights potential outcomes for children exposed to neglect.
The talk emphasizes the recurrent nature of neglect, its equal severity as physical abuse, and its long-term consequences on a child's peer relations, academic performance, and problem-solving skills. Special attention is given to children with special needs, who account for a significant percentage of child maltreatment fatalities.
Drawing from her rich experience in pediatric care and community education, Dr. Alvarez-Griffis unravels the devastating impact of neglect on children's growth, cognitive development, social skills and emotional wellbeing. Notably, she underscores poverty and insufficient social support as major risk factors, presenting a comprehensive exploration of neglect statistics.
The episode underscores the urgency of recognizing signs of physical neglect, fostering open, non-judgmental communication with caregivers, and effectively addressing potential issues. With detailed case studies, the discussion centers on the importance of thorough investigations and interventions. The significance of growth charts in identifying risk factors and possible neglect signs are also discussed.
Dr. Alvarez-Griffiths shines a spotlight on the severe consequences of medical neglect and emphasizes the need for a consistent medical regimen for children dealing with chronic conditions. The implications of neglectful behaviors, such as untimely medical care and poor home management of serious injuries, are explored in depth.
In conclusion, healthcare providers are urged to proactively leverage detailed examinations, thorough documentation, and persistent patient education to prevent child neglect and support affected families. This episode serves as a comprehensive guide, unpacking the intricate realities of child neglect, and proffering effective strategies for prevention and intervention.
Dr. Alvarez Griffis has dual undergraduate degrees of Pre-medical Biology and Political Science from University of Texas-Pan American (now UTRGV). She attended medical school at William Carey College of Osteopathic Medicine prior to completing her Pediatric Residency at UT Health Science Center in San Antonio where she continued to peruse a fellowship in Child Abuse Pediatrics. During fellowship training Dr. Alvarez Griffis has provided community education regarding child maltreatment to various audiences from pediatric residents to SAPD. She recently participated in updating the AAP Point of Care Quick Reference section on Physical Abuse and Neglect. She is a member of the Child Abuse and Neglect Committee of the Texas Pediatric Society and is also a member of the Council on Child Abuse and Neglect. Her fellows research project focuses on the importance of obtaining head circumferences in infants to prevent missed abusive head trauma.
Financial Disclosures: Mary Ann Alvarez Griffis, DO has no financial relationships with ineligible companies to disclose.
The Pediatric Grand Rounds Planning Committee (Deepak Kamat MD, PhD, Daniel Ranch, MD and Elizabeth Hanson, MD) has no financial relationships with ineligible companies to disclose. Planning Committee member Steven Seidner, MD has disclosed he receives funding from Draeger Medical for the Clinical Study to Evaluate the Safety and Effectiveness of the Infinity Acute Care System Workstation Neonatal Care Babylog VN500 Device in High-Frequency Oscillatory Ventilation (HFOV) Mode in Extremely Low Birth Weight (ELBW) Neonates for
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Music.
(00:05):
Dates, and discussions for the busy pediatric practitioner. Click on the link
in this podcast for MOC credit.
Today, I'm bringing you a Grand Rounds talk.
It's by Dr. Mary Ann Alvarez-Griffiths. She is a fellow in the Department of
Pediatrics at UT Health San Antonio Division of Child Abuse.
(00:26):
During her fellowship training, Griffiths has provided community education regarding
child maltreatment to various audiences, from pediatric residents to the San
Antonio Police Department.
She recently participated in updating the AAP Point of Care Quick Reference
section on physical abuse and neglect.
(00:46):
She's a member of the Child Abuse and Neglect Committee of the Texas Pediatric
Society and is also a member of the Council on Child Abuse and Neglect.
Her fellows' research project focuses on the importance of obtaining head circumference
in infants to prevent missed abusive head trauma.
Let's listen in to her talk on child neglect.
(01:09):
Neglect is usually typified by an ongoing pattern of inadequate care,
and it can actually do as much damage as physical abuse.
The neglect depends on the age of the child and can also result in a long-lasting
impact on them, their peer relations, and their school function.
There's also the possibility of impaired problem solving, delayed language,
(01:32):
and lower academic achievement, which we know is going to affect them later on in life.
So, the National Child Abuse and Neglect Data System, or NCANDS,
collects data on the types of reports that have been made to CPS,
so this is CPS data, and how the percentages of what has been founded or has been confirmed.
(01:55):
So, So just looking at the national statistics, neglect is the most common types
of reports made to CPS, which makes about two-thirds of the reports made.
And about 74% of these reports made have been confirmed for concern for neglect.
Just looking at these statistics, these are the most recent ones that we have.
(02:16):
In Texas and Bexar County, we could see that in Texas, there was about 2,000,
a little over 2,000 cases of physical neglect.
In Bexar County, constituted 165 of those. And then for medical neglect, we had a little over 900.
And in Bexar County, we had 97 of those cases. So, as we can see in the total
(02:38):
numbers below, that we do make up quite a percentile, about 10% of these confirmed
cases of neglect, unfortunately.
So, when people think of fatalities, most often the most common thought is,
oh, this child was abused and therefore died as a result of ongoing abuse or an abusive event.
(03:00):
But actually about 73% of child fatalities involve some form of neglect.
In our 22 data, we found that there was about 43% that were exclusively due
to physical and medical neglect.
Neglectful supervision is actually the most common neglect fatality,
(03:21):
but for the purposes of this talk, we're focusing on physical and medical.
We know that children with special needs are an increased risk for maltreatment.
And 31% of child maltreatment fatalities actually involve a child with special
medical needs or concerns.
So, this could be something as your bread and butter asthma to those that are
(03:42):
physically disabled, have CP, those that have feeding tube or medically complex children.
So, we all know about the social determinants of health and risk factors that
are associated for maltreatment and how they are all different levels of it.
So, it can be in the individual setting.
(04:02):
So, a baby that is born premature or has disabilities or special needs, has low birth weight.
It could also be risk factors within their relationship with their caregivers.
So if it's like a single parent, young parent, young maternal age,
if their caregivers have mental health issues or substance use,
(04:23):
also in their community, if there's a lack of social support or if there's increased
crime rate or stress or lack of social support.
So, we know that these are risk factors for maltreatment, and it's our job as
physicians to identify these risk factors in order to help and support and provide
resources to our families to prevent maltreatment.
(04:45):
So just because there are risk factors for maltreatment doesn't mean that every
case of abuse and neglect has one of these risk factors.
And the opposite is true. Many children and families may have one or several
of these risk factors, but it does not necessarily mean that they will be maltreated later on.
(05:07):
So, due to the medical literature that we have, the greatest risk factor for
neglect, as we know, is poverty or low socioeconomic status,
which is the most directly associated with neglect.
Children living in high-poverty areas are six times more likely to experience neglect.
There are high levels of unemployment. There's population loss where they reside,
(05:33):
or there's overcrowding in the impoverished neighborhoods.
There's fewer opportunities to meet their child's needs, including like health
care, fewer resources, including nutrition, clothing, hygiene,
playgrounds, transportation.
And poverty exacerbates other risk factors, such as like food insecurities,
poor material nutrition, caregiver depression, stressful life events,
(05:56):
living in higher crime or unsafe neighborhoods. hoods.
So really, the greatest risk factor is the low social support resources and
education that ties in with poverty and low socioeconomic status.
So again, a family may be low income, but it does not necessarily mean that
they are neglectful of their children.
(06:19):
We have also identified that there is, in addition to all the risk factors,
like the individual with the caregiver and their social status,
there's also risk at the professional level with that.
That being problematic communication, whether it be between the caregiver and the provider,
maybe the parents aren't understanding the child's condition or the treatment
(06:40):
plan, why their kid needs XYZ treatments or surgery or procedures.
And there's also with problematic communication between providers themselves,
not communicating properly regarding recommendations or treatment plans.
And this is seen more often with the children that are slow waking or failing
(07:01):
to thrive and the medically complex children.
So we've identified four possible options as far as consequences for neglect.
So there is no current harm done and no future harm is anticipated.
One of the examples would be leaving a child asleep in a crib who does not require
nighttime care while their caregiver is out partying on a Saturday night.
(07:24):
So no harm is done. The kid is in the crib, safe and secure,
even though unsupervised.
And they don't need any nighttime care like diaper changes, bottle changes,
and then no future harm is anticipated.
The other one is no current harm, but future harm is anticipated, such as co-sleeping.
Some families may co-sleep with their child and their child wakes up okay the
(07:47):
next morning, but there's always that risk of future harm that they may have
an asphyxia event due to a co-sleeping incident.
There's where the child experiences current harm, but no future harm is anticipated,
such as when a caregiver turns back for a few minutes and the child falls into to the pool.
(08:07):
So the child experienced that near drowning event, so that current harm,
but because of that event, caregivers tend to do all the things,
put up the gates, put in cameras or lock the doors, and then no future harm is anticipated.
There's also children that experience current harm and future harm as anticipated,
such as the failure to thrive kiddos.
(08:30):
So if we know that they're experiencing physical neglect, the caregivers aren't
feeding them adequately and aren't understanding the treatments or the feeds,
or just plain don't want to do it. So they're right now, failure to thrive, will wait.
And then there's that increased harm, increased risk for harm that they may
not continue giving them the appropriate caloric intake. type.
(08:51):
So, we have the raw outcome for neglect.
So, it varies between the age group. So, in infants, we usually see this as poor growth.
They'll have cognitive delays, poor social skills, and other psychosocial problems.
And this is usually seen, one of the studies showed that this is seen before the age of three.
And then with the school-aged children or adolescents, they're more likely to
(09:15):
develop developmental problems such as poor cognitive and school performances,
emotional and behavioral problems.
And then the behavioral problems, it's a spectrum. No one child is going to
act the same way to say, oh, pinpoint this child's neglected because they are withdrawn.
The opposite may be true. They may be more aggressive or they may be engaging
(09:36):
in high-risk behaviors, such as early initiation of sexual activity or substance use.
And as we know, neglect plays a part in our adverse childhood experiences.
It is one of the aces, and these increased aces may predispose for chronic health
problems, mental health problems, and increased risky behaviors.
(09:59):
So, as mentioned before, there are many types of neglect, including physical,
medical, dental, which is sometimes lumped into medical, depending on the medical
legal definition or the agency using these definitions.
Supervisional, emotional, and educational.
So, for physical neglect, this occurs when a parent or a caregiver does not
(10:21):
provide the child with basic necessities, which could be adequate food,
clothing, shelter, hygiene,
or really the lack that would cause a serious injury or illness.
So, people commonly think about a child not having adequate food to grow and
failure to thrive, and that's just one of the examples.
(10:44):
So, for physical neglect, there are some physical indicators and some behavioral
indicators. So, some physical indicators.
The child may have, you can see it through the growth parameters,
that if they're not getting adequate nutrition at home, that their weight starts
to drop, and then their height starts to drop off, and then their head circumference starts to drop off.
(11:06):
They may be consistently dirty or have a severe body odor.
So whenever I get consults and they tell me this child is dirty and uncancelled
or has like dirt under the fingernails, it's not really about having dirt under
their fingernails or on their feet because for all you know,
they may have been just laying outside before coming to visit you in your office, clinic, ED,
(11:30):
whatever setting you're at.
But we're talking about just consistently dirty, caked on, and with a severe odor.
And then another physical indicator is the lack of adequate clothing.
Here in San Antonio, this is kind of a little bit more difficult to gauge.
We don't have these strong winters where we would need puffy coats,
(11:52):
but usually that's one of the, usually what we think about is when it's winter
and these children don't have coats or it's summer and then these children are
still in like heavy clothing.
Some of the behavioral indicators could be that they're asking or begging for money, food.
(12:12):
They may stay extended time at school just for food and nutrition.
I know growing up in the valley at my school, we had a food program including after school.
So they may be doing that just to get another meal.
They may tell you, oh, that no one's at home and this is why they prefer to
stay at school or they'd rather be elsewhere.
(12:32):
They may be frequently absent. You may get calls from school saying,
hey, this kid is absent or from the nurse, or they may tell you,
the parents may tell you that they're just constantly fatigued.
So whenever you notice that there are some indicators, just know that it is
okay to ask the hard questions to understand the problem.
(12:55):
For the example of the child with like dirt taped on or under their fingernails,
it's okay to ask them or the caregivers, hey, I noticed this.
How are things going at home or is everything okay at home? So...
Talk to them in an unjudgmental way to see if there's something unidentifiable
(13:18):
problem in which we could help or provide resources.
So once we understand the problem, we can get the appropriate resources to them
and always use our wonderful social work and care coordination teams for these resources.
So maybe the parents may say, oh yes, the water stops working.
They cut off the water. I didn't have enough money to pay the water bill this month or something.
(13:43):
So there may be a reason as to why they are presenting that way.
So if you notice something, please provide the resources for them.
So some other indicators that may present, think about a child that has a chronic illness.
They have a Broviac placement or maybe a port-a-calf, and then they're supposed
(14:08):
to be maintaining it clean.
And then you see them come walking into your office or you go into the ED and they're just dirty.
The tegaderm is all soiled and they're coming in with frequent infections.
So that may be an indicator that, hey, maybe something is going on at home as
well, that maybe the home life is unhygienic for them,
(14:32):
for their level of immunocompromised level.
And then we find that once we get into the home, CPS or law enforcement,
sometimes, unfortunately, they do live in unhygienic conditions.
So you may not be seeing this yourself as physicians.
This isn't going to walk into their office. Families might not show you these
(14:56):
pictures, but just having these children coming in with frequent infections,
or they may be coming frequently unkept and with odor,
and they may be coming for multiple ailments.
And just some specific items that may be an indicator that maybe something is going on at home.
The most common physical neglect presentation in infants is failure to thrive
(15:19):
or slow weight gain as we're trying to move away from this term.
There are many aspects to consider when managing a child with failure to thrive.
It is multifactorial and it encompasses a lot of spheres.
So for us, It can encompass biologic, where growth failure is related to a medical
(15:40):
illness, whether acute or chronic.
So they may have feeding difficulties secondary to poor caloric intake.
Maybe they have some oral motor dysfunction or dysphagia, a neuro impairment.
They have inadequate absorption or excess loss, such as pyloric stenosis or CF or infection.
Or they may have something that has an increased caloric requirement such as
(16:02):
a congenital heart disease or chronic lung disease or an important area of metabolism.
The psychological component revolves around the mental health of the caregivers
and their competence including their IQ level.
The social sphere as we know poverty and low support system and low resources
(16:23):
is the most pervasive risk factors, and this also takes in part the food insecurity,
family stressors, and problematic interpersonal relationships between the caregivers.
So, an extensive workup, including thorough history,
seating history, family social history, review systems, labs,
exams, imaging, if needed, are recommended for these cases to roll out or to
(16:48):
parse out what could be causing the slow weight gain in these infants.
So here's an example of a failure to thrive baby.
So we can see that they have on the face lanugo.
So this is the body's reaction to kind of maintain no thermia.
And we can see their skin folds around the necks and how there's the loss of
(17:10):
the subcutaneous fat over in the buttocks. This is another example of failure
to thrive when this child is one who had not seen a doctor since two months of age.
And then when they were admitted, we can see some lanugo going on in the back
and the loss of subcutaneous tissue.
And then three weeks later, with adequate caloric intake, they regained that
(17:35):
fat as well. So this is one of those obvious cases on how adequate caloric intake
made a noticeable difference in change.
So we're going to go through some cases. And since we're not in person,
I'm not going to ask the hypothetical questions.
But for this example, how old would you think this child is based on these characteristics?
(17:56):
They're three feet tall, 30 pounds.
So, this is the average size of a two-year-old, and this child is actually six years old.
So, in this example, providers, this is just to show an example how providers usually see,
victims, so weight gain or failure to thrive is typically seen in infants,
(18:17):
but it can also happen in older children who are victims of physical neglect as well.
Sometimes the families may come in and say, oh, the child may have a poor appetite
or they have a bleeding disorder or an eating disorder, sorry,
that hasn't been confirmed when food may actually be withheld.
Now, in this case, for the six-year-old, it's an extreme example.
(18:38):
And he also has psychosocial dwarfism due to the extent of maltreatment he underwent,
which included physical and emotional neglect.
So we can see how his weight was affected, his height was affected,
and obviously we know his circumference falls as well.
And this is why he looks similar to a two-year-old more than a six-year-old.
(18:58):
Another example for physical neglect and risk factors at the professional level.
So there was the case of a one-month-old admitted for failure to thrive.
Their birth weight was 2.19 kilos and admission weight was 2.2 kilos.
When they were born, they were discharged from the hospital.
(19:19):
They follow up with their PCP appropriately the three days after delivery.
And per documentation, they were 1.84 kilos or 21% below birth weight.
The instructions were to follow up in one month.
And from their visit from the PCP's office to admission, this child had actually
(19:41):
gained about 16 grams per day.
So as we know, newborns may lose up to 10% of their birth weight and may take
7 to 14 days to regain it, which is slower in breastfed infants than formula fed.
And for the AAP, a loss of more than 10 to 12 percent should be investigated.
20 percent is significant, and these typically require hospital readmission,
(20:05):
if not very close follow-up.
And while the child was gaining weight, we know that it's suboptimal weight
gain, as average weight gain in this age group would be 20 to 30 grams a day.
So in this case was a risk at the professional level.
Just looking at the growth chart, looking at plotting these things can help
(20:26):
us identify if there's any risk factors that are needed.
So this child was admitted for failure to thrive with concern for failure for
physical neglect, but the child was gaining weight adequately and the weight
was not addressed at this visit, unfortunately.
Another example, a baby 9.2 months of age was seen in the ED and they were 7.8 kilos or 10 percentile.
(20:53):
They came back a little a few weeks later and they were 6.85 kilos or not the 0.5 percent.
For this one, on the day of admission, they were described as hectic with loose
skin around the neck, sunken eyes that were pale.
But interestingly enough the
(21:14):
day before admission they were described as
well-peering and non-toxic and that was the 6.85 kilo and they were there the
day before and the day of admission with same weight so in this case they had
gone to the ed for an outside and unrelated issue followed
(21:35):
up with a PCP per ED instructions the next day,
and the PCP was concerned that they were 67% at the six-month well-child check
and was now at the 0.5%, so they sent them to the ED for evaluation and admission.
So, here we have a copy of the growth chart. So, this is what was seen in the
(21:57):
ED, these first two points.
These other points were inpatient after the child gained getting linked with
the adequate nutrition.
So in this case, the weight issue was just recommended to be followed up in
the office and not necessarily addressed in the ED with this growth chart.
(22:18):
And it turned out that the mother was pregnant, didn't know that her supply
had dropped, and there was also concern for caregiver level cognition.
So it's really important to, you know, just take a moment, take a look at the
growth chart, address these issues as we see them and to provide your documentation
for everyone following up.
Another example, this child has several ED visits and in all of these,
(22:43):
between the ages of five and seven, almost seven years old, six and a half, they were noted.
The exam wasn't documented as unremarkable and the weight was not addressed. dressed.
This child's weight had been decreasing in the last one and a half years.
And there was no mention of the weight trend.
And then we see how the height over here on the right side has started to stall.
(23:05):
And then this child was starting to grow and then stall again.
So these pictures were taken one year apart.
And then this was the one to the right is one closer to admission.
I think this was the day they were admitted when they took this photograph.
So now the child had noticeably sunken eyes and appearance.
(23:27):
And this case is an extreme case of starvation and psychological maltreatment.
But here, what's important is just stressing the importance of looking at the growth chart.
Just take two seconds to take a look to see if there's anything identifiable,
any form of maltreatment that may be going on or any concerns or something that
(23:50):
we may prevent or help the family with.
So, for shifting gears to medical neglect now, medical neglect can take one of two forms.
It can be the failure to act on an obvious sign of serious injury or illness,
or it could be a failure to follow medical providers' There's instructions once
(24:10):
care and advice has been sought.
So traditionally, people think of those with asthma, diabetes,
or infections for the second bullet point.
And we will go through those shortly.
So an example of an acute setting.
So there is an 18-month-old that's coming in refusing to bear weight for two
(24:35):
days after splitting while running and landing in a split position.
On exam, there's an obvious deformity noted. They are non-variant.
They're attended to palpation. They're noted to be in mild distress.
You decide to get imaging, and this is what you see.
So you have minimally displaced, angulated spiral fracture of the feet.
(24:57):
So in this case, the child required surgery. So while this could have been an
accidental mechanism, there was a delay in care.
And while the delay in care did not change the medical management,
this child would have required surgery even if they came in within 30 minutes of their fall.
This child had obvious findings like that obvious deformity and they were obviously
(25:19):
in significant pain and did require a surgical intervention.
So this is the case where caregivers failed to act on an obvious serious injury.
And therefore concerning for medical neglect. Another example may be an eight-year-old
breaking leaves in a rural area.
There was an ash pile that they stepped through.
(25:40):
Caregiver saw them, heard them yell, took off their boot, and found this.
So here we know that there is a large burn, at least partial thickness burn
due to the blisters and bubbles.
And here the caregiver did not take them to the hospital until two days after the incident.
So it is not unreasonable for caregivers to try to manage sunburns at home.
(26:04):
In this case, medically speaking, it's a large area. It's crossing joints.
But the issues here are more with the child and what the child was experiencing.
So the child was in distress and pain. So there was inadequate pain control, limited mobility.
The child couldn't walk. They couldn't do ADLs or range of motions.
(26:25):
They couldn't put shoes on. And then they started to feel warm and tender.
Or so an infection was studied.
So, without the proper care, there's an increased risk for infection,
and now they may need surgical intervention.
Besides the debridements, they may need grafting, and there's also the risk
for decreased permanent decrease mobility without the appropriate therapies
(26:48):
like physical and occupational therapies that our burn children usually have.
So, in this instance, it's because it's medical neglect due to the significant
pain and the inability for the child to do any ADLs, including walking or putting boots on.
So in this case, it was an example of medical neglect.
(27:08):
So what about a seven-month-old presenting for a soft, squishy spot on their head?
The history their caregiver tells you is that they fell from a bed three days ago.
Caregiver witnessed it. There was no loss of consciousness. They cried right
away. They were asymptomatic.
And then they presented because now, fast forward three days,
(27:31):
they noticed the soft, squishy spot on their head two hours before getting to
you in the office or the ED. and there was no other history of trauma.
So, when you examine them, the exam is notable only for the scalp swelling.
So, you send them to the ED if they're not already there and then you scan them
and you see a right parietal skull fracture with an overlying scalp hematoma
(27:53):
and underlying minimal subdural hemorrhage.
So, in this case, this case is not concerning for medical neglect.
Yes, we do have an injury and a finding, but this child had an incident three
days prior, was asymptomatically otherwise appropriate and at their baseline,
and their caregiver sought care when there was a change in symptoms.
(28:19):
So as soon as the caregiver saw the squishy spot, they sought the medical care
right away. And then we know that these scalp hematomas after something like
this, like a fall, may present several days.
So scalp hematoma, the soft swelling of the scalp, may not happen right away.
It may take a few days to develop.
(28:40):
So in this case, this is why it is not really concerning for medical neglect.
So, we've talked about some of the acute, some of the children in the acute setting.
So, some examples of medical neglect with children with chronic conditions.
So, you have a known asthmatic is on their regimen.
They require a controller plus a rescue inhaler. They have their asthma action plan.
(29:04):
So, you know that they've had that education provided to them and the resources to them.
They haven't had their controller for three years. They've been going frequently
to the ED or urgent care for shortness of breath every two weeks.
The winter season, this is usually where things trigger up and get worse for
them, but they still don't have their controller and just ran out of their albuterol,
(29:27):
and now they're admitted for status asthmaticus.
So this is concerning because they had that education, they had the resources,
and the family did not follow through with the recommendations provided to them,
nor did they seek earlier care to get that controller.
Another example is a known diabetic with a long-acting and short-acting insulin
(29:49):
for control who's admitted for DKA.
They didn't have their insulin for about two months and were attempting dietary
management because guess what?
The kid doesn't like needles or shots.
I don't either. I tell my patients I'm the doctor and I don't like them either.
I have to take my shots when I have to, but hey.
So in this case, it's concerning for medical neglect because their caregiver
(30:12):
didn't use their resources, like going back to their providers,
whether it be the PCP or the endocrinologist for assistance,
like, hey, my kid does not really does not like needles. What can I do?
So because they didn't go back to those resources for assistance,
it's concerning for medical neglect.
(30:33):
Also, an example like a known epileptic with Keppra and they got their rescue.
They have their seizure action plan. So it's clear documentation of education and a plan.
But lo and behold, caregivers don't believe in medicine anymore.
Modern medicine, they're trying to leave the keto diet on their own and they're
using CBD because they read something online that it could help.
(30:57):
And now this child is admitted in status.
So, this is another great example of medical neglect because they had the education,
they had the resources, and it was documented.
And caregivers failed to provide that to their child, and now they were put in a harm's way.
So, now we get to dental neglect. Is dental neglect part of medical neglect?
(31:21):
It can be. So, dental neglect can be medical neglect.
It doesn't have to stand alone on itself and is usually in the same category.
It's a form of medical care and treatment.
So for our other example, you have a seven-year-old that has multiple caries and dental abscesses.
They're bringing her in due to three days of tooth pain.
(31:45):
They're bringing her into the pain and you get the history that they've never seen a dentist before.
So is this neglect? like? Well, there are several factors that we need to address.
So let's go ahead and assess the situation.
So we have to determine what has prevented the family from getting the appropriate
care. Maybe they didn't know the importance of dental care.
(32:08):
I know personally growing up in the Valley, my family probably didn't know the
importance of getting the annual checkups.
We certainly didn't go at the newborns. As soon as the first two came out and
every six months and then yearly, I just went across the border to Mexico.
That's what we do in the Valley.
Once it came time for braces as a teenager. So maybe they didn't know the importance of dental care.
(32:30):
Maybe there's transportation issues, finance issues, or maybe they just plain
didn't want to bring them in.
So in our example, the caregiver tells you, well, they don't brush her teeth.
I knew she had cavities, but I figured the teeth would fall out anyways.
We don't have dental insurance, but they did bring them in when the child was complaining of pain.
(32:56):
So is this neglect? So here we've identified multiple barriers and knowledge gaps.
So and the caregiver sought care when the child became symptomatic,
when they realized, hey, we need to seek care. So is this neglect?
Maybe not. Maybe not right now, since we know there was a lot of barriers.
(33:17):
So what do you do? You prescribe your antibiotics,
you provide the education on oral care and completing the course of antibiotics,
and then you instruct the caregiver to come back in three weeks for a follow-up,
and you document this conversation, and you document your plan of care.
And then since you've also identified that finances is an issue for this family,
(33:40):
you can enlist the help of social work to assist with helping them find dental coverage.
So you've done all the things you've identified the
gaps and the the risk factors you get
the help you document it clearly and then
she comes back two months later this time she's got an abscess that is more
(34:02):
painful than before you find out that she only took the antibiotic for four
days because because she felt better and that's why they didn't follow up as instructed because
it was better and they couldn't pay for another visit anyways.
So is this neglect now? Well, it depends.
Did we address the knowledge gap? Yes. Did we address the financial issues?
(34:28):
Will we enlisted the help of social workers who provided the resources for them
to get to get the finances that the insurance needed?
So, yes. Did we document those conversations?
So, in our example, it was clearly documented the education and the need for
(34:48):
the medication and the follow-up.
Caregiver had verbalized understanding, it had no questions,
and they didn't show up for the follow-up, they didn't complete the medication,
which resulted in further complications.
So now in this case, there is concern for medical neglect and is our duty to report it.
So when risk factors are identified, please, please, please,
(35:13):
it is very important for us to provide the resources when we see these things.
And that includes our social workers, our case management, our care coordination.
Some that I learned throughout my residency here was catforkids.org, San Antonio chapter.
This is an advocacy project and they have different tabs for different things,
(35:34):
which include like legal or if it's like the different illnesses or elements
that they need, or if it's resources for like food or something else,
they have different tabs,
which are easy to go through and they have the different resources per each category.
Any baby can also help with resources for family and also respite care if needed,
(35:56):
especially when we have our chronic kiddos.
And then the SA Food Bank, which assists families, which I found out during
my advocacy rotation, the residency, it's not just food, but they also assist
families in accessing state and federal benefits, including SNAP, Medicaid, and CHIP.
And then since we talked about the asthmatics, we also have our wonderful SA Kids Breathe program.
(36:18):
So use your resources when the risk factors are identified to help prevent the
risk of maltreatment later on.
So what's something else that we can do to prevent risk at the professional level?
So we can ensure that we address any barriers to understanding.
Look out for the vocabulary that we're using with the families,
(36:41):
making sure that it's at a level that they understand. Have them verbalize their understanding.
You can ask them, hey, can you repeat back to me what I just said?
Making sure you're talking in their preferred language and having interpreters
who interpret well if needed. in chart review for the prior visits or growth charts.
(37:03):
So really please pay attention. It takes two, three seconds just to click the
box, look at the growth points and review them. Make sure we're not missing anything.
Is there weight and height and head circumference? Are they all okay?
Is there something that we may potentially be missing?
They may not always come for weight concerns or or GI concerns.
(37:24):
And then you just by, they may be coming for a rash or a bump or something.
And then you find out later on just by chart reviewing that maybe they have
been going down, down on their weight point.
And also clear documentation to provide that assistance,
documenting the education that you've provided to the family, your treatment plans,
(37:47):
and also to help the providers later on that may see these children and also
clear communication with other providers so we can make a difference with these
families and help our colleagues out as well.
So when should you report? You should report if there's a suspected concern
for neglect or even any form of maltreatment.
And this is for the safety of your patient. And maybe there's other children
(38:11):
at home that may be neglected as well or maltreatment and you don't know because you're not seeing them.
So if you have a suspicion for neglect, please report it.
CPS is actually a very helpful resource. A lot of times people have a negative
connotation of CPS that, oh, if I call CPS and they're going to take their kids
away. They're never going to see them again.
(38:32):
But actually they are mandated by law to try to keep children with their families
together unless there's a clear reason not to or other avenues have been exhausted
to keep the children safely with their caregivers.
So there are cases that children need to be removed from their home for their
own safety, but this is very few cases.
CPS has resources for these families.
(38:55):
So maybe the family is going through a divorce, their primary breadwinner is leaving the home.
Maybe utilities stopped, someone lost a job, their car is not working,
that's why they can't make it to the appointment, or they have other life stressors.
So again, they try to work with families. They can use classes such as parenting
classes, substance abuse classes.
(39:16):
They can provide them with community resources, help them attain insurance,
provide transportation.
Sometimes Sometimes they can even provide assistance with daycare if needed.
So if a report is made, try to be transparent with a family if it is safe to do so.
So whenever there are issues.
(39:36):
Whenever you identify some risk factors or you think that there's a concern,
when you're trying to gauge safety, please check your biases.
Is there a tangible reason to fear the family if you tell them about CPS,
such as were they aggressive during your interview with them?
Were they threatening or menacing during the exam?
(39:57):
Or is it something that's your inherent bias of what you think of the family
based on what they look like or your own personal self?
Try to be empathetic and supportive and explain their concerns and try to be non-judgmental.
So you can say, you can tell them, hey, so I noticed, for example,
this bruise, and this is not a typical location for a bruise in a child this
(40:21):
age or a child this age shouldn't bruise.
I'm concerned that your child may have some underlying disorder that we just
want to roll out, or I may be concerned that something that's happening to your child.
And you can express them that this is for the health and safety of your child
and come to that joint consensus.
Like we both want your child to be safe and healthy, right?
(40:43):
If you don't feel that's good to do so, you can always say, well,
I have to make a report. I'm a mandated reporter.
This is our hospital policy or protocol or procedure to do so, to make these reports.
And then a disabled family is not necessarily a neglectful family.
If you see that a family is really riled up or being a little difficult,
(41:07):
take time to ask what their concerns are, what their needs are, what can we do to help?
I know when I was a resident, I was asked by trauma service.
Do consults on a difficult family, but something wasn't sitting right.
And then we'll tell you the demographics of the person consulting me and the
(41:27):
families, but you can just imagine.
But just medically speaking, this child was run over by a known drunk driver
who cops had released within 24 hours, drank again and got behind the wheel again.
So the family was, you know, obviously and noticeably distressed,
and they were being a little difficult because how could this happen?
(41:49):
The cops should have done better. This should have happened.
That should have happened.
So that's why they were being, quote unquote, difficult, because of their concerns
of other factors, not necessarily being aggressive towards the providers themselves.
It was just the situation that they were upset at. So take the time to really
talk to them and listen. So thank you all for your time.
(42:11):
And this is us at Set Up for Miracles. Our office is located over at Christus.
And please, if you ever have a concern for any form of maltreatment,
or if you're thinking of consulting CPS, please let us know.
We have a provider on call 24-7.
And we are more than happy to walk things through with you guys.
(42:33):
If you don't know if you should or shouldn't make a report, we're more than
happy to talk it through and assess the case with you.
But if you are making a report, please let us know. We would like to be involved
from the get-go in case there's other recommendations needed.
Music.
(42:56):
Fascinating talk. Click on the link in this podcast for MOC credit.
Coming up next week, a wake-up call.
Melatonin is incredibly important at this time.
The CDC reports that there were 11,000 infants and children who visited the
(43:16):
emergency room after accidentally taking melatonin.
This is a wake-up call for all of us. That's from sleep specialist Dr. Karen Hensel-Franks.
Also in this Pediatrics News Feed, we have an episode called The New Asthma
Guidelines, What Were They Thinking?
(43:37):
I interview a doctor who was on that expert panel who explains the guidelines.
Our sister podcast is Pediatrics Now for Parents.
That website is pediatricsnowforparents.com. That podcast can also be found
wherever you get your podcasts.
(43:57):
We cover a lot of the same topics that we cover here in Pediatrics Now for the
Practitioner, but it's in small bites for the busy parent.
We hope it's one less thing you have to say in the exam room.
That's our sister podcast, Pediatrics Now for Parents.
Music.
(44:20):
If you know someone who would be interested in this podcast, please share.
And I want to thank you all for all of the hard work that you're doing.
And I so appreciate you listening.
Our website is pediatricsnowpodcast.com. My email address is on there.
Please send me comments or episode ideas.
(44:42):
I'm Holly Wayment. Thank you so much for listening. And thank you for making a difference.
Music.
(00:05):
Dates, and discussions for the busy pediatric practitioner. Click on the link
in this podcast for MOC credit.
Today, I'm bringing you a Grand Rounds talk.
It's by Dr. Mary Ann Alvarez-Griffiths. She is a fellow in the Department of
Pediatrics at UT Health San Antonio Division of Child Abuse.
(00:26):
During her fellowship training, Griffiths has provided community education regarding
child maltreatment to various audiences, from pediatric residents to the San
Antonio Police Department.
She recently participated in updating the AAP Point of Care Quick Reference
section on physical abuse and neglect.
(00:46):
She's a member of the Child Abuse and Neglect Committee of the Texas Pediatric
Society and is also a member of the Council on Child Abuse and Neglect.
Her fellows' research project focuses on the importance of obtaining head circumference
in infants to prevent missed abusive head trauma.
Let's listen in to her talk on child neglect.
(01:09):
Neglect is usually typified by an ongoing pattern of inadequate care,
and it can actually do as much damage as physical abuse.
The neglect depends on the age of the child and can also result in a long-lasting
impact on them, their peer relations, and their school function.
There's also the possibility of impaired problem solving, delayed language,
(01:32):
and lower academic achievement, which we know is going to affect them later on in life.
So, the National Child Abuse and Neglect Data System, or NCANDS,
collects data on the types of reports that have been made to CPS,
so this is CPS data, and how the percentages of what has been founded or has been confirmed.
(01:55):
So, So just looking at the national statistics, neglect is the most common types
of reports made to CPS, which makes about two-thirds of the reports made.
And about 74% of these reports made have been confirmed for concern for neglect.
Just looking at these statistics, these are the most recent ones that we have.
(02:16):
In Texas and Bexar County, we could see that in Texas, there was about 2,000,
a little over 2,000 cases of physical neglect.
In Bexar County, constituted 165 of those. And then for medical neglect, we had a little over 900.
And in Bexar County, we had 97 of those cases. So, as we can see in the total
(02:38):
numbers below, that we do make up quite a percentile, about 10% of these confirmed
cases of neglect, unfortunately.
So, when people think of fatalities, most often the most common thought is,
oh, this child was abused and therefore died as a result of ongoing abuse or an abusive event.
(03:00):
But actually about 73% of child fatalities involve some form of neglect.
In our 22 data, we found that there was about 43% that were exclusively due
to physical and medical neglect.
Neglectful supervision is actually the most common neglect fatality,
(03:21):
but for the purposes of this talk, we're focusing on physical and medical.
We know that children with special needs are an increased risk for maltreatment.
And 31% of child maltreatment fatalities actually involve a child with special
medical needs or concerns.
So, this could be something as your bread and butter asthma to those that are
(03:42):
physically disabled, have CP, those that have feeding tube or medically complex children.
So, we all know about the social determinants of health and risk factors that
are associated for maltreatment and how they are all different levels of it.
So, it can be in the individual setting.
(04:02):
So, a baby that is born premature or has disabilities or special needs, has low birth weight.
It could also be risk factors within their relationship with their caregivers.
So if it's like a single parent, young parent, young maternal age,
if their caregivers have mental health issues or substance use,
(04:23):
also in their community, if there's a lack of social support or if there's increased
crime rate or stress or lack of social support.
So, we know that these are risk factors for maltreatment, and it's our job as
physicians to identify these risk factors in order to help and support and provide
resources to our families to prevent maltreatment.
(04:45):
So just because there are risk factors for maltreatment doesn't mean that every
case of abuse and neglect has one of these risk factors.
And the opposite is true. Many children and families may have one or several
of these risk factors, but it does not necessarily mean that they will be maltreated later on.
(05:07):
So, due to the medical literature that we have, the greatest risk factor for
neglect, as we know, is poverty or low socioeconomic status,
which is the most directly associated with neglect.
Children living in high-poverty areas are six times more likely to experience neglect.
There are high levels of unemployment. There's population loss where they reside,
(05:33):
or there's overcrowding in the impoverished neighborhoods.
There's fewer opportunities to meet their child's needs, including like health
care, fewer resources, including nutrition, clothing, hygiene,
playgrounds, transportation.
And poverty exacerbates other risk factors, such as like food insecurities,
poor material nutrition, caregiver depression, stressful life events,
(05:56):
living in higher crime or unsafe neighborhoods. hoods.
So really, the greatest risk factor is the low social support resources and
education that ties in with poverty and low socioeconomic status.
So again, a family may be low income, but it does not necessarily mean that
they are neglectful of their children.
(06:19):
We have also identified that there is, in addition to all the risk factors,
like the individual with the caregiver and their social status,
there's also risk at the professional level with that.
That being problematic communication, whether it be between the caregiver and the provider,
maybe the parents aren't understanding the child's condition or the treatment
(06:40):
plan, why their kid needs XYZ treatments or surgery or procedures.
And there's also with problematic communication between providers themselves,
not communicating properly regarding recommendations or treatment plans.
And this is seen more often with the children that are slow waking or failing
(07:01):
to thrive and the medically complex children.
So we've identified four possible options as far as consequences for neglect.
So there is no current harm done and no future harm is anticipated.
One of the examples would be leaving a child asleep in a crib who does not require
nighttime care while their caregiver is out partying on a Saturday night.
(07:24):
So no harm is done. The kid is in the crib, safe and secure,
even though unsupervised.
And they don't need any nighttime care like diaper changes, bottle changes,
and then no future harm is anticipated.
The other one is no current harm, but future harm is anticipated, such as co-sleeping.
Some families may co-sleep with their child and their child wakes up okay the
(07:47):
next morning, but there's always that risk of future harm that they may have
an asphyxia event due to a co-sleeping incident.
There's where the child experiences current harm, but no future harm is anticipated,
such as when a caregiver turns back for a few minutes and the child falls into to the pool.
(08:07):
So the child experienced that near drowning event, so that current harm,
but because of that event, caregivers tend to do all the things,
put up the gates, put in cameras or lock the doors, and then no future harm is anticipated.
There's also children that experience current harm and future harm as anticipated,
such as the failure to thrive kiddos.
(08:30):
So if we know that they're experiencing physical neglect, the caregivers aren't
feeding them adequately and aren't understanding the treatments or the feeds,
or just plain don't want to do it. So they're right now, failure to thrive, will wait.
And then there's that increased harm, increased risk for harm that they may
not continue giving them the appropriate caloric intake. type.
(08:51):
So, we have the raw outcome for neglect.
So, it varies between the age group. So, in infants, we usually see this as poor growth.
They'll have cognitive delays, poor social skills, and other psychosocial problems.
And this is usually seen, one of the studies showed that this is seen before the age of three.
And then with the school-aged children or adolescents, they're more likely to
(09:15):
develop developmental problems such as poor cognitive and school performances,
emotional and behavioral problems.
And then the behavioral problems, it's a spectrum. No one child is going to
act the same way to say, oh, pinpoint this child's neglected because they are withdrawn.
The opposite may be true. They may be more aggressive or they may be engaging
(09:36):
in high-risk behaviors, such as early initiation of sexual activity or substance use.
And as we know, neglect plays a part in our adverse childhood experiences.
It is one of the aces, and these increased aces may predispose for chronic health
problems, mental health problems, and increased risky behaviors.
(09:59):
So, as mentioned before, there are many types of neglect, including physical,
medical, dental, which is sometimes lumped into medical, depending on the medical
legal definition or the agency using these definitions.
Supervisional, emotional, and educational.
So, for physical neglect, this occurs when a parent or a caregiver does not
(10:21):
provide the child with basic necessities, which could be adequate food,
clothing, shelter, hygiene,
or really the lack that would cause a serious injury or illness.
So, people commonly think about a child not having adequate food to grow and
failure to thrive, and that's just one of the examples.
(10:44):
So, for physical neglect, there are some physical indicators and some behavioral
indicators. So, some physical indicators.
The child may have, you can see it through the growth parameters,
that if they're not getting adequate nutrition at home, that their weight starts
to drop, and then their height starts to drop off, and then their head circumference starts to drop off.
(11:06):
They may be consistently dirty or have a severe body odor.
So whenever I get consults and they tell me this child is dirty and uncancelled
or has like dirt under the fingernails, it's not really about having dirt under
their fingernails or on their feet because for all you know,
they may have been just laying outside before coming to visit you in your office, clinic, ED,
(11:30):
whatever setting you're at.
But we're talking about just consistently dirty, caked on, and with a severe odor.
And then another physical indicator is the lack of adequate clothing.
Here in San Antonio, this is kind of a little bit more difficult to gauge.
We don't have these strong winters where we would need puffy coats,
(11:52):
but usually that's one of the, usually what we think about is when it's winter
and these children don't have coats or it's summer and then these children are
still in like heavy clothing.
Some of the behavioral indicators could be that they're asking or begging for money, food.
(12:12):
They may stay extended time at school just for food and nutrition.
I know growing up in the valley at my school, we had a food program including after school.
So they may be doing that just to get another meal.
They may tell you, oh, that no one's at home and this is why they prefer to
stay at school or they'd rather be elsewhere.
(12:32):
They may be frequently absent. You may get calls from school saying,
hey, this kid is absent or from the nurse, or they may tell you,
the parents may tell you that they're just constantly fatigued.
So whenever you notice that there are some indicators, just know that it is
okay to ask the hard questions to understand the problem.
(12:55):
For the example of the child with like dirt taped on or under their fingernails,
it's okay to ask them or the caregivers, hey, I noticed this.
How are things going at home or is everything okay at home? So...
Talk to them in an unjudgmental way to see if there's something unidentifiable
(13:18):
problem in which we could help or provide resources.
So once we understand the problem, we can get the appropriate resources to them
and always use our wonderful social work and care coordination teams for these resources.
So maybe the parents may say, oh yes, the water stops working.
They cut off the water. I didn't have enough money to pay the water bill this month or something.
(13:43):
So there may be a reason as to why they are presenting that way.
So if you notice something, please provide the resources for them.
So some other indicators that may present, think about a child that has a chronic illness.
They have a Broviac placement or maybe a port-a-calf, and then they're supposed
(14:08):
to be maintaining it clean.
And then you see them come walking into your office or you go into the ED and they're just dirty.
The tegaderm is all soiled and they're coming in with frequent infections.
So that may be an indicator that, hey, maybe something is going on at home as
well, that maybe the home life is unhygienic for them,
(14:32):
for their level of immunocompromised level.
And then we find that once we get into the home, CPS or law enforcement,
sometimes, unfortunately, they do live in unhygienic conditions.
So you may not be seeing this yourself as physicians.
This isn't going to walk into their office. Families might not show you these
(14:56):
pictures, but just having these children coming in with frequent infections,
or they may be coming frequently unkept and with odor,
and they may be coming for multiple ailments.
And just some specific items that may be an indicator that maybe something is going on at home.
The most common physical neglect presentation in infants is failure to thrive
(15:19):
or slow weight gain as we're trying to move away from this term.
There are many aspects to consider when managing a child with failure to thrive.
It is multifactorial and it encompasses a lot of spheres.
So for us, It can encompass biologic, where growth failure is related to a medical
(15:40):
illness, whether acute or chronic.
So they may have feeding difficulties secondary to poor caloric intake.
Maybe they have some oral motor dysfunction or dysphagia, a neuro impairment.
They have inadequate absorption or excess loss, such as pyloric stenosis or CF or infection.
Or they may have something that has an increased caloric requirement such as
(16:02):
a congenital heart disease or chronic lung disease or an important area of metabolism.
The psychological component revolves around the mental health of the caregivers
and their competence including their IQ level.
The social sphere as we know poverty and low support system and low resources
(16:23):
is the most pervasive risk factors, and this also takes in part the food insecurity,
family stressors, and problematic interpersonal relationships between the caregivers.
So, an extensive workup, including thorough history,
seating history, family social history, review systems, labs,
exams, imaging, if needed, are recommended for these cases to roll out or to
(16:48):
parse out what could be causing the slow weight gain in these infants.
So here's an example of a failure to thrive baby.
So we can see that they have on the face lanugo.
So this is the body's reaction to kind of maintain no thermia.
And we can see their skin folds around the necks and how there's the loss of
(17:10):
the subcutaneous fat over in the buttocks. This is another example of failure
to thrive when this child is one who had not seen a doctor since two months of age.
And then when they were admitted, we can see some lanugo going on in the back
and the loss of subcutaneous tissue.
And then three weeks later, with adequate caloric intake, they regained that
(17:35):
fat as well. So this is one of those obvious cases on how adequate caloric intake
made a noticeable difference in change.
So we're going to go through some cases. And since we're not in person,
I'm not going to ask the hypothetical questions.
But for this example, how old would you think this child is based on these characteristics?
(17:56):
They're three feet tall, 30 pounds.
So, this is the average size of a two-year-old, and this child is actually six years old.
So, in this example, providers, this is just to show an example how providers usually see,
victims, so weight gain or failure to thrive is typically seen in infants,
(18:17):
but it can also happen in older children who are victims of physical neglect as well.
Sometimes the families may come in and say, oh, the child may have a poor appetite
or they have a bleeding disorder or an eating disorder, sorry,
that hasn't been confirmed when food may actually be withheld.
Now, in this case, for the six-year-old, it's an extreme example.
(18:38):
And he also has psychosocial dwarfism due to the extent of maltreatment he underwent,
which included physical and emotional neglect.
So we can see how his weight was affected, his height was affected,
and obviously we know his circumference falls as well.
And this is why he looks similar to a two-year-old more than a six-year-old.
(18:58):
Another example for physical neglect and risk factors at the professional level.
So there was the case of a one-month-old admitted for failure to thrive.
Their birth weight was 2.19 kilos and admission weight was 2.2 kilos.
When they were born, they were discharged from the hospital.
(19:19):
They follow up with their PCP appropriately the three days after delivery.
And per documentation, they were 1.84 kilos or 21% below birth weight.
The instructions were to follow up in one month.
And from their visit from the PCP's office to admission, this child had actually
(19:41):
gained about 16 grams per day.
So as we know, newborns may lose up to 10% of their birth weight and may take
7 to 14 days to regain it, which is slower in breastfed infants than formula fed.
And for the AAP, a loss of more than 10 to 12 percent should be investigated.
20 percent is significant, and these typically require hospital readmission,
(20:05):
if not very close follow-up.
And while the child was gaining weight, we know that it's suboptimal weight
gain, as average weight gain in this age group would be 20 to 30 grams a day.
So in this case was a risk at the professional level.
Just looking at the growth chart, looking at plotting these things can help
(20:26):
us identify if there's any risk factors that are needed.
So this child was admitted for failure to thrive with concern for failure for
physical neglect, but the child was gaining weight adequately and the weight
was not addressed at this visit, unfortunately.
Another example, a baby 9.2 months of age was seen in the ED and they were 7.8 kilos or 10 percentile.
(20:53):
They came back a little a few weeks later and they were 6.85 kilos or not the 0.5 percent.
For this one, on the day of admission, they were described as hectic with loose
skin around the neck, sunken eyes that were pale.
But interestingly enough the
(21:14):
day before admission they were described as
well-peering and non-toxic and that was the 6.85 kilo and they were there the
day before and the day of admission with same weight so in this case they had
gone to the ed for an outside and unrelated issue followed
(21:35):
up with a PCP per ED instructions the next day,
and the PCP was concerned that they were 67% at the six-month well-child check
and was now at the 0.5%, so they sent them to the ED for evaluation and admission.
So, here we have a copy of the growth chart. So, this is what was seen in the
(21:57):
ED, these first two points.
These other points were inpatient after the child gained getting linked with
the adequate nutrition.
So in this case, the weight issue was just recommended to be followed up in
the office and not necessarily addressed in the ED with this growth chart.
(22:18):
And it turned out that the mother was pregnant, didn't know that her supply
had dropped, and there was also concern for caregiver level cognition.
So it's really important to, you know, just take a moment, take a look at the
growth chart, address these issues as we see them and to provide your documentation
for everyone following up.
Another example, this child has several ED visits and in all of these,
(22:43):
between the ages of five and seven, almost seven years old, six and a half, they were noted.
The exam wasn't documented as unremarkable and the weight was not addressed. dressed.
This child's weight had been decreasing in the last one and a half years.
And there was no mention of the weight trend.
And then we see how the height over here on the right side has started to stall.
(23:05):
And then this child was starting to grow and then stall again.
So these pictures were taken one year apart.
And then this was the one to the right is one closer to admission.
I think this was the day they were admitted when they took this photograph.
So now the child had noticeably sunken eyes and appearance.
(23:27):
And this case is an extreme case of starvation and psychological maltreatment.
But here, what's important is just stressing the importance of looking at the growth chart.
Just take two seconds to take a look to see if there's anything identifiable,
any form of maltreatment that may be going on or any concerns or something that
(23:50):
we may prevent or help the family with.
So, for shifting gears to medical neglect now, medical neglect can take one of two forms.
It can be the failure to act on an obvious sign of serious injury or illness,
or it could be a failure to follow medical providers' There's instructions once
(24:10):
care and advice has been sought.
So traditionally, people think of those with asthma, diabetes,
or infections for the second bullet point.
And we will go through those shortly.
So an example of an acute setting.
So there is an 18-month-old that's coming in refusing to bear weight for two
(24:35):
days after splitting while running and landing in a split position.
On exam, there's an obvious deformity noted. They are non-variant.
They're attended to palpation. They're noted to be in mild distress.
You decide to get imaging, and this is what you see.
So you have minimally displaced, angulated spiral fracture of the feet.
(24:57):
So in this case, the child required surgery. So while this could have been an
accidental mechanism, there was a delay in care.
And while the delay in care did not change the medical management,
this child would have required surgery even if they came in within 30 minutes of their fall.
This child had obvious findings like that obvious deformity and they were obviously
(25:19):
in significant pain and did require a surgical intervention.
So this is the case where caregivers failed to act on an obvious serious injury.
And therefore concerning for medical neglect. Another example may be an eight-year-old
breaking leaves in a rural area.
There was an ash pile that they stepped through.
(25:40):
Caregiver saw them, heard them yell, took off their boot, and found this.
So here we know that there is a large burn, at least partial thickness burn
due to the blisters and bubbles.
And here the caregiver did not take them to the hospital until two days after the incident.
So it is not unreasonable for caregivers to try to manage sunburns at home.
(26:04):
In this case, medically speaking, it's a large area. It's crossing joints.
But the issues here are more with the child and what the child was experiencing.
So the child was in distress and pain. So there was inadequate pain control, limited mobility.
The child couldn't walk. They couldn't do ADLs or range of motions.
(26:25):
They couldn't put shoes on. And then they started to feel warm and tender.
Or so an infection was studied.
So, without the proper care, there's an increased risk for infection,
and now they may need surgical intervention.
Besides the debridements, they may need grafting, and there's also the risk
for decreased permanent decrease mobility without the appropriate therapies
(26:48):
like physical and occupational therapies that our burn children usually have.
So, in this instance, it's because it's medical neglect due to the significant
pain and the inability for the child to do any ADLs, including walking or putting boots on.
So in this case, it was an example of medical neglect.
(27:08):
So what about a seven-month-old presenting for a soft, squishy spot on their head?
The history their caregiver tells you is that they fell from a bed three days ago.
Caregiver witnessed it. There was no loss of consciousness. They cried right
away. They were asymptomatic.
And then they presented because now, fast forward three days,
(27:31):
they noticed the soft, squishy spot on their head two hours before getting to
you in the office or the ED. and there was no other history of trauma.
So, when you examine them, the exam is notable only for the scalp swelling.
So, you send them to the ED if they're not already there and then you scan them
and you see a right parietal skull fracture with an overlying scalp hematoma
(27:53):
and underlying minimal subdural hemorrhage.
So, in this case, this case is not concerning for medical neglect.
Yes, we do have an injury and a finding, but this child had an incident three
days prior, was asymptomatically otherwise appropriate and at their baseline,
and their caregiver sought care when there was a change in symptoms.
(28:19):
So as soon as the caregiver saw the squishy spot, they sought the medical care
right away. And then we know that these scalp hematomas after something like
this, like a fall, may present several days.
So scalp hematoma, the soft swelling of the scalp, may not happen right away.
It may take a few days to develop.
(28:40):
So in this case, this is why it is not really concerning for medical neglect.
So, we've talked about some of the acute, some of the children in the acute setting.
So, some examples of medical neglect with children with chronic conditions.
So, you have a known asthmatic is on their regimen.
They require a controller plus a rescue inhaler. They have their asthma action plan.
(29:04):
So, you know that they've had that education provided to them and the resources to them.
They haven't had their controller for three years. They've been going frequently
to the ED or urgent care for shortness of breath every two weeks.
The winter season, this is usually where things trigger up and get worse for
them, but they still don't have their controller and just ran out of their albuterol,
(29:27):
and now they're admitted for status asthmaticus.
So this is concerning because they had that education, they had the resources,
and the family did not follow through with the recommendations provided to them,
nor did they seek earlier care to get that controller.
Another example is a known diabetic with a long-acting and short-acting insulin
(29:49):
for control who's admitted for DKA.
They didn't have their insulin for about two months and were attempting dietary
management because guess what?
The kid doesn't like needles or shots.
I don't either. I tell my patients I'm the doctor and I don't like them either.
I have to take my shots when I have to, but hey.
So in this case, it's concerning for medical neglect because their caregiver
(30:12):
didn't use their resources, like going back to their providers,
whether it be the PCP or the endocrinologist for assistance,
like, hey, my kid does not really does not like needles. What can I do?
So because they didn't go back to those resources for assistance,
it's concerning for medical neglect.
(30:33):
Also, an example like a known epileptic with Keppra and they got their rescue.
They have their seizure action plan. So it's clear documentation of education and a plan.
But lo and behold, caregivers don't believe in medicine anymore.
Modern medicine, they're trying to leave the keto diet on their own and they're
using CBD because they read something online that it could help.
(30:57):
And now this child is admitted in status.
So, this is another great example of medical neglect because they had the education,
they had the resources, and it was documented.
And caregivers failed to provide that to their child, and now they were put in a harm's way.
So, now we get to dental neglect. Is dental neglect part of medical neglect?
(31:21):
It can be. So, dental neglect can be medical neglect.
It doesn't have to stand alone on itself and is usually in the same category.
It's a form of medical care and treatment.
So for our other example, you have a seven-year-old that has multiple caries and dental abscesses.
They're bringing her in due to three days of tooth pain.
(31:45):
They're bringing her into the pain and you get the history that they've never seen a dentist before.
So is this neglect? like? Well, there are several factors that we need to address.
So let's go ahead and assess the situation.
So we have to determine what has prevented the family from getting the appropriate
care. Maybe they didn't know the importance of dental care.
(32:08):
I know personally growing up in the Valley, my family probably didn't know the
importance of getting the annual checkups.
We certainly didn't go at the newborns. As soon as the first two came out and
every six months and then yearly, I just went across the border to Mexico.
That's what we do in the Valley.
Once it came time for braces as a teenager. So maybe they didn't know the importance of dental care.
(32:30):
Maybe there's transportation issues, finance issues, or maybe they just plain
didn't want to bring them in.
So in our example, the caregiver tells you, well, they don't brush her teeth.
I knew she had cavities, but I figured the teeth would fall out anyways.
We don't have dental insurance, but they did bring them in when the child was complaining of pain.
(32:56):
So is this neglect? So here we've identified multiple barriers and knowledge gaps.
So and the caregiver sought care when the child became symptomatic,
when they realized, hey, we need to seek care. So is this neglect?
Maybe not. Maybe not right now, since we know there was a lot of barriers.
(33:17):
So what do you do? You prescribe your antibiotics,
you provide the education on oral care and completing the course of antibiotics,
and then you instruct the caregiver to come back in three weeks for a follow-up,
and you document this conversation, and you document your plan of care.
And then since you've also identified that finances is an issue for this family,
(33:40):
you can enlist the help of social work to assist with helping them find dental coverage.
So you've done all the things you've identified the
gaps and the the risk factors you get
the help you document it clearly and then
she comes back two months later this time she's got an abscess that is more
(34:02):
painful than before you find out that she only took the antibiotic for four
days because because she felt better and that's why they didn't follow up as instructed because
it was better and they couldn't pay for another visit anyways.
So is this neglect now? Well, it depends.
Did we address the knowledge gap? Yes. Did we address the financial issues?
(34:28):
Will we enlisted the help of social workers who provided the resources for them
to get to get the finances that the insurance needed?
So, yes. Did we document those conversations?
So, in our example, it was clearly documented the education and the need for
(34:48):
the medication and the follow-up.
Caregiver had verbalized understanding, it had no questions,
and they didn't show up for the follow-up, they didn't complete the medication,
which resulted in further complications.
So now in this case, there is concern for medical neglect and is our duty to report it.
So when risk factors are identified, please, please, please,
(35:13):
it is very important for us to provide the resources when we see these things.
And that includes our social workers, our case management, our care coordination.
Some that I learned throughout my residency here was catforkids.org, San Antonio chapter.
This is an advocacy project and they have different tabs for different things,
(35:34):
which include like legal or if it's like the different illnesses or elements
that they need, or if it's resources for like food or something else,
they have different tabs,
which are easy to go through and they have the different resources per each category.
Any baby can also help with resources for family and also respite care if needed,
(35:56):
especially when we have our chronic kiddos.
And then the SA Food Bank, which assists families, which I found out during
my advocacy rotation, the residency, it's not just food, but they also assist
families in accessing state and federal benefits, including SNAP, Medicaid, and CHIP.
And then since we talked about the asthmatics, we also have our wonderful SA Kids Breathe program.
(36:18):
So use your resources when the risk factors are identified to help prevent the
risk of maltreatment later on.
So what's something else that we can do to prevent risk at the professional level?
So we can ensure that we address any barriers to understanding.
Look out for the vocabulary that we're using with the families,
(36:41):
making sure that it's at a level that they understand. Have them verbalize their understanding.
You can ask them, hey, can you repeat back to me what I just said?
Making sure you're talking in their preferred language and having interpreters
who interpret well if needed. in chart review for the prior visits or growth charts.
(37:03):
So really please pay attention. It takes two, three seconds just to click the
box, look at the growth points and review them. Make sure we're not missing anything.
Is there weight and height and head circumference? Are they all okay?
Is there something that we may potentially be missing?
They may not always come for weight concerns or or GI concerns.
(37:24):
And then you just by, they may be coming for a rash or a bump or something.
And then you find out later on just by chart reviewing that maybe they have
been going down, down on their weight point.
And also clear documentation to provide that assistance,
documenting the education that you've provided to the family, your treatment plans,
(37:47):
and also to help the providers later on that may see these children and also
clear communication with other providers so we can make a difference with these
families and help our colleagues out as well.
So when should you report? You should report if there's a suspected concern
for neglect or even any form of maltreatment.
And this is for the safety of your patient. And maybe there's other children
(38:11):
at home that may be neglected as well or maltreatment and you don't know because you're not seeing them.
So if you have a suspicion for neglect, please report it.
CPS is actually a very helpful resource. A lot of times people have a negative
connotation of CPS that, oh, if I call CPS and they're going to take their kids
away. They're never going to see them again.
(38:32):
But actually they are mandated by law to try to keep children with their families
together unless there's a clear reason not to or other avenues have been exhausted
to keep the children safely with their caregivers.
So there are cases that children need to be removed from their home for their
own safety, but this is very few cases.
CPS has resources for these families.
(38:55):
So maybe the family is going through a divorce, their primary breadwinner is leaving the home.
Maybe utilities stopped, someone lost a job, their car is not working,
that's why they can't make it to the appointment, or they have other life stressors.
So again, they try to work with families. They can use classes such as parenting
classes, substance abuse classes.
(39:16):
They can provide them with community resources, help them attain insurance,
provide transportation.
Sometimes Sometimes they can even provide assistance with daycare if needed.
So if a report is made, try to be transparent with a family if it is safe to do so.
So whenever there are issues.
(39:36):
Whenever you identify some risk factors or you think that there's a concern,
when you're trying to gauge safety, please check your biases.
Is there a tangible reason to fear the family if you tell them about CPS,
such as were they aggressive during your interview with them?
Were they threatening or menacing during the exam?
(39:57):
Or is it something that's your inherent bias of what you think of the family
based on what they look like or your own personal self?
Try to be empathetic and supportive and explain their concerns and try to be non-judgmental.
So you can say, you can tell them, hey, so I noticed, for example,
this bruise, and this is not a typical location for a bruise in a child this
(40:21):
age or a child this age shouldn't bruise.
I'm concerned that your child may have some underlying disorder that we just
want to roll out, or I may be concerned that something that's happening to your child.
And you can express them that this is for the health and safety of your child
and come to that joint consensus.
Like we both want your child to be safe and healthy, right?
(40:43):
If you don't feel that's good to do so, you can always say, well,
I have to make a report. I'm a mandated reporter.
This is our hospital policy or protocol or procedure to do so, to make these reports.
And then a disabled family is not necessarily a neglectful family.
If you see that a family is really riled up or being a little difficult,
(41:07):
take time to ask what their concerns are, what their needs are, what can we do to help?
I know when I was a resident, I was asked by trauma service.
Do consults on a difficult family, but something wasn't sitting right.
And then we'll tell you the demographics of the person consulting me and the
(41:27):
families, but you can just imagine.
But just medically speaking, this child was run over by a known drunk driver
who cops had released within 24 hours, drank again and got behind the wheel again.
So the family was, you know, obviously and noticeably distressed,
and they were being a little difficult because how could this happen?
(41:49):
The cops should have done better. This should have happened.
That should have happened.
So that's why they were being, quote unquote, difficult, because of their concerns
of other factors, not necessarily being aggressive towards the providers themselves.
It was just the situation that they were upset at. So take the time to really
talk to them and listen. So thank you all for your time.
(42:11):
And this is us at Set Up for Miracles. Our office is located over at Christus.
And please, if you ever have a concern for any form of maltreatment,
or if you're thinking of consulting CPS, please let us know.
We have a provider on call 24-7.
And we are more than happy to walk things through with you guys.
(42:33):
If you don't know if you should or shouldn't make a report, we're more than
happy to talk it through and assess the case with you.
But if you are making a report, please let us know. We would like to be involved
from the get-go in case there's other recommendations needed.
Music.
(42:56):
Fascinating talk. Click on the link in this podcast for MOC credit.
Coming up next week, a wake-up call.
Melatonin is incredibly important at this time.
The CDC reports that there were 11,000 infants and children who visited the
(43:16):
emergency room after accidentally taking melatonin.
This is a wake-up call for all of us. That's from sleep specialist Dr. Karen Hensel-Franks.
Also in this Pediatrics News Feed, we have an episode called The New Asthma
Guidelines, What Were They Thinking?
(43:37):
I interview a doctor who was on that expert panel who explains the guidelines.
Our sister podcast is Pediatrics Now for Parents.
That website is pediatricsnowforparents.com. That podcast can also be found
wherever you get your podcasts.
(43:57):
We cover a lot of the same topics that we cover here in Pediatrics Now for the
Practitioner, but it's in small bites for the busy parent.
We hope it's one less thing you have to say in the exam room.
That's our sister podcast, Pediatrics Now for Parents.
Music.
(44:20):
If you know someone who would be interested in this podcast, please share.
And I want to thank you all for all of the hard work that you're doing.
And I so appreciate you listening.
Our website is pediatricsnowpodcast.com. My email address is on there.
Please send me comments or episode ideas.
(44:42):
I'm Holly Wayment. Thank you so much for listening. And thank you for making a difference.
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