HISTORY, PHYSICAL EXAM, DIAGNOSTIC IMAGING, AND DIAGNOSIS
During a health supervision visit in the outpatient clinic, a patient was found to have an unexplained facial bruise. During this visit, the patient's mother also admitted to diluting the patient's formula. The mother was advised of the risks of formula dilution and the patient was referred to the emergency department (ED). The mother did not bring the patient to the hospital and could not be located by authorities. The patient presented to the ED one week later with tonic clonic seizures due to severe hyponatremia, which was found to be secondary to formula dilution, consistent with neglect. The evaluation for occult abusive injury was negative. When medically cleared, the child was removed from the mother's custody and placed in the care of her father and paternal grandmother.
One month later, the patient's father brought her to the pediatrician's office for a weight-check. During this appointment, she was incidentally found to have hematemesis and was referred to the ED. A CT scan of her chest and neck demonstrated pneumomediastinum, subcutaneous emphysema, right sided pulmonary consolidation concerning for a contusion or atelectasis, and a subacute healing fracture of fourth rib (not present on the skeletal survey during the initial hospitalization). A flexible nasopharyngoscopy showed a hypopharyngeal laceration and a presumed perforation. Caregivers denied any history of injury or trauma and the patient's injuries were found to be diagnostic of physical abuse. Her hospital course was complicated by the development of a neck abscess that resolved with antibiotic treatment, and she was discharged to foster care after two weeks of nasogastric tube feeds. Following discharge, her hypopharyngeal injury resolved and growth and development were appropriate.
DISCUSSION
Cases of life threatening abuse and near fatal neglect resulting in multiple hospitalizations are rare. We present a case of a previously healthy two month old female who was hospitalized twice in a one month span.
Child abuse and neglect constitute a significant number of ED visits and hospitalizations. Children below 1 year of age are the most vulnerable to victimization and one or both parents are identified as the alleged perpetrators of abuse or neglect in up to 92% of cases. Our case highlights that, although appropriate measures were taken when abuse and neglect were suspected at the initial admission, maltreatment continued even in a new environment.
Multiple caregivers can be perpetrators of child abuse and neglect, and the degree of suspicion must always remain high.
