Child maltreatment, including medical neglect, is a frequent contributor to the development of asthma as well as a barrier to its proper management. This article aims to review the role of medical neglect as a contributor to poor asthma control. Medical neglect can present as failure of the caretaker to recognize severe asthma symptoms in a child, non-adherence to medical management, failure to prevent chronic exposure to allergens or tobacco smoke, poor child nutrition leading to obesity, and allowing a young child to manage his/her illness without supervision. This article will explore the different factors leading to medical neglect (as illustrated by two cases) and suggest possible interventions aiming to prevent emergency department visits, hospitalizations, and asthma-related deaths.

This introduction provides an overview to the special issues on medical neglect in childhood guest edited by Barbara L. Knox, MD, FAAP, Clinical Professor of Pediatrics, University of Washington School of Medicine, The Children's Hospital at Providence, Medical Director of Alaska Child Abuse Response and Evaluation Services; Randell C. Alexander, MD, PhD, FAAP, Professor and Chief, Division of Child Protection and Forensic Pediatrics at the University of Florida-Jacksonville; Francois M. Luyet, MD, Clinical Assistant Professor, University of Wisconsin School of Medicine and Public Health; and Debra D. Esernio-Jenssen, Professor of Pediatrics at the Morsani College of Medicine USF Health in Tampa, Florida and the Chief of Child Protection Medicine at Lehigh Valley Reilly Children's Hospital. Ten articles are included in this special edition aiming to explore the role of medical neglect in situations commonly encountered by practitioners.

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BackgroundChild maltreatment is a leading cause of pediatric morbidity and mortality. We previously reported on development and implementation of a child abuse clinical decision support system (CA-CDSS) in the Cerner electronic health record (EHR). Our objective was to develop a CA-CDSS in two different EHRs.MethodsUsing the CA-CDSS in Cerner as a template, CA-CDSSs were developed for use in four hospitals in the Northwell Health system who use Allscripts and two hospitals in the University of Wisconsin health system who use Epic. Each system had a combination of triggers, alerts and child abuse-specific order sets. Usability evaluation was done prior to launch of the CA-CDSS.ResultsOver an 18-month period, a CA-CDSS was embedded into Epic and Allscripts at two hospital systems. The CA-CDSSs vary significantly from each other in terms of the type of triggers which were able to be used, the type of alert, the ability of the alert to link directly to child abuse-specific order sets and the order sets themselves.ConclusionsDissemination of CA-CDSS from one EHR into the EHR in other health care systems is possible but time-consuming and needs to be adapted to the strengths and limitations of the specific EHR. Site-specific usability evaluation, buy-in of multiple stakeholder groups and significant information technology support are needed. These barriers limit scalability and widespread dissemination of CA-CDSS.

Thoroughly revised and expanded, the 4th edition offers a practical, objective, evidence-based guide to the medical diagnosis and management of child abuse.https://shop.aap.org/child-abuse-medical-diagnosis-and-management-4th-ed-paperback/

Human Immunodeficiency Virus (HIV) causes a chronic illness requiring lifelong medical care to prevent opportunistic infections and death. It is important to identify medical neglect in children that are perinatally exposed to or living with human immunodeficiency virus and to take steps to prevent it. Diagnosis of medical neglect must be considered in the context of the caregivers' understanding of the risks of harm, and the logistical, cultural and social factors that may influence their actions or non-actions. When medical neglect as failure of treatment or prevention of infection is suspected, medical providers should work collaboratively with caregivers to assess and address barriers to adherence and to provide resources and support. Medical neglect may be diagnosed if repeated preventive efforts fail.

The term “Big Black Brain” was first coined in 1993 to describe cases of abusive head trauma associated with subdural hematoma(s), brain swelling, and uni- or bilateral hypo-density involving the entire supratentorial compartment on CT scan imaging. This constellation of findings was invariably followed by extensive cerebral parenchymal destruction and a dismal neurological outcome or death. We describe two such cases and review the pathophysiology and differential diagnosis of this entity.

When cases of suspected abusive head trauma are adjudicated in courts of law, one of the theories often presented by defense experts is that a normal, healthy infant or child suddenly neurologically deteriorates or dies several weeks to months after birth or minor injury because a preceding subdural hematoma spontaneously rebleeds after a minor traumatic event. This article reviews the underlying scientific basis of subdural hematoma rebleeding as it applies to this courtroom theory.

When Abusive Head Trauma (AHT) is suspected, the presence of extracranial lesions can be a decisive factor in confirming the diagnosis. In this article, we briefly review and illustrate some of the skin lesions and other extracranial injuries frequently associated with AHT.

We have recently encountered a series of cases where an obese caretaker is juxtaposed to a severely starved, malnourished dependent. The cases described all share a common characteristic: that the primary perpetrator was an obese caretaker who tried to exert absolute control over their victim's daily life in a way that included either a severe restriction or complete denial of food. Because the pathophysiology of both child abuse and obesity are incredibly complex and multifactorial, these cases are presented to encourage further discussion and more rigorous investigation into the validity of a hypothesis that has been derived from this set of cases: that the obesity of a child's caretaker may be an additional risk factor for child maltreatment by starvation.

When Abusive Head Trauma (AHT) is suspected in a child, a dilated eye examination by an ophthalmologist is an essential part of the medical workup, as the presence and pattern of retinal hemorrhages can have a high positive predictive rate for abusive head injury. This article proposes to review the clinical presentation, pathophysiology, natural history, sequelae, and differential diagnosis of retinal hemorrhages and other ocular lesions associated with AHT.

A 7-month-old male presented to the emergency department with his biologic parents for concerns of tissue discoloration and swelling of the floor of the child’s mouth. The child’s mother reported that she was home alone during the day with the child and his 2-year-old female sibling. At noon, the mother stated that she was in the kitchen when she heard her son start crying in the living room. On entering the room, the mother noted the 7-month-old child lying prone on the floor. She reported that he appeared to have some blood in his saliva and on the “tissues connecting the tongue to the bottom of the mouth.” She picked the child up and noticed some swelling and redness in the floor of his mouth. The mother denied any known trauma, but thought perhaps the child had sucked too hard on his pacifier or had fallen down with a toy in his mouth. The mother reported that the child was not yet cruising but could pull himself up and stand along furniture. Following the injury, the mother reported that the child cried for about 10 minutes and then subsequently fell asleep. On awakening from his nap at 2:00 pm, the mother stated that the child had worsening swelling of the sublingual tissues. She reported that they had now turned purple, and stated that there was a noticeable deviation of his tongue, elevating off the floor of his mouth. The biologic father returned home at approximately 4:00 pm. The child and his parents presented to a local emergency department at 8:00 pm because of concerns of increased swelling in the floor of the child’s mouth and worsening tongue deviation. Because of concern for development of a compromised airway, the child was airlifted to a tertiary care hospital for further evaluation and treatment. On presentation to the emergency department at the tertiary care facility, the child was examined by an otolaryngologist who noted multiple bruises on the patient’s forehead bilaterally (the largest bruise measured 2 cm × 0.5 cm on the right forehead). Additionally, there was a 0.7 cm × 0.7 cm bruise noted on the patient’s left cheek approximately 1 cm anterior to the inferior portion of the ear lobule (Figure 1). The oropharyngeal exam showed a partial tear in the lingual frenulum and a large violaceous sublingual hematoma extending the full lateral width of the tongue (Figure 2). The remainder of the exam was unremarkable. Concern for nonaccidental trauma (NAT) led to consultation of the hospital Child Protection Program for further evaluation. Birth history of the patient was documented as a normal spontaneous vaginal delivery at term with no reported prolonged maternal vaginal bleeding or transfusion requirement in the peripartum period. Family history was positive for a maternal history of increased bruising and previous instances of facial petechiae following episodes of severe retching and emesis. The paternal family history was negative for bleeding disorders and coagulopathies.

This paper describes clinical findings and case characteristics of children who are victims of severe and multiple forms of abuse; and proposes clinical criteria that indicate child abuse by torture. Medical records, investigation records, and transcripts of testimony regarding a non-consecutive case series of 28 children with evidence of physical abuse, neglect, and psychological maltreatment, such as terrorizing and isolation, were reviewed for types of injuries, duration of maltreatment, medical and physical neglect, social and family history, and history of prior Child Protective Services (CPS) involvement. The median age was 7.5 years (9 months to 14.3 years). Thirty-six percent died. Duration of abuse ranged from 3.5 months to 8 years (median 3 years). Ninety-three percent of children were beaten and exhibited cutaneous injury; 21 % had fractures. There were 25 victims of isolation (89 %), as well as 61 % who were physically restrained and 89 % who were restricted from food or water. All of the children were victims of psychological maltreatment; 75 % were terrorized through threats of harm or death to themselves or loved ones and 54 % were degraded and/or rejected by caregivers. Nearly all children were medically neglected. Half had a history of prior referrals to CPS. The children in this case series were physically abused, isolated, deprived of basic necessities, terrorized, and neglected. We define child torture as a longitudinal experience characterized by at least two physical assaults or one extended assault, two or more forms of psychological maltreatment, and neglect resulting in prolonged suffering, permanent disfigurement or dysfunction, or death.

You care called to the emergency department to evaluate a 4-month old girl with multiple areas of purpura, including a distinctive bruise on the later aspect of the left thigh. The child's mother states that she noticed these lesions after picking up the infant from her biologic father, whose was watching the child alone. No trauma history is reported. The child has been otherwise in good health, with no signs of infection.

A 3-month-old Albanian female infant presented to the emergency department with her biologic mother and father after allegedly falling from her swing onto her face. Through an interpreter, the biologic mother reported swaddling the baby and putting her in an electric swing. The swing was placed on a wooden stool. A few minutes after starting the mechanical swing, mother stated that it toppled off the wooden stool. The infant subsequently landed face down onto a carpet runner overlying the ceramic tile floor. The mother reported that the baby cried immediately and had blood coming from her mouth. She did not report loss of consciousness, apnea, or vomiting. Physical examination showed a sleeping 3-month-old girl resting comfortably. A blood clot was noted along a 1-inch skin flap that extended from the front to the middle of the upper right gum line. Conjunctiva were clear. Upper, lower, and sublingual frenula were intact. Her skin was significant for a rather faint petechial injury along the left upper lip vermilion border. The remainder of the exam was normal. The infant was born at term via spontaneous vaginal delivery without complications. Family history was negative for connective tissue disorders, frequent bone fractures, or other inherited bone diseases. Computed tomography (CT) revealed a minimally displaced comminuted fracture of the right mandibular ramus extending to the base of the condylar process; the study was negative for intracranial hemorrhage or other injury (Figure 1). A skeletal survey was performed and showed a questionable cortical irregularity of the right distal ulna that was seen on only one view. An ophthalmologist observed no retinal hemorrhages. Blood work, including serum electrolytes, liver function tests, and a complete blood count were all within normal limits. The pediatric plastic surgery service expressed concern that a mandibular fracture is exceedingly rare in infants. The pediatric radiologist queried whether this traumatic injury was induced nonaccidentally. Thus, given the rare nature of these fractures in infants and implausibility of the reported mechanism of injury, the primary team consulted the hospital child protection program for concern of nonaccidental trauma. Child Protective Services (CPS) was contacted and, in conjunction with law enforcement, conducted a scene investigation while the infant remained in the hospital. It was discovered that the electric swing had been placed atop four small wooden circular barstools that were 18 inches high; the total height of the stools and swing came to 40 inches (Figure 2). The swing initially appeared stable when placed on the stools; however, once turned on, it became unsteady. Further inspection revealed that the plastic grippers on the base of the swing were worn off in 3 locations. The child protection program concluded that the unilateral mandibular fracture was consistent with the accidental mechanism initially reported, and CPS formally cleared the infant for discharge to home in the care of her parents. The child protection program recommended a 2-week follow-up appointment with a repeat skeletal survey to reevaluate the distal ulna lesion, which proved to be normal.