[khanar]

A 10 months old male child has been brought to the pediatric office for routine follow up. His weight and length are both below 5th percentile. A look at his previous records showed that he was on the 50th percentile when he was 6 months old. Mother stated that she returned to work and is now leaving her son with his grandmother who's giving him 10 oz formula feeds every 4 hours. On examination you noted that the infant is active does not look pale or in distress. Some hair loss noted in the occipital area and impetiginized diaper rash was seen.
What is the best next step?
A- Review with the grand mother how the formula is prepared
B- Admit the child to the pediatric ward and investigate for possible child abuse
C- Order stool and urine samples
D- Increase the child's dietary intake and treat the diaper rash with topical creams.
E- Ask about family history of cystic fibrosis

 

[ath.pantelis]

Probably the correct answer is A; the onset of developmental disruption correlates more or less with the transferring of child care from mother to grandmother. Asking the grandmother how she prepares the formula would be the ideal step to start with, before applying any intervention (choices C & D). A child that is active and not in distress can safely rule out cystic fibrosis (choice E), as well as child abuse (choice B). Furthermore, occipital hair loss and the diaper rash should be attributed to iron, zinc and vitamin deficiency due to poor feeding, not some kind of abuse.

 

[khanar]

I think it's abuse

Probably the correct answer is A ..... not some kind of abuse.

I agree with you to a certain extent. However, I believe we should have a low index of suspicion when it comes to child abuse (specially in here in US and so in USMLE exams). Remember child abuse by definition also includes neglect, so that grandma is simply old and not very active in taking care of her grandson so she's leaving him supine most of the time (occipital hair loss) and forgetting to change the diaper frequently (diaper rash with secondary bacterial infection).
She might as well have problems in preparing the formula but what's more important right now is to exclude the abuse.
If I were to receive this child in the ER or in the office, I'd admit him right away and ask for appropriate documentation of formula intake and encourage solid foods and change the diaper frequently and see how he is doing in a couple of days. Involvement of a social worker or Child Protective Services seems a good idea also. If neglect is confirmed we'd proceed with education of both the mother and the grandma.

 

[ath.pantelis]

Thank you, Dr. Mary, you 've got a very important point here. I just pushed myself not to blindly chose child abuse!!! I absolutely agree that neglect is a kind of abuse (along with physical, sexual and emotional ones) and the threshold of suspicion for such a condition should be very low... But would it be moral to admit the child without even asking the carers first? Should we seek for social service intervention right away? Shouldn't we make some preliminary investigations of our own as physicians? Apart from that, I think that a series of labs must be performed before admission for abuse takes place.

After all these rhetorical questions, I have to admit that I totally agree with you, the child should be treated as a case of neglect. I tried to cheat myself on this but it was futile!!!