Physicians Academy
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Table Of Contents
Editorial :
 Bacterial Infections in Patients with Leukemia
Article 1 :
 What after a Suicide Attempt?
Article 2 :
 Neglected Child with severe Bronchopneumonia
Picture of The Month :
 Picture of The Month November 2017
Drug Update :
 VELCADE (Bortezomib)
Abstracts from Other Journals :
 Abstracts from Other Journals-November 2017

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Nov 2017 (Volume -11Number -11)

Article 2
Neglected Child with severe Bronchopneumonia
Ghulam Nabi, MD; Omar Nabi Siraj, MBBS; Amr Hussain, MD
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Neglected Child with severe Bronchopneumonia

Ghulam Nabi, MD; Omar Nabi Siraj, MBBS; Amr Hussain, MD

INTRODUCTION

Neglect is act of omission and Abuse is an act of commission. Maltreatment (including abuse and neglect) of children is a pervasive problem in nations throughout the world with short and long-term physical, mental health and social consequences to the child, family, community, and society at large. Child neglect is generally defined as an ongoing failure to meet a child’s basic physical, mental, and emotional needs. It may involve a failure to supply sufficient nourishment, shelter, clothing, or other varieties of physical deprivation. Alternatively or additionally, it may involve a failure to see that a child is properly educated or able to grow in an adequate, socially nurturing environment, or to receive emotional support and love1. Child neglect is often, but not always, accompanied by other forms of abuse, including physical and sexual abuse. Of all the forms of child abuse, neglect is perhaps the least well researched and documented academically. There is dearth of studies on this subject in low-resource countries and those where the cultural norm has been suppressed including open discussion of maltreatment to children2. In addition to the child healthcare, a professional’s responsibility is to identify maltreated children and help ensure their protection and health. They should assume vital role related to prevention, treatment, and advocacy. Rates and policies of child neglect and abuse vary greatly among nations and often within nations. Rates of maltreatment and provision of services are affected by the overall policies of the country, province, or state governing recognition and responses to child abuse and neglect. Two broad approaches have been identified: a child and family welfare approach, with a focus on the family as a whole and a child safety approach, with the focus on the child perceived to be at risk. It is better to have achild safety approach3. A neglected child may be malnourished, always sick, or never at school. Due to neglect more girls suffer than boys.

Keywords: Neglected Child, Severe Bronchopneumonia.

CASE REPORT

12 years old girl non Saudi brought to Accident and Emergency department of our hospital with history of cough, fever 7 days and respiratory distress one day. Patient got treatment at home with no response. Patient had difficulty in breathing, drowsy, peripheral cyanosis. Respiratory rate 45 per minute, heart rate 120/min, temperature 37.20C, blood pressure 100/60 mmHg, and weight 33.2 kilograms (10th percentile). On examination undernourished, sick looking, drowsy child. Chest full of crepitation and ronchi. Oxygen humidified 6 liters per minute given by facial mask, oxygen saturation 72 to 86%. Intravenous cannula inserted and blood sample taken for routine investigations. Intravenous fluid (Dextrose 5% with half strength saline) was started. Patient got respiratory arrest, resuscitation was done and endotracheal tube was put and mechanical ventilation with high setting started. Patient was shifted to intensive care unit (Figure1). Blood gas showed severe acidosis (ph. 6.66, pco2, 85, po2, 28, base excess -24, Bicarbonate 5 mmol/l). Sodium bicarbonate given in appropriate dose. X-ray chest, complete opacification of both lung fields severe Bronchopneumonia (Figure 2). In view of unstable blood pressure and high ventilatory setting ionotropes and heavy sedation was started. Full antibiotic cover and restricted intravenous fluids given. Nebulization started for bronchodilatation. Repeated blood gas after 7 hours showed ph.7.25, pco2 49, po2 55, base excess -4.7, bicarbonate 20. Blood result showed low hemoglobin and hematocrit, and C-reactive protein high, blood transfusion was given to correct the anemia. Tuberculin and human immune deficiency virus tests were negative. Liver function tests, protein and albumin low. Urine analysis showed urinary tract infection and was treated with appropriate antibiotic. Blood culture no growth. In view of clinical improvement patient was extubated on day five. On day six patient suddenly started deteriorating and got respiratory arrest, inspite of intensive resuscitative measures patient did not respond and was declared dead.



DISCUSSION

Neglect refers to omissions in care, resulting in actual or potential harm. Omissions include inadequate healthcare, education, and supervision, protection from hazards in the environment, and unmet physical needs e.g. clothing and food, and emotional support2. Neglect occurs when a need is not adequately met and results in actual or potential harm, whatever the reasons4. A child whose health is jeopardized or harmed by not receiving necessary care experiences medical neglect5. Many children experience emotional abuse and neglect. Rates of child abuse overall and both corporal and psychological vary greatly of lower and middle income nations6. Although more difficult to detect and therefore probably underestimated, reports of psychological abuse tend to be somewhat higher than those of physical abuse and neglect, mostly occur behind closed doors and often are a well-kept secret. Nevertheless, there were 3.4 million reports involving 6.2 million children in the United States in 2011. Out of 681,000 children with substantiated reports, 78.5% experienced neglect, 17.6% physical abuse, 9.1% sexual abuse, and 9% psychological maltreatment. These rates of substantiated maltreatment continue a trend where neglect has remained at a steady rate since the early 1990s1. A Hawaii father, mother, and grandmother are charged with murder after allegedly starving a 9-year-old girl; they are accused of denying the girl food, water, and medical treatment for about a year. She was taken to a hospital, where she died in June 20167. Almuneef et al from Saudi Arabia reported from their study that physical abuse was the most common form of abuse (42%), followed by neglect (39%), sexual abuse (14%), and emotional abuse (4%). Regarding neglected children living in larger Households (≥6) were 1.5 times as likely to be neglected by their parents as were children living in smaller households (<6)8.Medical neglect is the failure to provide appropriate healthcare for a child. The child may exhibit signs of poor health, such as fatigue, infected cuts, and constant itching or scratching of skin. Our patient had no stay permit of the host country. Parents did not register her name with the concern authorities. No vaccination given (vaccination in children is compulsory in Saudi Arabia for school admission). No school admission for fear of arrest by the concerned authorities. For any ailment she was not taken to medical center. For the present problem they brought her to hospital too late when she was dying and was admitted in intensive care unit. Besides severe Bronchopneumonia, she had anemia and urinary tract infection and was undernourished. In our long experience this is the first case of such type of negligence we have seen9. Hospital authorities informed local police department, and case was registered as illegal stay and child negligence. The following are general principles that the team workers should keep in mind. Help and ensure the child’s safety, often in conjunction with child protection service (CPS). Convey concerns of maltreatment to parents in a kind manner. Avoid blaming them. It is natural to feel anger or pain towards parents of maltreated children, but they need support and deserve respect. Have a means of addressing the difficult emotions child maltreatment can evoke in us. Know your national and state laws and/or local CPS policies on reporting child maltreatment. Reporting child maltreatment is never easy10. Parents are frequently concerned that they might lose their child11. Child healthcare professionals can cautiously reassure parents that CPS is responsible for helping children and families and that, in most instances, children remain with their parents12. In 2008, the Saudi National Health Council (NHC) approved the hospital-based child protection teams (CPTs). Each CPT is composed of a core multidisciplinary team (pediatricians, social workers, psychologists) in addition to adhoc members (surgeons, legal service providers, nurses, and others). Healthcare professionals are mandated to report all suspected cases of child abuse and neglect13.

CONCLUSION

The circumstances surrounding each child and/or incident of suspected abuse or neglect may be complex and highly variable, precluding specific steps. Help address contributory factors, prioritizing those most important and amenable to being remedied. Accessing nutrition programs, obtaining health insurance, enrolling children in preschool programs, and help finding safe housing can make a valuable difference. Parents may need their own problems addressed to enable them to adequately care for their children14. An important aspect of prevention is that many of the efforts to strengthen families and support parents should promote children’s health, development, and safety, as well as prevent child abuse and neglect. Preventing the problem is preferable. An ongoing relationship offers opportunities to develop trust and knowledge of a family’s circumstances. Consider the possibility of neglect when the child is frequently absent from school; steals or begs for food or money, lacks needed medical or dental care and immunization; is consistently dirty and has severe bad odor; lacks sufficient clothing for the weather. Consider the possibility of neglect when the parent or other adult caregiver appears to be indifferent to the child and seems apathetic or depressed, behaves irrationally or in a bizarre manner.

REFERENCES:

 

1.    Stoltenborgh M, Bakermans-Kranenburg MJ, Van IJzendoorn MH (2013). The neglect of child neglect: a meta-analytic review of the prevalence of neglect. Soc Psychiatry Psychiatr Epidemiol 48: 345-355.

2.    Alsehaimi A and Alanazi A. The Extent of Negligence of Children in Saudi Arabia: A Literature Review J Child Dev Disord. 2017, 3:3. doi: 10.4172/2472-1786.100041

3.    Dubowitz H. Lane WG. Abused and Neglected Children. Nelson Text Book of Pediatrics 20th edition volume 1. Elsevier Philadelphia. 236-44.

4.    Naughton AM, Maguire SA, Mann MK, et al: Emotional, behavioral, and developmental features indicative of neglect or emotional abuse in preschool children: a systematic review, JAMA Pediatr 10:1–7, 2013.

5.    Dubowitz H: Neglect in children, Pediatr Ann 42(4):73–77, 2013.

6.    Dubowitz H, Feigelman S, Lane W: Pediatric primary care to help prevent child maltreatment: the Safe Environment for Every Kid (SEEK) Model, Pediatrics123:858–864, 2009.

7.    Hawaii Family Starved Girl to Death over a Year. Newser Editors and Wire Services. Jul 15, 2016.

8.    Almuneef MA, Alghamdi LA, Saleheen HN. Family profile of victims of child abuse and neglect in the Kingdom of Saudi Arabia. Saudi Med J 2016; Vol. 37 (8): 882-888.

9.    Nabi G. Family profile of victims of child abuse and neglect in the Kingdom of Saudi Arabia. Saudi Med J 2016. 37(12) 1418-19.

10.  Butchart A, Kahane T, Harvey AP, et al: Preventing child maltreatment: a guide to taking action and generating evidence, Geneva, 2006, WHO and International Society for the Prevention of Child Abuse and Neglect

11.  Dubowitz H, Lane WG, Semiatin JN, et al: The SEEK model of Pediatric Primary care: can child maltreatment be prevented in a low-risk population? Acad Pediatr 12(4):259–268, 2012.

12.  Flaherty EG, Stirling J, and The Committee on Child Abuse and Neglect: The pediatrician’s role in child maltreatment prevention, Pediatrics 126(4):833–841,2010.

13.  Almuneef MA, Al-Eissa M. Preventing Child Abuse and Neglect in Saudi Arabia: Are We Ready? Ann Saudi Med. 2011 Nov-Dec; 31(6): 635–640.

14.  Macmillan HL, Wathen CN, Barlow J, et al: Interventions to prevent child maltreatment and associated impairment, Lancet 373(9659):2009.250–266.

Author Information: Dr. Ghulam Nabi, MD is Pediatric Consultant and Neonatologist at the Bugshan Hospital, Jeddah, Kingdom of Saudi Arabia. Dr. Amr Hussain, MD is Head of the Pediatric Department and Consultant at the Bugshan Hospital, Jeddah, Kingdom of Saudi Arabia. Dr. Omar Nabi Siraj, MBBS is Head of the Patient Affairs Department, Thumbay Hospital, Ajman, United Arab Emirates.

Corresponding Author: Dr. Ghulam Nabi, MD. PO Box: 5860 Jeddah 21432. Saudi Arabia. Mobile. 00966 502310661. Email: drgnabi2@gmail.com

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