Multiple Foreign Bodies in A 5-Year-Old: Non-Accidental Trauma
Mulewa Mulenga, Patricia Shirondo, Bruce Chikasa Bvulani
University of Zambia University Teaching Hospital, Lusaka, Zambia.
Correspondence to: Dr. Mulewa Mulenga, University of Zambia University Teaching Hospital, Lusaka, Zambia. Email: email@example.com. Telephone: +260974761028.
Foreign bodies, a significant proportion of which are a result of non-accidental trauma are common, but under reported. Paediatric foreign body injuries can be inconsequential, severe or even fatal, and cause long lasting morbidity and the need of treatment and hospitalization. Evaluation of injury or death requires elements of detection, pattern recognition, interpretation and comparison, all based on clinical, radiological and forensic experience with normal and abnormal findings. We, the authors, report an unusual and strange case of non-accidental trauma in a young child who presented to our surgical services, with 44 sewing needles and wires in his body. The patient had specific characteristics or risks for abuse. His injuries were evaluated, recognized, documented and reported. He was medically surgically treated for peritonitis, malnutrition, and the foreign bodies were surgically removed using staged operations under image guidance. Patient’s recovery was uneventful.
Key words: Multiple foreign bodies, Trauma.
Ann Afr Surg. ****; **(*):***
Conflicts of Interest: None
© 2020 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.
The definition of child abuse has long been argued. Finkelhor (1) was one of the many authors to suggest a definition. The dimensions for an act to be ‘maltreatment’ include: intentional act; socially censored in locale in which it occurred; abusive according to international consensus; harm to a child rather than an adult (2). Some of the above-mentioned dimensions were seen in this particular case study, such as socially censored locale and harm caused to him.
According to the Affiliation and Maintenance of Children Act (1995) (3), a child is a person below the age of 18 years. Though there are many definitions of child abuse our laws define it as any non-accidental behavior by parents, caregivers, other adults and adolescents that is outside the norms of conduct and entails a substantial risk of causing physical or emotional harm to a child. Some forms of negligence or omissions are not an exception (3).
In defense abusers cite the need to discipline a child as reason for the injury. However, there is a difference between discipline and abuse. Discipline teaches children right from wrong and does not make them live in fear. The opposite is true about child abuse (4).
There are four main types of abuse. These are: physical, neglect, sexual and emotional. Physical abuse inflicts physical injury as a result of punching, beating, kicking, biting, burning, to mention but a few. The surgeon is mostly involved with physical abuse but should be aware of other forms.
Perpetrators are parents 75% of the time, 10% unknown people; 8% relatives/ babysitter, 3% partner of a parent. And though the numbers may be different in other reports, parents still constitute the majority of abusers (5).
Abuse is often inflicted on children with specific characteristics and particular relationships with the perpetrators. Those at risk include single parent homes, unemployed parents, parents who were previously abused, prematurity, disability, step children, unplanned children, and first-born children. Not all risk factors are present in any case. However, they provide an overview (2,6). There is strong evidence that poverty and economic disadvantage are associated with child maltreatment. Children from that background were almost twice as likely, to be involved in substantiated maltreatment investigations (7). Huang examined the relationship between non-accidental trauma and the economy and found a doubling in the rates of non-accidental trauma during the economic recession (8).
Non accidental trauma in children is common. Foreign bodies are common in children, despite interventions in their prevention (9). Foreign bodies comprise 7% of all visits to paediatric trauma units (10). Among these a significant proportion is attributed to non-accidental trauma.
In many African Countries insufficient attention has been paid to abuse (11). Historically, child protection and child abuse prevention services have been fragmented and generally lack unified centres and/ or systems to deal with it appropriately (2).
There has been an increasing movement to harmonize national laws and policies in line with relevant international and regional human rights instruments pertaining to children. However, despite this progress, international commitments to protect children from violence are often not translated into action (12). The development of a National Child Protection System is still in the early stages in Zambia (12).
Children’s Foreign Body injuries remain to be an important cause of morbidity, hospital stay and interventions. Pediatric foreign body injuries can be inconsequential, severe or even fatal, and cause long lasting morbidity (9).
We report a case of multiple needles and wires in a 5-year-old boy. Despite non accidental trauma of such magnitude being unusual in the eyes of many, we write this report to raise awareness to the fact that it does occur in our environments. We would also like to draw the attention of clinicians dealing with child trauma, to maintain a high index of suspicion to non-accidental trauma
A 5-year-old boy was taken to local hospital by his biological mother for abdominal pains, vomiting, scrotal swellings and inability to walk; for 18 months, 1 week, 2 weeks and 2 weeks respectively. He also complained of cough associated with change of position and had history of intermittent fever. This was after the mother noticed that her sick child’s condition was worsening.
His past medical, surgical and drug history were non-significant. He was fully immunized for age and attained developmental milestones, on time. He was a first-born son of a teenage mother, born at term, with birth weight of 3Kg. His parents divorced and re-married. The boy moved between homes of his parents and their new spouses. He also stayed with his paternal and maternal grandparents, and with other relatives for varied periods of time.
On examination: the boy was irritable and emaciated (see Figure 1). The abdomen was soft, non-tender, but had palpable abdominal masses, and a peri-umbilical abscess, for which an incision and drainage was done. At incision and drainage, a long wire, measuring 15cm was found, traversing the abscess cavity, and entering the abdomen. He subsequently developed peritonitis. X-rays revealed metallic foreign bodies, consistent with sewing needles and wires of various sizes, in the neck, chest, abdomen and perineum.
Exploratory laparotomy was done findings of which were: peritoneal contamination with faeculent materials, inter-loop abscesses, and 13 wires and 12 sewing needles of different sizes piercing the stomach and small intestines. The needles and wires ranged from 3cm to 17cm length, and variable thickness. Twenty-five needles and wires were removed from the abdomen; bowel repair and peritoneal lavage was done. Patient nutrition was optimized and full recovery was made.
Patient was transferred to a tertiary hospital for removal of remaining needles in the chest, abdomen and perineum (see figures 2 and 3). A multidisciplinary team (MDT) consisting of Paediatric Surgeons, Paediatricians, Nurses, Anaesthetists, Radiologists, Medical Laboratory Scientists, Physiotherapists, Nutritionists, Social Welfare, and Counselors, was constituted.
The patient was then optimized in readiness for the next operative procedures. The remaining foreign bodies were removed with the aid of an image intensifier in a cath lab. Surgery was staged and at the first procedure, 9 needles were removed. Two needles removed in the neck via midline neck incision. One was lying anterior to the trachea and the other obliquely in left lateral neck. Modified trap-door incision revealed 1 needle anterior to left brachiocephalic vein and another lying between thymus and pericardium. Via right thoracotomy incision, a needle was removed from lung tissue, and 1 needle was found lying within superficial tissue of the lateral chest wall. Three more needles were removed from liver parenchyma via right transverse abdominal incision.
The patient was nursed in ICU. He made full recovery and was discharged 3 weeks after his last operation (see figure 4). He was placed in a Social Welfare Home to allow Child Care and Protection Services to investigate the safety of his home environment. In total, between the first local hospital admission to his placement in the Social Welfare Home, he stayed in hospital for 3 months. To date counselors and social welfare services have continued providing their respective services to this child and his family.
Non-accidental trauma presents itself with treatment challenges. Like in other non-accidental injuries this patient’s case presented to our medical services with many ethical, medical and legal dilemmas. It was not clear who the perpetrator was because there was a lack of a confession or a conviction. However, to determine whether this was accidental trauma or not the expert panel approach was used to determine the nature of the injury. The standardized questions answered were adopted from Lorenz, (2018) (13). Targeting specific type of injury approach further helped to arrive at a conclusion.
This patient had 44 needles pierced into his body. Though not established these insertions were believed to have occurred at different times. The intention was not clear. The act became known to us only because he became sick and was in need of surgical care. Though the risk factors in our environment have not been fully studied, this patient presented with a number of risks factors documented in literature. Patient was first born male child of economically disadvantaged parents; his parents divorced and they, each found new partners. He was a step child in two homes and he stayed in different homes under various care givers. Once surgery was done and patient recovered, patient needed to be placed under social and protective services. It remains unclear the effect this separation of patient from the mother will have on him. The need to have medical psychologists involved in cases like this, right from the start, cannot be over-emphasized. This patient has siblings left in the environment he was separated from. The question still remains of what you do about them, as they are at risk too.
This case exposes the weaknesses we have in our Child Protection Services. Patient stayed for a while in our medical wards long before he was placed in a social welfare home. We needed to enter his case in a trauma register or more specifically in a non-accidental trauma register for children. This is not available. Should we, then escalate the smart care system and incorporate this into it? Why did it take social welfare so long to move this patient from the hospital environment?
The role of a surgeon’s prompt surgical evaluation is necessary to determine the scope of the injury. Admission to the trauma service and a thorough tertiary survey should be considered for all patients (14). Indeed, a high index of suspicion must be maintained in order to diagnose non-accidental trauma, such as a physical exam finding of multiple injuries in various stages of healing. In other words, depending on the circumstances, any screening clinician is to thoroughly evaluate children looking out for clues or red flags in history such as: delay in presentation, reluctance in explanation, inconsistencies between the injury and the story given, inconsistencies in the narratives between child and caregiver. All children with suspected abuse must be given a complete general and orthopaedic examination. To achieve this, these children must be fully exposed, checked for cutaneous manifestation of chronic and acute trauma, and palpated for orthopaedic injuries. The genitalia and anus must be inspected too.
Common findings include fork marks, cigarette burns, immersion burns, fractures in different stages of healing, sternal fractures, femur fracture in an infant, humeral shaft fracture in a child less than 3 years old, bucket handle fractures, posterior rib fractures, digit fractures in non-ambulatory infants and children (15). Suspected abuse needs to be thoroughly investigated with the assistance of child protection. For instance, in the Netherlands, professionals who suspect abuse are required by law to follow a reporting code for domestic violence and child abuse (16). Evaluation of injury or death requires elements of detection, pattern recognition, interpretation and comparison, all based on radiologic experience with normal and abnormal findings (17).
Differential diagnosis of non-accidental trauma includes accidental trauma, osteogenesis imperfecta, metabolic bone disease, birth trauma, vertically transmitted infections, physiologic periostitis etc. Patient in this case had non-significant past medical and surgical history. In addition, the specific injuries inflicted on this child begs not for a differential diagnosis.
The importance of the pediatric surgeon in the assessment or management cannot be downplayed, as seen in a paper written by Mauricio (18) that speaks of the position statement of trauma committee, board of Governors and members of American Pediatric Surgical Association. They state that the pediatric surgeon is in a unique position to assess, stabilize and manage a victim of child physical abuse (18). This patient was managed using a multi-disciplinary approach. The multidisciplinary team was led by the Head Pediatric Surgeon. This team assessed, optimized the patient for surgery and surgical approaches were planned with input from all the members of the team. Patient was operated on in a staged approach.
Throughout his hospital stay the patient received nutritional support. He, his mother and grandmother received psychosocial counselling and support. The pediatricians provided rehabilitation for the patient’s neural development. Once treated for all injuries, patient must be isolated from the harmful home and linked to social, child care and protection services as mandated by the law. This patient was placed in a social welfare home. He was isolated from the suspected environment of abuse. He has continued to do well, physically and socially.
It is important to have clear and precise documentation as often the clinician is the only one capable of denouncing the crime to the legal authorities (19). The medical records are well documented and elaborate. However, there has been no trauma registry into which this patient and others with similar circumstances should be entered, for record keeping, and also to raise red flags of alert to unsuspecting health workers who possibly attend to this child and other children in future.
Non accidental trauma is not a rare occurrence in children. A clinician must maintain a high index of suspicion, have detailed documentation, treat and isolate the child from suspected abusers and report the matter to Child protection services, a focal person of which must be erected in any hospital.
Dr Makupe Alex, Consultant General Surgeon; Head Clinical Care, Ministry of Health
Dr Kasoma Donald, General Surgeon, Chipata Central Hospital
Dr Mbinga Mbinga, Physician, Chipata Central Hospital
Dr Sunkutu Veronica, Consultant Radiologist
Dr Chanda Christopher, Consultant Pediatric Anaesthetist
Finkelhor D. Prevalence of child victimization, abuse, crime and violence exposure. In, JW. White, M.P. Koss, & A.E Kazdin (Eds.), Violence against women and Children: Mapping the terrain. Washington, DC: American Psychological Association, 2011; 9 -29
Janssen.T.L, M. van Dijk, I. Al Malki et al. Management of physical child abuse in South Africa: literature review and children’s hospital data analysis. Paediatric International Child Health. 2013; 33, 213 – 27
Zambian Laws, Affiliation and Maintenance of Children Act. Laws of Zambia. 1995
Vaishali DT, Kulkani BD. Child Abuse, a harsh way to discipline children: a survey report from rural Wardha. 2017; 24, 253 - 60
Caniano D.A, Beaver B.L, Boles. T.E. Child abuse: an update of surgical management in 256 cases. Ann Surg. 1985; 2, 219-24
Mulpuri K, Slobogean BL, Tredwell SJ. The epidemiology of nonaccidental trauma in children. Clin Orthop Relat Res. 2011; 469:759-67.
Lefebvre R, Fallon B, Vanwert M, et al. Examining the relationship between economic hardship and child maltreatment using data from the Ontario Incidence Study of reported child abuse and neglect. Behav Sci Basel. 2017; 1, 7
Huang MI, O’Riordan MA, Fitzenrider E, et al. Increased incidence of nonaccidental head trauma in infants associated with the economic recession. J Neurosurg Pediatr. 2011; 8: 171-6.
Sinikumpu J.-J, Serlo W. Confirmed and suspected foreign body injuries in children during 2008 – 2013: a hospital – based single centre study in Oulu University hospital. 2017
Rattya J, Serlo W. The analysis of children’s injury-related admission to Oulu University Hospital during the summer. Oulu, Finland: Oulu University Master’s Graduation, 2007
Omidiji O.T.A, Atalabi O.M, Evbuomwan O.E et al. Unusual presentation of child abuse: A report of two cases, and the role of imaging. Afr J Pediatr Surg. 2016;13, 213-16
Baseline 2010: National Child Protection System in Zambia: Protecting Children in Zambia from violence, abuse neglect and exploitation. 2010.
Lorenz DJ, Pierce MC, Kaczor K, et al. Classifying injuries in young children as abusive or accidental: Reliability and Accuracy of an expert panel approach. J Pediatr 2018;198, 144 - 50
Larymer EL, Fallon SC, Westfall J, et al. The importance of surgeon involvement in the evaluation of non accidental trauma patients. J pediatr Surg. 2013; 48, 6
Alexandra RP, Matthew AA. Non-accidental trauma in pediatric patients: a review of epidermiology, pathophysiology, diagnosis and treatment. Transl Pediatr. 2014; 3, 195 - 207
Clemente MA, Tegola L, Mattera M. Forensic Radiology: An update; Journal of the Belgian Society of Radiology. 2017; 101, 1 – 4
Mauricio. A, Wallenstein. K, Christison-Lagay.E et al. Child abuse and the paediatric surgeon: A position statement from the Trauma Committee, the Board of Governers and the Membership of the American Paediatric Surgical Association. J Ped Surg. 2019;
Roche AJ, Fortin G, Labbé J, et al. The work of Ambroise Tardieu: the first definitive description of child abuse. Child Abuse Negl. 2005; 29: 325-34