Randell C. Alexander

Magnetic resonance imaging of intracranial injuries from child abuse.

Magnetic resonance imaging (MRI) and computed tomography (CT) were compared in four children who had evidence of intracranial injury caused by shaking. All children had intracranial bleeding, neurologic impairment, and history or physical examination findings suggestive of child abuse. Three had bilateral retinal hemorrhages, and three had visual impairment. MRI revealed bilateral subdural hematomas in all four children, but CT showed this in only one. Skull fractures in one patient were visualized by CT alone. MRI alone demonstrated posterior fossa bleeding in one patient and intraparenchymal bleeding in another; an additional patient in whom CT showed relatively diffuse atrophy also had defined areas of focal atrophy apparent on MRI. Subarachnoid hemorrhages were equally well detected using CT or MRI. Overall, MRI was superior to CT for detection of intracranial injury caused by shaking, and may help to document milder instances of this form of child abuse.

Early identification and treatment necessary to prevent malnutrition in children and adolescents with severe disabilities

Children with severe developmental disabilities frequently have nutrition and growth problems that range from moderate to severe. Because of notable continuing medical concerns and lowered growth expectations, parents and physicians may fail to recognize gradual deterioration in nutritional status before severe medical complications occur. The two cases reported in this article illustrate the need for early identification and treatment to prevent the development of notable morbidity secondary to malnutrition. Children and adolescents who have growth parameters consistently below age norms require assessment and monitoring by a registered dietitian to detect feeding problems and intake changes and to provide early intervention to help prevent negative consequences (eg, dehydration, protein-energy malnutrition, decubitus ulcers, increased rate and duration of infections, and altered bowel motility). An initial assessment should consist of measurement of length or height, weight, triceps, and subcapsular skinfolds; dietary and feeding history and a review of medical history; and biochemical testing as indicated by the medical and dietary histories. Monitoring frequency, which is determined by age, severity of condition, and response to treatment, may vary from weekly to bimonthly.

Munchausen syndrome by proxy presenting as a developmental disability

Munchausen syndrome by proxy (MSBP) is a form of child abuse in which a parent falsifies illness in a child by fabricating or producing symptoms and presenting the child for medical care while disclaiming knowledge as to the cause of the problem. This report presents the case history of a child diagnosed with MSBP who was portrayed as having multiple developmental disabilities by her mother. Three elements of the case are noteworthy. The emphasis by the mother on multiple developmental disabilities has not been reported. The complexity of this case is unusual and may reflect the complexity of the mothers psychopathology. The interdisciplinary team evaluation was instrumental in making the diagnosis.

Fusiform Bacterial Sepsis Metastases with Osteomyelitis and Hepatic Abscess Occurring in a Chaotic Family

Cases of fusiform bacteria sepsis have been reported infrequently in the pediatric literature. This case demonstrates the severe metastatic complications of fusiform bacterial sepsis including osteomyelitis, with multiple pathological fractures, sepsis, and abscesses of the liver. In the diagnostic evaluation of the etiology for this uncommon infection, child abuse was discovered in all children of this family. In children with uncommon infections and no underlying etiology, child abuse should be considered.

Medical and Nursing Interventions

Historically, physicians have been perceived as diagnosing, treating, and if possible, curing disease states. Nurses have been viewed as providing holistic case assessment, care, and patient education. However, in recent years there has been a blurring of traditional physician/nurse roles in response to the need for ongoing interventions for individuals with chronic disabling conditions. Nowhere is the importance of such a physician/nurse primary health team effort more apparent than in the delivery of care to individuals with Prader-Willi syndrome (PWS).

A Team Approach to Case Management

Meeting the needs of children with Prader-Willi syndrome (PWS) and their families requires that the knowledge and skills of professionals who serve them be delivered through an efficient interdisciplinary system. The term “interdisciplinary” implies that health, educational, and social service specialists share information and work together. Ideally, this approach encourages collaborative development of appropriate assessment and management strategies.