Acute Myelopathy in Childhood

Acute myelopathy presenting in childhood can be clinically classified based on the location of injury (with resulting spinal syndrome) or the cause (broadly traumatic or non-traumatic). Types of nontraumatic myelopathy include ischaemic, infectious, inflammatory, nutritional, and metabolic causes, some of which may be part of a systemic illness such as systemic lupus erythematosus or a demyelinating disease such as multiple sclerosis. Nonaccidental injury is an important consideration in cases of traumatic myelopathy, which may often be associated with other injuries. Assessment should include neuroimaging of the brain and spinal cord, with further investigations targeted based on the most likely differential diagnoses; for example, a child with suspected demyelinating disease may require specialist cerebrospinal fluid and serological testing. Management also will differ based on the cause of the myelopathy, with several of these treatments more efficacious with earlier initiation, necessitating prompt recognition, diagnosis, and treatment of children presenting with symptoms of a myelopathy. Important components of holistic care may include physiotherapy and occupational therapy, with multidisciplinary team involvement as required (for example psychological support or specialist bowel and bladder teams).

Fatal Exsanguination Following Rupture of an Iliac Artery Aneurysm in an Infant With Menkes Disease

Menkes disease (MD) usually presents in infancy with respiratory and neurological complications. Severe isolated vasculo-connective tissue involvement in infancy is rare, and hence the precise and timely diagnosis is difficult. We report a case of an 8-week-old male infant who succumbed to acute, severe exsanguination, and hemorrhagic shock secondary to a large retroperitoneal hematoma due to rupture of a right iliac artery aneurysm. Perimortem musculoskeletal findings raised suspicion of nonaccidental injury. However, postmortem review of facial traits raised the suspicion of MD. MD was subsequently confirmed on genetic testing. Child health clinicians must remain aware of MD as a rare cause of infant vasculopathy or atypical skeletal abnormalities.

Signs of Abuse

An estimated 3.6 million reports of possible child abuse or neglect, also known as nonaccidental trauma (NAT) or nonaccidental injury, involving approximately 6.6 million children were made to child protective services in the United States in 2014. The annual societal cost of child abuse and neglect is estimated conservatively to be over $103 billion. Understanding the history and physical findings specific to NAT will allow physicians to identify those children at risk and avoid missed injuries and recurrent child abuse. Bruising in particular is a cardinal physical finding for NAT. Certain diagnostic tools, such as skeletal surveys and retinal examinations, are used in evaluating for NAT. Abusive head trauma is the most common and deadliest injury. Although less common, abdominal injuries have a high mortality due to nonspecific symptoms and delayed presentation. Solid-organ abdominal injuries and duodenal hematomas can be managed nonoperatively, with a low failure rate. Up to 25% of skeletal fractures for children less than 1 year old are due to NAT. Tools to help medical personnel identify NAT are vitally important because children with recurrent NAT have a higher mortality compared with those identified at the initial episode. In Europe and the United States, checklists and algorithms have been established to standardize management of children with NAT. NAT carries significant morbidity, mortality, and cost to families and hospital resources. The key to prevention is early identification of children with NAT and early involvement of general or pediatric surgeons. Key words: abusive head trauma, ATOMAC guidelines, bruising, child abuse, children, nonaccidental injury, nonaccidental trauma, pediatric surgery, skeletal survey

Double Jeopardy: Insurance, Animal Harm, and Domestic Violence

Although the role of companion animals within the dynamic of domestic violence (DV) is increasingly recognized, the overlap of animal harm and insurance discrimination for victims/survivors of DV has not been considered. Prompted by a case study presented in a National Link Coalition LINK-Letter, this research note examines “Pet Insurance” policies available in Australia and whether nonaccidental injury caused by an intimate partner would be covered. We discuss the implications of exclusion criteria for victims/survivors of DV, shelters providing places for animals within a DV dynamic, and, more broadly, for cross- or mandatory-reporting (of animal harm) initiatives.

Signs of Abuse

An estimated 3.6 million reports of possible child abuse or neglect, also known as nonaccidental trauma (NAT) or nonaccidental injury, involving approximately 6.6 million children were made to child protective services in the United States in 2014. The annual societal cost of child abuse and neglect is estimated conservatively to be over $103 billion. Understanding the history and physical findings specific to NAT will allow physicians to identify those children at risk and avoid missed injuries and recurrent child abuse. Bruising in particular is a cardinal physical finding for NAT. Certain diagnostic tools, such as skeletal surveys and retinal examinations, are used in evaluating for NAT. Abusive head trauma is the most common and deadliest injury. Although less common, abdominal injuries have a high mortality due to nonspecific symptoms and delayed presentation. Solid-organ abdominal injuries and duodenal hematomas can be managed nonoperatively, with a low failure rate. Up to 25% of skeletal fractures for children less than 1 year old are due to NAT. Tools to help medical personnel identify NAT are vitally important because children with recurrent NAT have a higher mortality compared with those identified at the initial episode. In Europe and the United States, checklists and algorithms have been established to standardize management of children with NAT. NAT carries significant morbidity, mortality, and cost to families and hospital resources. The key to prevention is early identification of children with NAT and early involvement of general or pediatric surgeons. Key words: abusive head trauma, ATOMAC guidelines, bruising, child abuse, children, nonaccidental injury, nonaccidental trauma, pediatric surgery, skeletal survey