Case

A four-year-old male is brought via EMS for diabetic ketoacidosis (DKA). The EMS technician expresses frustration because this is the third time in four months that she has transported the child for DKA.

Discussion

In 2021, 588,229 children were the victims of child abuse and neglect.¹ Neglect is the most common form of child abuse, comprising 76 percent of cases. Neglect can be classified as follows:²

• Physical neglect: Failure to provide adequate food, clothing, or shelter, and inadequate supervision
• Emotional neglect: Failure to provide love, attention, and security
• Educational neglect: Failure to enroll the child in school, and truancy without a medical cause
• Medical neglect: Failure to seek medical care or nonadherence with health care recommendations, resulting in actual or potential harm to the child

In the U.S., medical neglect accounts for approximately 2 percent of child-abuse cases. In these cases, either the caregivers fail to obtain medical care when the child has obvious signs of serious injury or illness, or they fail to follow through with recommended medical care once care has been sought. Emergency physicians have a unique opportunity to recognize these cases and to intervene, as medically neglected children may be brought to the ED once illness becomes severe.

Medical neglect should be considered when a child presents later in the course of a serious illness or injury than a “reasonable person” would have sought care. It should also be considered when a child presents with illness that would not have occurred had caregivers followed through with previously recommended care. The child’s condition must pose a risk of significant harm, and the recommended treatment’s benefit must outweigh its risks and side effects for medical neglect to be diagnosed. In the case above, the child is known to have insulin dependent diabetes, which poses a significant risk of harm if left untreated.

Caregivers may neglect the medical care of children for varied reasons. When medical neglect is suspected or diagnosed, emergency physicians should seek to determine the reason for medical neglect, as targeted interventions are most likely to be effective. Families under financial stress may find it difficult to afford appointments and medications. Caregivers may not be able to provide transportation to appointments. Caregivers may not be able to take time off work for appointments, or appointments may not be readily available. Language barriers may make obtaining medical care difficult. Families may lack medical knowledge, not understanding the severity of illness or how to treat a sick child. Children with caregivers impaired by addiction or mental illness may be at higher risk for medical neglect. The recent pandemic demonstrated a significant lack of trust in the healthcare system which may make parents hesitant to seek medical care for their children.

Caregivers may cite religious beliefs as the reason for not seeking care for an ill child. While adults may decline lifesaving care for themselves, they may not do so for minor children. As noted in Prince v Massachusetts, “The right to practice religion freely does not include the liberty to expose the community or child to communicable disease, or the latter to ill health or death.”³ In cases such as this, the courts may require a caregiver to permit medical treatment for their child, regardless of their religious beliefs.

Health care providers are mandatory reporters of child abuse and neglect. In most jurisdictions, physicians or child protective service agencies are able to work with law enforcement and the judicial system to take custody of a child who requires emergent medical care if the caregivers cannot or will not permit that care. Because various types of child abuse may co-exist, emergency physicians need to do a thorough evaluation of the child to rule out concomitant injuries. Additional laboratory and radiographic evaluations (skeletal survey) may be required.

Case Conclusion

The patient’s mother is tearful and states, “I lost my job a few months ago and just can’t afford his insulin.” Following appropriate medical treatment in the ED, the patient is hospitalized. The hospital social-work team works with the county Children, Youth, and Families office to obtain insulin for the child and to ensure that the family has transportation to medical appointments.

Dr. Rozzi is an emergency physician, director of the Forensic Examiner Team at WellSpan York Hospital in York, Pennsylvania, and chair of the Forensic Section of ACEP.

Dr. Riviello is chair and professor of emergency medicine at the University of Texas Health Science Center at San Antonio.

References

1. U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child maltreatment 2021. HHS website. https://www.acf.hhs.gov/sites/default/files/documents/cb/cm2021.pdf. Published February 9, 2023. Accessed October 11, 2023.
2. Rozzi HV, Riviello R. Spotting and reporting child neglect cases. ACEP Now website. https://www.acepnow.com/article/spotting-and-reporting-child-neglect-cases/. Published May 1, 2018. Accessed October 11, 2023.
3. Rutledge WB, Supreme Court of the United States. Prince v Massachusetts. 32 US 158, 64 SCt 438, 88 LEd 645 (1944). Online version scanned from original. Available at: https://tile.loc.gov/storageservices/service/ll/usrep/usrep321/usrep321158/usrep321158.pdf. Accessed October 11, 2023.