The death of a child with diabetes from neglect. A case study

Medical Neglect in Children and Adolescents with Diabetes Mellitus

Diabetes mellitus was a fatal disease for thousands of years, but the discovery of insulin in 1921 and major substantial improvements in care have made living with diabetes a chronic rather than fatal disease for many people, including children and adolescents. Diabetes mellitus is a lifestyle-altering diagnosis for the entire family. In some families, children and adolescents do not get the daily care they depend upon. This article reviews the consequences of medical neglect of children with diabetes and the optimal community response to concerns of medical neglect of diabetes. Criteria for placement in foster or substitute care are suggested.

Missed Medical Appointments and Disease Control in Children With Type 1 Diabetes

The need exists to identify children with type 1 diabetes who are at risk for poor outcomes, and we hypothesized that missed appointments could be a useful indicator. We aimed to describe the frequency of missed medical appointments in children with type 1 diabetes and evaluate the relationship between missed appointments and poor disease control. Medical records of 1,002 children aged 0-17 years with type 1 diabetes and two or more scheduled appointments during a 43-month period were reviewed. Sixty-eight percent of patients missed no appointments, 17% missed one appointment, and 15% missed two or more appointments. Compared with patients who missed no appointments, patients who missed two or more appointments were three times more likely to have a diabetic ketoacidosis episode and three times more likely to have a hemoglobin A1c level equal to or greater than 8.5%. They were also more likely to be a member of a racial/ethnic minority group and be publicly insured. Missed appointments may be an important indicator of poor treatment adherence, requiring targeted interventions.

Characteristics of Children Reported to Child Protective Services for Medical Neglect

OBJECTIVES

Medical neglect can have serious consequences. There is little evidence base to guide medical neglect management and research. Our objective was to describe a group of children reported to child protective services (CPS) for medical neglect to define this population as well as identify prevention and intervention approaches.

METHODS

This was a retrospective descriptive study of all patients at a pediatric hospital reported to CPS for medical neglect over a 6-year period. Data about health, health care, CPS involvement, and social history were obtained through medical record review.

RESULTS

Of the 154 patients reported for medical neglect, 140 (91%) had chronic illness. The most common diagnoses were type 1 diabetes, organ transplantation, and prematurity-related conditions. Most patients (83%) were black or Hispanic and 90% were publically insured. More than half of patients (54%) had >1 CPS report during the study period. Almost all patients (88%) returned to the hospital for care subsequent to the medical neglect report. Risk factors for child maltreatment, family stressors in the year preceding the report, and practical barriers to care were documented in more than two-thirds of patients.

CONCLUSIONS

Overall, children reported for medical neglect have serious chronic medical conditions. There is need and opportunity for improved interventions. Avenues for future study include interventions tailored to the underlying diagnosis, racial/ethnic disparities, effectiveness of CPS interventions, and targeted prevention for at-risk families with medically complex children.

Child death related to insulin omission by mother

A 4-year-old child was found dead in her house. She had been suffering from insulin-dependent diabetes mellitus (IDDM) for 3 years. She had been admitted to hospital three times, and attended the hospital once a month. Her glycaemic control remained poor. Autopsy findings revealed a remarkably fatty liver and lack of beta cells in the pancreatic islets of Langerhans. The laboratory reported ketoacidosis, ketonuria, glycosuria, and high levels of vitreous glucose and ketones. Her father had been absent for the 3 days before her death, and the mother should have fed her. Her mother was found drunk on the floor. No detailed history was available because of the mother's death, but the probability of the mother's omission of the insulin injection was suggested. Poor control of IDDM might have also been closely connected to general neglect by the mother. This case was considered child abuse.

Nonadherence with pediatric human immunodeficiency virus therapy as medical neglect

OBJECTIVE

To examine the results of an interventionist approach applied to human immunodeficiency virus (HIV)-infected children for whom caregiver nonadherence was suspected as the cause of treatment failure.

METHODS

The medical records of a cohort of 16 perinatally HIV-infected children whose care was managed at the Arkansas Children's Hospital Pediatric HIV Clinic for an uninterrupted period of >or=3 years were reviewed through July 2003. Data collected included date of birth, dates of and explanations for clinic visits and hospitalizations, dates of laboratory evaluations, CD4(+) T cell percentages, plasma HIV-1 RNA levels, antiretroviral medications, viral resistance tests (eg, phenotype and genotype), and physician-initiated interventions to enhance adherence to the medication regimen. A stepwise interventionist approach was undertaken when patients continued to demonstrate high viral loads, despite documented viral sensitivity to the medication regimen and caregivers' insistence that medications were being administered regularly. Step 1 was prescribing a home health nurse referral, step 2 was administering directly observed therapy (DOT) while the patient was hospitalized for 4 days, and step 3 was submitting a physician-initiated medical neglect report to the Arkansas Department of Human Services.

RESULTS

The results for 6 patients for whom this stepwise approach was initiated are reported. Home health nurse referrals failed to result in sustained improvements in adherence in all 6 cases. Viral load assays performed before and after DOT provided an objective measure of the effect of adherence, with 12 hospitalizations resulting in a mean +/- SD decrease in HIV RNA levels of 1.09 +/- 0.5 log(10) copies per mL, with a range of 0.6 to 2.1 log(10) copies per mL. Four families responded to DOT hospitalization, and sustained decreases in the respective patients' viral loads were noted. In 2 cases, medical neglect reports were submitted when DOT did not result in improved adherence. These patients were eventually placed in foster care, with subsequent improvements in their viral loads and CD4(+) T cell percentages.

CONCLUSIONS

Nonadherence with antiretroviral therapy can be established on the basis of persistently elevated HIV RNA levels that decrease with DOT. Nonadherence poses a danger to the child that is grave and potentially irreversible. Caregivers should be offered all available resources to help them adhere to a sound treatment plan. In cases of demonstrated inability to provide needed care, it is necessary to consider seeking child protection, even for apparently healthy children.

Medical neglect of a child: challenges for pediatricians in developing countries

OBJECTIVE

To conceptualize the underlying causes of the medical neglect of children in a developing country and to provide suggestions for the management of neglect by pediatricians.

METHODS

A case history of a 4-year-old boy from Turkey with neglect of the required treatment for acute lymphoblastic leukemia is used to examine the causes and management of medical neglect.

RESULTS

Although epidemiological studies on child neglect are lacking, this case exemplifies how in DEVELOPING countries, reasons for neglect or non-compliance with medical recommendations and the roles and actions taken by the health care and the social service systems may differ from western populations. Common to both western and developing countries, the characteristics of the child, family, and society may be reasons for medical neglect. However, cultural fatalistic beliefs profoundly present in the developing world may also contribute to the medical neglect of a child. Identification of the neglect, a comprehensive, multidisciplinary assessment emphasizing the strengths within the family and the society, and the determination of the pediatric team to act in the best interest of the child may result in resolution of the neglect even in circumstances where resources within systems are not sufficient.

CONCLUSIONS

In developing countries, increased emphasis on child neglect, its prompt recognition and management within the pediatric profession as well as at a health care and social service system levels are needed to address this prevalent and potentially fatal child health problem.