ABSTRACT
This 4-year-old boy had chronic severe asthma necessitating frequent admissions to hospital. During an outpatient clinic at the tertiary care hospital, his parents said he had a bad nappy/diaper rash, despite being dry during the day. This healing rash was noted on examination (Image 113). On further examination, he was also noted to have a large healing ulcerated lesion, diameter 3 cm on his left forearm, which the parents had failed to mention and for which they had no explanation. The general examination was otherwise unremarkable although the boy appeared anxious and withdrawn. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig113.jpg"/>
What are your concerns?
What other information would you seek?
How would you manage the case initially?
258The boy has healing ulcers in the nappy area. These are unusual in shape and site, especially in a boy who is not in nappies/diapers continuously. They are not characteristic of napkin/diaper dermatitis or of a rash from a systemic disease. This together with the unexplained ulcerated lesion of his left forearm lead to concerns about inflicted injury with a caustic substance or factitious illness.
The doctor asked the parents about the boy’s past medical history and they said he had fractured his left femur 5 months previously when he was playing on a sofa. They had taken him to their local hospital for treatment and the parents appeared to be very caring. The doctor also reviewed the boy’s attendances at all the tertiary care hospital departments and found an attendance with an injury to the upper right humerus resulting in subperiosteal new bone but with no fracture recognizable on x-ray. There was no history of any injury. The doctor also consulted the childcare agencies, but the child and family were unknown to the police or social care. However, despite this, the doctor had increasing concerns about child maltreatment. He considered the skin marks on the nappy area and the left forearm could be due to the application of a caustic substance.
In view of the doctor’s concerns, he did not allow the child home with the parents, but admitted him to the hospital. He also referred the case to social care services and the police and a full child protection investigation followed. The child was subsequently taken into the care of the local authority and placed with foster carers. After family law proceedings, he was eventually adopted. Neither parent was charged with any criminal maltreatment. 1
