P3A163: TPN, Total Parenteral Nutrition or Total “parental” Nutrition: A Profound Case of Medical Child Abuse

Introduction: Medical child abuse is defined as “a child receiving unnecessary and harmful or potentially harmful medical care at the instigation of a caretaker.” The incidence of medical child abuse (MCA) is reported as 0.5-2/100,000 children. This number is thought to be falsely low due to lack of recognition of signs and symptoms until the case becomes extreme. There is a lack of education for medical students, residents, social workers, and child protective workers regarding MCA which strongly hinders recognition and leads to patient harm.

Case Description: A 13 year old female was admitted to the hospital for “running out of TPN” after being dismissed by her prior gastroenterologist (after due process). She was noted to be jaundiced with transaminitis and elevated bilirubin due to TPN cholestasis. Her alleged neurologic degenerative condition was reported by parents as the cause of all symptoms, including GI conditions and TPN dependence. She was admitted on list of medications including anti-epileptics and Oxycodone for palliative care. An extensive chart review of Care Everywhere showed many discrepancies including negative genetic studies for neurologic condition, multiple moves from state-to-state and provider-to-provider, and parental reports of symptoms and diagnoses not confirmed by studies. Most pressing notes were from Palliative Care reporting intolerance of oral feeds and desire to preserve quality of life in setting of debilitating pain and neurologic deterioration. In the course of three weeks, the patient was weaned off TPN and all medications and eating full regular diet. After multiple conversations with Department of Children & Families and social work, she was sheltered from family and placed in foster care where she is thriving without further medical issues.

Discussion: Signs and symptoms of MCA are often vague and elusive early in the care of a patient. It takes diligent history taking, chart review and combing through years of data to confirm the diagnosis. Once a child is down the path of interventions such as TPN or invasive surgeries, palliative care involvement or debilitating diagnoses they are left with two options – a miracle cure or death. A case this drastic makes it vitally important to recognize signs before irreparable harm to the child occurs. The positive outcomes for this child show that mandatory reporting, advocacy, and diligence are paramount to saving a life.

Conclusion: The severity of this case of medical child abuse, crossing state borders and multiple medical institutions, makes it a story from which all levels of medical providers can learn and potentially make changes to practice. The difficulties encountered during the course of this case highlight the gaps in care and protection of victims of medical child abuse and the areas where improvements are necessary - education, communication, and early recognition of cases.