Needle Insertion in a Child: A Rare Form of Child Abuse.

Needle insertion is a rare form of child abuse that, though prevalent in the society as an attempted infanticide/homicide, remains undiagnosed and underreported. One should have strong suspicion for occurrence of child abuse in a child with history of needle injury. Here, we report an unusual case of 3-month-old boy with history of hypodermic needle extrusion from multiple sites of body and suspicion of possible child abuse.

INTRODUCTION

Child abuse, though underreported, is one of the overwhelming global problems and can present in various forms. Insertion of sewing needles into the child's body through the skin or natural orifices is one of the rarer forms of child abuse. It has been reportedly linked to homicide/infanticide attempts in some communities and regions of world particularly with intracranial insertion, and sometimes, a part of cultural practice/belief.[12345] There have also been reports of insertion of needles to the other parts of victims' body such as chest and abdomen, heart, feet, forearm, neck, gluteal region, perineum, oral cavity, and rectum from various other parts of the world.[12345] We present a case of suspected child abuse by hypodermic needle insertion into body and evidenced by X-ray of whole body and computerized tomography (CT) scanning of head.

CASE REPORT

A 3-month-old boy was admitted with history of recurrent multiple small eruptions over skull, abdomen, and both lower limbs followed by extrusion of sharp needle-like objects from same sites accompanied by excessive crying and fever for 1 month and hematuria for 4 days. There was history of similar complaints followed by death in one of his sibling (male) at the age of 1 year in the past 2 years back. However, his other 2-year-old elder sister is alright. None of the parents, despite detailed interview, had any knowledge of person who had inserted the needles into the child's body. On examination, the child looked well and active and had heart rate of 108/min, respiratory rate 26/min, and temperature 99°F. Detailed clinical examination revealed multiple scar marks over abdomen and both lower limbs; however, no visible swelling or bruise was seen anywhere in the body. The abdomen was soft, lax, and nontender. On per-rectal examination, sharp foreign body was felt anteriorly in the urethra. The investigation revealed normal complete hemogram, coagulation profile, and renal profile. On complete radiographic skeletal survey, multiple radiopaque linear densities were projected in skull, abdomen, perineum, gluteal region, and thighs [Figure 1a–e]. Ultrasound abdomen revealed no abnormal findings. CT head revealed intracerebral and extradural linear sharp foreign bodies along anterior falx and parafalcine region going up to corpus callosum, the region of right caudate nucleus, and internal capsule [Figure 1f–i]. However, no intervention was done as child was asymptomatic as per opinion of neurosurgeon. However, cystourethroscopy was performed due to history of hematuria and per-rectal palpation of sharply pointed objects in urethra. Cystourethroscopy revealed two broken hypodermic needles in the posterior urethra [Figure 2], however, could not be retrieved through cystourethroscope. Therefore, these two broken hypodermic needles were removed from the posterior urethra through transperineal approach. The patient was kept on perurethral catheter drainage for 10 days. The patient was discharged under satisfactory condition. With strong suspicion of child abuse, incidence was also reported to child protection authorities. The child was also kept in strict regular monthly follow-up. The child remained asymptomatic at regular follow-up up to 2 years.

Figure 1

(a-e) X-ray skull and neck anteroposterior and lateral view, chest and abdomen anteroposterior and lateral view and lower limbs anteroposterior view showing multiple linear radiopaque densities; (f-i) computerized tomography scan of head coronal and sagittal sections showing intracerebral and extradural linear sharp foreign bodies along anterior falx and parafalcine region going up to corpus callosum, the region of right caudate nucleus, and internal capsule

Figure 2

Cystourethroscopy showing two broken hypodermic needles embedded in posterior urethra; these needles were removed from urethra through transperineal approach

Due to limited expressibility of child, finding the culprit may be challenging. In most of reports in literature, stepmothers, psychopathic mothers, aunt, stepsister, babysitter, housemaids, and midwives have been mentioned as possible offending persons for needle insertion.[5] However, in some cases, none of the parents had knowledge of person who inserted the needles. They even did not have any knowledge whether it was a failed infanticidal attempt or accidental,[1] as was in our case. There may also be similar type of history in other siblings as also noticed in our case. With positive history of similar presentations in one of the siblings of our case and finding of multiple needles in X-ray whole body and CT head, we had a strong suspicion for possibility of child abuse and reported the matter to child protection authorities simultaneously.

There should be a high index of suspicion for child abuse in children with history of needle insertion or extrusion of needle-like objects and evidence of needles on radiographic images of body. Early management along with collaboration with protecting authorities can be given to protect these children and other children in family further being victim of child abuse.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.