Child neglect cases encompass a vast range of situations that include medical neglect (withholding or delaying the seeking of medical care), nutritional neglect (failure to thrive), educational neglect (truancy of a minor), inadequate supervision, reckless endangerment, emotional neglect, failure to plan, abandonment, and excessive corporal punishment. The New York State Child Abuse and Maltreatment Law distinguishes excessive corporal punishment as a form of maltreatment rather than a form of physical abuse. If the case has not already been reported, report any suspicions of neglect to the State Central Register (1-800-635-1522) or local hotline. Most incidences of neglect can be remedied with strong and continued support services for the family. However, some cases require medical intervention, particularly infants and children diagnosed with medical neglect or failure to thrive and newborns with a positive toxicology screen.
Medical Neglect
Medical neglect, delaying or withholding medical care to an ill child, may result in worsening of the child's medical status if there is no aggressive intervention. This intervention includes educating the caregivers about the child's illness and the importance of continued medical care. In follow-up with these cases, work closely with outside agencies to ensure the family remains compliant with the medical plan. Social support is key and may include providing financial and transportation assistance. If the child has been removed from the family and is in foster care placement, try to provide continuity of care so that the child does not get lost to follow-up.
Failure to Thrive
Most children with nutritional failure to thrive can be managed as outpatients with close medical follow-up. However, some children require hospital admission to implement a structured feeding regimen and document weight gain. Laboratory testing is usually unnecessary, but may help differentiate between organic and inorganic etiology. For more information, see LABORATORY: Failure to Thrive.
In cases of failure to thrive, close monitoring of the family and the child's growth is imperative to promote a successful outcome. When a child is discharged from the hospital or are seen in the outpatient setting, frequent medical visits are strongly recommended to document weight gain, obtain diet histories, and lend familial support. You may be able to facilitate access to medical care through assistance for transportation or disabilities, if this is needed.
The follow-up for failure to thrive should be aggressive, and the family needs to be aware that any deviation from the charted plan could constitute reason to notify or re-notify Child Protective Services. This follow-up plan should include:
Weekly office visits or public health nurse visits to home with contact with physician's office
Calorie count tables or forms and caregiver access to food sources
Regular communication with the office regarding any difficulties with feeding or medical concerns
Chart documentation regarding what was told to the caregiver, including consequences for not following up
Report to the State Central Register or local hotline any suspicions of neglect or deviation from plan (i.e., missed appointments)
Positive Newborn Toxicology Screen
Treatment of newborns diagnosed with a positive urine or serum toxicology screen varies depending on the identified drug and the presence of neonatal abstinence syndrome. For more information on screening, see LABORATORY: Toxicology Screening in Newborns. Neonatal abstinence syndrome is characterized by behaviors exhibited by newborns who are withdrawing from maternal drug use and may require medical treatment. For more information, see Neonatal Abstinence Syndrome.
Carefully monitor children with low birth weight for gestational age (IUGR), drug or alcohol related birth defects, or characteristic facial dysmorphism that are showing signs of withdrawal (particularly from opiates or cocaine) for stable vital signs, feeding problems, and irritability. Alcohol withdrawal symptoms occur within 12 hours of birth. Opiate withdrawal symptoms may occur within 48 to 72 hours of birth or may be delayed up to a week. Withdrawal symptoms can include central nervous system dysfunction (high pitched cry, hypertonicity, tremors, seizures) and symptoms of fever, sweating, sneezing, apnea, frequent yawning, frantic sucking, poor feeding, vomiting, and diarrhea. Methadone, used to treat heroin addiction, has effects on the fetus that are similar to heroin. Onset of methadone withdrawal symptoms may be delayed as long as two weeks. Scales to measure symptoms of withdrawal (Finnegan scale) will assist with determining the degree of the problem and the need for pharmacologic treatment. Monitor these infants closely and determine the need for phenobarbital or morphine sulfate on a case-by-case basis.
Children with positive toxicology screens in the newborn period warrant referral for services via a report to the State Central Register. Ensure services for the mother on methadone who is returning home with her child. Foster care may be indicated if maternal drug use suggests further neglect of the infant's needs. Determine the safety of the home environment prior to discharging the infant from the nursery.
The well-child care plan for infants with a positive newborn urine toxicology screen should include, at a minimum, weekly visits by public health nursing and/or weekly visits to the office. These are designed to look for signs of withdrawal, check weight gain, and assess development until you are assured that the child is no longer suffering from withdrawal and is growing normally. Because of the behaviors resulting from drug withdrawal, such as irritability and sleeplessness, these children are at risk for abuse by the caregiver. At each evaluation provide an opportunity to discuss the difficulties of caring for the infant.
