P0422 - A Tale of Two Twins

Introduction- Siblings of a physically abused child are known to be at high risk of abuse with twins at even higher risk than non-twin contacts. Early detection of abuse is crucial as abuse often escalates over time. Despite this, there are variable rates and screening protocols of siblings, even among child abuse pediatricians. Here we describe a case of twin infants in which the index twin remained protected by continued hospitalization; however, the sibling twin met an untimely end despite undergoing screening for abuse.

Case Description- A 3 month old former 34 week gestation twin female was admitted to the hospitalist team after her father witnessed a 15 minute episode of arm stiffening and generalized body shaking.

Physical exam was significant for decreased responsiveness and a full anterior fontanelle. A lumbar puncture revealed elevated white blood cells, protein and red blood cells. A head CT showed non-specific fluid accumulation in the frontal cerebral areas. She was given intravenous antibiotics until CSF culture remained negative.

Follow-up MRI clarified that the cerebral fluid was subdural hematomas. Ophthalmologic exam revealed severe bilateral retinal hemorrhages. An abuse report was filed with Child Protective Services (CPS). Other workup, including EEG, skeletal survey, and labs, was normal.

Coincidentally, the patient's twin brother was hospitalized the following day for a scheduled inguinal hernia repair. The hospitalist team notified the surgical team, and the brother underwent a negative abuse screen, including head CT, skeletal survey, and labs.Following his surgical procedure, he was cleared by CPS for discharge home to his parents.

The sister remained in the hospital for an additional 3 weeks due to need for continued neuroimaging and subdural taps. Five days after discharge, the brother presented to an outside hospital in critical condition and was unable to be resuscitated. The father, who was home alone with the infant, claimed that death was due to co-sleeping. Further investigation by the police remains ongoing.

Discussion- Despite consensus that siblings of a victim of abuse are at increased risk of abuse, there remains lack of an established protocol to guide screening. This case was unique in that the twin of the index case was admitted for a different reason and to a different treatment team who determined a different discharge date than the index twin. These factors, along with lack of established guidelines for CPS workers, likely contributed to the twin boy’s death.

Conclusion- Further research into developing a protocol for screening high-risk groups such as siblings, particularly twins, is indicated. In addition, protocols to assist CPS workers with disposition and initiation of protective measures in these cases, whether or not evidence of abuse is found in the sibling, could potentially prevent future similar negative outcomes.