Legal Definition of a Child in Malaysia and the Definition of Statutory Rape

Image downloaded from Microsoft Office website. Available at here.

I made a mistake when discussing on the legal definition of a child in Malaysia and the definition of statutory, and so I thought it would be a good idea to revise on this topic.

I mistakenly thought that a child in Malaysia is defined as one aged 18 years old and below. I was wrong. According to the Malaysian Child Act 2001 or Act 611, a child is defined as

a person under the age of eighteen years or below 18 years old (NOT 18 years and below)

However, as Nadesan and Omar (2002) writes, the consenting age for sexual intercourse in Malaysia is 16 years old. As such, statutory rape is defined as sexual intercourse (regardless of whether WITH or WITHOUT consent) with a girl BELOW 16 years old (AND NOT with ANY child).

This definition is according to Section 376 of the Malaysian Penal Code (or Act 574).

Therefore, there exist a time period where a person under the age of 18 years old AND above the age of 16 years old, CAN consent to sexual intercourse, but cannot give consent to medical procedures and treatment (because she is below 18 years old).

The article written by Nadesan and Omar in 2002 is an excellent treatise of the current rape scenario in the Malaysian context. The article can be downloaded here.

The criteria of rape as per Section 375 of the Penal Code is as below:

1. Against her will
2. Without her consent
3. With her consent, when her consent has been obtained by putting her in fear of death or hurt to herself or any other person, or obtained under a misconception of fact and the man knows or has reason to believe that the consent was given in consequence of such misconception 
4. With her consent, when the man knows that he is not her husband, and her consent is given because she believes that he is another man to whom she is or believes herself to be lawfully married or to whom she would consent
5. With her consent, when, at the time of giving such consent, she is unable to understand the nature and consequences of that to which she gives consent
6. With or without her consent, when she is under sixteen years of age (statutory rape)

The word rape originates from the Latin word "rapere", which means "to snatch".  Often, to snatch something from someone would entail some amount of violence imposed. Furthermore, according to Section 375 of the Penal Code above, rape is defined when the sexual intercourse is done "against her will". As such, this places the burden on the victim and the prosecution team to establish the evidence of violence and "against her will". This can pose serious problems because, as Nadesan and Omar (2002) said:

".....the absence of injuries does not necessarily mean that the woman was a willing partner. Owing to many reasons, a victim may not resist the rapist and in that event the chances of a physical attack by the rapist is reduced. When victims are taken by surprise they may be too scared to resist. More importantly, in many instances the rapist is an immediate family member, a close relative or a friend. Several cases are actually incest and many more are statutory rapes where the victims are under the age of sixteen years."

In many countries, the burden of proof has been shifted to the defendant (alleged perpetrator) to prove that there was consent for sexual intercourse, but in Malaysia, the position still remains unchanged for the prosecution to establish that the woman did not consent.

Another thing I learned from the article by Nadesan and Omar (2002) is that amendment to the 1988 Section 146A of the Evidence Act (Act 56) states that no question in cross-examination shall be adduced or asked concerning the sexual activity of the complainant with any other person other than the accused. Previously, victims during cross-examinations were asked about their sexual encounters with persons other than the suspect in order to discredit their moral behavior.

Doctors and nurses working in the emergency departments should have a general knowledge of this important issue as these victims will be presented to the One Stop Crisis Center (OSCC) in emergency department. It is of utmost importance that such victims be accorded to utter privacy and confidentiality. No gossiping of the nature of the suffering inflicted upon the victim should be discussed among healthcare professionals!

My previous post on OSCC: click here.

Reference:

1. Nadesan K, Omar SZ. Rape--the Malaysian scenario. Malays J Pathol. 2002 Jun;24(1):9-14. [Click here to download the FREE full text in pdf]

The Rule of SIX in Drug Dosing and Infusion

Image credited to zeathiel at stock.xchng

Supposed as a junior medical officer, you want to start dopamine infusion for a patient in hypovolemic shock (with persistent low BP despite adequate fluid resuscitation). You look up at the drug formulary (just to counter-check) and it states that the dosage for dopamine is "5 mcg/kg/min, increasing gradually using 5-10 mcg/kg/min increments......". Most drug formularies will list dopamine dosages in the form of xxx mcg/kg/min.

So, you decide to start the patient on 10 mcg/kg/min. You remember well what you were taught in med school: dopamine infusion in the range 3 - 5 mcg/kg/min is predominantly for its dopaminergic effect (dopaminergic receptors are present abundantly in the mesenteric vasculature, brain, heart and the kidneys); dosing range from 5 - 10 mcg/kg/min is predominantly for its beta effects and dosage ranges above 10mcg/kg/min up to 20 mcg/kg/min is for its alpha effects.

You inform the staff nurse on duty: "Staff nurse, could you start dopamine infusion for this patient, start with 10 mcg/kg/min, titrating until a desirable blood pressure achieved. Erm.. I think this patient's weight is around 70 kg" Unfortunately, the staff nurse on duty is a junior staff nurse. She looks at you and said "Doctor, can you tell me how do I prepare for the infusion? Each ampoule of dopamine is 200 mg." You look a little bit annoyed, thinking to yourself "you mean you didn't learn that in your nursing school???" Regardless, still the sole responsibility of giving clear, concise and detailed instruction rests on the shoulder of the doctor in charge. You cannot blame the staff nurse of whether she learns that in nursing school or not.

Since you can't get an "answer" from the junior staff nurse, you turn around and ask a senior staff nurse. The senior staff nurse said, "Doctor, I don't know about this 10 mcg/kg/min. But from my experience, if you break open 1 ampoule of dopamine (200 mg) and diluted it into 50 cc, usually most doctors will run the drug at 10 ml/hr.

Huh??? You got more confused!!!

The above scenario is not uncommonly seen. Many nurses, from my experience, either do not understand or have forgotten about the correlation between the xxx mcg/kg/min that is stated in most books and the actual running of how many ml/hr of the diluted dopamine in 100-ml or 50-ml syringe.

The secret of calculating that is by using the RULE of SIX for drug infusion. And I am amazed how many medical students do not know this and how many of them actually do not even know how to derive this formula.

So, in this blog post, I will first prove that this formula is true by deriving it from basic mathematics and then to discuss on the variants of this formula for the ease of practicality.

The Rule of Six for drug infusion states that:

When (6 * body weight of patient) mg of a drug is diluted in 100 ml,

every ml/hr of the drug infused is equal to one mcg/kg/min

In other words,
(6 * BW) mg diluted in 100ml, 1 ml/hr = 1 mcg/kg/min, where BW - body weight

How do we derive that formula? Basic simple algebra......
We break up that equation into two parts:
1 ml/hr ..................... (A)
1 mcg/kg/min ......................(B)

and then we will attempt to prove that (A) = (B)


Now, let's look at the first part of the equation, part (A), namely 1 ml/hr

Let's assume BW = a kg
So,
(6a) mg of Drug A ---- in 100 ml (diluted into 100 ml)

therefore,
1 ml of Drug A = (6a)mg/100

But 1 ml of Drug A is infused over 1 hour (= 60 min)

Therefore, for every min, the amount of drug A infused is:
(6a)mg/(100*60)

But every 1 mg = 1000 mcg.
Therefore, for every min, the amount of drug A infused is:
(6a)*1000 mcg/(100*60)

simplify the equation, for every min, the amount of drug A infused is:
(a) mcg

In other words, part A of the equation (1 ml/hr) can be written as:
(a) mcg...........................(1)


Now, look at part B of the equation, 1 mcg/kg/min

We have assumed that the BW = a kg,

therefore, for every min, the amount of drug A infused is:
(a) mcg............................(2)

Since, (1) = (2), therefore
1 ml/hr = 1 mcg/kg/min if (6*BW) mg of the drug is diluted into 100 ml.

Unfortunately, 100-ml syringes are not easily available in my hospitals. Most of the large syringes are 50-ml syringes.

Nevermind, the rule of 6 can still be applied, but for 50-ml dilution,

(3*body weight) mg of drug A in 50 ml, 1 ml/hr = 1 mcg/kg/min

(this simply because 50 = 100/2, therefore we take 6/2, which is 3 !!).

In other words, the rule of 6 can also be written as:

When (3 * body weight of patient) mg of a drug is diluted in 50 ml,

every ml/hr of the drug infused is equal to one mcg/kg/min

and, by using the same premise,

When (0.3 * body weight of patient) mg of a drug is diluted in 50 ml,

every ml/hr of the drug infused is equal to 0.1 mcg/kg/min

and...

When (0.03 * body weight of patient) mg of a drug is diluted in 50 ml,

every ml/hr of the drug infused is equal to 0.01 mcg/kg/min

Now, let's come back to our case scenario.

Let's apply the rule of 6 in our case. The patient's body weight is 70 kg. Most adults' body weight would be in the range of 60 - 70- kg. Assuming that we are going to dilute into 50 ml, therefore we use the variant:

When (3 * body weight of patient) mg of a drug is diluted in 50 ml,

every ml/hr of the drug infused is equal to one mcg/kg/min

Therefore,
(3*70) mg of dopamine is diluted in 50 ml, every ml/hr is equal to 1 mcg/kg/min.
In other words, 210 mg of dopamine is diluted in 50 ml, 10 mcg/kg/min requires 10 ml/hr.

210 mg ~ approximately 200 mg. Remember that most dopamine ampoules contain 200 mg each.

Therefore, for convenience sake, break open 1 ampoule of dopamine (200 mg), dilute in 50 ml, and just run 10 ml/hr (that will give you 10 mcg/kg/min). No wonder that's what the senior staff nurse said! You see, most drugs are prepared in such a way that it is convenient to use (especially for adult patients) and most people (especially those in places like emergency departments and ICUs), doctors and staff nurses included, are doing it routinely without really understand the principles behind.

In other words, you would not have much problem, if you are infusing drugs such as dopamine, where the drug ampoules are conveniently prepared.

But you will have troubles when it comes to pediatric patients (where the Rule of 6 is particularly useful) and when it comes to infusing other drugs such as adrenaline or noradrenaline (also known as epinephrine and norepinephrine respectively).

Adrenaline infusion, for example, the dosage range is 0.05 mcg/kg/min - 0.2 mcg/kg/min. So how are you going to prepare the dilution and rate of infusion? Bearing in mind too that most adrenaline ampoules come in 1mg/ml packaging. If you apply the rule of 6, then you will have to take your time to break 200 ampoules!! (while the patient is hanging there in a state of shock). Furthermore, since the dosage range is around 0.05 mcg/kg/min, the rate infused per min will be in the decimals - minute amount!

Therefore, we use this variant of the rule:

When (0.03 * body weight of patient) mg of a drug is diluted in 50 ml,

every ml/hr of the drug infused is equal to 0.01 mcg/kg/min

So, for adrenaline, (0.03 * 70) mg of adrenaline diluted in 50 cc, 1 ml/hr = 0.01 mcg/kg/min.

Therefore, for convenience, you just need to break 2 or 3 ampoules (2 - 3 mg) of adrenaline, dilute it to become 50 ml, and infuse at the rate of 5 ml/hr (if you are aiming for 0.05 mcg/kg/min). Bearing in mind too that the rule need not to be applied rigidly, because in the first place, the weight that you estimate is just as it is - an estimation. You can always titrate the infusion rate up and down. But the decimal point and the variant of the rule you are going to use must be decidedly correct because there has been anecdotal report that states that a baby died as a result of "misplaced decimal point (when applying the rule of 6) and the preparation of a dopamine infusion that was 10 times more concentrated than required" (Click on the link to read the article).

I disagree with the writer of that article that the use of the Rule of 6 should be abandoned. The rule of 6 is just a scientific, standalone formula that can be derived objectively from first principles. It is neutral. It is only when we do not understand the principles behind properly, then we will just follow blindly and thus, courting disaster!

Happy infusing!

© 2010 by Dr. Keng Sheng CHEW


The Rule of SIX in Drug Dosing and Infusion by Dr. Keng Sheng CHEW is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.

Insect Bite Diagnostic Aid: S-C-R-A-T-C-H

(The above image is a linked image from the article by Hernandez and Cohen)

Hernandez and Cohen developed a diagnostic guidelines when they found that a majority of children with a final diagnosis of an insect-bite hypersensitivity reaction had undergone costly, unnecessary and extensive lab tests and skin biopsies before they were referred to Johns Hopkins Children's Center.

This set of principles (termed "SCRATCH") are intended to aid clinicians in making an early and accurate clinical diagnosis of insect bite:

S = Symmetry — Most patients with insect-bite hypersensitivity reactions present with symmetrical eruptions on the face, neck, arms, and legs, with sparing of the diaper area, palms, and soles of the feet.

C = Clusters — Lesions usually appear in a 'meal cluster,' sometimes described as 'breakfast, lunch, and dinner.

R = Rover Not Required — The diagnosis is not dependent on the presence of household pets. Exposure could come from periodic visits to a relative's house, for example.

A = Age-specific — The condition is most prevalent in children between the ages of two and 10.

T = Target Lesions/Time — Bull's-eye-rashes are typical of insect-bite reactions. The time refers to the chronic nature of the eruption and the need for patience and watchful waiting. Parents are advised to prevent secondary infections with appropriate use of nail and hand hygiene and moisturizers.

C = Confusion — Parents are often confused by the conflicting information they have been given, and the referring practitioner may find it hard to accept the diagnosis of an admittedly confusing condition.

H = Household — Unlike scabies or dermatitis, insect-bite reactions may affect only one household members who are hypersensitive

The FULL TEXT of the article by Hernandez and Cohen can be downloaded FREE in pdf format here.

Can We Avoid Head CT scan in Some Pediatric Patients With Head Trauma?

In a multicenter trial published in Lancet recently, Kuppermann N et al. enrolled 42,412 children (age, ≤18 years) with mild head trauma (defined as Glasgow Coma Scale score >13) to derive and validate decision rules for two separate age groups:
- those below 2 years and
- those aged 2 years and above.

In that paper, the authors highlighted the need to identify pediatric patients with very low risk of clinically important brain injuries who might not need a CT scan after all:

1. 40 - 60% of those with traumatic brain injuries seen on CT scan are from this group of patients with minor head injuries or those with GCS 14 and 15.

2. But the converse is not true - less than 10% of those with minor head injuries show traumatic brain injuries

3. Furthermore, even if there are head trauma identified, injuries needing neurosurgery are very uncommon in children with GCS scores of 14 - 15

4. The risk of radiation exposure. Ionising radiation from CT scans can cause lethal malignancies. The estimated rate of lethal malignancies from CT is between 1 in 1000 to 1 in 5000 pediatric cranial CT.

But predictive models in such cases are not new. There have been predictive models to identify low risk patients where Head CT may probably be avoided. However, in that paper, it is stated that the problems with previous predictive models:

- are limited by small sample size
- lack of validation
- no independent assessment of preverbal children (less than 2 years old)

From that study, the authors identified that:

The Decision To Avoid CT in Children with Head Trauma could be made:

A. In Children less than 2 years old if
* Normal mental status
* No scalp hematoma except frontal hematoma
* LOC<5 seconds
* Non severe mechanisms of injuries (see below for the list)
* No palpable scalp fracture
* Normal behavior

B. In Children 2 years and above if
* Normal mental status
* No LOC
* No vomiting
* Non severe mechanisms of injuries (see below for the list)
* No signs of base of skull fracture
* No severe headache

Non severe mechanisms of injuries:
# death of a passenger in the accident
# ejection of patient from the vehicle
# rollover
# pedestrian or bicyclist without helmet struck by the vehicle
# fall more than 1.5 m for children above 2 years old and more than 0.9 m for children less than 2 years
# head struck by high impact object

In the validation group of 2216 children younger than 2 years, the rule had 100% sensitivity and negative predictive value. In the validation group of 6411 children 2 years and older, the rule had 96.8% sensitivity and 99.5% negative predictive value.

Using the list of features identified, the suggested algorithm for mild head trauma in that paper:
A. In Children less than 2 years old:
Step 1:
Is the patient with altered mental status OR a palpable skull fracture: If yes - CT;
If no, then proceed to Step 2

Step 2:
Is the patient has occipital or parietal or temporal scalp hematoma OR LOC 5 or more seconds OR severe mechanism of injury OR "not acting normally" as per parent:
if yes: (use clinical judgement with the following in mind)
Observation vs CT on the basis of other clinical features include
- physician experience
- multiple versus isolated findings
- worsening symptoms of signs after emergency department observation
- age of less than 3 months
- parental preference


if not
- then CT SCAN IS NOT RECOMMENDED

B. In Children 2 years or older

Step 1:
Is the patient with altered mental status OR other signs of basilar skull #: if yes - CT

If no, then proceed to Step 2:

Step 2:
Is the patient with history of LOC OR vomiting OR severe mechanism of injury OR severe headache:

If yes, again Observation vs CT on the basis of other clinical factors including:
- physician experience
- multiple versus isolated findings (see note below)
- worsening symptoms or signs after emergency department observation
- parental preference

If no, then CT SCAN IS NOT RECOMMENDED.

Note: Patients with certain isolated findings (i.e. without other findings suggestive of traumatic brain injury) such as
- isolated LOC
- isolated headache
- isolated vomiting
- certain types of isolated scalp hematomas in infants older than 3 months
have risk of clinical important TBI (traumatic brain injuries) of less than 1%.

In general, if risk of clinically important TBI is exceedingly low, lower than risk of CT induced malignancies, then CT scans are not indicated.

In short, while using this rule may identify pediatric patients at very low risk of having clinically important TBI when ALL of the CRITERIA are fulfilled; the converse is not true. Doctors still have to use their own clinical judgment to see which patients they would order a CT scan. Nevertheless, as always, extra caution is still advisable in children younger than 3 months, in whom clinical evaluation may be less reliable.


Reference:
Kuppermann N et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: A prospective cohort study. Lancet 2009 Sep 15; [e-pub ahead of print]. (http://dx.doi.org/10.1016/S0140-6736(09)61558-0)

Pediatric Protocols For Malaysian Hospitals FREE download in MPA website

The Pediatric Protocols for Malaysian Hospitals is available for FREE download at the Malaysian Pediatric Association Website. I am awaiting to purchase a printed copy because eventually I find reading from a laptop screen is very tiring and straining the eyes.

Anyway, you may click here to download the protocol in pdf. Click here to access the website of Malaysian Pediatric Association.

Henoch-Schönlein purpura

Case:

This 7-years old boy was seen in the emergency department about a month ago with the main complaint of sudden onset of colicky abdominal pain. After been given pain relief, his abdomen was soft, non tender and non guarded. He was, otherwise, fully alert and conscious; vital signs are normal, not toxic looking and no signs of meningisms.

The easy part is he has been suspected of having Henoch Schonlein Purpura from his first visit based the skin rash appearance about a week earlier.

However, we should not be misled by any preconceived diagnosis without examining him carefully. If he presented with signs of meningism and appeared toxic looking, the first thing that comes to my mind with that kind of rash appearance would be have been meningococcal septicaemia!! As emergency physician, I must rule out meningococcal septicemia first especially if the history fits. In fact, all literature cited meningococcal septicemia as a differential for the rash per se.

Definition of Henoch-Schönlein purpura (HSP)

HSP is described as non-thrombocytopenic, purpuric and systemic vasculitis of childhood that occurs twice as often in males as in females.

Every word in that definition is keyword to understand HSP:

Henoch-Schönlein purpura is a

Nonthrombocytopenic

- Very important to know that HSP is non-thrombocytopenic because a normal platelet count helps to differentiate HSP from thrombocytopenic purpura

purpuric

- And it is palpable

- Palpable purpura is present in almost 100% of patients with Henoch-Schönlein purpura

- Is a presenting sign in 50% of patients

- Some patients present with predominantly smaller petechial lesions, some present with mainly purpuric lesions, and others present with a mixture of lesion types, some may have target-like lesions (central punctate hemorrhage surrounded by circumferential regions of pallor and hemorrhage)

- The characteristic of the purpura is it is gravity and pressure dependent. This may cause a typical sock line (for those who wear socks regularly – not present in this boy as he did not wear sock)

- Note: The sock line picture is clearly seen in an article by Ponce de Souza et al. in 2005. Click here to go to the article.

systemic vasculitis of

- HSP essentially is an IgA-mediated systemic vasculitis of small blood vessels

- There is diffuse vasculitis secondary to deposition of immune complexes

- Unknown cause but has been associated with various factors, especially a preceding RTI (more than half) particularly a group A strep organism

- Other than that, literature also shows that it has been associated with vaccinations, allergens in foods, drug reactions, etc etc.

- Note: this blog post is not meant to be an exhaustive description of HSP because there are some very good articles available free online. See references below for the links

- Though it is systemic, it is often described as presenting with classical triad of symptoms: a palpable purpuric rash on the lower extremities, abdominal pain or renal involvement, and arthritis.

- This patient has typical rash, as well as severe acute abdominal pain. In fact, when he first arrived in ED, he was groaning in pain, but his pain much improved after given pain relief

- The most serious sequela of HSP is the renal involvement because it can progress to ESRF

- The most common manifestation of renal disease in HSP is hematuria.

childhood

- in fact, HSP is the most common form of vasculitis in children

- Approx 75% of cases occur in children between two and 11 years of age.

- Twice as often in males as in females (this patient is a boy)

References:

Note: these three articles are excellent articles for review.

1. Kraft DM, McKee D, Scott C. Henoch-Schonlein purpura: a review. Am Fam Physician 1998; 58 (2):405-8, 11.

http://www.aafp.org/afp/980800ap/kraft.html
(This article is a good description of HSP, easy to understand)

2. Leung AK, Chan KW. Evaluating the child with purpura. Am Fam Physician 2001; 64 (3):419-28.

http://www.aafp.org/afp/20010801/419.html
(This is a superb article regarding the approach of purpura in general)

3. Ponce de Souza E, Usatine RP. Palpable purpura and a visible sock line. J Fam Pract 2005; 54 (6):520-3.

http://www.jfponline.com/pages.asp?aid=1957&UID=#bib1
(This article has good pictures on the sock lines in the distribution of rash in gravity dependant position. Wonder how the distribution of the rash would be if one of the patient is an astronaut!)