Sexually transmitted diseases in children: Introduction

Sexually

transmitted

diseases

in

children:

Introduction

S

Estreich,

G

E

Forster

Introduction

Although

sexually

transmitted

diseases

are

a

major

health

problem

worldwide,

there

are

few

data

on

the

incidence

and

prevalence

of

these

conditions

in

children

and

young

adoles-

cents.

The

diagnosis

of

a

sexually

transmitted

disease

(STD)

in

a

child,

where

this

has

been

confirmed

by

an

evaluated

technique,

can

raise

a

number

of

concerns

for

the

clinician.

The

possibility

of

sexual

abuse

should

be

con-

sidered,

with

its

attendant

social

and

medico-

legal

implications.

However,

transmission

of

STDs

following

sexual

abuse

must

be

differen-

tiated

from

vertical

or

accidental

transmission

of

the

same

infection.

Close

non-sexual

physical

contact

and

voluntary

sexual

activity

should

also

be

excluded.

This

review

will

consider

the

historical

aspects,

epidemiology,

routes

of

transmission,

clinical

presentation

and

diagnosis

of

STDs

in

children.

The

individual

infections

will

be

covered

in

detail

in

subsequent

articles.

Department

of

Genitourinary

Medicine,

St

Helier

Hospital,

Carshalton,

Surrey

SM5

1AA

S

Estreich

The

Ambrose

King

Centre,

The

Royal

London

Hospital,

London

El

1BB

G

E

Forster

Address

correspondence

to

Dr

S

Estreich

Historical

perspective

Syphilis

was

the

first

STD

to

be

recognised

in

childhood.

In

1497,

Torella

described

some

of

the

clinical

manifestations

of

syphilis

in

nurs-

ing

infants'

and

several

theories

were

put

forward

in

the

sixteenth

century

to

explain

how

children

became

infected.

Infants

were

thought

to

contract

syphilis

from

infected

wet

nurses.

Those

women

who

were

known

to

have

the

"French

disease",

whether

active

or

cured,

were

prevented

from

working

as

wet

nurses.2

Paracelsus

believed

that

"hereditary

syphilis"

was

transmitted

from

infected

father

to

son,3

a

view

still

supported

by

Hutchinson

and

others

in

the

nineteenth

century.4

In

1810,

Bertin

was

the

first

to

give

a

detailed

description

of

the

clinical

features

of

congenital

syphilis

and

to

recognise

the

importance

of

bony

lesions.5

In

1837,

Colles'

Law

stated

that

syphilitic

infants

could

not

infect

their

own

mothers

whilst

they

could

transmit

the

disease

to

healthy

wet

nurses.6

Diday

described

the

skin

and

visceral

manifestations

of

congenital

syphilis

in

1854.

He

realised

that

the

mother

of

an

infected

infant

usually

had

syphilis,

whether

she

was

symptomatic

or

not

and

recommended

that

treatment

should

be

given

to

all

children

of

infected

parents,

whether

or

not

they

appeared

healthy.7

In

1858,

Fournier

advised

infected

adults

to

abstain

from

sexual

inter-

course

for

at

least

two

years

after

all

signs

of

disease

had

cleared

to

prevent

congenital

syphilis.8

Between

1857

and

1863,

Hutchinson

des-

cribed

most

of

the

clinical

manifestations

of

"hereditary

syphilis".

He

was

the

first

to

Genitourin

Med

1992;68:2-8

recognise

an

association

between

dental

defor-

mities,

interstitial

keratitis

and

deafness

in

late

congenital

syphilis.9

Both

Diday

and

Hutchinson

observed

that

syphilitic

mothers

were

less

likely

to

give

birth

to

infected

infants

in

subsequent

pregnancies.

These

findings

were

incorporated

into

Kassowitz's

Law

in

1876.'

With

the

discovery

of

Treponema

pallidum

in

1905,10

it

was

realised

that

the

organism

was

too

large

to

be

carried

by

spermatozoa

and

that

direct

infection

of

the

foetus

by

the

father

could

not

occur.

Maternal

infection

had

been

recognised

as

being

necessary

for

transmission

and

that

this

could

be

symptomatic

or

asymp-

tomatic

was

demonstrated

serologically

with

the

introduction

of

the

Wasserman

Reaction

in

1906.`1

The

risk

of

transmission

from

infec-

ted

mother

to

child

was

determined

in

the

Oslo

study

of

untreated

syphilis.

Of

infants

born

to

syphilitic

mothers

49%

had

congenital

disease,

25%

had

latent

disease

and

were

seropositive,

whilst

26%

were

seronegative.`2

There

is

very

little

information

on

acquired

syphilis

in

children

which

may

present

as

a

manifestation

of

sexual

abuse.

In

the

eighteenth

century,

ophthalmia

neonatorum

was

associated

with

the

presence

of

maternal

vaginal

discharge.

This

condition

was

thought

to

be

transmitted

from

the

mother

via

the

blood

stream

to

her

child.'3

Ophthalmia

neonatorum

was

a

common

and

serious

disease

in

the

nineteenth

century,

being

described

in

1-15%

of

live

births

in

the

United

States

and

Europe.'4

In

1807,

Gibson

was

the

first

to

suggest

measures

that

might

prevent

the

development

of

neonatal

conjunctivitis.'5

He

advised

wash-

ing

the

infant's

eyes

as

soon

as

possible

after

delivery.

Further

work

on

the

prophylaxis

of

ophthalmia

neonatorum

was

carried

out

by

Crede

in

the

1870s.16

In

1879,

Neisser

demonstrated

Gram

negative

intra-cellular

diplococci

in

stained

smears

from

the

conjunctivae

of

adults

with

gonococcal

ophthalmia.'7

Gonococcal

ophthal-

mia

neonatorum

was

first

recognised

as

a

separate

disease

in

1881.16

In

the

same

year,

Crede

described

the

topical

application

of

silver

nitrate

solution

into

the

eyes

of

newborn

infants

to

prevent

ophthalmia

neonatorum.

He

realised

that

this

condition

was

contracted

during

the

passage

of

the

baby

through

an

infected

birth

canal.

There

was

an

immediate

reduction

in

the

number

of

reported

cases

with

the

introduction

of

Crede's

method.'8

Non-gonococcal

ophthalmia

neonatorum

was

differentiated

from

gonococcal

conjunc-

tivitis

in

1884.'`

It

was

known

that

the

symptoms

and

signs

were

less

severe

and

that

blindness

did

not

occur.

In

1907,

2

Sexually

transmitted

diseases

in

children:

Introduction

Halberstaedter

and

von

Prowazek

described

inclusions

both

in

conjunctival

scrapes

from

infants

with

ophthalmia

neonatorum

and

from

their

mother's

genital

tracts.'

In

1959,

Jones

et

al

isolated

Chlamydia

trachomatis

from

the

cervix

of

a

mother

whose

baby

had

inclusion

conjunctivitis.`

Vulvo-vaginitis

in

children

was

originally

regarded

as

a

symptom

of

"hereditary

syphil-

is".

This

belief

waned

with

the

discovery

of

the

gonococcus.

In

the

late

nineteenth

century

there

was

controversy

as

to

whether

gonor-

rhoea

was

solely

sexually

transmitted

or

could

be

transferred

by

fomites

as

well.22

In

1885

Fraenkel

demonstrated

an

organism

morpho-

logically

identical

to

the

gonococcus

in

the

vaginal

discharge

of

girls

affected

in

a

hospital

epidemic.23

However,

he

was

not

convinced

that

this

was

the

gonococcus

since

he

failed

to

induce

ophthalmia

in

three

dying

children

after

innoculation

of

vaginal

pus

onto

their

conjunctivae.

There

followed

a

series

of

reports

of

hospital

epidemics

of

gonococcal

vulvo-vaginitis

in

children.

Supposed

modes

of

transmission

included

criminal

assault,

rec-

tal

thermometers,.

sharing

of

bath

tubs

and

night

nurses'

fingers.

Associated

with

these

cases

were

complications

including

arthritis,

conjunctivitis,

proctitis

and

upper

genital

tract

infection.'

The

first

case

report

of

herpes

simplex

virus

infection

in

childhood

appeared

in

1853.

A

7

year

old

girl

was

described

who

acquired

genital

herpes

after

sexual

molestation.24

Herpes

keratitis

in

association

with

neonatal

herpes

was

reported

in

1934.25

The

his-

tological

findings

in

this

condition

were

des-

cribed

one

year

later.6

The

first

case

report

of

genital

wart

virus

infection

in

childhood

appeared

in

the

English

language

in

1940.

A

3

year

old

girl

was

described

who

had

both

gonorrhoea

and

warts

involving

the

genitalia,

perineum

and

lips.27

Children

infected

with

HIV

were

reported

in

1982.

Sexually

trans-

mitted

diseases

were

diagnosed

in

54

(13%)

of

409

children

who

were

examined

over

a

4

year

period

following

suspected

sexual

abuse.28

Neinstein

concluded

that

the

non-sexual

transmission

of

STDs

was

an

infrequent

occurrence

in

the

prepubertal

child

outside

the

neonatal

period.'

Epidemiology

Infection

in

pregnancy

and

the

neonate

Those

sexually

transmitted

diseases

which

present

in

the

neonatal

period

are

usually

acquired

from

the

mother

at

or

before

delivery

and

reflect

the

prevalence

of

those

infections

in

the

adult

female

population.

Congenital

syphilis

was

extremely

common

throughout

the

world

until

the

1950s,

when

the

incidence

declined

in

Europe

and

the

United

States

following

the

introduction

of

penicillin

therapy

and

routine

antenatal

screening.?

In

children

under

2

years

of

age,

there

was

only

one

case

of

congenital

syphilis

reported

in

Britain

in

1983

(0

13/100

000

live

births),

the

lowest

recorded

level

since

reports

began.

In

1986

there

were

nine

cases

(1

19/100

000

live

births)

and

in

1990,

the

year

for

which

the

most

recent

data

are

available,

there

were

two

cases.

The

number

of

children,

aged

two

years

and

over,

and

adults

with

the

stigmata

of

congenital

syphilis,

have

shown

a

steady

decline

from

over

300

cases

in

1965

to

less

than

100

per

year

since

1983.31-35

This

is

in

contrast

to

the

situation

in

the

United

States

where

one

in

10

000

live

births

were

infected

with

syphilis

in

1986.

More

cases

of

congenital

syphilis

were

reported

in

that

year

than

in

any

of

the

preceding

15

years.6

From

1986

to

1988,

there

was

an

increase

of

more

than

500%

(from

57

to

357)

in

reported

cases

of

congenital

syphilis

in

New

York

City.

This

increase

in

congenital

syphilis

paralleled

a

rise

in

the

number

of

cases

of

infectious

syphilis

in

young

women,

which

was

associated

with

the

use

of

cocaine/crack.

Furthermore,

the

exchange

of

sex

for

drugs

was

considered

to

be

an

important

factor

in

the

overall

incidence

of

syphilis

in

adults

in

the

USA.37

In

the

developing

world,

congenital

syphilis

is

still

extremely

common.

In

many

parts

of

Africa,

a

seroprevalence

of

at

least

10%

is

found

if

pregnant

women

are

screened

for

syphilis.8

Signs

of

congenital

syphilis

were

present

in

1

%

of

babies

who

were

delivered

at

the

University

Teaching

Hospital,

Lusaka.

Another

6.8%

of

infants

were

healthy

but

seroreactive

at

birth.39

Blindness,

as

a

consequence

of

gonococcal

ophthalmia

neonatorum,

was

common

in

Europe

and

North

America

during

the

nine-

teenth

century.

The

prevalence

declined

with

the

introduction

of

neonatal

ocular

pro-

phylaxis.

6`8

In

industrialised

countries,

the

annual

incidence

of

gonococcal

neonatal

con-

junctivitis

does

not

exceed

0.6/1000

live

births.'"

In

England,

there

were

31

reported

cases

of

gonococcal

ophthalmia

neonatorum

in

1989

and

seven

in

1990.

However,

returns

to

the

Department

of

Health

were

incomplete

for

both

years.

35

In

many

parts

of

Africa,

the

prevalence

of

gonorrhoea

amongst

pregnant

women

is

10%

and

a

majority

of

isolates

are

penicillinase

producing.

In

these

countries,

the

annual

incidence

of

gonococcal

ophthalmia

neo-

natorum

ranges

from

5-60/1000

live

births.8

Gonococcal

ophthalmia

was

present

in

3.6%

of

newborn

infants

screened

in

one

study

from

Kenya.4'

Prevalence

rates

for

the

asymptomatic

endocervical

carriage

of

C

trachomatis

in

preg-

nancy

have

ranged

from

2-22%.

However,

the

reliability

of

these

data

depend

upon

the

population

studied,

and

the

availability

of

confirmatory

diagnostic

tests.'2

In

industrial-

ised

countries,

the

annual

incidence

of

chlamydial

ophthalmia

neonatorum

does

not

exceed

4/1000

live

births.43

In

England,

there

were

only

42

reported

cases

of

chlamydial

neonatal

conjunctivitis

in

1989

and

56

in

1990.34

35

The

incidence

of

neonatal

herpes

per

yeai

ranges

from

1/2000-1/5000

deliveries

in

the

United

States"

to

less

than

3/100

000

live

births

in

Britain.45

However,

reported

adult

cases

of

herpes

simplex

virus

(HSV)

infection

in

England

were

the

highest

in

1989/90

for

over

10

years.34

There

are

no

data

on

the

prevalence

of

neonatal

wart

virus

infection.

In

England,

3

Estreich,

Forster

there

was

a

slight

increase

in

the

number

of

reports

of

genital

warts

in

women

in

1989/90

compared

with

the

previous

year.34

In

the

United

States,

approximately

3500

infants

become

chronic

carriers

of

hepatitis

B

virus

each

year.'

There

are

limited

data

on

the

incidence

and

prevalence

of

other

STDs

in

the

neonatal

period.

Infection

in

children

The

possibility

of

sexual

abuse

should

be

considered

in

any

prepubertal

child

where

a

sexually

transmitted

disease

has

been

diag-

nosed.

In

the

United

States,

the

incidence

of

gonococcal

infection

in

children,

aged

0-9

years,

remained

at

6.5/100

000

in

1980

and

1985.'`

In

England,

there

were

24

reported

cases

of

prepubertal

gonorrhoea

in

1989

and

16

in

1990.3'

`

In

both

countries,

more

cases

were

diagnosed

in

girls.

In

England,

there

were

179

new

cases

of

prepubertal

chlamydial

infection

in

1989.

Three

boys

acquired

their

infection

homo-

sexually.'

There

were

180

cases

reported

in

1990.35

However,

returns

for

both

years

were

incomplete

and

limited

information

was

given

as

to

possible

routes

of

transmission.

Nigerian

children

were

found

to

acquire

antibodies

to

herpes

simplex

virus

type

2

between

the

ages

of

3

and

5

years.

Non-

venereal

transmission

of

infection

was

suggested.47

Infection

in

adolescents

STDs

in

adolescents

may

be

associated

with

voluntary

sexual

activity

and/or

sexual

abuse.

There

are

limited

data

for

these

infections

in

the

under

16

age

group

in

England.

Between

1976

and

1986,

new

cases

of

acquired

syphilis

and

gonorrhoea

fell

from

1.

2

to

0

4/100

000

and

86-4

to

42-9/100

000

respectively.

First

attack

genital

wart

virus

infection

was

the

most

com-

mon

condition

reported

in

both

1989

and

1990

(table

1).

More

STDs

were

diagnosed

in

girls

than

in

boys.

However,

returns

for

both

years

were

incomplete.3`35

The

overall

prevalence

of

STDs

in

girls

aged

15-19

years

attending

a

genitourinary

medicine

(GUM)

clinic

in

London

was

shown

to

be

unchanged

in

the

years

1972

and

1982.48

Two

hundred

and

ten

girls,

aged

12-16,

who

were

in

residential

care

in

Leeds

between

1978

and

1985

showed

a

prevalence

of

infection

with

N

gonorrhoeae,

C

trachomatis

and

Trichomonas

vaginalis

of

13-7%,

16-2%

and

16%

respec-

tively.'9

This

was

a

selected

population

in

that

places

were

provided

for

girls

awaiting

court

appearances

and,

in

particular,

for

those

with

identified

behavioural

problems.

Most

of

them

were

sexually

active

and

47

(22%)

had

engaged

in

prostitution,

while

seven

(3%)

gave

a

history

of

sexual

abuse.

A

later

study,

looking

at

an

older

population

with

a

mean

age

of

17

2

years

(range

14

to

18)

attending

two

GUM

clinics

in

London

and

Cardiff,

noted

that

all

these

adoles-

cents

had

at

least

one

infection

whereas

18%

of

total

attenders

at

both

clinics

had

no

evidence

of

infection.5'

Asymptomatic

carriage

of

C

trachomatis

was

found

in

five

of

57

(9%)

sexually

active

adolescent

boys

attending

a

Teen

Clinic.5'

A

recent

report

from

the

USA

supported

Table

1

STDs

in

adolescents

(under

16

age

group)

in

England

Year

Condition

1989

1990

Acquired

syphilis

1

5

Gonorrhoea

148

166

Chlamydia

298

296

HSV-first

episode

78

89

Genital

warts-first

episode

414

366

HIV

4

5

Total

943

927

References

34,

35.

voluntary

sexual

activity

as

a

route

of

transmis-

sion

for

STDs

in

adolescents.

During

the

1970s

and

1980s

first

sexual

intercourse

occurred

at

a

younger

age,

and

more

women

were

reporting

premarital

sex.52

Further

information

on

STDs

in

children

is

derived

from

case

reports

and

series

of

sexually

abused

children

in

the

USA.28

29

Routes

of

transmission

(Tabte

2)

Transplacental

Congenital

infection

with

syphilis,

herpes

sim-

plex

virus

(HSV),

human

papilloma

virus

(HPV),

hepatitis

B

virus

(HBV)

and

human

immunodeficiency

virus

(HIV)

can

all

arise

from

transplacental

spread

from

mother

to

infant.

In

the

Oslo

study

of

untreated

syphilis,

74%

of

infants

had

either

congenital

infection

or

were

seropositive

as

a

result

of

vertical

trans-

mission

from

an

infected

mother.'2

A

later

study

reported

that

healthy

seronegative

infants

were

delivered

in

about

one

third

of

syphilitic

pregnancies.53

Very

few

cases

of

symptomatic

congenital

disease

have

been

described

in

HSV

infection.

However,

both

transplacental

and

ascending

infection

can

contribute

to

intrauterine

infec-

tion

with

HSV.

Acquisition

of

HPV

before

delivery

has

been

suggested

by

several

case

reports

including

that

of

a

male

infant

with

perianal

warts

present

at

birth.54

The

detection

of

HPV

DNA

in

the

foreskins

of

circumcised

healthy

newborn

male

infants

also

supports

transplacental

transmis-

sion.55

Whilst

intrauterine

transmission

of

HBV

and

HIV

has

been

suggested,

most

infections

probably

occur

at

the

time

of

delivery.

Perinatal

Transmission

of

Ngonorrhoeae,

C

trachomatis,

HSV,

HPV,

HBV

and

HIV

can

occur

at

the

time of

delivery.

Persistence

of

asymptomatic

Table

2

Routes

of

transmission

of

STDs

in

children

Transplacental

-

intrauterine

infection

-

ascending

infection

Perinatal

-

transmission

via

birth

canal

-

transmission

via

breast

milk

Accidental

-

skin-to-skin

transmission

-

fomite

transmission

-

autoinoculation

Sexual

abuse

Voluntary

sexual

intercourse

4

Sexually

transmitted

diseases

in

children:

Introduction

gonococcal

infection

has

not

been

demon-

strated

outside

the

neonatal

period,

ophthalmia

neonatorum

being

the

most

common

presenta-

tion.

In

contrast,

C

trachomatis

can

be

isolated

from

the

sputum,

nasopharynx,

vagina

and

rectum

in

addition

to

the

conjunctivae

of

infants

with

chlamydial

ophthalmia.5`58

Vaginal

and

rectal

colonisation

in

infants

is

usually

asymptomatic.

Studies

from

San

Fran-

cisco

and

Nairobi

reported

that

60%

and

37%,

respectively,

of

exposed

infants

were

culture

positive

for

C

trachomatis.59

6

Persistent

carriage

of

C

trachomatis

for

up

to

two

years

from

the

vagina

and

rectum

and

three

years

from

the

nasopharynx

has

been

reported.6'

Perinatal

transmission

should

always

be

con-

sidered

when

chlamydial

infection

is

diagnosed

and

sexual

abuse

suspected.

The

colonisation

of

multiple

anatomical

sites

supports

the

prin-

ciple

of

systemic

therapy,

in

particular,

for

neonatal

ophthalmia.

Neonatal

HSV

infection

is

a

rare

but

serious

disease.62

The

majority

of

neonates

are

infected

as

a

consequence

of

primary

genital

herpes

in

the

mother

at

or

around

the

time

of

delivery,

and

a

small

number

as

a

consequence

of

re-

current

infection.

Inapparent

maternal

herpes

accounts

for

70%

of

neonatal

infections.636"

Perinatal

HPV

transmission

is

demonstrated

by

the

association

of

laryngeal

papillomatosis

with

maternal

ano-genital

warts.

Condylomata

in

infants

can

develop

at

other

anatomical

sites.

However,

the

time

interval

after

birth

at

which

perinatal

transmission

of

HPV

can

be

excluded

is

unknown.

This

is

due

to

the

variable

and

prolonged

incubation

period

of

HPV,

but

is

thought

not

to

exceed

two

years.65

Transmission

of

HBV

occurs

in

70-90%

of

infants

born

to

"high

risk"

(e

antigen

positive)

carrier

mothers

and

85-90%

of

these

infants

become

chronic

carriers.'4

Assessment

of

trans-

mission

rates

of

HIV

are

complicated

by

pas-

sive

transfer

of

maternal

antibodies

which

may

persist

for

18

months

or

more.

Studies

have

reported

that

13-39%

of

babies

born

to

HIV-

infected

mothers

have

detectable

antibody

after

18

months,

the

higher

rates

of

transmission

being

reported

from

African

countries.66--"

However,

the

risk

of

transmission

may

depend

on

maternal

co-factors

such

as

stage

of

HIV

disease.69

Both

HBV

and

HIV

have

been

isolated

from

breast

milk.70'7

However,

there

is

no

epidemiological

evidence

supporting

HBV

transmission

by

this

route.

There

are

case

reports

of

HIV

transmission

via

breast

milk

from

mothers

infected

after

delivery.72

This

may

represent

a

special

situation

of

high

risk

associated

with

maternal

viraemia

at

the

time

of

HIV

sero-conversion.

This

interpretation

is

supported

by

series

which

show

no

difference

in

transmission

rates

between

breastfed

and

non-breastfed

babies

bom

to

HIV-infected

mothers.73"7

Accidental

Modes

of

accidental

transmission

of

STDs

to

children

have

been

suggested.

Before

sexual

abuse

was

recognised,

most

infections

were

attributed

to

close

physical

contact

with

either

an

adult

or

another

child

or

to

fomite

transfer,

and

it

is

not

uncommon

for

children

to

have

intimate

non-sexual

contact

with

adults

or

to

sleep

or

bathe

with

their

parents

or

siblings.75

Thus

it

is

conceivable

that,

for

example,

ano-

genital

warts

can

be

transmitted

by

skin-to-

skin

contact

in

a

non-abusive

setting.76

A

mechanism

for

the

accidental

transmission

of

STDs

to

prepubescent

girls

has

been

sugges-

ted.

Prior

to

puberty,

the

vagina

is

lined

with

relatively

thin,

atrophic

columnar

epithelium

and

the

pH

is

6.5

to

75.77

Thus

vaginitis

rather

than

cervicitis

can

be

caused

by

bacteria,

including

N

gonorrhoeae

and

C

trachomatis,

in

girls.

Many

early

reports

of

STDs

in

children,

usually

gonorrhoea,

emphasised

the

impor-

tance

of

fomite

transfer.

Household

objects

such

as

towels,

bed

linen,

toilet

seats

and

toilet

paper

were

implicated.

Several

studies

were

undertaken

under

controlled

conditions

of

temperature

and

humidity,

to

determine

the

viability

of

various

transmissible

organisms

on

inanimate

objects.

Toilet

seats

were

found

to

sustain

laboratory

suspensions

of

N

gonor-

rhoeae

for

up

to

24

hours,

HSV

type

2

for

up

to

two

hours

and

T

vaginalis

for

one

hour.

However,

infection

requires

more

than

the

presence

of

an

organism.

In

practice,

N

gonor-

rhoeae

was

never

isolated

from

toilet

seats

in

public

institutions

when

this

was

attempted.29

No

cases

of

cross

infection

were

recorded

in

a

ward

used

by

children

with

and

without

gon-

orrhoea

who

shared

toilet

facilities.78

Human

papillomavirus

DNA

has

been

detected

on

surgical

gloves

and

instruments

used

in

the

management

of

patients

with

genital

HPV

disease.

Infectivity

was

not

evaluated.79

Thus

it

seems

that

fomite

transmission

of

these

infec-

tions

is

a rare

event.

Presumed

autoinoculation

of

HPV

from

non-genital

to

genital

skin

has

been

reported

in

a

child80

and

suggested

by

more

recent

studies.76

It

has

been

suspected

that

HSV

type

1

infections

of

the

genitalia

in

children

may

be

caused

through

autoinoculation

from

oral

lesions.8'

However,

other

children

in

the

same

study,

also

with

HSV

type

1

genital

infection,

had

been

sexually

abused.

The

overall

con-

clusion

of

all

these

studies

would

suggest

that

accidental

transmission

of

STDs

to

children

is

an

exceptionally

uncommon

mode

of

trans-

mission.

Sexual

abuse

Child

sexual

abuse

(CSA)

as

a

mode

of

STD

transmission

has

only

recently

been

appre-

ciated.28

Victims

of

abuse

may

be

unable

or

unwilling

to

disclose

their

history.

Young

chil-

dren

may

lack

the

vocabulary

to

describe

their

experience

and

older

children

may

be

Table

3

STDs

in

child

sexual

abuse

STD

confirmed

Sexual

abuse

Gonorrhoea*

+ +

Syphilis*

+ +

Chlamydia*

+

Genital

warts*

+

Trichomoniasis

+

Genital

herpes

HSV

type1

+/-

HSV

type

2

+

*Excludes

vertical

transmission.

+

+Highly

probable.

+

Probable.

+

/-Possible.

5

Estreich,

Forster

intimidated

into

silence

by

the

perpetrator.

In

paediatric

practice

a

history

is

usually

taken

with

family

members

present,

who

may

them-

selves

be

responsible

for

or

colluding

with

the

abuse.

Therefore,

this

possible

route

of

trans-

mission

may

be

overlooked

and

others

sub-

stituted.

Many

cases

of

sexual

abuse

remain

unreported.

Published

statistics

are,

therefore,

likely

to

be

underestimates.

However,

Feldman

reviewed

earlier

studies

and

concluded

that

the

prevalence

rate

for

CSA

had

remained

at

10%

to

12%

since

the

1940s

in

girls

aged

less

than

14

years.82

The

National

Society

for

the

Preven-

tion

of

Cruelty

to

Children

(NSPCC)

figures

for

England

and

Wales

are

collected

from

11

areas

where

the

NSPCC

manage

the

child

abuse

registers.

These

areas

account

for

9%

of

the

total

child

population.

There

were

1586,

2137

and

2304

registered

cases

of

CSA

in

1985,

1986

and

1987

respectively.83

In

the

United

States,

the

American

Humane

Association

reported

123

000

cases

of

CSA

in

1985.84

Most

of

the

victims

are

female,

aged

7

to

8

years,

and

have

been

abused

by

a

known

older

male,

usually

a

father

or

father

substitute.85

In

these

cases,

abuse

may

extend

over

several

years.

Stranger

abuse

tends

to

occur

in

older

victims

on

a

single

occasion.

Children

are

subjected

to

vaginal

and/or

anal

penetration,

oro-genital

contact

and

genital

fondling.

The

presence

of

an

STD

may

raise

suspicion

about

child

sexual

abuse

but

many

children

present

with

behavioural

rather

than

physical

disorders.

Determination

of

the

risk

of

STD

acquisi-

tion

is

confounded

by

the

same

variables

as

in

adult

victims

of

sexual

assault.86

Infection

may

predate

the

time

of

the

alleged

abuse

and

in

children

the

possibility

of

perinatal

transmis-

sion

exists

(table

3).

In

addition,

the

long

incubation

period

and

asymptomatic

carriage

of

some

STDs

can

lead

to

delayed

presentation.

The

prevalence

of

gonococcal

infection

and

syphilis

in

sexually

abused

children

from

North

America

ranges

from

0%-12%

to

0%-

1.5%

respectively.

Asymptomatic

gonococcal

infection

occurred

in

up

to

44%

of

cases.

Chlamydial

infections

have

been

documented

in

4%-17%

of

abused

children

and

coincident

infection

with

C

trachomatis

has

been

observed

in

up

to

27%

of

children

with

gonorrhoea.

T

vaginalis

infection

has

been

reported

in

6%-25%

of

children

examined

in

smaller

studies.87

There

are

case

reports

of

HSV

and

HIV

acquisition

following

sexual

abuse.818889

Voluntary

sexual

intercourse

It

is

possible

for

children

to

acquire

STDs

from

sexual

partners

with

whom

they

are

having

voluntary

sexual

intercourse.

In

England

and

Wales,

the

age

of

consent

for

heterosexual

sex

is

16

years

and

for

homosexual

sex

is

21

years.

A

child

aged

less

than

16

years

is

below

the

age

of

consent

for

medical

examination

or

treat-

ment.'

This

can

lead

to

a

conflict

between

the

patient's

right

to

confidentiality,83

particularly

in

GUM

clinics,

and

the

need

to

obtain

consent

for

examination

or

treatment

from

the

parents

or

guardian.

Often,

these

children are

ap-

proaching

the

age

of

16

and,

depending

on

their

understanding,

may

be

regarded

as

capable

of

giving

consent.

In

these

circumstances,

it

is

reasonable

to

apply

the

same

principles

as

those

recommended

for

the

provision

of

contracep-

tive

services

to

patients

aged

less

than

16.

Thus,

it

would

be

best

for

the

child

to

discuss

these

issues

with

his

or

her

parents

or

legal

guardian

and

to

have

a

joint

consultation.

However,

the

child

may

not

wish

for

his

or

her

parents

to

be

informed

and,

if

the

doctor

considers

him

or

her

to

be

sufficiently

mature,

the

right

of

the

child

should

prevail.

Some

children

may

be

experiencing

both

voluntary

sexual

intercourse

and

abuse.

It

is

important

that

the

child

has

access

to

appropriate

counselling

on

sexuality,

safer

sex

and

contraception.

In

departments

of

GUM,

this

could

be

undertaken

in

conjunction

with

the

clinic

health

advisers.

Clinical

presentation

Clinical

features

of

STDs

in

children

may

differ

from

those

in

adults

due

to

physiological

changes

in

target

organs

and

routes

of

trans-

mission.

Congenital

syphilis

has

distinctive

mucocutaneous

and

inflammatory

lesions

in

early

disease

which

can

progress

to

malforma-

tions

or

stigmata.

In

late

disease

the

target

organs

and

manifestations

are

similar

to

acquired

tertiary

disease

except

for

the

absence

of

cardiovascular

involvement.

Vaginitis,

rather

than

cervicitis,

is

the

prominent

clinical

feature

for

both

gonococcal

and

chlamydial

infections

of

the

prepupertal

genital

tract.`

The

prevalence

of

asymptomatic

carriage

of

these

infections

when

sexually

acquired

and

whether

they

can

clear

sponta-

neously

over

time

is

not

known.

In

a

study

of

409

cases

of

suspected

CSA,'

there

were

46

cases

of

gonorrhoea.

Nine

of

these

patients

(20%)

were

asymptomatic.

Vaginal

discharge

may

also

be

the

presenting

feature

of

T

vagin-

alis

and

bacterial

vaginosis

(BV).

As

in

adults,

there

is

some

debate

as

to

whether

BV

is

always

sexually

transmitted

or

due

to

colonisation

of

the

pre-pubertal

vagina

by

anaerobes.

Genital

warts

in

children

occur

in

a

similar

anatomical

distribution

to

those

of

adults

with

a

predilection

for

the

perianal

area

in

very

young

children.9`

Laryngeal

papillomas

result

from

perinatal

transmission,

the

mother

having

ano-

genital

warts

during

her

pregnancy.

Children

with

HIV

disease

are

susceptible

to

the

wide

range

of

opportunistic

infections

that

occur

in

adults.

In

addition,

they

may

fail

to

thrive,

have

recurrent

severe

bacterial

infec-

tions

and

develop

lymphoid

interstitial

pneumonitis.

In

general,

CSA

should

be

excluded

in

any

child

in

whom

an

STD

is

diagnosed

and

where

perinatal

transmission

cannot

be

proven.

Examination

of

these

children

should

take

place

in

a

quiet

non-clinical

room

by

a

consul-

tant

or

his

or

her

deputy

because

of

the

issues

already

presented.

Collaboration

with

other

practitioners

involved,

in

accordance

with

individual

District

policy,

should

aim

to

keep

the

number

of

examinations

to

a

minimum.

The

clinical

assessment

should

include

a

gen-

eral

examination

prior

to

examination

of

the

ano-genital

region.

Injuries

and

physical

signs

should

be

recorded,

preferably

using

photo-

graphs.

Consideration

must

be"given

to

the

lack

of

knowledge

of

normal

genital

anatomy

in

children.

There

is

no

physical

sign

that

is

6

Sexually

transmitted

diseases

in

children:

Introduction

diagnostic

of

CSA

and

a

medical

examination

is

usually

only

a

small

part

of

the

evidence

collected.

It

may

be

necessary

to

screen

the

parents

and

other

children

in

the

family

if,

for

example,

gonococcal

vulvovaginitis

is

diag-

nosed

in

a

schoolgirl.

A

multidisciplinary

approach

is

necessary

in

the

management

of

suspected

CSA.83

9'

Diagnostic

methods

When

an

STD

is

suspected,

it

is

important

to

screen

for

and

exclude

other

infections.77

90

Microscopy

of

any

genital

or

anal

discharge

should

be

performed.

Furthermore,

cultures

for

N

gonorrhoeae

and

C

trachomatis

should

be

obtained

from

all

potentially

infected

mucosal

surfaces

even

if

there

is

no

history

of

sexual

exposure.

Children

may

not

disclose

all

types

of

assault

through

fear,

embarrassment

or

lack

of

understanding.'

Additional

investigations

may

include

biopsy

and

HPV

typing

of

genital

warts,

cultures

of

lesions

for

herpes

simplex

virus

and

serologic

tests

for

syphilis,

hepatitis

B

and

HIV.

Laboratory

investigations

and

follow-up

evaluations

should

be

kept

to

the

minimum

necessary

to

exclude

infection.

Laboratory

investigations

necessary

for

the

diagnosis

of

STDs

have

not

been

extensively

evaluated

in

children.

Results

should

therefore

be

interpreted

with

caution.

In

a

minority

of

cases

the

finding

of

an

STD

will

be

used

as

legal

evidence

in

suspected

CSA.

It

is

therefore

advisable

to

confirm

the

diagnosis

using

a

regional

reference

laboratory.

In

the

diagnosis

of

gonorrhoea,

difficulties

have

been

reported

with

the

misidentification

of

non-pathogenic

Neisseria

species.93

This

possibility

can

be

minimised

by

reference

laboratory

confirma-

tion

of

a

positive

culture.

The

diagnosis

of

chlamydial

infection

in

adults

is

increasingly

made

by

non-culture

methods

using

antigen

detection.

Direct

immunofluorescence

and

enzyme

immunoassay

are

the

two

most

commonly

used

techniques.

However,

when

used

in

low

prevalence

popula-

tions

their

predictive

values

are

variable.

There

are

no

data

on

their

use

in

children

for

sites

such

as

vagina,

pharynx

and

rectum,

where

other

micro-organisms

can

cross-react

in

antigen

detection

methods

producing

false

positive

results.

Thus,

until

these

tests

have

been

evaluated

further,

cultures

should

be

used

to

diagnose

or

confirm

chlamydial

infection

in

childhood.'

Bacterial

vaginosis

has

been

diag-

nosed

in

pre-pubertal

girls

with

evidence

of

sexual

contact.95

The

diagnostic

criterion

of

a

vaginal

pH

greater

than

4

5

cannot

be

applied

as

the

pre-pubertal

vagina

has

a

higher

pH

than

in

the

adult.

The

increasing

availability

of

HPV-typing

may

help

to

differentiate

between

genital-type

warts

and

common

warts

which

are

more

likely

to

have

been

autoinoculated

or

transmitted

by

fomite

spread.76

Restriction

endonuclease

analysis

can

match

isolates

of

HSV

between

sexual

contacts.

Treatment

The

treatment

of

STDs

in

children

follow

similar

guidelines

to

those

for

adults.

Specific

regimes

will

be

described

in

later

contributions

to

this

series.

General

considerations

include

the

avoidance

of

drugs

with

known

adverse

effects

in

childhood,

for

example,

tetracyclines.

The

oral

rather

than

parenteral

administration

of

drugs

may

prove

less

traumatic

for

the

child.

Prophylactic

antibiotic

therapy

is

not

recom-

mended

in

suspected

CSA

since

the

prevalence

of

STDs

appears

low

in

published

studies.`7

Conclusions

The

majority

of

STDs

described

in

adults

have

now

been

reported

in

children.

In

the

past,

most

descriptions

of

childhood

STDs

related

to

those

of

transplacental

or

perinatal

origin.

Older

children

with

STDs

were

thought

to

have

acquired

them

through

accidental

or

fomite

transmission.

It

is

clear

that

these

are

not

the

only

routes

of

transmission

and

that

CSA

and

voluntary

sexual

activity

can

occur.

This

is

a

complex

subject

and

should

not

be

managed

by

a

doctor

in

isolation.

The

incidence

and

prevalence

of

childhood

STDs

is

largely

unknown.

Their

diagnosis

in

children

may

be

limited

by

inaccurate

interpretation

of

unevaluated

or

unconfirmed

investigations.

More

data

are

needed

in

these

areas

to

assist

in

the

management

of

children

presenting

with

STDs

and

to

determine

whether

all

cases

of

CSA

should

be

screened

for

infection,

regard-

less

of

symptomatology.

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1990:821-42.

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