title: Anogenital and respiratory tract human papillomavirus infections among children: age, gender, and potential transmission through sexual abuse.
abstract: OBJECTIVE
  To evaluate human papillomavirus (HPV) presentation among children <13 years of age and its association with suspected child sexual abuse (CSA), and to assess sexual abuse consideration among different clinical services treating these children.
  
  
  METHODS
  Records of children <13 years of age from 1985 to 2003 were selected for review if the children had a HPV-related International Classification of Diseases, Ninth Revision, code or had been examined in the CSA clinic. Abstracted data included demographic features, clinical findings, clinical services involved, age at diagnosis, age when care was first sought, and age when symptoms were first noted.
  
  
  RESULTS
  HPV was identified by clinical examination and/or biopsy for 124 children, 40 with laryngeal lesions, 67 with anogenital lesions, 10 with oral lesions, and 7 with both anogenital and oral lesions. The mean age at HPV diagnosis was 4.0 +/- 2.9 years, compared with 6.4 +/- 3.0 years for 1565 HPV-negative children. Among 108 HPV cases with data for age when symptoms were first noted, the mean age was 3.3 +/- 2.9 years (median: 2.2 years) for children with anogenital and oral HPV and 2.4 +/- 2.3 years (median: 1.9 years) for children with laryngeal HPV. Among HPV-positive patients, 56% were female, compared with 82% of HPV-negative children. Fifty-five (73%) of 75 children with anogenital HPV infections were referred to the CSA clinic for evaluation, compared with none of 49 children with laryngeal or oral HPV infections treated by the otolaryngology service. Laryngeal cases presented earlier than anogenital and oral lesions. Abuse was considered at least possible for 17 of 55 children with any CSA evaluation. The mean age of likely abused, HPV-positive children was 6.5 +/- 3.8 years (median: 5.3 years), compared with 3.6 +/- 2.3 years (median: 2.6 years) for likely not abused, HPV-positive children. The likelihood of possible abuse as a source of HPV infection increased with age. The positive predictive value of HPV for possible sexual abuse was 36% (95% confidence interval: 13-65%) for children 4 to 8 years of age and 70% (95% confidence interval: 35-93%) for children >8 years of age.
  
  
  CONCLUSIONS
  The data from this epidemiologic study of HPV suggest that many anogenital and laryngeal HPV infections among preadolescent children are a result of nonsexual horizontal transmission, acquired either perinatally or postnatally. It seems that many children >2 years of age acquire HPV infection from nonsexual contact. Different subspecialties vary greatly in their suspicion and evaluation of CSA. At this time, there remains no clear age below which sexual abuse is never a concern for children with anogenital HPV infections. Every case needs a medical evaluation to determine whether enough concern for abuse exists to pursue additional investigations.
authors.affiliation: Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC 27105, USA.
authors.forename: Kelly A
authors.initials: KA
authors.lastname: Sinclair
authors.forename: Charles R
authors.initials: CR
authors.lastname: Woods
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Kirse
authors.forename: Sara H
authors.initials: SH
authors.lastname: Sinal
mesh_terms: D002648:Child; D002650:Child Abuse, Sexual / Q000175:diagnosis; D002675:Child, Preschool; D003218:Condylomata Acuminata / Q000209:etiology*; D005260:Female; D006801:Humans; D007822:Laryngeal Neoplasms / Q000209:etiology* / Q000821:virology; D008297:Male; D009062:Mouth Neoplasms / Q000209:etiology* / Q000821:virology; D010212:Papilloma / Q000209:etiology*; D027383:Papillomaviridae; D030361:Papillomavirus Infections / Q000635:transmission*