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Acquired syphilis in children: A widely neglected public health issue

I read with great interest the article “Acquired syphilis in children: A retrospective study over two-and-a-half decades in a tertiary care center in northern India” by Surabhi Dayal et al in this month's journal. Syphilis is primarily a sexually transmitted disease (STD) caused by Treponema pallidum (T pallidum). We know that children can become infected with syphilis not only through vertical transmission during pregnancy or delivery (congenital syphilis), but also in ways similar to adults (acquired syphilis). However, although much concern is focused on congenital syphilis, acquired syphilis in children receives little attention. The vast majority of cases of acquired syphilis in children are caused by sexual transmission such as sexual abuse or assault by an infected adult, especially in underdeveloped areas. Some cohorts being assessed for sexual abuse in children reported around 1%-5% of cases having a STD. 1,2 Reading et al reported 15 cases of children with STDs, of whom 11 had physical signs associated with sexual abuse.3 In another report of 96 cases of patients with STD under 14 years old, 67% cases of all STD and 90% of syphilis infections were confirmed to have a history of sexual abuse, while in the remaining cases there was high suspicion.4 In fact, it is difficult to verify sexual abuse in some cases unless there is sufficient evidence, for example, allegations made by the child or others, identification of the same infection in alleged perpetrators, or physical signs of genital trauma. Although acquired syphilis in children is most often attributed to sexual abuse, infection can occur through nonsexual transmission. T pallidum can be present in various body fluids such as saliva, blood, sperm, and also in active skin lesions. When family members or caregivers have active syphilis, it can be transmitted to children via kissing, fondling, breastfeeding, prechewed food feeding, or even by sharing contaminated utensils. Previously, we had reported three cases of preschool children with syphilis, acquired non-sexually via close contact with infected family members but without any evidence of sexual abuse.5 The intimate relationship between infected caregiver and child make such transmission possible, yet this mode of transmission has not been fully recognized. Therefore, routine examination and follow-up of familial contacts with patients with active syphilis should be carried out. There have only been scattered cases of acquired syphilis in children reported in the past. As the authors stated, the actual prevalence might have been significantly underestimated, in part because of social inhibitions and reluctance to report child sexual abuse. Early recognition and treatment of syphilis in children is important for prevention of transmission to others and development of tertiary cardiovascular and neurosyphilis. When skin lesions on the genital or peri-genital area occur in a child, syphilis should be suspected and screened. Once syphilis is confirmed in a young child, sexual abuse should be actively considered and investigated, and further epidemiologic investigation needs to be conducted. However, preventing syphilis infection in children is long-term and challenging work, due to the high incidence of syphilis infection in adults.