Abuse, Pediatric (Nonaccidental Trauma [nat])



  • Child abuse impacts up to 14 million or 2–3% of U.S. children each year
  • 1,200–1,400 children die of maltreatment each year in the U.S. Of these, 80% <5 yr and 40% <1 yr
  • Mandated reporters of suspected abuse or neglect include all health care workers
  • Risk factors:
    • Child: Usually <4 yr, often disabled or special needs (“vulnerable child”), premature birth, or multiple birth
    • Abusive parent: Low self-esteem, abused as child, violent temper, mental illness history, rigid and unrealistic expectations of child, or young maternal age
    • Family: Monetary problems, isolated and mobile, or marital instability
    • Poor parent–child relationship, unwanted pregnancy
    • Abuse affects all races, ethnicities religious, and socioeconomic groups


Signs and Symptoms

  • Begin with open-ended questions about injury and mechanism
  • No all-inclusive list of signs of abuse
  • Seek environmental information from prehospital personnel
  • Patterns of presentation that should raise concern for abuse or neglect:
    • History and mechanism inconsistent with injury or illness
  • Unexplained death, apnea, and injury
  • Unexplained ingestion or toxin exposure:
    • Recurrent injury
    • Parent/caregiver reluctant to give information or denies knowledge of how injury occurred
    • Discrepant or inconsistent histories among different caregivers
    • History of injury incident changes over time
    • Injury does not correlate with child's developmental abilities
    • Inappropriate response of care provider to injury or illness; delay in seeking care
  • Munchausen by proxy:
    • Recurrent illness without medical explanation
    • Unexplained metabolic disorder suspicious for poisoning
  • Failure to thrive:
    • Inadequate caloric intake secondary to poor parental bonding/neglect
    • Review of past ED encounters and primary care visits may be helpful to identify trends in development and weight gain

Physical Exam
  • Injury not consistent with history
  • Injuries from nonaccidental trauma are generally of greater severity than from accidental trauma
  • Cutaneous bruising/contusions:
    • Before child is mobile. Bruising is uncommon before 5 mo without trauma
    • Regular pattern, straight line of demarcation, regular angles, slap marks from fingers, dunking burns (stocking or glove burns or doughnut shaped), bites, strap, buckle, cigarette burns
    • Location: Buttocks, hips, face (not forehead), arms, back, thighs, genitalia, or pinna
    • Aging of bruises:
      • Often different ages of bruises
      • Yellow bruises are older than 18 hr
      • Red, blue and purple, or black color may occur from 1 hr after injury to resolution
      • Red may be present irrespective of age
      • Bruises of identical age and cause on the same person may appear to be different
  • Skeletal trauma:
    • Usually multiple, unexplained, various stages of healing
    • Metaphyseal or corner (classic metaphyseal lesions) fractures (pathognomonic)
    • Skull fractures that cross suture lines
    • Posterior rib fractures (rib fractures almost never occur in infants from CPR)
    • Spiral fractures of long bones
    • Subperiosteal new bone formation
    • Uncommon fractures (vertebrae, sternum, scapula, spinous process) without significant mechanism
  • CNS:
    • Altered mental status or seizure
    • Head trauma is leading cause of death in child abuse
    • Skull fracture: Must consider child abuse in children <1 yr
    • Subdural hematoma, subarachnoid hemorrhage
    • Shaken baby syndrome with shearing and rotational injury
  • Ocular findings:
    • Retinal hemorrhage or detachment:
      • 65–90% of abusive head injury has retinal hemorrhage (commonly bilateral) while present in only 0–10% severe accidental trauma
      • Rare in the absence of evidence of head trauma and normal neuroimaging
    • Hyphema
    • Corneal abrasion/conjunctival hemorrhage
    • Ophthalmologic exam recommended for children under 3 yr in setting of suspected abuse
  • Oral trauma
  • Abdominal injuries:
    • Lacerated liver, spleen, kidney, or pancreas
    • Intramural hematoma (duodenal most common)
    • Retroperitoneal hematoma
  • Anogenital/sexual abuse:
    • May have normal genitourinary exam
    • May have contusion, erythema, open wounds, scarring, or foreign material (hair, debris, or semen)
    • Presence of STD or pregnancy in child <12 yr
  • Death:
    • Unexplained death

Essential Workup

  • Formal report to appropriate child welfare agency
  • Family and environmental evaluation, in cooperation with responsible child welfare agency
  • Thorough documentation of examination findings
  • Diagram or photograph of bruises is especially helpful

When suspected, health professionals have a legal obligation to report their suspicion to the appropriate authorities

Diagnostic Tests and Interpretation

  • Bleeding screen if there is a history of recurrent bruising or bruising is the prominent manifestation; may usually be done electively: CBC, platelets, PT/PTT, or bleeding time (or PFA collagen epinephrine)
  • If significant blunt trauma, CBC, LFT, amylase, lipase, and urinalysis for hematuria
  • Toxicology, chemistry, and metabolic screens in children with altered mental status
  • Consider other differential considerations

  • Guidelines for obtaining skeletal survey in children without verifiable accidental trauma, inconsistent history, underlying bone fragility, or a significant history of birth trauma:
    • 0–23 mo olds with any of the following with associated fracture(s):
      • History of confessed abuse
      • History of injury during domestic violence
      • History of impact from toy or other object causing fracture
      • Delay in seeking care >24 hr
      • No history of trauma to explain fracture except for following in child >12 mo: Distal buckle fracture of radius/ulna or distal spiral or buckle fracture of tibia/fibula with consistent mechanism
    • 0–11 mo olds with any type of fracture except in the following cases if no additional concerns:
      • Distal radial/ulna fracture or toddler fracture of tibia/fibula in cruising child ≥9 mo with trauma history
      • Linear, unilateral skull fracture in child >6 mo with history of significant accidental fall
      • Clavicle fracture attributable to birth
    • 12–23 mo olds with any of following fractures:
      • Rib fracture
      • Classic metaphyseal fracture
      • Complex or ping pong skull fracture
      • Humeral fracture with epiphyseal separation from short (<3 ft) fall
      • Femur diaphyseal fracture from a fall
    • Skeletal survey may be appropriate as clinically indicated
  • Global assessment:
    • Indicated for children <2 yr to exclude unsuspected injuries when abuse suspected
    • In children 2–5 yr, in selected cases where physical abuse is strongly suspected
    • In older children, radiographs of individual sites of injury suspected on clinical grounds
    • Radiographic skeletal survey:
      • Anteroposterior (AP) and lateral skull
      • Lateral cervical spine
      • AP and lateral thoracic and lumbar spine
      • AP and obliques of chest
      • AP pelvis
      • AP humerus, forearm, and hands (bilateral)
      • AP femur, tibia, and feet (bilateral)
    • If fracture identified, get at least 2 views, 90 degrees to original view
    • May need coned-down view of joints for visualization of classic metaphyseal lesions
    • Skeletal scintigraphy provides adjunctive screening if suspicion exists beyond skeletal survey
  • Visceral imaging:
    • Suspected thoracoabdominal injury:
      • Abdominal CT scan with IV and possibly oral contrast
  • Neuroimaging:
    • Nonenhanced head CT with brain, subdural, and bone windowing
    • MRI:
      • Adjunctive in evaluation of acute, subacute, and chronic intracranial injury; useful for shear injuries, evolving hemorrhage, contusion, or secondary hypoxic/ischemic injury

Differential Diagnosis

  • General:
    • Trauma – accidental or birth/obstetrical
  • Cutaneous:
    • Burn – accidental
    • Infection
    • Impetigo/cellulitis
    • Staphylococcal scalded skin syndrome
    • Henoch–Schönlein purpura
    • Purpura fulminans/meningococcemia
    • Sepsis
    • Dermatitis: Contact or photo
    • Hematologic/oncologic disorder (idiopathic thrombocytopenic purpura [ITP], leukemia)
    • Bleeding diathesis (hemophilia, von Willebrand)
    • Nutritional deficiency: Scurvy
    • Cultural healing practices (coining, cupping)
  • Skeletal:
    • Osteogenesis imperfecta
    • Nutritional (rickets, copper deficiency, or scurvy)
    • Menkes syndrome
    • Peripheral sensory impairment (indifference to pain)
  • Ocular:
    • Conjunctivitis
  • Abdomen and GU tract:
    • GI disease (obstruction, peritonitis, or inflammatory bowel disease)
    • GU tract infection/anomaly
  • CNS:
    • Intoxication, ingestion (CO, lead, or mercury)
  • Infection:
    • Metabolic: Hypoglycemia
    • Epilepsy
  • Death:
    • SIDS, apparent life-threatening event (ALTE)


Pre Hospital

  • Diagnosis relies on physical evidence in child and inconsistency with the history and mechanism
  • Examination of the scene may be useful:
    • Evaluate validity of mechanisms
    • General appearance of home
    • Consistency of history by multiple caregivers
    • Evaluation of parent–child interaction

Initial Stabilization/Therapy

As indicated by specific injury

Ed Treatment/Procedures

  • Medical and trauma management as required
  • If child abuse team or specialist available at facility, consult them early in evaluation
  • Mandatory reporting to local child welfare agency of any suspected child abuse to determine appropriate social disposition:
    • This does not imply or require 100% certainty of abuse
    • Expedited family, environmental, and social evaluation
    • Essential to be nonjudgmental
  • Communication with family about report and primary concern is responsibility of child welfare:
    • Security may be required to protect child and staff
  • Siblings and other household children must be examined in appropriate time frame

Ongoing Care


Admission Criteria
  • Observation and intervention for traumatic injury
  • Concerns about disposition or lack of availability of child welfare receiving site, if required
  • Goal must always be to ensure safety of child and siblings

Discharge Criteria
  • Adequate ED evaluation and medical follow-up
  • Safe setting for child must determine disposition
  • An abused child has a significant chance of further abuse so disposition must be determined in collaboration with social services and family evaluation
  • Child (and siblings) may require placement in foster care

Issues for Referral
  • All patients require referral to the appropriate child welfare agency
  • Other family members may require evaluation before disposition is determined

Pearls and Pitfalls

  • A history inconsistent with the physical findings should lead to a suspicion of NAT
  • Specific injuries are associated with child abuse and necessitate further investigation
  • When child abuse is suspected, it must be reported
  • Medical and trauma management must be implemented in a timely fashion

Additional Reading

  • Escobar MA Jr, Flynn-O'Brien K, Auerbach M, et al. The association of nonaccidental trauma with historical factors, examination findings, and diagnostic testing during the initial trauma evaluation. J Trauma Acute Care Surg. 2017;82:1147–1157.
  • Estroff JM, Foglia RP, Fuchs JR. A comparison of accidental and nonaccidental trauma: It is worse than you think. J Emerg Med. 2015;48:274–279.
  • Fisher-Owens SA, Lukefahr JL, Tate AR. Oral and dental aspects of child abuse and neglect. Pediatrics. 2017;140(2):e20171487.
  • Kleinman PK, ed. Diagnostic Imaging of Child Abuse. 3rd ed. Cambridge, UK: Cambridge University Press; 2015.
  • Maclean MJ, Sims S, Bower C, et al. Maltreatment risk among children with disabilities. Pediatrics. 2017;139(4):e20161817.
  • Mulder TM, Kuiper KC, van der Put GJM, et al. Risk factors for child neglect: A meta-analytic review. Child Abuse Negl. 2018;77:198–210.
  • Pawlik MC, Kemp A, Maguire S, et al. Children with burns referred for child abuse evaluation: Burn characteristics and co-existent injuries. Child Abuse Negl. 2016;55:52–61.
  • Pierce MC, Magana JN, Kaczor K, et al. The prevalence of bruising among infants in pediatric emergency departments. Ann Emerg Med. 2016;67:1–8.
  • Shaahinfar A, Whitelaw KD, Mansour KM. Update on abusive head trauma. Curr Opin Pediatr. 2015;27:308–314.
  • Slovis TL, Strouse PJ, Strauss KJ. Radiation exposure in imaging of suspected child abuse: Benefits versus risks. J Pediatr. 2015;167(5):963–968.
  • Wood JN, Fakeye O, Feudtner C, et al. Development of guidelines for skeletal survey in young children with fractures. Pediatrics. 2014;134:45–62.

See Also


Jody A. Vogel
Suzanne Z. Barkin

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