Abuse, Pediatric (Nonaccidental Trauma [nat])
Basics
Description
Description
- 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
Diagnosis
Signs and Symptoms
HistorySigns 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
- Retinal hemorrhage or detachment:
- 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
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
ALERT
When suspected, health professionals have a legal obligation to report their suspicion to the appropriate authorities
Diagnostic Tests and Interpretation
LabDiagnostic 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
Imaging
- 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
- 0–23 mo olds with any of the following with associated fracture(s):
- 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
- Suspected thoracoabdominal injury:
- 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
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)
Treatment
Pre Hospital
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
Initial Stabilization/Therapy
As indicated by specific injury
Ed Treatment/Procedures
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
Disposition
Admission CriteriaDisposition
- 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
See Also
Authors
Jody A. Vogel
Suzanne Z. Barkin
© Wolters Kluwer Health Lippincott Williams & Wilkins
Citation
Schaider, Jeffrey J., et al., editors. "Abuse, Pediatric (Nonaccidental Trauma [nat])." 5-Minute Emergency Consult, 6th ed., Lippincott Williams & Wilkins, 2020. Emergency Central, emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307677/all/Abuse__Pediatric__Nonaccidental_Trauma_[nat]_.
Abuse, Pediatric (Nonaccidental Trauma [nat]). In: Schaider JJJ, Barkin RMR, Hayden SRS, et al, eds. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307677/all/Abuse__Pediatric__Nonaccidental_Trauma_[nat]_. Accessed December 9, 2024.
Abuse, Pediatric (Nonaccidental Trauma [nat]). (2020). In Schaider, J. J., Barkin, R. M., Hayden, S. R., Wolfe, R. E., Barkin, A. Z., Shayne, P., & Rosen, P. (Eds.), 5-Minute Emergency Consult (6th ed.). Lippincott Williams & Wilkins. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307677/all/Abuse__Pediatric__Nonaccidental_Trauma_[nat]_
Abuse, Pediatric (Nonaccidental Trauma [nat]) [Internet]. In: Schaider JJJ, Barkin RMR, Hayden SRS, Wolfe RER, Barkin AZA, Shayne PP, Rosen PP, editors. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. [cited 2024 December 09]. Available from: https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307677/all/Abuse__Pediatric__Nonaccidental_Trauma_[nat]_.
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