Overview
Definition:
Non-accidental trauma (NAT) refers to physical injuries inflicted upon a child by a caregiver or another person in a position of trust
Recognizing red flags for NAT in the emergency department (ED) is crucial for timely identification, intervention, and protection of the child.
Epidemiology:
Child abuse, including physical abuse, is a significant public health issue worldwide
Prevalence varies, but studies indicate a substantial number of children present to EDs with injuries that warrant suspicion for NAT
Age, socioeconomic factors, and caregiver stress are associated risk factors.
Clinical Significance:
Failure to identify NAT can lead to severe consequences, including ongoing abuse, significant morbidity, and mortality
Prompt recognition and appropriate reporting protocols are paramount to ensure child safety and provide necessary medical and social support.
Clinical Presentation
History Gathering:
Inconsistent or vague history provided by caregiver
History that does not match the injury
Delay in seeking medical care
Story changes over time
History of prior injuries or unexplained hospitalizations
Caregiver anxiety or evasiveness
Lack of social support.
Injury Patterns:
Injuries in different stages of healing
Pattern injuries consistent with inflicted force (e.g., belt marks, handprints, cigarette burns)
Fractures in infants under 1 year
Metaphyseal fractures (bucket-handle fractures)
Rib fractures
Bilateral fractures
Injuries to posterior aspects of body
Injuries in unusual locations for accidental trauma (e.g., ears, neck, abdomen).
Childs Demeanor:
Excessive fear or timidity
Lack of crying or seeming unresponsive to pain
Aggression or withdrawal
Signs of regression (e.g., bedwetting)
Reports of abuse by the child (if verbal)
Delay in reporting pain or distress.
Diagnostic Approach
History Taking:
Obtain a detailed history from the child (if age-appropriate and possible) and from the caregiver separately
Ask specific questions about the mechanism of injury
Document the caregiver's explanation verbatim
Inquire about the child's behavior and any concerns about safety at home
Always consider the possibility of NAT, especially with concerning injury patterns or inconsistent histories.
Physical Examination:
Perform a thorough, head-to-toe physical examination
Document all injuries meticulously, including location, size, shape, color, and stage of healing
Examine skin for bruises, burns, lacerations, and abrasions
Pay close attention to the ears, neck, trunk, buttocks, and extremities
Assess for signs of sexual abuse
Check for retinal hemorrhages
Note any signs of neglect (e.g., poor hygiene, failure to thrive).
Imaging Studies:
Skeletal survey for infants and young children with suspected NAT to identify occult fractures
Consider X-rays of specific injured areas
CT scan of the head for suspected head injury
Abdominal imaging (ultrasound or CT) for suspected intra-abdominal injuries
Funduscopy to rule out retinal hemorrhages.
Laboratory Investigations:
Complete blood count (CBC), liver function tests (LFTs), coagulation profile may be useful in cases of severe trauma or suspected internal bleeding
Toxicology screen if substance abuse is suspected in the caregiver
Urine drug screen for the child if appropriate.
Differential Diagnosis:
Accidental trauma (ensure all possibilities are considered and investigated)
Congenital conditions (e.g., osteogenesis imperfecta, bleeding disorders)
Infantile scurvy
Infantile syphilis
Osteomyelitis
Epidermolysis bullosa
Burns from non-accidental causes vs
accidental scalds or contact burns.
Red Flags Checklist
Injury Characteristics:
Injuries in different stages of healing
Unexplained injuries
Patterned injuries
Fractures in infants
Metaphyseal fractures
Rib fractures
Multiple fractures
Injuries to posterior surfaces.
History Inconsistencies:
Vague or conflicting history
History not matching injury
Delay in seeking care
Caregiver evasiveness
Repeated unexplained injuries.
Child Behavior:
Extreme fear, withdrawal, or aggression
Lack of appropriate emotional response
Reports of abuse by the child.
Caregiver Factors:
Lack of social support
History of substance abuse or domestic violence
Previous reports of child abuse
Dominant caregiver who controls information.
Management And Reporting
Immediate Actions:
Provide immediate medical care to the child
Stabilize any life-threatening injuries
Ensure the child is safe and protected from further harm within the ED environment
Consider separation of child and caregiver if safety is a concern.
Multidisciplinary Approach:
Involve a multidisciplinary team, including pediatricians, ED physicians, nurses, social workers, child protective services (CPS), and law enforcement
This collaborative approach ensures comprehensive assessment and appropriate care planning.
Reporting Protocols:
Follow institutional and legal mandates for reporting suspected child abuse to Child Protective Services and/or law enforcement
Documentation must be thorough, objective, and include all observations, history, examination findings, and investigations
Maintain confidentiality as per legal requirements.
Supportive Care:
Provide emotional support to the child
Address pain management
Ensure adequate nutrition and hydration
Offer psychological support for the child and any non-offending caregivers.
Key Points
Exam Focus:
Recognize that any injury in a young child (especially < 2 years) can be non-accidental until proven otherwise
The classic "bucket-handle" fracture and rib fractures are highly suggestive of NAT
Always consider NAT in cases of unexplained injuries, especially in infants and toddlers
Mandated reporting is a legal and ethical obligation.
Clinical Pearls:
Separate caregivers for history to elicit more accurate information
Look for injuries on the posterior surfaces of the body
Do not hesitate to consult with social work or child protection services
Thorough documentation is critical for legal and medical purposes.
Common Mistakes:
Assuming an injury is accidental without thorough investigation
Failing to obtain a complete history or perform a detailed examination
Not considering the possibility of NAT in atypical injury presentations
Delaying reporting to authorities
Inadequate documentation.