Nonaccidental Trauma

EXECUTIVE SUMMARY

• The child’s medical history should be assessed for “red flags,” such as an inconsistent or changing history provided by the caretakers, an unwitnessed injury, any delay in presentation to the emergency department, multiple prior visits, a history of domestic violence at the home, prematurity in the infant, low birth weight, and any chronic medical conditions.
• As much as possible, the physical exam should be conducted and thoroughly documented before any care is initiated. Routine interventions, including line placement, laboratory draws, bandaging, skin preparation, or catheter placement, may alter any physical evidence and confound future investigation.
• Bruises are the most common sentinel injury of nonaccidental trauma (NAT). In many cases, bruising may be the sole indicator of physical abuse. Unfortunately, it is the most common injury to be missed on initial diagnosis before death or near death due to NAT.
• TEN-4-FACESp may be used as a screening tool for high-risk bruising. Any bruising on the torso, ears, and neck in children aged ≤ 4 years can be considered high risk for abuse. The TEN-4-FACESp screening tool has a sensitivity of 96% and a specificity of 87%. Simultaneously, any bruising in pediatric patients younger than 6 months of age can be considered high risk.
• Oral NAT may result from sexual abuse. Abrasions and bruising to the palate, particularly the junction between the soft and hard palate, should be regarded with a high degree of suspicion.
• Cases of abusive head trauma (AHT), often due to violent shaking or intentional impact, are an exceptionally lethal subset of NAT, with 25% to 30% of cases fatal. Even moderate cases of AHT have been shown to have higher rates of morbidity and mortality when compared to similar cases of accidental traumatic brain injury.
• Retinal hemorrhages are present in up to 85% of AHT cases, and they have a sensitivity and specificity for NAT of approximately 75% and 93%, respectively.
• In cases of suspected acute AHT, noncontrast head computed tomography should be used for an acute assessment. Magnetic resonance imaging may be used subsequently to assess for vascular injuries, diffuse axonal injury, and edema.

Nonaccidental trauma is a significant problem in emergency medicine and serves as the frontline of defense and protection for children. All providers must have a high degree of suspicion for the sometimes subtle presentation of an abused child. Early diagnosis and timely intervention are the only ways to allow these vulnerable children a chance at a normal, healthy life.

— Ann M. Dietrich, MD, Editor

Introduction

Nonaccidental trauma (NAT), or physical child abuse, poses a significant threat to pediatric health in the United States.¹ In 2014, approximately 702,000 children in the United States were abused or neglected.² In 2015, 683,000 children experienced NAT or neglect, leading to a cost of approximately $103 billion. These data likely significantly underestimate the scale of the problem.³ Some sources estimate the annual number of children victimized by NAT in the United States is closer to 1 million.⁴ Research into this area often is poorly funded and challenging to publish, particularly when dealing with the details of individual cases.⁵

The negative effects of NAT may linger for a lifetime. Since the Centers for Disease Control and Prevention (CDC)-Kaiser adverse childhood experience (ACE) study of the late 1990s, a growing body of research demonstrates that adults who had ACEs as children have significantly higher mortality than their peers, with a significantly increased risk in the nervous, musculoskeletal, cardiovascular, gastrointestinal, and metabolic systems, as well as higher rates of substance abuse and psychological distress.^6-9 ACEs encompass several categories of abuse, including sexual, emotional, and physical.⁶ Having four or more ACEs appears to double the risk of chronic diseases such as type 2 diabetes. Six or more ACEs can reduce expected lifespan by up to 20 years.⁶ Poor health behaviors and a reduced ability to cope with stress can linger for decades afterward.¹⁰ Given this, the potential long-term sequelae of NAT cannot be overstated.⁶

The burden on society from NAT and neglect continues to rise. In the United States alone, approximately 1,660 children are known to have died from these causes in 2015, with a subsequent increase to 1,710 in 2017 and 1,840 in 2019. This estimate likely significantly underestimates the extent of the problem.¹¹ Unfortunately, the incidence of NAT appears to have significantly increased during the COVID-19 pandemic, possibly due to an increase in economic insecurity, social isolation, and reduced access to safe childcare facilities such as daycares and schools.¹² Emergency department (ED) physicians must be able to accurately and thoroughly screen, evaluate, diagnose, and treat NAT in an effective and timely manner.

Screening

Approximately two of every three patients younger than 1 year of age who died from NAT were evaluated in an emergency department (ED) prior to the fatal incident, with rates of recurrent injuries due to NAT as high as 30% to 50%.^4,13 Mortality from NAT also increases with recurrent episodes. An initial episode of NAT has a mortality of approximately 10%, compared to 25% for repeated episodes.⁴ One retrospective study of 1,361 children with suspected NAT found that 25% of children presented with recurrent episodes within one year. Typically, their initial presentation was judged as a “minor” injury by the clinician who assessed them.¹³ Given this, ED clinicians must use effective screening tools for early recognition of NAT.

Unfortunately, screening for suspected child abuse often is difficult in the ED. Factors limiting screening include physician bias, a desire to believe caregivers, limited time and resources, and a lack of ongoing contact with a family.¹⁴

Currently, there is no universally accepted screening tool for NAT. Tools for screening vary across hospitals and institutions. Several red flag presentations are recommended in most screening tools, generally organized into three categories: history, physical exam, and laboratory/radiographic findings.⁴

The child’s medical history should be assessed for an inconsistent or changing history provided by the caretakers, an unwitnessed injury, any delay in presentation to the ED, multiple prior visits, a history of domestic violence at the home, prematurity in the infant, low birth weight, and any chronic medical conditions.⁴ (See Table 1.) Social history is particularly important, and providers often neglect this area. The caregivers’ history of drug/alcohol use, mental health, and criminal history must be assessed. Any discomfort in gathering this history can be mitigated by using a standardized note in the electronic medical record (EMR) and framing the questions as a routine inquiry.⁴ Delays in presentation after the injury may be indicative of NAT and may raise the risk of mortality.⁵

Age is another risk factor for NAT. The majority of NAT victims are younger than the age of 2 years.¹⁵ Children younger than 1 year of age have a 10-fold increased risk of mortality from NAT than older children.¹⁶ African-American children have a higher risk of mortality due to NAT; in a 2007-2014 review of the National Trauma Databank, researchers found that African-American children were disproportionately represented in 27% of all cases of NAT.^1,15 Socioeconomic status also is a significant factor. Children in a household with an income of less than $15,000 annually are 22 times more likely to experience generalized maltreatment than children with household incomes greater than $30,000.¹⁷ Further factors to assess in caregivers include a lack of community support, depression, history of suicide attempts, unplanned pregnancy, abandonment as a child, short birth intervals, and an elevated number of separations from the child in the first year of life.¹⁵

Economic factors may play a role. One study found a doubling in the rate of nonaccidental head trauma during an economic recession.¹⁵ Another study conducted at a Level I pediatric trauma center found that NAT was responsible for 4% of all pediatric trauma patients in 2019; this increased to 13% during the COVID-19 epidemic. The researchers proposed economic insecurity as one of the possible drivers for this significant increase.¹² However, it is essential to emphasize that NAT is found across all socioeconomic groups. It is important that providers understand their bias and avoid anchoring. Up to one-third of cases of abusive head trauma (AHT), a subset of NAT, are missed by clinicians. These missed cases tend to be found in younger, white families with two parents.¹⁶

Screening tools to identify NAT also are particularly effective in low-resource settings and are recommended in settings such as a community or rural ED.³ Unfortunately, standardized screening tools are less likely to be used at non-pediatric trauma centers or hospitals that encounter low levels of NAT.³ Given their proven effectiveness, hospitals should use a standard checklist of concerning past medical history and social history findings for suspected NAT.³ Even including a simple standardized flowchart to facilitate the workup of suspected NAT cases may improve screening.¹⁸ Using a standardized tool can reduce the likelihood of bias by making the workup for NAT standardized.

History

Gathering a thorough history from pediatric patients in the ED setting often is difficult for several reasons, including overcrowding and lack of a prior relationship with the patient.¹⁹ It is important for ED physicians to remember that most children being evaluated for abuse will have full forensic interviews, coordinating law enforcement, medical services, and child protective services, at a Children’s Advocacy Center (CAC).²⁰ Interviews in the ED should focus instead on determining if there are any life-threatening causes of injury. Physicians should ask pediatric patients brief and open-ended questions such as “Do you know why you are here?” or “Is there anything that hurts you at all?” Children should not need to repeat themselves when possible, given the risk of changing their story. If appropriate, rapport-building strategies, such as talking, sharing toys, and drawing projects, also may be employed.²¹

Physical Exam

As much as possible, the physical exam should be conducted and thoroughly documented before any care is initiated. Routine interventions, including line placement, laboratory draws, bandaging, skin preparation, or catheter placement, may alter any physical evidence and confound future investigation.¹⁶ Photographs should be used to document any external signs of injury, particularly bruising.²² However, some institutions may require photographs to be taken by a police officer or forensic investigator. Given that perpetrators of NAT are only found guilty in 29% of cases, it is strongly encouraged that providers be extremely diligent and careful about following their institution and local law enforcement guidelines regarding photographic documentation.²³ Rulers should be included in all pictures for scale, and photographs should be consistent with the descriptions in the chart’s written documentation. While suspected victims of NAT typically are brought to the hospital due to an isolated injury — most often bruising, followed by an extremity fracture — it is essential that a full physical exam be conducted in these patients because of the number of other injuries that may be present.²⁴ It is recommended that clinicians use phrases such as, “We are going to get a checkup just like at the doctor’s office” and “We have to look at every little bit of you to make sure you are healthy” during the exam to normalize the process and reassure the patient.

General Presentation

The initial stages of a physical exam should assess the patient for signs of altered mental status. This may present as inconsolable crying, irritability, lethargy, or drowsiness. The patient’s Glasgow Coma Scale (GCS) score also should be assessed. The possibility of AHT should be taken very seriously by clinicians; a GCS score of 9-11 in a child with moderate AHT is comparable in severity to a severe accidental traumatic brain injury (TBI) with a GCS score of less than 9.¹⁶ Cases concerning for severe AHT should be treated as trauma patients, with attention paid to advanced trauma life support (ATLS) and the identification of life-threatening injuries first. Once the patient is stabilized, the remainder of the NAT workup can be completed.

Skin Exam

Bruises are the most common sentinel injury of NAT.¹⁶ In many cases, bruising may be the sole indicator of physical abuse.²⁵ Unfortunately, it is the most common injury to be missed on initial diagnosis before death or near death due to NAT.²⁶ Age is an important factor in the assessment of bruising — it is rare for infants younger than the age of 9 months to display bruising before they are able to cruise; children younger than 6 months of age have a prevalence of any bruising of approximately 0.6%.¹⁶ Bruising is exceptionally uncommon in the first five months of life; a 2017 study found a bruising prevalence of less than 2% in this patient population.²⁷ Bruising increases in prevalence as pediatric patients are able to cruise, typically between 6 and 12 months of age.²⁷ Of note, no specific method currently exists for determining the age of a bruise based on appearance. However, one concerning feature is bruises in multiple stages of healing without explanation.²⁸

Bruises are missed in up to one-third of cases of NAT. Bruising in young children should be taken seriously and documented thoroughly.²⁷ Bruises should be evaluated in terms of their location, shape, and pattern.¹⁵ Bruises due to NAT tend to be located away from bony prominences and on the cheeks, neck, genitals, buttocks, and back.¹⁵

In addition to this, a 2021 cross-sectional study of 2,161 children found that the buttocks, genitals/anus, angle of the jaw, and neck were the most specific regions for bruising in the setting of NAT.²⁶ In the recent literature, researchers also have identified palmar bruising in infants as possible evidence of NAT. This may be caused by forceful squeezing of an infant’s hand, leading to bruising on the palmar eminences, interdigital creases, and palmar creases.²⁹ Multiple bruises from a single reported incident also should be investigated with high clinical suspicion.²² Bruises that present with the shapes of hands, belts, utensils, cords, and other objects used to cause the injury also are strongly indicative of NAT.¹⁵ Up to 94% of patterned bruises in a study of more than 2,000 children were categorized as NAT.²⁶ One popular clinical decision rule, the TEN-4-FACESp, may be used as a screening tool for high-risk bruising. Any bruising on the torso, ears, and neck in children aged ≤ 4 years can be considered high risk for abuse. The TEN-4-FACESp (torso, ears, neck, frenulum, angle of the jaw, cheeks, eyelids or subconjunctivae; infants 4 months of age or younger with any bruise; and patterned bruising are suggestive of abuse) screening tool has a sensitivity of 96% and a specificity of 87%.²⁶ Simultaneously, any bruising in pediatric patients younger than 6 months of age can be considered high risk.²⁵ Perineal bruising appears to be particularly associated with increased morbidity and mortality.⁴

Of note, bruising also may have benign causes, such as bleeding disorders, birthmarks, or simple accidental bruises.²⁵ Accidental bruises typically are found over the bony prominences (for example, the knees, elbows, and forehead) in children who are able to cruise or walk.¹⁵ Certain cultural practices, such as cupping, may imitate abusive bruising.¹⁶ Cupping is a 2,000-year-old therapy that originated in ancient China.³⁰ People who receive this treatment may develop signature bruising.

Other false positives include birthmarks and bruises not present in high-risk areas for children of cruising age or older.²⁵ In addition to this, bruising may be more challenging to visualize in children with darker skin tones.²⁶ When in doubt, areas of concern should be documented thoroughly, preferably with high-quality photographs and uploaded to the patient’s EMR.²²

Burns

In the United States, burn injuries are the third most common cause of pediatric mortality.³¹ As of 2015, there are nearly 110,000 annual visits to U.S. EDs for pediatric thermal burns.³² While the majority of pediatric burns are accidental, burn injuries may be involved in 6% to 20% of child abuse cases.³¹

Burns generally are associated with younger children. Approximately 70% of pediatric patients who present with burns are younger than 5 years of age, typically due to exploring their environment and accidental exposures to common household items, such as hot liquids or stoves.³³ However, even accidental burns at a sufficiently young age are cause for concern. Children younger than 3 years of age who present with burns are seven times more likely to suffer from NAT or neglect by the age of 6 years, regardless of the cause of their initial burn.³³ Scalds are the most common burn type in young children and the predominant burn type associated with NAT.³³ Scalding due to immersion in hot water appears to be significantly associated with NAT, while scalding secondary to hot food or drink is more likely accidental in nature.³³ Accidental contact burns, such as those sustained by touching an iron or hot surface, are more likely to be found on the hands. Contact burns due to NAT have a wider distribution to the extremities as well.³³ Up to 45% of genital and perineal burns can be attributed to abuse.¹⁵

There are conflicting data regarding burn severity in cases of accidental burns vs. NAT. Some studies have found no significant difference in burn size and depth between these two groups, while others have concluded that NAT cases are significantly more likely to have larger and more severe burns.^31,34,35 Likewise, there are conflicting data regarding any significant difference between the mechanism of the burn and the burn’s location between accidental and NAT-caused burns.³¹ However, recent literature suggests that NAT-associated burns are more likely to present with hot water as a mechanism, immersion scalding, full-thickness burns, and other injuries. An inadequate explanation by caregivers also appears to be significantly associated with NAT, along with factors such as blaming a sibling or a “trigger event,” such as the child soiling themselves prior to the burn.³³ Recent data also suggest that burns involving the buttocks, genitalia, and lower limbs are more associated with NAT than burns on the arms, face, neck, and torso, which are more likely to be associated with accidents.³³ Burns to the lower extremities appear to be particularly associated with NAT.³⁶

Children presenting with suspicious burns must be thoroughly investigated in the ED. A 2016 study found that children who presented with burns had a less thorough workup than children with other concerning features for NAT. The most glaring absence was the widespread failure of ED physicians to order skeletal surveys in the presence of burns with associated occult fractures.³³

Oral Injuries

More than half of NAT cases present with injuries to the head or neck.³⁷ Despite accounting for approximately 12% of NAT injuries, intraoral injuries often are underreported and undiagnosed.³⁸ This underreporting may be attributed due to poor clinician awareness of underlying NATs — the actual incidence is likely much higher.³⁹ Many children who experience this type of abuse are denied adequate dental care due to fear of exposure by their abusers.³⁷ Given this, there exists a significant gap in the current medical literature regarding this subset of NAT.⁴⁰ Even with this underreporting, intraoral injuries are the second most common sentinel injury of NAT after bruising.³⁹

Further complicating the issue is the high prevalence of dental trauma in the pediatric population. A 2019 study of 1,546 North Carolina children ranging in age from 24-71 months had a 47% prevalence of traumatic dental injury.⁴¹ Although many of these cases ranged from simple crown fractures to extensive fractures, 8% of these cases still were considered severe traumatic dental injury.⁴¹ Given this high prevalence, ED clinicians should thoroughly assess the patient’s history and remaining physical presentation for any other signs of possible NAT.

NAT most commonly presents in the oral system as lacerations and bruising to the lips.³⁹ Further oral injuries include a wide range of pathologies, such as abrasions; intraoral burns of the palate, lips, mucosa, and tongue; jaw and tooth fractures; and even discoloration of the teeth from previous trauma.^39,40 Mechanisms of abuse include sharp objects, caustic and scalding liquids, and forceful insertion of foreign objects.³⁹ Lingual and labial frenula tears also are associated with NAT in pre-cruising infants.³⁹ Any injuries to the hypopharynx and esophagus — from penetrating trauma, caustic substance ingestion, or forced foreign body ingestion — are much rarer, but immediate evaluation and treatment should include assessment for possible NAT.³⁹

Oral NAT may result from sexual abuse as well. Abrasions and bruising to the palate, particularly the junction between the soft and hard palate, should be regarded with a high degree of suspicion.³⁹ Testing for oral sexually transmitted infections (STIs) in this patient population remains controversial, as oral gonorrhea is rarely seen, and oral human papillomavirus (HPV) often is an incidental finding.³⁹ It is important to note that the presence of an STI in pediatric patients can have extremely serious legal consequences.⁴² Many common STI tests are not admissible in court.⁴² A full discussion of the legal ramifications is outside the scope of this article.

As with other injuries, oral injuries should be regarded with more suspicion in the event of conflicting/inconsistent history or unwitnessed events. Patients still unable to cruise are particularly vulnerable to oral injuries sustained from NAT.³⁹ Evidence of extensive dental neglect also should be cause for suspicion.³⁹ Providers should obtain a thorough history. Children may sustain oral injuries from falling while running with objects in their mouths. However, in the absence of a compelling story, providers should have a high degree of clinical suspicion. Oral injuries are rarely iatrogenic; even in cases of endotracheal intubation, pediatric patients are unlikely to sustain any injuries that may mimic NAT.⁴³

Unfortunately, the data on oral manifestations of NAT remain lacking, with no specific signatory pattern currently identified in the literature out of 26 recent publications.⁴⁰ Presentations of NAT in this subset may be highly heterogeneous.⁴⁰ Given this, it is recommended that even apparently minor oral injuries be taken with a high degree of clinical suspicion and thoroughly documented. When possible, dental professionals should be consulted.³⁷

Fractures

Fractures may be concerning for NAT, especially in younger patients. They typically require more strength to inflict than soft tissue injuries and so are concerning for particularly violent outbursts of abuse, often incited by feelings of stress, anger, or frustration.⁴⁴ One in eight pediatric patients younger than the age of 18 months presenting with a fracture may be the victim of NAT.¹⁵ Approximately 5.6% of fractures in children younger than the age of 36 months may be caused by NAT.⁴⁴

Fractures are extremely rare before children are able to ambulate.⁴⁴ Caregivers may attempt to explain pre-ambulatory fractures through a child getting a leg entrapped in a crib or cot’s bars. However, this is an unlikely cause of injury, especially given pediatric bones’ natural resistance to tensile loading; any history that involves this as a mechanism should be regarded with suspicion.⁴⁴ In general, if the reported accident and the child’s developmental stage are inconsistent with the fracture, clinicians should investigate further.⁴⁴ Multiple fractures, fractures in various stages of healing, and other injuries also significantly raise the risk for NAT.⁴⁴

Classical metaphyseal lesions (CMLs), also known as “corner” or “bucket-handle” fractures, are considered pathognomonic for NAT. CMLs occur through significant torsion/traction on the growth plate, creating a fracture through immature metaphyseal bone.⁴⁵ CMLs are strongly associated with other traumatic injuries — a 2016 retrospective study found that 84.0% of children with a CML had at least one additional fracture.⁴⁶ Physicians who find any evidence of CMLs should immediately order a skeletal survey and assess for any further evidence of abuse.⁴⁶

Rib fractures — particularly in the absence of any associated trauma to the chest — often can be caused in NAT cases by violent squeezing and compression.¹⁵ One retrospective study found that 69.4% of rib fractures in children aged 0-11 months were caused by NAT.⁴⁴ Even in older age groups, rib fractures are highly predictive of abuse, and in the absence of a compelling history such as a motor vehicle collision (MVC) or confirmed accidental trauma, have a 71% probability for NAT.⁴⁴ While rare, rib fractures can occur in accidental trauma; however, in these cases, the rib fractures will present acutely and will not display evidence of healing consistent with NAT.⁴⁷ Posteromedial rib fractures are particularly specific for NAT.⁴⁸ Rib fractures in children younger than 18 months of age have an odds ratio of 23.7 that the fracture was due to NAT.⁴⁹ Computed tomography (CT) imaging is significantly more effective at identifying rib fractures than X-ray imaging of the chest.⁵⁰ Per recent American College of Radiology (ACR) guidelines, adding oblique views of the ribs to the skeletal survey (discussed later) also significantly increases the detection of rib fractures.⁵¹

More than half of all fractures to the radius, ulna, tibia, and fibula in this patient population also were attributed to NAT.⁴⁴ Other presentations include spiral or oblique fractures to the long bones. Spiral fractures of the humeral shaft often are found in NAT as a result of twisting injuries.¹⁵ However, recent evidence has shown that spiral fractures of the tibial shaft may be due to accidental causes in toddlers who are able to ambulate.⁴⁴ Recent guidelines do not recommend skeletal surveys be ordered routinely in toddlers with spiral fractures of the tibia/fibula if the patient fell while running, nor in buckle fractures of the distal radius/ulna if the patient fell onto an outstretched hand.⁵² Likewise, a history of diseases such as chronic renal disease, osteogenesis imperfecta, and rickets may be a benign cause of fractures in multiple stages of healing.¹⁵ However, even children who are able to ambulate have an extremely low risk of femur fractures or epiphyseal dislocations, which require significant amounts of force.⁴⁴

Skull fractures are common in both infancy and early childhood.⁴⁴ A large meta-analysis of 6,646 children with isolated skull fractures (ISF) concluded that clinically stable patients with linear, nondisplaced, and isolated fractures may be safely managed in an outpatient setting.⁵³ Although this condition typically is considered low risk, it is recommended that children presenting with ISF be screened for NAT.^54,55 Clinical decision-making rules, such as the Pediatric Emergency Care Applied Research Network (PECARN), Canadian Assessment of Tomography for Childhood Head Injury (CATCH), and Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) tools, are effective at identifying any children with head trauma that may require further intracranial imaging.⁵⁶ Patients with skull fractures secondary to NAT often have much more severe injuries and are more likely to require significant neurosurgical intervention.⁵⁷ The PECARN traumatic brain injury low-risk criteria accurately identified infants younger than 3 months of age at low risk of clinically important traumatic brain injuries. However, infants at low risk for clinically important TBIs remained at risk for TBIs on CT, suggesting the need for a cautious approach in these infants.

Spine fractures are a rare complication of NAT, appearing in less than 1.5% of cases, with an average age of 7 months.¹⁵ These cases typically are managed conservatively.¹⁵

Table 2 lists concerning fractures for NAT.

Abusive Head Trauma

Cases of AHT, often due to violent shaking or intentional impact, are an exceptionally lethal subset of NAT. Commonly referred to as “shaken baby syndrome,” 25% to 30% of cases are fatal, and only 15% of victims will survive without any sequelae.¹⁵ Even moderate cases of AHT have been shown to have higher rates of morbidity and mortality when compared to similar cases of accidental TBI.¹⁶ Permanent disability, including blindness, seizures, and cerebral palsy, is common.¹⁵ While cases are difficult to track, they appear to occur at approximately 27.5 to 32.2 out of 100,000 infants younger than the age of 1 year.¹⁶

Unlike a relatively minor ISF, AHT is the deadliest complication of NAT.⁵⁸ AHT may be challenging to diagnose because it may present with vague symptoms, such as lethargy, reduced appetite, vomiting, or irritability.¹⁵ These cases should not be missed; mortality is as high as 25%. Survival is associated with extremely poor neurological outcomes, ranging from epilepsy to cognitive and behavioral disorders.⁵⁹

The early neurodevelopment of the pediatric brain makes it especially vulnerable to trauma and long-term sequelae.⁶⁰ Cases of AHT are more severe in younger children; infants are especially susceptible to cerebral injuries due to an enlarged cranium. Most cases occur in children younger than 2 years of age; anywhere from 17% to 56% of TBI in infants may be due to AHT.⁵⁹ Male children appear to be at a higher risk.⁶⁰

Clinical diagnosis of AHT depends on a number of factors. In addition to the nonspecific symptoms discussed earlier, a significant number of patients will have seizures on presentation; patients also may have apnea as well.^15,60 Unlike ISF, AHT patients may present with complex skull fractures.⁶⁰ Retinal hemorrhages are present in up to 85% of AHT cases, and they have a sensitivity and specificity for NAT of approximately 75% and 93%, respectively.^15,60 In addition to retinal hemorrhages, AHT patients may present with lacerations to the eyelid, periorbital hematomas, cataracts, glaucoma, papilledema, and other ocular manifestations.¹⁵ Unfortunately, a proper funduscopic examination often is difficult in the ED setting, particularly with pediatric patients, and may be functionally impossible to perform.¹⁵ An initial neurological exam may show evidence of hypotonia, acute motor deficits, a rapid increase in the circumference of the head, or even sudden death.⁵⁹ Clinicians may use a number of clinical tools, such as the Pediatric Brain Injury Network (PediBIRN) rule, the Predicting Abuse Head Trauma (PredAHT) rule, and the Pittsburgh Infant Brain Injury Score (PIBIS), to aid in assessing AHT from several clinical indicators.^61-63

A wide range of intracranial injuries can result from AHT. These include epidural, subdural, and subarachnoid hemorrhages.¹⁵ Subdural hemorrhages, due to shearing and rotational forces that tear the bridging veins, occur in more than 70% of AHT cases; slightly less than half of AHT cases will display evidence of chronic subdural hemorrhages.^15,60 Subdural hemorrhage may lead to hemispheric hypodensity in infants, a poor diagnosis that is subsequently associated with rapid cortical atrophy.¹⁵ Due to the prevalence of subdural hemorrhage in AHT patients, it is one of the indicators used in the PediBIRN rule.⁶⁰ Clinicians should be aware that conditions, such as benign enlargement of the subarachnoid space (BESS), may be confused for subarachnoid hemorrhage on an initial noncontrast CT scan.⁶⁰ Other complications include intraventricular hemorrhages, cortical contusions to the frontal and temporal regions of the brain, and diffuse axonal injury (DAI).¹⁵

Cerebral edema may result in AHT patients, typically within 24-28 hours.^15,60 Due to generally lower arterial pressures, pediatric brains also are more at risk for hypoperfusion in watershed areas.¹⁵ Further swelling and herniation may result. Other complications include hydrocephalus due to impairment of cerebrospinal fluid (CSF) reabsorption or CSF leakage through basilar skull fractures, increasing the likelihood of opportunistic infections.¹⁵

In cases of suspected acute AHT, noncontrast head CT should be used for an acute assessment. Magnetic resonance imaging (MRI) may be used subsequently to assess for vascular injuries, DAI, and edema.⁶⁰ Although spinal injuries appear to be uncommon in NAT, cases of AHT are associated with injuries to the cervical spine; this area also should be assessed with MRI.^15,60

Management of AHT is a difficult process that requires the aid of multiple pediatric specialists; approximately 69% of these patients will require neurosurgical intervention.^15,60 In the ED setting, physicians should take measures to ensure cerebral health while arranging transport to a trauma center with pediatric neurosurgery, neurology, trauma surgery, and the other specialists available.⁶⁰ The 2019 Guidelines for the Management of Pediatric Severe Traumatic Brain Injury recommend these patients have an intensive level of care, with the possibility of intracranial pressure (ICP) monitoring, hyperosmolar therapy for ICP control, possible external ventricular drain (EVD) drainage as needed, and early seizure prophylaxis.⁶¹

In a resource-limited setting, or if there is a prolonged time for transfer, ED physicians should focus on avoiding any secondary injury to the patient through mechanisms such as hypotension, hypoxia, hypercarbia, and increasing ICP.⁶² The patient’s airway should be managed and kept patent. Intubation should be used in cases where the GCS score is ≤ 8. Both hypoxia and hyperoxia should be avoided, with a goal oxygen saturation of above 90% and a goal PaO₂ above 60 mmHg and below 300 mmHg.⁶² Mean arterial pressure (MAP) should be maintained at 80 mmHg to 90 mmHg, with fluids and vasopressors as needed to avoid hypotension.⁶² Other simple implementations, such as a neutral head position and elevating the head of the bed to 30°, and maintaining a normothermic body temperature, can be implemented easily in the ED.⁶³ Antiepileptic medications may be required in the ED, since 33% of AHT patients develop seizures within the first seven days of admission.¹⁵ Early administration of antiepileptics may reduce the incidence of these early post-traumatic seizure (EPTS) events by up to 80%.¹⁵

Intra-Abdominal Injuries

Intra-abdominal injuries are rare in NAT, with an estimated prevalence of 2% to 3% in all NAT cases.⁶⁴ However, following AHT, intra-abdominal injuries are the next most common cause of death resulting from NAT. Below the age of 1 year, NAT may be responsible for up to 25% of cases of abdominal trauma that require hospitalization; between 1 and 5 years of age, it ranges from 10% to 16%.³⁹

Typically, NAT-associated intra-abdominal trauma presents in younger children, often with a delay in care.⁴¹ Often the family will provide a history of a recent fall. However, viscus perforation and significant abdominal trauma are extremely rare in cases of falls, even from higher-level falls down stairs.³⁹ One study of 729 pediatric falls found a prevalence of significant intra-abdominal injuries of approximately 1% to 2%, even when the falls were, on average, greater than 15 feet.⁶⁴ While injury to the small bowel is possible in accidental trauma, particularly focused injuries such as those sustained from bicycle handlebars, trauma from falls in younger children should be treated with a high degree of clinical suspicion.^16,65

While bruising is the most common sentinel injury of NAT, it often is not present in intra-abdominal NAT, likely because of the elasticity of the abdominal wall vessels in the pediatric population.^16,39 In general, the physical exam is less effective in these cases — evidence shows that tenderness, bruising, distension, and abnormal bowel sounds in these exams have low sensitivities.⁶⁴

There is no single pathognomonic presentation for NAT intra-abdominal injury.⁶⁴ However, injuries to the liver — whether through lacerations, contusions, or subscapular hematomas — appear to predominate.³⁹ Likewise, injuries to the hollow viscus and pancreas are more common in NAT cases than accidental trauma.⁶⁴ A 2005 Lancet publication found that abused children have a relative risk of 2.2 in sustaining gut injuries when compared to children injured in a road-traffic accident, and 5.72 when compared to pediatric fall injuries.⁶⁵ Other concerning injuries or evidence of malnourishment also increases the possibility of NAT.⁶⁶ A 2005 Lancet article proposes that bruising in the lower abdominal wall may be suggestive of sexual abuse in addition to NAT; injuries to the rectum also may be implicated.⁵ However, specific abnormal anogenital signs in children in suspected cases of sexual abuse appear to be relatively uncommon.⁵

Clinical decision-making tools are available to assess blunt abdominal trauma in children, such as those developed by PECARN. These rules are, unfortunately, less effective in cases of suspected NAT. The tool developed by PECARN is meant to focus on injuries that may lead to death or therapeutic intervention.⁶⁴ Many NAT intra-abdominal injuries, such as liver contusions, may be managed nonoperatively or present after the 24-hour window in which the PECARN rule is effective.^39,64 In cases of suspected NAT, this and other decision-making tools for intra-abdominal trauma have reduced efficacy.⁶⁴ Ultimately, the workup for abdominal trauma with concern for NAT depends on the clinician’s judgment.

Polytrauma

A 2022 Netherlands study of 1,623 pediatric polytrauma cases — defined as an Injury Severity Score (ISS) of more than 15 — concluded that NAT was the cause in 11% of these severe cases. In polytrauma in preschool-age children, NAT was the etiology in 41% of cases.⁶⁷ Retrospective studies have shown that NAT patients present with higher ISS scores, intensive care unit admission rates, and mortality than accidental trauma patients.⁶⁸ In recent years, the hospitalization rates for these children also have increased, suggesting the presence of more severe injuries secondary to NAT.¹¹

Recently, it has been proposed that the ISS scoring for children should be adjusted so that a score above 25 defines “severe injury.”⁶⁹ The debate around this is ongoing; ED clinicians should work with their trauma coworkers to create a consistent definition for their facility. Nevertheless, all pediatric cases of polytrauma should be thoroughly worked up for evidence of NAT.

Workup

Laboratory Data

A thorough laboratory workup should be performed in all children presenting with evidence of NAT (see Table 3). Unfortunately, physicians often neglect this essential aspect of the workup.⁷⁰ In addition to providing valuable medical data, these objective data also have significant legal implications by ruling out the possibility of underlying medical conditions.⁷¹

Child maltreatment — whether due to emotional and psychological stress, NAT, or other factors — appears to be associated with higher levels of inflammatory markers, including C-reactive protein (CRP), fibrinogen, and proinflammatory cytokines.⁷²

In cases of fractures, testing for various markers of bone metabolism — such as serum calcium, phosphorus, alkaline phosphatase, parathyroid hormone, and 25-hydroxy-vitamin D — is indicated to rule out possible conditions such as osteogenesis imperfecta.⁷⁰

In cases of suspected AHT or intracranial hemorrhage, prothrombin time, activated partial thromboplastin time, factor VIII level, factor IX level, complete blood count, D-dimer, and fibrinogen levels should be gathered.¹⁵ Further coagulation studies such as von Willebrand factor antigen and anti-thrombin III should be ordered in cases of suspected NAT.⁷⁰ Similarly, the Biomarker of Infant Brain Injury Score (BIBIS) may be used to assess serum hemoglobin and three other biomarkers. The BIBIS score has been shown to identify 89.3% of infants with an acute intracranial hemorrhage.⁶⁰

Physicians may use hepatic transaminases, such as alanine transaminase (ALT) and aspartate aminotransferase (AST), to risk stratify children at a higher risk of intra-abdominal trauma. A recent prospective study of children younger than 5 years of age suggests a cutoff of > 80 IU/L for AST and ALT.⁶⁴ Pancreatic enzymes also may be used, with a suggested cutoff of 50 U/L for amylase and 100 U/L for lipase.⁶⁴ Hematuria on urinalysis does not appear to be an effective indicator for intra-abdominal injury.⁶⁴

Serum cardiac troponin I often is elevated in children younger than 2 years of age with suspected NAT, often due to possible occult cardiac injury resulting from abdominal trauma, rib fractures, or other injury.⁷³

Preexisting conditions, such as bleeding disorders, may be confounders and mimic evidence of NAT. A thorough family history and personal history of previous epistaxis, bleeding following routine procedures, and any other excessive bleeding history should be taken to assess the possibility of an undiagnosed bleeding disorder.¹⁵ A 2014 retrospective study of 427 patients found that routine laboratory evaluation for common bleeding disorders, such as von Willebrand disease, is only rarely done in suspected NAT patients.⁷⁴ Similarly, there are cases in the literature where bruising consistent with NAT has been found to be due to leukemia.⁷¹ As discussed earlier, it is essential that physicians order laboratory tests not just for diagnosis, but also to rule out the possibility of underlying medical conditions in preparation for legal proceedings.⁷¹

Imaging

While radiation exposure is always a concern in the pediatric population, the risk from missed cases of NAT to the child’s health is significantly greater.⁷⁵ Radiation exposure should be a secondary concern in these cases.

NAT often is associated with polytrauma.⁴ Skeletal surveys are an effective tool for assessing for suspected NAT. There are a range of different protocols for skeletal surveys, ranging from 15 different radiographs optimized to minimize radiation exposure to 20 radiographs.^52,76 ED providers should be aware of their institution’s skeletal survey protocol. At a minimum, skeletal surveys should follow the 2021 ACR guidelines, with at least one radiograph of each extremity, anteroposterior and lateral imaging of the axial skeleton, right and left posterior oblique views of the rib cage, and additional views as needed for areas of concern.⁷⁷

Given this, skeletal surveys should be ordered in all concerning NAT cases with fracture.¹⁵ However, there are a number of scenarios where skeletal surveys do not need to be routinely ordered, such as in distal radial/ulna or tibia/fibula buckle fractures sustained in cruising children, distal spiral fractures of the tibia/fibula in toddlers who fell while running, and distal radial/ulna buckle fractures in toddlers who fell on an outstretched hand.⁵² In addition, the AAP recommends skeletal surveys in cases where physical abuse is suspected, which includes children younger than 2 years of age with unexplained head trauma, suspicious burns, and bruising that is high risk. Table 4, developed from Wood’s 2014 paper, provides further recommendations.⁵²

In cases where NAT is more ambiguous and has a less specific initial workup, skeletal surveys may identify old healing fractures.⁷⁷ Follow-up skeletal surveys are an effective tool to assess for further evidence of NAT.⁷⁸ The American Academy of Pediatrics recommends any follow-up skeletal surveys be ordered within 10-21 days of initial assessment.⁷⁵ This should be done by a child advocacy center and the child protection team. Unfortunately, follow-up skeletal studies may be difficult to obtain in this population.⁷⁵ Bone scintigraphy with technetium-99m diphosphonate may be added to complement skeletal surveys and has been shown to identify new findings in 12% of studies.^75,79 Unfortunately, bone scintigraphy is less available than conventional radiography and carries significant cost and radiation exposure.⁷⁹ In cases where the patient has siblings, any siblings younger than the age of 2 years also should have a routine skeletal survey performed.⁷⁵

A chest CT is effective at detecting multiple rib fractures at various stages of healing but carries with it the risk of significant radiation exposure.⁷⁵ In cases where screening AST/ALT is positive for suspected intra-abdominal injury, physicians should order abdominal CT imaging with intravenous (IV) contrast.⁶⁴ Physicians also should order CT imaging with IV contrast for suspected intra-thoracic injury.⁷⁵

Noncontrast head CT is the modality of choice for suspected AHT.⁷⁵ MRI imaging is highly sensitive to injury to the parenchyma and effectively maps any hematomas, in all stages of healing, that may be present.⁷⁵ MRI also is more effective at diagnosing diffuse axonal injuries, which are more likely to occur in TBI due to NAT.^15,80 MRI can be scheduled at three to five days and three to six months after the initial injury as a means of providing prognostic information for the managing team.⁷⁵ The American Academy of Pediatrics recommends that all patients with suspected TBI undergo a CT scan, an MRI, or both imaging modalities.¹⁵

Prevention

Preventive measures regarding NAT have had mixed results. An educational program in New York State reduced AHT by 47% over a six-year period, while similar programs in Pennsylvania and North Carolina did not have a significant impact.¹⁶ A 2002 workshop meant to increase parental knowledge in Quebec was hampered by low attendance rates.⁸¹ However, some interventions have had promising results. A 2009 meta-analysis examining 26 other meta-analyses of a total of 298 publications concluded that interventions such as home-visiting, parent education, abusive head trauma prevention, and multi-component interventions hold promise in reducing pediatric maltreatment.⁸²

Reporting

A 2015 retrospective study of 254 AHT patients found 20% mortality and extremely high levels of morbidity in this patient population and in only 29% of the cases were perpetrators tried and found guilty.²³ Likewise, only 37% of these patients were removed to foster care.²³ While the data are limited, ED providers have endorsed a number of factors — including familiarity with the patient’s family, limited follow-up, and fear of negative consequences in court — that prevent proper reporting of suspected child abuse.⁸³

It is absolutely mandatory that ED providers report any cases of suspected child abuse or NAT. Given the risk of sibling exposure to NAT, as well as legal and ethical implications, it is imperative that ED physicians follow the mandated reporting standards of their locality.⁷⁵ Unfortunately, this often is difficult since physicians regard mandated reporting as a redundant and time-consuming process.¹⁴ Testifying in court often is an intimidating process for physicians and may act as another unconscious barrier.¹⁴ However, these biases may be overcome by discussing suspected cases with peers and supervisors and further understanding that reports made to Child Protective Services are not malicious. They may provide further service to families rather than “division of a family unit.”¹⁴ A streamlined in-hospital means of assessing and reporting suspected NAT cases also may aid in overcoming these limitations.¹⁴ Studies have shown that minority patients are more likely to be evaluated and reported for suspected AHT than white/non-Hispanic patients, implying the presence of provider bias.⁸⁴ EDs should follow standardized protocols to minimize the chance of such bias.

Cases where medical documentation is thorough and follows forensic standards, with descriptions that are clear and understandable to a legal audience, are more likely to result in successful prosecution of the perpetrator.⁸⁵

Nurses also are mandated reporters, and are required to call Child Protective Services even without physician guidance if they are concerned for abuse. Professionals in medicine, education, public services, religion, and social services are legally obligated to report cases of suspected NAT.⁸⁶

Physician Care

Exposure to cases of NAT often is tied to secondary traumatic stress and burnout in physicians and other professionals.⁸⁷ Risk factors include young age, less training, poor social support, or having a similar history to the patient assessed.⁸⁷ We recommend that ED physicians exposed to cases of NAT take steps to manage their wellness and prevent burnout.

Summary

• The ED is the front line for screening for NAT.
• ED physicians should screen for suspicious medical history and familial social history.
• The physical exam should be thorough and well-documented, with particular emphasis on bruising, burns, and fractures.
• Laboratory data should rule out other conditions, such as osteogenesis imperfecta or bleeding disorders.
• In suspicious cases, skeletal surveys and other imaging should be ordered.
• All suspected cases of NAT must be reported as soon as possible to the relevant authorities.

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