Pediatric non-accidental trauma is abuse that is purposefully inflicted, results in damage to the child, and is not the result of an accidental incident.
Non-accidental trauma most commonly presents as injuries to skin and soft tissue, but approximately one-third of non-accidental trauma results in fractures. Abusive head trauma is typically the most serious concern in children suffering from abuse, usually occurring during the first year of life with an estimated 25% to 30% mortality rate.1
Epidemiology including risk factors and primary prevention
There is a 25% risk of serious injury and 5% risk of death in all cases of physical abuse. Non-accidental trauma is the second leading cause of mortality in infants and children.2 Although the incidence of child abuse in the US decreasing, In 2018, the US Department of Health and Human Resources still identified 678,000 children as victims of child abuse and estimated 1,770 fatalities as a result.3 Mortality rates are more than doubled (25% vs 10%) in recurrent victims of non-accidental trauma.4
Risk of suffering child abuse is inversely related to age, with the highest rates in children less than 2 years of age. Premature birth and complex medical conditions are also associated with greater risk for suffering child abuse.5
Parents who have substance abuse problems or were abused have a higher likelihood of becoming abusers. Abusive parents are more likely to be female, however male abusers are more likely to inflict trauma resulting in death.6 No evidence has been found correlating abuse to socioeconomic status. Familial dysfunction including a history of substance abuse, psychiatric disorder, or violent criminal record are identified in a family member in most cases of pediatric non-accidental trauma.7
Presenting signs and symptoms that raise suspicion for non-accidental trauma:8
- Pattern of injury inconsistent with the provided history
- Delay in seeking medical care
- Retinal hemorrhages, secondary to rapid acceleration and deceleration effects. Present in 60-85% of non-accidental trauma. Severe retinal hemorrhages are almost always due to abuse.
- Mental status changes, seizures, vomiting, poor feeding, and lethargy are non-specific, but raise concern for abusive head trauma
- Poor parent-child interaction
- Bite marks
- Bruising over sites other than bony prominences
- Burns in a stocking-glove distribution sparing creases, palms, or soles are suggestive of immersion into scalding water
- Burns in the shape of a distinctive object such as a cigarette
- Spiral fractures of the arm or leg secondary to a child being dragged or pulled forcefully
- Posterior rib fractures from being held by the chest and shaken
- Sternal fractures from being struck in the chest with force.
- Humerus fracture in children under 3 years old, as they do not generate enough force to fracture this bone in typical activities
- Metaphyseal corner (bucket-handle) fractures due to traction of ligaments on bone attachment points.
- Femur fracture prior to age of walking
- Fractures at multiple stages of healing, indicating multiple episodes of trauma
ESSENTIALS OF ASSESSMENT
Inconsistencies or changes in the clinical history should raise suspicion of nonaccidental trauma. Look for incompatibility of the severity of the injury and the explanation of how it occurred. If the explanation is reluctantly provided, contradictory, or vague, there should be suspicion. Finally, if there have been several presentations of trauma, the usage of multiple emergency departments, or several failed routine appointments, the provider should be suspicious. A history of failure to thrive or factitious infirmities is also important to elicit in the history.
Start with the standard primary survey. Check for bruises in unusual locations, and/or bruises of varying ages. An imprint of an object, such as a hand, belt buckle, or cord, is also suggestive. Several benign entities, such as Mongolian spots and hematomas should not be confused with signs of trauma.9 A thorough examination of the skin, a neurologic exam, and an examination of the abdomen are important steps. Retinal hemorrhages, spiral fractures or femur fractures in a child who is not yet ambulatory, and unexplained visceral injuries all raise suspicion for non-accidental injury. Eisenbrey & Guilland regard retinal hemorrhage as diagnostic of child abuse when accompanied by intracranial injuries in the absence of a verifiable history.10
Observe the child’s behavior and how they interact with the parent, the providers, and other members of the family. Assess if there is an overly accommodating nature, a significant change in the patient’s abilities relative to baseline, or if there are elements of the child that are developmentally regressed from what would be expected for their chronologic age.
Complete blood count, prothrombin time (PT), activated partial thromboplastin time, (aPTT) international normalized ratio (INR), Factor VIII and IX levels, and fibrinogen should be tested, particularly in the setting of ICH, to rule out bleeding dyscrasias that may otherwise explain the clinical picture.2 For repeat fractures, genetic testing for osteogenesis imperfecta should be considered as well.
Computed tomography scan of the head is preferred as the initial evaluation tool in all children with suspected intracranial injury because of the rapid availability, cost-effectiveness, and sensitivity for hemorrhage.
Magnetic resonance imaging (MRI) should also be considered as an adjunct in non-accidental head trauma. MRI may help identify chronic lesions and DWI is helpful in detecting early ischemic injury. Spinal cord injury without radiographic abnormality (SCIWORA) is often found with abusive head injuries and should be suspected in children with symptoms of myelopathy with negative CT findings.11 Children with intracranial lesions should therefore also undergo a cervical spine MRI due to the higher detection rates of spinal cord damage compared to CT.12
A skeletal survey should always be obtained in any of the following circumstances: child under 2 years with suspicion of abuse, child under 5 years with suspicious fracture, or any child unable to communicate areas of pain. Negative skeletal surveys may need to be repeated in 7-10 days to reveal missed fractures if suspicion remains.13 Patients that have metabolic or other causes of osteopenia typically have signs of bone demineralization along with fractures on imaging.
An abdominal ultrasound is performed when there are clinical indices that lead to suspicion of visceral damage.
Supplemental assessment tools
A dilated fundoscopic examination by ophthalmology is recommended if abusive head trauma is strongly suspected.
Impairment based measurement
Notation of the Glasgow Coma Scale or use of a trauma scoring index to assess severity of presentation is useful for future prognosis.
Translation into practice: practice “pearls” / performance improvement in practice (PIPs) / changes in clinical practice behaviors and skills
There are some medical conditions that may be confused with nonaccidental trauma. Children with bleeding disorders, such as hemophilia and von Willebrand disease, frequently present to emergency departments with significant bruising that is out of proportion with the amount of trauma. They also have bruises of different ages. These children can be identified via coagulation studies and genetic testing.
Another class of patients that can be confused with those suffering from nonaccidental trauma are those with bone disorders. Osteogenesis imperfecta, osteopenia of prematurity, and metabolic bone disease can repeatedly present to the emergency room and have fractures of varying ages that are out of proportion to the reported trauma. These patients can be diagnosed via laboratory work and genetic testing.
Early predictions of outcomes
Negative outcomes after non-accidental trauma are more often seen in children with severe initial injuries, injuries affecting the central nervous system, and younger ages. An estimated 50% of children who are victims of non-accidental head injury will have some degree of permanent cognitive and behavioral deficits.14 Along with cognitive and behavioral effects, impairments are often observed in the form of motor development (spastic quadriplegia/diplegia 15-64%), epilepsy (11-32%), cortico-subcortical atrophy (61-100%), visual impairment (18-48%), and language disorders (37-64%). Worse outcomes in non-traumatic head injury patients are more likely in children presenting with coma, seizures, associated cranial fracture, or evidence of cerebral atrophy. 15,16,17 Late neurologic and cognitive sequelae have been found to correlate with Pediatric Trauma Score and Glasgow Coma score, but not with age or with mechanism of injury.18
Factors predicting positive functional outcomes are isolated musculoskeletal or limited dermatologic findings. However, emotional outcomes are not easily predicted by the severity of physical findings. Children who are relatively physically intact can still have lasting deficits from abuse that negatively impacts emotional, social, and cognitive development.
Nonaccidental trauma can happen to persons of any race, religion, ethnicity or socioeconomic status. The bias the examiner may have of the presenting victim and their family may affect the likelihood that nonaccidental trauma is recognized.
Social role and social support system
The involvement of child life, social work, and physician specialists equipped to further evaluate and support victims is critical. These personnel or the initial reporter should involve law enforcement authorities when information supporting the suspicion of nonaccidental trauma is accrued.
Mandatory reporting of possible abuse is required of nearly all medical providers in U.S. jurisdictions, but state law should be consulted for clarity. Thus, if a physician, mid-level provider, nurse, therapist, or para-medical professional suspects abuse, they must report it to the appropriate governmental authorities for investigation.
REHABILITATION MANAGEMENT AND TREATMENTS
Available or current treatment guidelines
Children with central nervous system injuries are stratified as having mild, moderate, or severe impairments. Inpatient or outpatient therapy services should be considered in these populations. American College of Surgeons (ACS) recommends a physiatrist as part of the team at all level 1 trauma centers. PM&R should be involved in cases of non-accidental trauma.19 Children that are victims of head trauma, both abusive and non-abusive in nature, show significant functional and expressive language improvements with inpatient rehabilitation.20
Children with musculoskeletal deficits are classified based on fracture classification systems relevant to their injury. These children may also benefit inpatient or outpatient therapy services depending on their level of impairment.
All children who are victims of abuse should be evaluated for and receive ongoing psychiatric and psychosocial support as indicated.
Coordination of care
- Parallel practice: Individual practitioners should involve a team of professionals to address the medical, social, legal, and emotional issues related to nonaccidental trauma. It is contrary to best practice to do all aspects of care in isolation.
- Coordinated: Efforts between the medical staff, the psychosocial support team, and the law enforcement and government agencies is essential for treating the child and maintaining them in a safe environment.
- Integrated: Documentation is critical to the process. When directly quoting information from the victim and/or the perpetrator, quotation marks should be used. Legible and careful notation is important. Drawings, sketches, and descriptions of the physical findings are encouraged. Police and governmental agencies use medical records to follow up on the incident of abuse.
Patient & family education
The involvement of the family in the treatment and education process is ultimately determined by the circumstances around the abuse. Many advocacy groups have organized campaigns to promote awareness. However, most are geared towards the public as opposed to medical professionals.
Follow-up and long-term management
Given the high risk of severe impairments in these patients, long-term comprehensive care should be coordinated to monitor development and implement appropriate interventions. Recommended intervention measures may range from education, psychosocial support, and family counseling. Fostering a supportive family environment is important, as studies suggest that deleterious TBI effects are buffered by a positive family unit and exacerbated by negative family units.21
Children with non-accidental head trauma are likely to require and benefit from special intervention services. Available services include mental health, speech language pathology, rehabilitation, and special education. Special education services are provided through an Individual Education Plan (IEP) program, which outlines an individualized plan for children with more severe cognitive and behavioral disabilities, or the 504 plan, which provides extra accommodations in the classroom for children not requiring a full IEP.22
CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Cutting edge concepts and practice
Evolving and increasingly sophisticated imaging techniques are expected to provide a tool for improved detection of non-accidental trauma and may lead to better prediction of outcomes.
GAPS IN THE EVIDENCE-BASED KNOWLEDGE
Gaps in the evidence-based knowledge
Even in cases with similar imaging findings and clinical presentation, long-term outcomes remain highly variable among individuals with non-accidental head injuries.23 More evidence is still needed to help with predicting and improving outcomes in this population.
- Center of Disease and Control. Child Maltreatment: Fact-sheet. Atlanta: National Center for Injury Prevention & Control; 2007. [cited 14 Feb 2014].
- Paul A.R., Adamo M.A. Non-accidental trauma in pediatric patients: a review of epidemiology, pathophysiology, diagnosis and treatment. Transl Pediatr. 2014;3(3):195–207.
- US Department of Health and Human Services, A.f.C.a.F., Administration on Children, Youth, and Families, Children’s Bureau, Child Maltreatment 2018.
- Deans KJ, Thackeray J, Askegard-Giesmann JR, et al. Mortality increases with recurrent episodes of nonaccidental trauma in children. J Trauma Acute Care Surg 2013;75:161-5.
- Leventhal JM, Thomas SA, Rosenfield NS, et al. Fractures in young children: distinguishing child abuse from unintentional injuries. Am J Dis Child 1993;147:87-92.
- Mulpuri K, Slobogean BL, Tredwell SJ. The epidemiology of nonaccidental trauma in children. Clin Orthop Relat Res 2011;469:759-67.
- Vinchon M, Defoort-Dhellemmes S, Desurmont M, et al. Accidental and nonaccidental head injuries in infants: a prospective study. J Neurosurg 2005;102:380-4.
- Weber, L. Practical Guidelines For Identifying Non-Accidental Trauma in Children. gillettechildrens.org/assets/uploads/for-medical-professionals/Guidelines_for_Non-Accidental_Trauma_Pediatric_Perspectives_Vol._24_No.2.pdf
- Eisenbrey AB. Retinal hemorrhage in the battered child. Childs Brain 1979;5:40-4.
- Szwedowski D, Walecki J. Spinal cord injury without radiographic abnormality (SCIWORA)-clinical and radiological aspects. Pol J Radiol. 2014;79:461–464
- Bays J. Conditions mistaken for child physical abuse. In: Reece RM, Ludwig S. eds. Child abuse and neglect: Medical diagnosis and management (2nd ed.). Philadelphia: Lippincott Williams & Wilkins, 2001:177-206.
- Baerg J, Thirumoorthi A, Vannix R, et al. Cervical spine imaging for young children with inflicted trauma: Expanding the injury pattern. J Pediatr Surg 2017; 52:816.
- Section on Radiology, American Academy of Pediatrics . Diagnostic imaging of child abuse. Pediatrics 2009;123:1430-5.
- Duhaime AC, Christian C, Moss E, et al. Long-term outcome in infants with the shaking-impact syndrome. Pediatr Neurosurg 1996;24:292-8.
- Chevignard MP, Lind K. Long-term outcome of abusive head trauma. Pediatr Radiol. (2014) 44:548–58. 10.1007/s00247-014-3169-8
- Costine-Bartell BAMcGuone DPrice GCrawford EKeeley KLMunoz-Pareja J: Development of a model of hemispheric hypodensity (“big black brain”). J Neurotrauma 36:815–8332019
- Debelle GDMaguire SWatts PNieto Hernandez RKemp AM: Abusive head trauma and the triad: a critique on behalf of RCPCH of ‘Traumatic shaking: the role of the triad in medical investigations of suspected traumatic shaking’. Arch Dis Child103:606–6102018
- Barlow KM, Thomson E, Johnson D, Minns RA: Late neurologic and cognitive sequelae of inflicted traumatic brain injury in infancy. Pediatrics 116:e174–e1852005
- American College of Surgeons Trauma Committee: American College of Surgeons Verification Review ConsultationVReview Agenda. 2014;
- Risen SR, Suskauer SJ, Dematt EJ et al.: Functional outcomes in children with abusive head trauma receiving inpatient rehabilitation compared with children with nonabusive head trauma. The Journal of pediatrics 2014, 164(3):613–619. e611–612.
- Yeates KO, Taylor HG, Walz NC, Stancin T, & Wade SL (2010). The family environment as a moderator of psychosocial outcomes following traumatic brain injury in young children. Neuropsychology, 24(3), 345–356.
- Canadian Paediatric Society multidisciplinary guidelines on the identification, investigation, and management of suspected abusive head trauma. 2013
- Forsyth R, Kirkham F. Predicting outcome after childhood brain injury. CMAJ. 2012;184(11):1257–64. doi: 10.1503/cmaj.111045.
Original Version of the Topic:
Maurice Sholas, MD, PhD. Physical Abuse (Nonaccidental Trauma). Publication Date: 10/11/2011.
Previous Revision(s) of the Topic
Maurice Sholas, MD, PhD. Physical Abuse (Nonaccidental Trauma). Publication Date: 8/16/2016
Heakyung Kim, MD
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Matthew Erby, MD
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