Pediatric Non-Accidental Trauma (NAT)

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Taking care of children in the ED isn't just diagnosing viruses - child abuse/neglect is more prevalent than we'd like to think:
            - 2-10% of children presenting to the ED are victims of abuse or neglect
            - children that are abused often have multiple healthcare visits before it is recognized
 
Child maltreatment includes neglect and abuse
Neglect
- failure to meet the most basic needs of a child (food, shelter, supervision, nurturance)
- can be educational, psychological, emotional, medical neglect, or supervisory
            - by far the most common type of maltreatment - about ⅔ of cases
            - very difficult to identify diagnose
Abuse
- includes physical abuse, sexual abuse, emotional abuse, and medical child abuse
* medical child abuse is the current term for Munchausen Syndrome by proxy
- physical abuse (also referred to as non-accidental trauma or NAT) is often the most recognizable type of abuse
- makes up 16% of maltreatment cases
 
Providers should be mindful of sentinel injuries - injuries without a plausible explanation
            - knowing basic developmental milestones can be helpful
                        4-5 months - rolling over
                        6 months - sitting unassisted
                        9 months - pulling to a stand and walking
                        12 months - walking
 
**soft tissue injuries - bruising in children who cannot cruise, or in high risk areas
            - normal childhood bruises occur on surfaces that take impact when the child falls
                        bruising on the knees and shins isn’t alarming
                        bruising on areas like the back, buttocks, thighs, abdomen is concerning
- TEN-4 FACES P can help you identify injuries that suggest potential abuse
            * bruising on the Trunk, Ears, or Neck in a child less than 4 years old
* ANYbruising on a child less than 4 months
* injuries/bruising to the Frenulum, Auricular area, Cheek, Eyes, Sclera or
* Patterned bruising is a red flag
 
**skeletal injuries are the second most common presentation of abuse - certain fractures should raise your suspicion for abuse
- rib fractures (make sure you check that CXR ordered to look for pneumonia)
- any fracture in a child that cannot walk
- long bone fractures in an infant or toddler
 
**abusive head trauma (formally known as “shaken baby syndrome”)
                  - this is the most common cause of death following abuse
                  - 30% of cases are missed initially – remember to consider it in cases of excessive fussiness or altered mental status
 
**chest and abdominal injuries
            - the abdomen can hide injuries and hold a lot of blood - you won’t always see bruising
            - elevated liver enzymes or lipase should raise your concern for occult intra-abdominal injury
 
What can you do to help prevent a missed diagnosis of abuse?

• Perform a “top-toe” exam on every patient and examine their skin for bruising (this means everyone should be in a gown)
• Make sure the explanation of the injury makes sense developmentally – “those who don’t cruise rarely bruise”
• If you’re concerned about possible abuse, initiate a screening work up or admit the child to a service that can complete an abuse evaluation
• Remember that you are a mandated reporter – involve Social Work early, even if you plan to refer the child to another hospital for evaluation.​

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ACEP Now. The Recognition of Child Abuse. May 1, 2012.
 
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Lindberg DM, Beaty B, Juarez-Colunga E, et al. Testing for Abuse in Children With Sentinel Injuries. PEDIATRICS. 2015; 136(5): 831-838.
 
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Sheets LK, Leach ME, Koszewski IJ, et al.  Sentinel Injuries in Infants Evaluate for Child Physical Abuse. PEDIATRICS. 2013; 131(4): 701-107.
 
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Teeuw AH, Hoytema van Konijnenburg EM, Sieswerda-Hoogendoorn T, et al.  Parents’ Opinions About a Routine Head-to-Toe Examination of Children as a Screening Instrument for Child Abuse and Neglect in Children Visiting the Emergency Department.  Journal of Emergency Nursing. 2016; 42(2): 128-138.