Nonaccidental Injury in Pediatric Patients: Detection, Evaluation, and Treatment -
Publication Date: July 2017 (Volume 14, Number 7)
Gunjan Tiyyagura, MD
Assistant Professor of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, CT
Meghan Beucher, MD
Pediatric Emergency Medicine Fellow, Department of Pediatrics Section of Emergency Medicine, Yale New Haven Hospital, New Haven, CT
Kirsten Bechtel, MD
Associate Professor of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, CT
Daniel Lindberg, MD
Associate Professor of Emergency Medicine and Pediatrics; University of Colorado School of Medicine, Aurora, CO
Mandy O’Hara, MD, MPH
Child Abuse Pediatrician and Assistant Professor, Department of Pediatrics, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY
Emergency clinicians are likely to encounter physical abuse in children, and they must be prepared to recognize its many manifestations and take swift action. Pediatric nonaccidental injury causes considerable morbidity and mortality that can often be prevented by early recognition. Nonaccidental injuries present with a wide array of symptoms that may appear to be medically inconsequential (such as bruising in a premobile infant), but are actually sentinel injuries indicative of child abuse. This issue provides guidance regarding factors that contribute to abuse in children, key findings on history and physical examination that should trigger an evaluation for physical abuse, and laboratory and radiologic tests to perform when child abuse is suspected.
Excerpt From This Issue
A mother brings her 3-month-old boy to the ED for vomiting and irritability. She says that the boy's father told her the baby wouldn’t stop crying and had vomited several times. The mother states the baby had been fine when she left for work that morning. The patient’s medical history is significant for colic and an episode of blood from his mouth 1 month ago. On physical examination, the baby is irritable, his anterior fontanelle is full, and his pupils react bilaterally. The patient continues to vomit several times in the ED and remains irritable and afebrile. You are worried that the vomiting and irritability are signs of abusive head trauma and you consider how to approach brain imaging in this patient. You then wonder whether you should order laboratory tests and assess for other occult injuries with a skeletal survey. Would an ophthalmological examination be indicated in this patient? Finally, you consider how and when to approach the family about a child protective services referral.
A 2-month-old boy was transported to the ED by EMS. A neighbor had called 911 because of concerns of domestic violence between the parents. The mother denies domestic violence and says that the baby seems to be having some difficulty breathing. On physical examination, the patient is fussy but consolable. He is afebrile, but is breathing rapidly, with a respiratory rate of 70 breaths/min. There are bruises on his anterior and posterior torso and crepitus of his chest wall. When asked how the patient may have sustained the bruises, the mother states the baby may have “rolled” and hit the edge of the crib. You are concerned about physical abuse as a cause of your patient’s presentation. You wonder if domestic violence between caregivers is a risk factor for physical abuse in children. Should the developmentally implausible history provided by the mother make you more worried about abuse? You start to consider which laboratory, imaging tests, and consultations you should pursue to evaluate both for possible physical abuse and to exclude other diagnoses, such as a bleeding disorder.