Pediatric Nonaccidental Trauma: Evaluation and Management in the Emergency Department -

Emergency Department Evaluation and Management of Nonaccidental Trauma in Pediatric Patients (Trauma CME)

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Table of Contents

About This Issue

A child may present to the healthcare setting multiple times before nonaccidental trauma (NAT) is diagnosed. Emergency clinicians must be able to recognize sentinel and severe signs of NAT and appropriately manage suspected NAT to prevent further injury. This issue offers evidence-based recommendations for the identification and management of NAT in children. In this issue, you will learn:

Risk factors associated with NAT, including child risk factors, perpetrator risk factors, and environmental risk factors

Sentinel injuries that are suggestive of NAT

Which bruising patterns are indicative of accidental injuries and which are associated with NAT

Clinical decision rules, historical features, and physical examination findings that can help identify patients with potential NAT who need further workup

Recommendations for when screening laboratory studies are indicated and which studies should be ordered

Which children need a skeletal survey and when a follow-up study should be performed

Diagnostic studies to consider, based on injury type

Recommendations for which specialists and organizations to involve to help ensure appropriate care and follow-up

Guidance for documentation and reporting

Table of Contents
  1. About This Issue
  2. Abstract
  3. Case Presentations
  4. Introduction
  5. Critical Appraisal of the Literature
  6. Etiology and Pathophysiology
    1. Risk Factors
      1. Child Risk Factors
      2. Perpetrator Risk Factors
      3. Environmental Risk Factors
    2. Injuries Suggestive of Abuse
      1. Sentinel Injuries
      2. Bruises
      3. Fractures
      4. Head Trauma
  7. Differential Diagnosis
  8. Prehospital Care
  9. Emergency Department Evaluation
    1. History
    2. Physical Examination
      1. Injury Patterns Suggestive of Nonaccidental Trauma
        • Bruises
        • Burns
        • Abusive Head Trauma
  10. Diagnostic Studies
    1. Laboratory Testing
    2. Imaging Studies
    3. Ophthalmic Evaluation
    4. Additional Testing
  11. Treatment
  12. Documentation and Reporting
  13. Special Circumstances
    1. Domestic Violence
    2. COVID-19 Pandemic
  14. Controversies and Cutting Edge
    1. Bias
    2. Clinical Decision Tools
    3. Follow-Up Skeletal Surveys
  15. Disposition
  16. Summary
  17. Management Pitfalls for Nonaccidental Trauma in Pediatric Patients
  18. 5 Things That Will Change Your Practice
  19. Time and Cost-Effective Strategies
  20. Case Conclusions
  21. Clinical Pathway for Emergency Department Management of Nonaccidental Trauma in Pediatric Patients
  22. Tables and Figures
  23. References


Children who have suffered physical abuse may present to the healthcare setting multiple times before a diagnosis is made. Emergency clinicians must be able to recognize sentinel and severe signs of nonaccidental trauma and pursue an appropriate evaluation to prevent further injury. This issue offers evidence-based recommendations for the identification and management of nonaccidental trauma in children. Key historical and physical examination findings that should trigger an evaluation for physical abuse are reviewed. Recommendations are given for obtaining diagnostic studies and consulting with specialists. Guidance is provided for documenting and reporting findings when nonaccidental trauma is suspected.

Case Presentations

A 2-month-old boy is brought to the ED by his mother for lethargy and a seizure at home…
  • The mother states that earlier that day the child had been fussier than usual, then he had a seizure lasting about 3 minutes. Since the seizure, the child has been very sleepy.
  • The boy’s temperature and vital signs are normal. On examination, the infant appears lethargic, with poor tone. He vomits once in the ED.
  • What is on your differential for this patient? What are the next steps in management?
A 13-month-old boy is brought to the ED by his grandmother for 3 days of fever and runny nose...
  • On examination, the child has a fever of 38.2°C, rhinorrhea, bilateral tympanic membrane erythema, and a 1-cm bruise to the pinna of the left ear.
  • What other workup is indicated at this time? Is the bruise likely an accident? Does this warrant a Child Protective Services referral?
A 5-month-old girl is brought to the ED by her babysitter after falling earlier in the day…
  • The babysitter says the child was pulling to stand on a coffee table then fell down and has been inconsolable since.
  • On examination, the child cries when you palpate her right lower extremity.
  • You wonder whether this injury make sense for the child’s age...

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Clinical Pathway for Emergency Department Management of Nonaccidental Trauma in Pediatric Patients

Clinical Pathway for Emergency Department Management of Nonaccidental Trauma in Pediatric Patients

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Tables and Figures

Table 2. Additional Diagnostic Studies to Consider, by Injury Type
Figure 8. Pediatric Brain Injury Research Network (PediBIRN) Abusive Head Trauma Screening Tools
Table 1. Motor Developmental Milestones, by Age

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. Children’s Bureau -- An Office of the Administration for Children & Families. Child maltreatment 2020. 2022. Accessed August 1, 2023. (Federal data report)

4. * Christian CW. The evaluation of suspected child physical abuse. Pediatrics. 2015;135(5):e1337-e1354. (Clinical report) DOI: 10.1542/peds.2015-0356

10. * Barrett R, Ornstein A, Hanes L. Minor injuries… major implications: watching out for sentinel injuries. Paediatr Child Health. 2016;21(1):29-30. (Review) DOI: 10.1093/pch/21.1.29

16. * Colbourne M, Clarke MS. Child abuse and neglect. In: Tintinalli J, Stapczynski J, Ma OJ, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. McGraw-Hill Education/Medical; 2015:999-1003. (Textbook chapter)

19. * Duhaime AC, Christian CW, Rorke LB, et al. Nonaccidental head injury in infants--the “shaken-baby syndrome.” N Engl J Med. 1998;338(25):1822-1829. (Review) DOI: 10.1056/nejm199806183382507

21. * Deutsch SA. Understanding abusive head trauma: a primer for the general pediatrician. Pediatr Ann. 2020;49(8):e347-e353. (Review) DOI: 10.3928/19382359-20200720-01

26. * Pierce MC, Kaczor K, Lorenz DJ, et al. Validation of a clinical decision rule to predict abuse in young children based on bruising characteristics. JAMA Netw Open. 2021;4(4):e215832. (Observational study; 2161 patients) DOI: 10.1001/jamanetworkopen.2021.5832

40. American College of Radiology, the Society for Pediatric Radiology. ACR–SPR practice parameter for the performance and interpretation of skeletal surveys in children. 2021. Accessed August 1, 2023. (Guideline)

41. * Harper NS, Lewis T, Eddleman S, et al. Follow-up skeletal survey use by child abuse pediatricians. Child Abuse Negl. 2016;51:336-342. (Observational study; 2890 patients) DOI: 10.1016/j.chiabu.2015.08.015

Subscribe to get the full list of 51 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: nonaccidental trauma, NAT, abuse, child abuse, child mistreatment, child maltreatment, sentinel injuries, TEN-4-FACESp, BuRN-Tool, PediBIRN, bias in reporting, social risk factors, child risk factors, perpetrator risk factors, environmental risk factors, abusive head trauma, abusive head injury, occult fracture, nonaccidental fracture pattern, nonaccidental bruising pattern, abusive bruising patterns, metaphyseal corner fracture, motor developmental milestones, skeletal surveys, racial disparities in reporting, documentation, reporting

Publication Information

Gwendolyn Hooley, MD; Sylvia E. Garcia, MD

Peer Reviewed By

Andrea G. Asnes, MD, MSW; Melissa Siccama, MD

Publication Date

September 1, 2023

CME Expiration Date

September 1, 2026    CME Information

CME Credits

4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-B Credits.
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credit, subject to your state and institutional approval.

Pub Med ID: 37606603

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