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| ==Background==
| | #REDIRECT[[Nonaccidental trauma]] |
| *Infant and children with disabilities are at higher risk
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| *In >80% of cases, the parent or primary guardian is the abuser
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| *Report suspicion
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| **Transparent, frank discussion with caregivers
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| **Social work or child protection agency involvement
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| ***Protect the child first, admit if suspicious
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| ***Social work may follow-up as outpatient for very low risk cases
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| ===Risk Factors===
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| *Domestic violence
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| *Maternal depression
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| *Drug and alcohol abuse
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| *Premature birth
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| *Children with disabilities or children who require significant medical care
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| *Unrealistic expectations for the child
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| ===Red flags===
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| *History given is inconsistent with the mechanism of injury
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| *Changes in caregivers report
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| *Significant delays in care
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| *Any injury to a young, pre-ambulatory infant
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| *Injuries to multiple organ systems
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| *Injuries in different stages of healing;
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| *Patterned injuries
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| *Injuries to nonbony or other unusual locations, (torso, ears, face, neck, or upper arms)
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| *Significant injuries that are unexplained
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| *Other evidence of child neglect.
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| ==Clinical Features==
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| ===Bruises===
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| *Bruises, ecchymosis, and soft-tissue injuries on the face, cheeks, buttocks, ears, torso, neck if the child is not cruising yet
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| *Bruises in clusters or patterned marks
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| *Bruising of any child less than or equal to 6 months of age (or non-ambulatory) warrants a full child abuse work-up
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| ===Oral injuries===
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| *Torn frenulum in premobile children is highly associated with physical abuse
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| *Other reported oral injuries include laceration/bruising to the lips, mucosal lacerations, dental trauma, tongue injuries, and gingival lesions
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| ===[[Burns]]===
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| *Most commonly immersion injuries of the extremities, buttocks, or perineum
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| *More likely symmetrical with clear upper margins
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| *Many will also have occult fractures; children <24mo should undergo a skeletal survey
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| ===Fractures===
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| *[[Fractures]] highly suspicious of abuse:
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| **[[Rib fracture]], especially posterior
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| **Metaphyseal or [[Corner Fracture (Bucket Handle)]]
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| **[[Scapula fracture]]
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| **Spinous process fractures
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| **[[Sternum fracture]]
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| **Fracture not consistent with developmental stage
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| *Fractures moderately suspicious of abuse:
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| **Long-bone transverse or spiral fracture of the diaphysis of the femur, humerus, tibia
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| **Multiple bilateral fractures
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| **Different stages of healing with multiple fractures
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| **Epiphyseal separations
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| **Vertebral body separation
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| **Complex [[Skull fracture (peds)|skull fractures]]
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| **[[Pelvic fractures]]
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| ===[[Pediatric head trauma|Head Trauma]]===
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| *Leading cause of death in abused children <2 years old
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| *[[Shaken baby syndrome]] - Retinal Hemorrhages
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| **Present in up to 75% of cases and are virtually pathognomonic
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| **Described as “dot and blot” hemorrhages or flame or splinter hemorrhages
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| ===Abdominal Trauma===
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| *Most from a direct blow or from being thrown
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| *Any abrasion or bruise on the abdominal area should prompt an evaluation for possible trauma
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| *Consider abuse in preschool aged children with any hollow viscus or pancreatic injury
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| ==Differential Diagnosis==
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| {{Template:Child abuse DDX}}
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| {{Crying infant DDX}}
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| ==Evaluation==
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| *Skeletal survey for all children < 2 years of age, non-verbal, or severe developmental delay. Note: Follow-up skeletal survey should be performed within 10 to 14 days
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| **Skull AP and lateral view (left and right)
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| **Chest AP and lateral view
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| **Right and left oblique of the chest
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| **AP of the abdomen to include pelvis and hips
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| **AP and lateral spine to include cervical, thoracic, and lumbar vertebrae
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| **AP bilateral humerus
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| **AP bilateral forearms
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| **AP bilateral femurs
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| **AP bilateral tibia and fibula
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| **Posterior view of the hands
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| **Dorsoplantar view of the feet
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| *[[Head CT]] without contrast for any child < 1 year with suspicion of abuse or >1 year with concerning signs of head trauma
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| *Trauma labs: CBC, CMP, PT, PTT, lipase, and urinalysis (looking for blood; use bag specimen). Consider urine tox screen
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| **Consider CPK and platelet function studies if extensive bruising is present
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| **If trauma labs are abnormal, obtain a CT of abdomen/pelvis with IV contrast
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| *Consider a dilated fundoscopic exam if under 2 years
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| *Photograph injuries
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| *Obtain a social work consult
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| ===Inpatient Workup<ref>Children's Hospital of Georgia NAT Workup Protocol. Medical College of Georgia at Augusta University. Last reviewed 2016.</ref>===
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| *Ophtho consult for retinal hemorrhages
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| *CBC
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| *CMP, Mg, phos
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| *PT/INR/aPTT, fibrinogen
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| *PTH, iCa, 25-hydroxy-Vit D, 1,25-dihydroxy-Vit D
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| *vW panel (vW AT, ristocetin cofactors, factor VIII)
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| ==Management==
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| *Treat injuries as indicated
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| *Report abuse to the appropriate state child protection authority
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| ==Disposition==
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| *Admit for medical treatment or if any question of child's safety
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| ==See Also==
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| *[[Trauma (peds)]]
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| ==External Links==
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| *[http://pemplaybook.org/podcast/vomiting-in-the-young-child-nothing-or-nightmare/ Pediatric Emergency Playbook -- Vomiting in the Young Child: Nothing or Nightmare]
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| ==References==
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| <references/>
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| [[Category:Pediatrics]]
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