View source for Nonaccidental trauma

==Background==
*Newer term that encompasses child abuse
*Infant and children with disabilities are at higher risk
*In >80% of cases, the parent or primary guardian is the abuser
*Report suspicion
**Transparent, frank discussion with caregivers
**Social work or child protection agency involvement
***Protect the child first, admit if suspicious
***Social work may follow-up as outpatient for very low risk cases

===Risk Factors===
*[[Interpersonal Violence|Domestic violence]]
*Maternal [[depression]]
*[[Substance abuse|Drug]] and [[alcohol Abuse|alcohol abuse]]
*Premature birth
*Children with disabilities or children who require significant medical care
*Unrealistic expectations for the child

===Red flags===
*History given is inconsistent with the mechanism of injury
*Changes in caregivers report
*Significant delays in care
*Any injury to a young, pre-ambulatory infant
*Injuries to multiple organ systems
*Injuries in different stages of healing; 
*Patterned injuries
*Injuries to non-bony or other unusual locations, (torso, ears, face, neck, or upper arms)
*Significant injuries that are unexplained
*Other evidence of child neglect.

==Clinical Features==
===Bruises===
*Bruises, ecchymosis, and soft-tissue injuries on the face, cheeks, buttocks, ears, torso, neck if the child is not cruising yet
*Bruises in clusters or patterned marks
*Bruising of any child less than or equal to 6 months of age (or non-ambulatory) warrants a full child abuse work-up

===Oral injuries===
*Torn frenulum in premobile children is highly associated with physical abuse
*Other reported oral injuries include laceration/bruising to the [[lip Laceration|lips]], mucosal lacerations, [[dental fracture|dental trauma]], [[tongue laceration|tongue injuries]], and gingival lesions

===[[Burns]]===
*Most commonly immersion injuries of the extremities, buttocks, or perineum
*More likely symmetrical with clear upper margins
*Many will also have occult fractures; children <24mo should undergo a skeletal survey

===Fractures===
[[File:Child Protection - Child Abuse and Neglect - Bucket Handle Fracture (XRAY).jpg|thumb|Bucket Handle Fracture (Courtesy of Michael Mojica<ref>Mojica, Michael. 2015. PEM Guides. NYU Langone Health.</ref>)]]
[[File:Child Protection - Child Abuse and Neglect - Metaphyseal Chip Fracture (XRAY).jpg|thumb|Metaphyseal Chip Fracture (Courtesy of Michael Mojica)]]
*[[Fractures]] highly suspicious of abuse:
**[[Rib fracture]], especially posterior
**Metaphyseal or [[Corner Fracture (Bucket Handle)]]
**[[Scapula fracture]]
**Spinous process fractures
**[[Sternum fracture]]
**Fracture not consistent with developmental stage (any fracture in non-ambulatory child)

*Fractures moderately suspicious of abuse:
**Long-bone transverse or spiral fracture of the diaphysis of the [[femur fracture (peds)|femur]], [[humerus fracture (peds)|humerus]], [[tibia fracture (peds)|tibia]]
**Multiple bilateral fractures
**Different stages of healing with multiple fractures
**Epiphyseal separations
**Vertebral body separation
**Complex [[Skull fracture (peds)|skull fractures]] (i.e. depressed or cross suture lines)
**[[Pelvic fractures]]

===[[Pediatric head trauma|Head Trauma]]===
*Leading cause of death in abused children <2 years old
*[[Shaken baby syndrome]] - [[Retinal hemorrhage]]s
**Present in up to 75% of cases and are virtually pathognomonic
**Described as “dot and blot” hemorrhages or flame or splinter hemorrhages

===[[Abdominal Trauma]]===
*Most from a direct blow or from being thrown
*Any abrasion or bruise on the abdominal area should prompt an evaluation for possible trauma
*Consider abuse in preschool aged children with any hollow viscus or pancreatic injury

===[[sexual assault|Sexual Trauma]]===
*Even among children who report vaginal or anal penetration, the rate of abnormal physical examination findings is only 5 to 15%
*Consult your local sexual assault response team or transfer to an appropriate facility as indicated.
*Females
**Preferred positioning for adequate examination: child lying supine with her hips externally rotated and knees flexed (frog-leg) or the prone knee-chest position.
**Examine hymen for lacerations, transections, and bruising.
**Prepubertal females do not require a speculum exam unless there is active bleeding.
**Vaginal discharge in a prepubertal female should prompt testing for sexually transmitted infections.
**The diameter of the hymenal orifice is not a marker for whether or not vaginal penetration occurred.
*Males
**Examine for lacerations, burns, bite marks, and bruises to the genital region. Penile and anal injuries are more common than scrotal injuries. 
**Swab any anal or penile discharge for sexually transmitted infections.

==Differential Diagnosis==
{{Template:Child abuse DDX}}
{{Crying infant DDX}}

==Evaluation==
[[File:Fractured ribs.jpg|thumb|Multiple rib fractures in an infant secondary to child abuse.]]
*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
**Skull AP and lateral view (left and right)
**[[CXR|Chest]] AP and lateral view
**Right and left oblique of the chest
**AP of the [[KUB|abdomen]] to include pelvis and hips
**AP and lateral spine to include cervical, thoracic, and lumbar vertebrae
**AP bilateral humerus
**AP bilateral forearms
**AP bilateral femurs
**AP bilateral tibia and fibula
**Posterior view of the hands
**Dorsoplantar view of the feet
*[[Head CT]] without contrast for any child < 1 year with suspicion of abuse or >1 year with concerning signs of head trauma
*Trauma labs: CBC, CMP, PT, PTT, lipase, and urinalysis (looking for blood; use bag specimen). Consider urine tox screen
**Consider CPK and platelet function studies if extensive bruising is present
**If trauma labs are abnormal (AST or ALT > 80, lipase > 100), obtain a CT of abdomen/pelvis with IV contrast 
*Consider a dilated [[fundoscopic exam]] if under 2 years
*Photograph injuries
*Obtain a social work consult
===Inpatient Workup<ref>Children's Hospital of Georgia NAT Workup Protocol. Medical College of Georgia at Augusta University. Last reviewed 2016.</ref>===
*Ophtho consult for [[retinal hemorrhage]]s
*CBC
*CMP, Mg, phos
*PT/INR/aPTT, fibrinogen
*PTH, iCa, 25-hydroxy-Vit D, 1,25-dihydroxy-Vit D
*vW panel (vW AT, ristocetin cofactors, factor VIII)

==Management==
*Treat injuries as indicated
*Keep alleged perpetrator separate from the patient if possible and/or keep patient supervised at all times
*Report abuse to the appropriate state child protection authority

==Disposition==
*Admit for medical treatment or if any question of child's safety

==See Also==
*[[Trauma (peds)]]
*[[Abusive head trauma]]

==External Links==
*[http://pemplaybook.org/podcast/vomiting-in-the-young-child-nothing-or-nightmare/ Pediatric Emergency Playbook -- Vomiting in the Young Child: Nothing or Nightmare]
*https://www.childhelp.org/wp-content/uploads/2019/02/CPS-Phone-Numbers-2.1.19.pdf
*[https://pedemmorsels.com/tag/abuse/ Pediatric EM Morsels: Abuse]

==References==
<references/>

[[Category:Pediatrics]]
[[Category:Trauma]]