Non-accidental trauma and neglect (pediatrics): Clinical sciences

Non-accidental trauma refers to any intentional act by a caregiver that causes physical or psychological harm, while neglect refers to inadequate provision of a child’s basic needs, which causes or could potentially cause harm. Non-accidental trauma, which is also called child maltreatment or child abuse, can be sub-categorized as neglect, physical abuse, sexual abuse, psychological abuse, or medical abuse.

When a pediatric patient presents with a chief concern suggesting non-accidental trauma or neglect, first perform an ABCDE assessment to determine if they are stable or unstable. If unstable, stabilize their airway, breathing, and circulation. Next, obtain IV access, consider IV fluids, and put your patient on continuous vital sign monitoring, including blood pressure, heart rate, and pulse oximetry. Finally, provide supplemental oxygen, if needed.

Here’s a clinical pearl to keep in mind! Abusive head trauma, previously known as “shaken baby syndrome” occurs in children under the age of 2 through blunt force, trauma, shaking, or a combination of these. It can manifest with vomiting, seizures, or coma due to intracranial hemorrhage and brain swelling. This condition might be misdiagnosed or missed but early identification of this type of abuse can be life-saving.

Okay, let’s go back to the ABCDE assessment and look at stable patients. First, obtain a focused history and physical exam, making sure to interview caregivers and children separately when possible. Children often don’t volunteer information about maltreatment, so look for behavioral changes, like social withdrawal or acting out. In the case of injury, there may have been a delay in seeking care; or the reported history might not explain the injury. Meanwhile, physical exam findings are often unremarkable, but some patients demonstrate poor growth or evidence of a physical injury. With these findings, suspect non-accidental trauma or neglect; and assess the subtype.

Let’s start with physical abuse. In these cases, the reported history is often inconsistent with the injury’s severity, pattern, mechanism, or timing; or with the child’s development. Red flags suggesting abuse include any trauma in nonmobile infants or fractures in nonambulatory children. The exam may also reveal bruising in unusual places like the torso, ears, or neck; as well as skin lesions with distinct patterns, such as handprints, cigarette burns, or even bite marks. You might also detect circumferential immersion burns on hands or feet. Any of these findings should make you suspect physical abuse.

Here’s another clinical pearl! Distinguishing physical abuse from accidental injury can be challenging, but specific findings can provide important clues. For example, while accidental injuries commonly occur over bony prominences, such as elbows and shins; non-accidental injuries often involve unusual locations like the torso, neck, mouth, or ears. Be concerned for abuse when you see fractures of the posterior or lateral ribs, scapulae, or vertebrae; as well as metaphyseal “corner” or “bucket-handle” fractures. Remember that some benign findings masquerade as abuse, including skin lesions produced by cultural remedies such as cupping and coining; and birthmarks such as congenital dermal melanocytosis. Finally, conditions like hemophilia or osteogenesis imperfecta can mimic physical abuse by predisposing patients to bleeding or fractures.

Okay, once you suspect physical abuse, order X-rays of affected bones and joints, as well as a skeletal survey if the patient is under 2 years old. If you suspect head or abdominal trauma, obtain a head or abdominal CT scan, and consider a dilated fundoscopic exam.

Imaging may reveal fractures in different stages of healing or in unusual locations, while a CT scan might reveal an intracranial or intra abdominal injury. If fundoscopy was performed, it may detect retinal hemorrhages. Any of these findings suggest physical abuse.

As a mandatory reporter, you are required to report suspected abuse to your local child protective services agency and inform caregivers of your report. Using a multidisciplinary team approach, you should also consult a provider specializing in child maltreatment for further evaluation, as well as medical and mental health treatment. Finally, arrange a safe disposition for the child, which may include temporary hospitalization or an emergency custody arrangement.

Let’s move on to neglect. In this case, caregivers do not provide sufficient medical, nutritional, educational, or emotional care; or they provide inadequate supervision and safety. Affected children often have poor school attendance or difficulty gaining weight. Physical exam may demonstrate poor hygiene; inappropriate clothing; dental caries; or severe diaper dermatitis. Any of these findings suggest neglect.

Whenever you suspect neglect, report it to your local child protective services agency and inform caregivers of your report. Using a multidisciplinary team approach, consult a provider specializing in child maltreatment for further evaluation as well as medical and mental health treatment, and to arrange a safe disposition for the child.