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

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Introduction0:00–0:34

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.

Unstable Patient0:34–1:33

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.

Stable Patient1:33–2:18

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.

Physical Abuse2:18–5:14

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.

Neglect5:14–6:11

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.

Sexual Abuse6:11–9:05

Now let’s discuss sexual abuse. These patients experience forced or developmentally inappropriate sexual contact or are exposed to sexually explicit acts or media.
Additionally, affected children often display age-inappropriate sexualized behaviors. Perpetrators may “groom” a child to establish trust or threaten a child in order to maintain secrecy, which prevents patients from reporting abuse to trusted adults.
Affected children sometimes describe symptoms like dysuria or enuresis; and genital pain, discharge, or bleeding. Physical exam is often unremarkable, but it may reveal genital injury.
These findings suggest sexual abuse, which could include both physical and psychological abuse. Once you suspect sexual abuse, report it to your local child protective services agency and inform caregivers.
Using a multidisciplinary team approach, consult a trained provider specializing in child maltreatment, provide medical and mental health treatment, and arrange a safe disposition for the child.
Next, assess the need for immediate forensic evaluation, such as evidence collection, which must be done within 72 to 120 hours of a suspected assault, depending on the patient’s age.
Other indications for evaluation include an acute injury or significant abnormal physical or psychiatric symptoms; infection or pregnancy requiring prophylactic treatment; concerns about the child’s or family’s safety; or caregiver anxiety or concern.
atients without any indications don’t require an immediate forensic evaluation, so in this case, you can continue current management.
On the other hand, patients with one or more indications require immediate forensic evaluation by a trained provider. It’s critical to perform this exam in the presence of a chaperone; and if possible, include a trusted caregiver for support.
Remember to document any injuries or other concerning findings with photographs and detailed written descriptions. Finally, consider testing for sexually transmitted infections, or STIs.
Now, if the physical exam reveals a genital or anal injury; or if STI testing is positive; treat the STI with antimicrobials.
Depending on the age of the patient, you can offer STI prophylaxis, especially in postpubertal children, where there’s a risk of pelvic inflammatory disease and a chance they could be lost to follow-up.
Lastly, consider preventative treatment for HIV, Hepatitis B, and pregnancy. Next, let’s talk about psychological abuse.

Psychological Abuse9:05–10:16

These children experience verbal or nonverbal threats, humiliation, exploitation, or isolation; and they may witness frightening behaviors such as intimate partner violence.
Psychological maltreatment also includes intentional or unintentional neglect of a child’s social or emotional needs. It can be difficult to recognize this form of maltreatment, so look for subtle clues, like vague somatic symptoms; anxiety or depression; declining school performance; or developmental regression.
Any of these findings may suggest psychological abuse, which often occurs simultaneously with other forms of abuse. Whenever you suspect psychological abuse, report it to your local child protective services agency and inform caregivers.
Using a multidisciplinary team approach, consult with a trained provider specializing in child maltreatment, provide medical and mental health treatment, and arrange a safe disposition for the child.

Medical Child Abuse10:16–11:32

Finally, let’s discuss medical child abuse, which goes by several names, including Factitious Disorder Imposed on Another.
In this case, a caregiver fabricates symptoms that aren’t witnessed by anyone else, and they request invasive testing or procedures for their child, despite no evidence of underlying illness.
If providers don’t order the requested tests or procedures, caregivers often seek second opinions. If a provider does offer treatment, and the patient improves, the caregiver doesn’t express relief or satisfaction.
When a caregiver appears to fabricate, exaggerate, or actively cause symptoms; or demands unnecessary interventions for their child; you should suspect medical child abuse.
This form of maltreatment was previously called Munchausen Syndrome by Proxy. When it comes to management, report abuse to your local child protective services agency and inform caregivers.
Using a multidisciplinary team approach, consult with a trained provider specializing in child maltreatment, provide medical and mental health treatment, and arrange a safe disposition for the child.

Review11:32–12:09

Alright, as a quick recap… Non-accidental trauma refers to intentional acts that cause harm, while neglect refers to omissions of care that cause, or could potentially cause harm.
The main types include physical abuse, neglect, sexual, psychological, and medical abuse. Manage maltreatment using a multidisciplinary approach, by reporting to child protective services, informing caregivers, and consulting a trained provider for further evaluation, appropriate medical and mental health treatment, and a safe disposition.
Non-accidental trauma and neglect (pediatrics) | Osmosis