EM@3AM: Pediatric Non-Accidental Trauma

A 3-month-old previously healthy male is brought to the ED by his parents. His father says he rolled off the couch onto a hardwood floor, started crying immediately, and then seemed sleepy and more fussy than usual. On exam, the patient is minimally consolable with a small bruise on his left forehead. Vitals are stable. There are no palpable skull fractures. Due to the age and mechanism, you obtain a head CT which shows a subdural hematoma without midline shift. You obtain a skeletal survey which shows a healing posterior rib fracture.

Question: What is the diagnosis?

Answer: Pediatric Non-Accidental Trauma (NAT)

Epidemiology

• The fatality rate stemming from NAT in the United States (US) is estimated at 1.05 children per 100,000, which translates to approximately one to two deaths per day.¹
• A quarter of all cases occur in children under one year of age.¹
• Overwhelmingly caused by parental figures.
  • 38% mothers, 23.9% fathers, 20.0% both parents.
  • Linked to but not specifically caused by parental stress, family history of psychological disorders, personal history of intimate partner violence (IPV), victim of childhood trauma, substance use disorder, post-traumatic stress disorder (PTSD). Also consider other social stressors like financial hardship, inadequate housing, food insecurity, history of criminal background, reliance on public assistance.¹

Presenting Symptoms/Injury pattern

• Nonspecific, wide spectrum of signs and symptoms.
• Strongest historical predictor is incongruence between HPI and patient presentation.²
  • Consider mechanisms that don’t align with developmental age, delays in seeking medical care, inconsistencies with stories.
  • Typically, there are no or minimal neurologic symptoms from a short fall from couch height.
• For infants => Sentinel injury: visible or detectable minor injury in a pre-cruising infant that is poorly explained and therefore suspicious for physical abuse³ recedes abuse in 27.5% of cases of NAT, can be a missed opportunity to catch NA.
  • Pre-cruising infant
  • Visible or detectable to caregiver
  • Poorly explained and unexpected

Bruise or intraoral injury

• Most common form of NAT.
• Intraoral injury: frenulum tears in non-ambulatory child (common in toddlers) or an unexplained injury to lips/teeth/soft palate.
• Mimics/Differential Diagnosis: accidental bruising in ambulatory child (forehead, shins, knees), coagulopathies (Factor V Leiden, von Willebrand), disorders of collagen (Ehlers-Danlos), dermal melanocytosis (formerly known as Mongolian spot), coin rubbing/cupping/moxibustion (cultural practices), port-wine stains (HSP, ITP).

• Consider Ten-4-FACESp for bruising in children <4 years of age concerning for NAT (Figure 1)

Fractures

• Only 1.5% of fractures requiring admission presenting to ED are from NAT⁵ so consider patterns of fracture and age of patient (most significant predictive factor for identifying fracture from NAT, as 69% of fractures related to NAT occurred in patients <1 year).
• Most common fractures associated with NAT: multiple fractures, especially at different stages of healing,mandible⁶, humerus⁷, ribs, femur⁸ (transphyseal distal 13x more likely to be NAT versus supracondylar), tib/fib, clavicle.
• 65% of rib fractures in pediatric trauma patients from NAT.
• Mimics/Differential Diagnosis: Rickets, Osteogenesis imperfecta (OI), fractures during delivery, osteopathy of prematurity, Hyper-IgE syndrome, Caffey Disease.

Burns

• Immersion burns, look for burns on buttocks and extremities (gloves and stocking)
• Cigarette burns (blistering circular burn).
• Consider tools like the BuRN-Tool to screen a burn for NAT (Figure 2).
  • Mimics/Differential Diagnosis: SJS, Staph scalded skin syndrome, contact dermatitis.

Abusive Head Trauma (AHT)

• Highest fatality rate from NAT (25%) due to increase in risk of intracranial hemorrhage, hypoxia-ischemia.
• Formerly known as “Shaken Baby Syndrome” – shearing forces lead to retinal hemorrhage/intracranial hemorrhage.
• Retinal hemorrhages have been deemed in litigation to be from birth trauma or CPR, but can be differentiated by presence of blood in macula (traumatic retinoschisis) present in NAT.¹¹
• PECARN guidelines are not validated in cases where NAT is suspected because PECARN relies on accurate history.¹²

Mimics/Differential Diagnosis: Subdural hemorrhage from Vitamin K deficiency, coagulopathies, vasculopathies (Ehler’s Danlos, Osteogenesis Imperfecta (OI)), AV malformations, biliary atresia (associated with intracranial hemorrhage)¹², benign enlargement of subarachnoid space during infancy.¹³

Management

• THOROUGH history and undressed physical exam (emphasis on skin exam, developmental history, family history for bleeding disorders, identify discrepancies in story).
• Skeletal Survey
  • Obtain in children <2, children 2-5 with suspicious fracture and child unable to communicate/perform full neuro exam (intellectually disabled).
  • Complete Skeletal Survey: AP humerus, AP forearms, PA hands, AP femurs, AP lower legs, PA/AP feet, AP/lateral thorax including clavicles, AP pelvis, lateral lumbosacral spine, AP and lateral cervical spine, frontal//lateral of skull. Consider oblique views of the ribs, as well.
  • Includes at least 21 individual X-rays to be adequate.¹⁷ NO Babygrams
• CT Head wo Contrast if concerned for ICH
  • MRI Head/C-Spine if CT head findings equivocal/concerning.¹⁸
• CT Abdomen/Pelvis wo Contrast if concern for abdominal trauma.
• Dilated fundoscopic exam/ophthalmology consult for patient < 12 month with intracranial hemorrhage.
• Labs: CBC with Diff/PT/PTT/LFTs/Lipase/UA.
• Social: Social work, Child Protective Services, child abuse pediatrics team (if your institution has one).
• Additional Tests: laboratory assessment for bone health (Vit D level, iPTH, Ca, Mg, Phos, alk phos), coagulopathy workup.
• CPS consultation, SW consultation. Determine need for sitter based on conversations with SW/CPS.
  • Consult child abuse specialist. If not available in local institution, consider if transfer is necessary for in-person evaluation by child abuse expert or for higher level of care.

Disposition

• Admit for continued observation, work-up, safety planning, placement if new guardian required. Collaborate with your state’s Child Protective Services (CPS) and child abuse specialist.
• Disposition usually dependent on CPS in conjunction with social worker.
• Ensure comprehensive follow-up care is arranged before discharge.
• Discharge education to parents, support services (i.e. chaplaincy, local wellness resources).
• Avoid judgment and use trauma-informed, culturally sensitive care.
• Document communication, decisions, medical thought process meticulously and thoroughly. If taking pictures, take clear photos before dressing any injuries.

Pearls

• Consider any bruise in child under 4 months requires an occult injury work-up.
• If NAT is on differential, PECARN guidelines for head CT does NOT apply (low threshold for getting head imaging).
• A child that has a mimic for NAT bruising/fracture does not necessarily rule out NAT.
• Acute rib fractures are difficult to identify in an acute setting before they start having evidence of healing. Fractures require a minimum of 7 days to show evidence of healing (periosteal reaction).