PEDIATRIC

NONACCIDENTAL
TRAUMA
Angela Long, RN

Cheryse Jackson, RN

Reginald Degrafenreid, RN
Andre Foster, RN

OBJECTIVES
Awareness of epidemiology of and risk factors for
child physical abuse
Increased recognition of non-accidental trauma
(NAT) based on history, physical exam findings,
and radiologic studies
Understanding how to report suspected abuse
and/or neglect

EXTENT OF ABUSE
Approximately 10% of all ED visits for children <5
years old are related to NAT
3 million reports and 1 million substantiated cases
per year incidence of 42 per 1,000 children

Have

you ever reported abuse?

True extent of abuse unknown; many cases go

unreported
Child maltreatment encompasses:

Physical

abuse 23%
Sexual abuse 12%
Neglect 60%
Emotional abuse 4%

WHY WE NEED TO BE AWARE

Very common
High morbidity & mortality
Opportunity to intervene
Responsibility to intervene
Requirement to report

MARYLANDS DEFINITION OF
ABUSE

The physical or mental injury of a child by any

parent or other person who has permanent or
temporary care or custody, or responsibility for
supervision of a child, or by any household or
family member, under circumstances that
indicate that the childs health or welfare is
harmed or at substantial risk of being harmed

KEEPING CHILDREN AND FAMILIES

SAFE ACT (JUNE 2003)

Defines child abuse and neglect as, at a

minimum, any recent act or failure to act:
Resulting

in imminent risk of serious physical or

emotional harm, death, sexual abuse, or exploitation
Of a child (person <18 years old)
By a parent or caregiver (including any employee of a
residential facility or any staff person providing outof-home care) who is responsible for the childs
welfare

NURSE PRACTITIONERS
RESPONSIBILITY

Maryland law mandates that all medical

providers report suspected abuse or neglect to
Child Protective Services (CPS) or other law
enforcement agencies
Medical

Providers may be held liable for failure to

report
Immunity from civil liability and criminal penalty if a
report is made in good faith

RED FLAGS: WHEN TO SUSPECT

ABUSE
Unexplained injury
History and/or developmental abilities inconsistent
with injury
Varying, changing histories
Delay in seeking treatment
Frequent injury/illness

Less common:

Child accuses adult

One parent accuses other parent
Alleged self- or sibling-inflicted injury
Eyewitness
Perpetrator confesses

RISK FACTORS FOR ABUSE

Family stress
Economic

difficulty/unemployment
Poor housing/crowding
Illness

Parents psychology
Impulse

control disorder
Depression
Psychosis
Drug/alcohol abuse
Retardation

Child factors
Provocative

behavior
Illness/disability/ developmental
delay
Multiple children in household

Parenting factors

Lack of preparation
Poor role models
Unrealistic expectations of
child
Use of corporal punishment
Unsupportive spouse/partner
Nonbiologic parent present
(especially Moms boyfriend)
Inconsistent parenting

Social factors

Social isolation
Distant/absent extended family
High expectations for all
parents
Violence considered acceptable
in society

BEFORE ANY EXAM HISTORY,

HISTORY, HISTORY!

Initial Introduction:

Explain the evaluation process

Make the child as comfortable as possible

Caregiver Interview/History of Events:

Allow caregiver an opportunity to describe concerns

(with the child OUT OF THE ROOM)
Let caregiver provide PMHx (especially easy bleeding or
bruising in patient or family), ROS, home
environmental situation, prior abuse history, and relate
any information about the current suspected abuse
Explain the mandatory sharing of information with CPS
and law enforcement

HISTORY FROM THE CHILD

Most NAT in children <2 years old, so history from child often not
possible
If it is

Once rapport has been established, ask the child why they have come
to see the doctor
Use simply worded, open ended questions
Avoid yes or no questions
Glean additional information with a tell me more & and then what
happened approach
Gather specific details regarding the abuse
Use the childs terms for body parts and actions
Finish the interview by encouraging the child and praising them for
disclosing the information
Prepare them for the physical examination

HISTORICAL INDICATORS OF ABUSE

Is the history one of inflicted injury?
Is there an absence of history a magical injury?
Could the injury have been avoided by better care and
supervision?
Are there inconsistencies or changes in the history?
Is there a history of repeated injury or hospitalization?
Was there a delay in seeking medical care?
Does the history over- or underestimate the injury?
Is there a medical history of prematurity, failure to
thrive, and/or failure to receive adequate medical care,
such as immunization?
Is this a high-risk history (e.g., fall down stairs, dropped
baby)?

MANIFESTATIONS OF PHYSICAL
ABUSE
Skin: lesions (lacerations, punctures, &
abrasions), burns, hair loss
Skeletal system: fractures, periosteal hematomas
CNS: direct trauma, shaking injures
GI system: mouth injuries, blunt abdominal
trauma
Cardiopulmonary and GU trauma
Unusual: ingestions, drowning, punishment
diets, Munchausen syndrome by proxy (aka:
Factitious disorder by proxy)

BRUISES, BURNS, AND

OTHER
ABUSIVE SKIN FINDINGS

ACCIDENTAL VERSUS SUSPICIOUS

BRUISES

Accidental
Extensor

surfaces of extremities, forehead, bony

prominences
Ambulatory child

Suspicious
Shape:

imprint of object
Location: upper arms, anterior thigh, trunk, genitalia,
buttock, face, ears, neck
Pattern: symmetry or pairs
Multiple locations
Different ages
Not compatible with history, especially non-ambulatory
child children who dont cruise shouldnt bruise

PATTERN BRUISES: HANDSLAP

Pattern: the appearance of the
injury suggests the object used
to cause the injury
Injuries caused by a highvelocity injury such as a slap
mark create a negative imprint
or outline of the object that
contacted the skin with
surrounding confluent
petechiae

PATTERN BRUISES: BELT

OTHER PATTERN BRUISES

Wire brush

Switch

Chip clip

EAR BRUISING

Petechiae

Mastoid bruising

Although accidental injuries to the

pinna occasionally occur, abusive
injuries from direct blows to the side
of the head, pulling, or grabbing are
seen often in abused children. Note
how linear bruises run along the top
of her pinna, where it was crimped
against her underlying scalp by the
blow.

Fingernail marks

BITE MARKS

ATTEMPTED STRANGULATION

Notice the abrasions and

bruises from the cord in
addition to the petechiae about
the face. Petechiae about the
neck and face are common in
these cases because of the
elevated venous pressure
experienced during the
strangulation attempt.

PERIORBITAL ECCHYMOSES
Can be secondary to
accidental forehead
trauma

Non-accidental eye
trauma often causes
subconjunctival
hemorrhage in addition
to bruising

MULTIPLE BRUISES

PATTERN BURNS: CIGARETTE

LIGHTERS

Smiley-face

PATTERN BURNS: CIGARETTE

LIGHTERS

PATTERN BURNS: CIGARETTES

Cigarette burns are sometimes indistinguishable from healing

contusions and impetigo. One must observe the injuries for
quantity, symmetry, location, and size. Burns are typically about 7
to 8 mm wide, although this depends on the type of cigarette, and
have a deeper, central ulcer or eschar where the most heat from the
cigarette contacts the skin. These injuries have been directly
imprinted and are multiple, not the single, amorphous burn that
usually occurs with an accidental brushing of a lit cigarette.

WATER/SCALD BURNS

Spill and Splash

Burns

Varying depth of burn

Deeper burns in area of
first contact
May see inverted triangle
shape
Multiple areas of burn
Indistinct borders
Splash marks
Accidental or inflicted

Immersion Burns

Uniform depth of burn

Stocking or glove
distribution
Buttocks, lower back &
perineum with sparing of
flexor creases
Unvaried appearance
Distinct borders with
sharply defined water
lines
No splash marks
Usually inflicted

IMMERSION BURNS

Stocking glove appearance

Note sparing of flexural creases

SCALD BURNS

Hand held under hot water

REFERENCES AND THANKS

Many images and captions courtesy of

Dr. Forrest Closson, Department of Pediatrics, University of Maryland,

Hospital for Children
Visual Diagnosis of Child Abuse on CD-ROM, 3 rd edition, AAP, 2008

AAP, Diagnostic imaging of child abuse, Pediatrics, 2000; 105: 13451348.

Feldman KW, Brewer DK, Child abuse, cardiopulmonary resuscitation,
and rib fractures, Pediatrics, 1984; 73: 339.
Kellogg ND, AAP Committee on Child Abuse and Neglect: Evaluation
of suspected child physical abuse, Pediatrics, 2007; 119: 1232-1241.
Von Waldenburg-Hilton, Saskia, Chapter 17: Differentiating the
Accidentally Injured from the Physically Abused Child, Practical
Pediatric Radiology, 3rd edition, Philadelphia: Saunders-Elsevier, 2006.
Wood, JN and Ludwig, S, Chapter 132: Child Abuse, Textbook of
Pediatric Emergency Medicine, 6th edition, Philadelphia: Lippincott
Williams & Wilkins, 2010.