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Hot Topic 1: Non-Accidental Trauma in Children

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Brief Review:
(T. Larsen, M. Johnston and H. Altamirano) The pediatric trauma society guideline committee identified screening for non-accidental trauma (NAT) as a key area for guideline development. A muldisciplinary work group was created including PTS members and international experts in NAT. Subgroups were then created to summarize and assess the quality of the evidence describing the correlation between NAT and the following: Bruising, burns, abusive head trauma, abdominal injuries, fractures, historical, and oral trauma. Each subgroup evaluated the literature utilizing a standardized methodology.

Why this article is relevant or important.
NAT is a leading cause of child traumatic injury and death and has an increased incidence of high ISS, craniotomy, exploratory laparotomy, prolonged ICU and hospital length of stay, and mortality when compared to unintentional trauma. The definition and screening tools vary widely in the literature because there are no random control trials or prospective trials with large effect size. A systemic review of 50 years of published studies evaluating screening tools found a lack of a gold standard for determination of abuse.

Title, Authors, Abstract:
Escobar, M.A., Auerbach, M., Flynn-O’Brien, K., Tiyyagura, G., Borgman, M.A., Duffy, S.J., Falcone, K., Burke, R, Cox, J.M., Macguire, S. J Trauma Acute Care Surg 2017 Jun;82(6):1147-1157 The association of non-accidental trauma with historical factors, exam findings and diagnostic testing during the initial trauma evaluation.

Early identification of non-accidental trauma (NAT) is a critical component of pediatric trauma care. Literature searches were conducted related to the association of NAT with seven key areas: history, exam findings (burns, oral trauma, bruising) and imaging (fractures, abdominal and brain injuries). When available, odds ratios (OR) with 95% confidence intervals (CI) for associations with NAT are presented. Systematic reviews have been published in six of the seven key areas and are described. The operational definition of NAT was widely variable across studies, prohibiting meta-analysis. Select highly associated findings included bruising in a pre-mobile child, clustering of bruises (OR 4.0, CI 2.5-6.4), petechiae (OR 9.3, CI 2.9-30.2), chemical burns 24.6 (4.94-135); contact burns 5.2 (1.6-22.9); scald burns 17.4 (6.4-72), burns to hand 1.8 (1.3-2.6), feet 6.3 (4.6-8.6), buttocks 3.1 (2.2-4.5), and perineum 2.5 (1.7-3.7), subdural hematoma (OR 8.2, 6.1-11), hypoxic ischemic injury (OR 4.2, CI 0.6-2.7), and retinal hemorrhages (OR 14.7, CI 6.4 to 33.6) among others. Of note, hollow viscus injuries, particularly duodenal injuries in children < 4 years were indicative of NAT. While there is substantial research on factors associated with NAT, future work is needed to standardize the definition of NAT for investigation and practice, such that evidence-based guidelines can be created to inform trauma providers when a comprehensive NAT evaluation is indicated.

Some of the highlighted findings included:

Bruising patterns suggestive of NAT depend on stage of the child’s development. The presence of bruising in healthy non-abused infants is low. Bruising in children less than 4 years on the trunk, ears, neck; or any bruising in infants less than 4 months of age is NAT until proven otherwise.

Scalds to the buttocks, perineum, bilateral lower limbs or unilateral limbs are highly associated with NAT. Other risk factors include any burn in a child less than 5 years of age, multiple contact burns, or clearly demarcated edges to the burns.

Intracranial Injuries
Acute Head Trauma (AHT) is the leading cause of morbidity and mortality in children suffering from physical abuse. AHT is associated with SDH, hypoxic –ischemic injury, diffuse axonal injury, metaphyseal fractures, rib fractures, retinal hemorrhages, apnea, and seizures.

Abdominal Injuries
Victims of NAT < 4 years of age suffer from a higher percentage of hollow viscus injury, particularly duodenal perforation

Fractures among non-ambulating children, including no clear correlating history, fractures of the proximal and midshaft humerus, femur fractures in non-ambulatory children, rib fractures without associated major trauma, and occult fractures in children less than 2 years are all suggestive of NAT.

The two best predictors of NAT are injury inconsistent with the history and if the patient was referred to a clinician for suspected abuse.

Intraoral injury
Intraoral injury in non-ambulatory children are highly suspicious for NAT. These injuries are often under-reported because a documented oral exam is often lacking in the evaluation of an injured child. Future work relating to standardizing the definition of NAT as well as creation of a standardized screening tool and injury based algorithm is needed.

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