Pediatric Trauma Screening For Non-Accidental Trauma: Pediatric Trauma Series...
With Dr. Tony Escobar & Dr. Kristen Crichton · StayCurrentMD
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Non-accidental Trauma 3 items
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What the experts said
In Mary Bridge's retrospective cohort, 89% of NAT cases had inconsistent or missing history, 79% had unwitnessed injuries, and almost 40% of patients had a prior ED visit
60% of NAT patients with prior ED visits were less than a year of age
41% to 73% of NAT patients were missing social history data in the chart
Perineal bruising or injury was found in a small number of patients, but the majority were less than 4 years of age and there was significantly increased risk of mortality and morbidity with this finding
60% of NAT patients less than a year of age had fractures, with a fraction having undiagnosed healing fractures in other sites
A third of NAT patients had rib fractures, which were significantly associated with severe injury (ISS ≥16) and other undiagnosed healing fractures
In the retrospective cohort, 9 patients died, and 2/3 of those had a prior ED visit
The use of head CT did not change after implementing the NAT screening protocol
After implementing standardized NAT screening at Mary Bridge, ED length of stay did not change
After implementing standardized screening, the number of admissions went down, possibly because more standardized screening in the ER led to safer disposition planning and fewer medical holds
In Ohio's TRAIN collaborative baseline data, around 40% of kids less than 6 months with a bruise were getting skeletal surveys
In a TRAIN collaborative study of 367 infants <6 months with bruising, significantly more infants with public insurance had skeletal surveys than those with private insurance, with no racial difference seen
Posterior rib fractures, classic metaphyseal fractures, and pattern bruises will all get better without medical intervention, but identifying them provides information to protect children
Child abuse is more common than every bleeding disorder
A skeletal survey following American College of Radiologists and AAP guidelines requires about 24 separate X-rays, not a single babygram
At Nationwide Children's, an automatic consult to the child abuse team is triggered for any child under age 5 admitted to the hospital, which has increased team visibility and access without increasing length of stay or imaging studies
The risk of dying from repeated abuse is far higher than the risk of brain cancer from a head CT
48% of child fatalities each year are a result of physical abuse
Approximately 12% of child abuse fatalities involve families that had CPS intervention in the last 5 years prior to the fatality, with the majority of these children less than 4 years of age
In Carol Jenny's study, approximately 30% of children with abusive head trauma had NAT not originally considered or recognized by physicians
Kate Dean's group demonstrated that patients with recurrent NAT had significantly higher mortality than during their first presentation
The 10-4 clinical prediction rule (torso, ears, neck bruising in children <4 years, or any bruising in infants <4 months) is highly suspicious for NAT
In the most recent systematic review of burns, up to 25% of children admitted to burn centers had been abused
Greater than 95% of patients with intentional burns were aged less than 5 years
Hollow viscous injuries, specifically duodenal injuries in children less than 4 years old, are highly suggestive of abuse
Abusive abdominal injury can occur without external signs such as bruising
Screening for elevated liver function tests is recommended, and if elevated, further axial imaging is recommended to evaluate for intraabdominal injury
Frenulum tears in mobile children have equivalent incidence between accidental and non-accidental trauma, so in and of themselves there is not sufficient evidence to recommend a child abuse workup
In a national study of primary care providers, PCPs often fail to report injuries concerning for child abuse to CPS due to familiarity with the family, perceived lack of value from CPS involvement, or use of their own alternative management plan
In a study of pediatric nurses, barriers to reporting included difficulty with cases that aren't clear cut, especially in small infants where injuries can be non-severe or non-specific
In a Dutch study of ED physicians, barriers included lack of time, fear of inaccurate suspicion, insufficient communication skill, and turnover of ED staff
In Carol Jenny's 1999 study of missed abusive head trauma, children where abuse was missed were significantly more likely to be white and in dual parent homes
Wendy Lane and colleagues found minority children had higher rates of evaluation for abuse and higher reports of suspected abuse, separate from any racial disparity in actual abuse
Physical abuse is considered more often in children with low socioeconomic status
In a 2018 study of 746 child abuse pediatrician consult notes, CAP perception of a child's socioeconomic status was strongly linked to perception of risk, even when other social cues were accounted for
In a 2015 study by Dan Lindberg, only 20% of infants under 6 months old who had a bruise had a skeletal survey done, though by AAP guidelines most should have
Joanne Wood found that 68% of children less than a year old with traumatic brain injury had a skeletal survey done
At Mary Bridge, standardized NAT screening eliminated racial and socioeconomic disparities in screening