Non-accidental Trauma in Pediatrics

Introduction:

Non-accidental trauma leads to injuries involving skin, soft tissue, and fractures. The most serious one among non-accidental trauma is abusive head trauma, which is majorly seen in children undergoing exploitation in the first year of life, leading to increased mortality rates. Parents who have low self-esteem, who are less successful, have mere knowledge of normal child development, who are young and impatient, and who have less competence in parenting are the ones who tend to indulge in child abuse.

Parent unemployment rates are directly proportional to child maltreatment rates, and also parents who were once victims of child abuse are more prone to repeat the same in their children. The role of an emergency physician is vital in careful physical examination of child abuse, as in many cases, it may go unnoticed when the patient presents to the department. A detailed personal, medical, and family history, clinical signs, and symptoms should be recorded to derive an apt diagnosis, preventing such cases from going untreated and being curbed from getting proper medical care.

What Is Non-accidental Pediatric Trauma (NAT) or Child Abuse?

Non-accidental trauma (NAT) refers to a child getting purposefully injured for various reasons. Also termed as child abuse. At the cellular level of skin abuse, musculoskeletal and neurological systems are affected. Due to the imbalance in energy requirements to dendrites and synapses, blood flow, and neurotransmitters in a young, immature brain, increased apoptosis and excitotoxicity facilitating neuroplasticity increases the risk of secondary injury as a result of abuse-induced apoptosis and increased neuroinflammatory response post-injury. This affects axonal and dendritic growth in such children.

What Are the Risk Factors Associated With Child Abuse?

• Children brought up in isolated (less connected with the community), low socio-economic status backgrounds.

• Born to parents with low self-esteem, depression, a history of suicide attempts, frustration, and already being a victim of child abuse.

• Unwanted pregnancy.

• One of the parents engaged in criminal activity.

• Drug abuse.

• Long-term separation from the child.

• Poor communication skills with poor people management.

• Shorter birth intervals.

• Psychiatric disorder.

• Perinatal illness of the child.

• History of getting sentenced to jail as a child.

What Are the Red Flag Signs or Clinical Features to Be Looked for in an Abused Child?

Cutaneous Features:

• Bite marks.

• Bruising in infants aged below four months.

• Bruises in nonambulatory children in the region, excluding bony prominences.

• Bruising of the trunk, ears, neck, frenulum, angle of the jaw, cheek, eyelid, and subconjunctival.

• Inflicted with patterned bruising.

• Burns suggestive of immersing hands in hot water.

• Burns are caused by cigarettes.

Musculoskeletal Features:

• Spiral fractures in the hands or legs are caused by forced dragging or pulling.

• Posterior rib fractures are caused by getting held by the chest.

• Getting forcefully struck by the chest causes sternal fractures.

• Femur fractures are seen in children before the age of walking.

• Humerus fracture in children below three years.

• Metaphyseal corner (bucket-handle) fractures are caused due to ligament traction from bone attachments.

• Multiple traumatic episodes are indicative of scars in the healing regions.

Neurological Manifestations:

• Altered mental status.

• Vomiting.

• Seizures.

• Lethargy.

• Poor appetite.

What Are the Differential Diagnosis for Non-accidental Trauma?

• True accidental injury.

• Osteogenesis imperfecta.

• Osteopenia.

• Scurvy.

• Copper deficiency.

• Menkes disease.

• Disuse osteopenia in nonambulatory or minimally ambulatory children.

• Chronic liver and kidney disease.

How Is Non-accidental Trauma (NAT) Diagnosed?

Physical Examination:

• A thorough physical examination should be attempted so as not to miss any findings that lead to a diagnosis.

• Findings indicating abuse, such as cigarette burns, multiple trauma at the site of healing, inconsistent history, and the presenting features, should not be overlooked.

• Features like neglected care altered mental status, and bruises in the pinna, neck, abdomen, and genital region should not be missed.

• Some features that exactly mimic child abuse like petechiae on the face and shoulders caused by frequent cries, coughing, and retching, Mongolian spots, and appearance as bruises in the lumbosacral region, coagulopathies, pathologic bone diseases like osteogenesis imperfecta, rickets, chronic renal diseases which cause suspicion should be ruled out.

Laboratory Investigations:

• The Committee on Child Abuse and Neglect has advised appropriate blood tests to rule out the features being caused either by child abuse or bleeding disorders.

• An important key factor that helps in arriving at a proper diagnosis is taking a detailed family and past medical history of bleeding disorders in evaluating signs like epistaxis and excessive bleeding following minor procedures.

• Prothrombin time (PT) and activated partial thromboplastin time (aPTT), which detect fibrinolytic defects, defects of fibrinogen, and platelet disorders, should be investigated to rule out bleeding disorders that mimic child abuse.

• When suspecting the chances of child abuse causing intracranial hemorrhage, PT, aPTT, Factor VIII level, Factor IX level, complete blood count (CBC), d-dimer, and fibrinogen tests are investigated.

Skeletal Survey:

• A skeletal survey should be advised if abuse is suspected in a child less than two years old, suspicious fracture in a child below five years, or an older child who finds it difficult to communicate about the injury (mentally challenged child).

• A more confirmatory diagnosis is obtained by radionuclide bone scan.

• The skeletal survey can be repeated after seven to ten days from the day of injury to check for healing fractures that might be missed during the initial evaluation.

Intracranial Imaging:

• The American Academy of Pediatrics has advised cranial CT (computed tomography), MRI (magnetic resonance imaging), or both for children suspected of intracranial injury.

• CT without intravenous contrast is the gold standard diagnostic tool in assessing retinal hemorrhage and acute neurological manifestations.

• Acute intracerebral and extra-axial hemorrhages are more clearly detected in CT rather than MRI.

• Skull and facial fractures are more readily diagnosed by CT scans, being cost-effective and easily available than MRI.

• However, in cases of shear axonal injuries and for assessing the precise timing of intracranial hemorrhage, MRI is preferred.

• Early ischemic injury is detected by diffusion-weighted imaging (DWI) and can also predict the prognosis.

• Magnetic resonance spectroscopy is useful in determining the NAT outcomes.

Abdominal Computed Tomography (CT):

• In case of an abdominal injury, abdominal CT, along with liver and pancreatic enzymes, should be advised.

How Is Non-accidental Trauma (NAT) Managed?

• Healthcare professionals are obligated to report child abuse or neglect as soon as they come in contact with it, and if they fail to do so, they will be charged with a crime for failure to report the same.

• Social workers and pediatricians should be involved as a part of a multi-disciplinary approach for better treatment outcomes.

• Once the diagnosis is confirmed, necessary measures have to be taken to treat the cause accordingly.

• Infants with fractures are admitted to the hospitals immediately, and child protective services should be consulted.

• Splinting and casting of the fractures need to be carried out immediately to prevent callus formation.

• Surgical interventions are indicated in case of ischemia and hemorrhage.

Conclusion:

Emergency physicians form an integral part of the effective management of non-accidental trauma (NAT) cases. Carrying out a detailed physical examination and gathering medical and family history provide accurate information in ruling out other conditions from child abuse that mimic the same. Also, child protective services need to be intimidated as soon as possible, aiding in timely management and providing better treatment outcomes.