Non-Accidental Trauma

Non-accidental trauma is a pattern-recognition diagnosis anchored in developmental age, injury distribution, and occult injury screening. In infants and young children, bruising in soft-tissue locations, unexplained vomiting or altered mental status, and fractures out of proportion to the history should trigger a child-abuse workup and mandatory reporting review.

Recognizing and Working Up NAT

• Developmental age mismatch: Mechanism only makes sense in the context of what the child can actually do; a history like a young infant “rolling off” furniture should immediately raise concern for inflicted injury.
• Bruising pattern red flags: Bruises over bony prominences can be accidental, but bruising on softer areas or across the body is far less reassuring and should push abuse higher on the differential.
• Complete exposed exam: The initial evaluation starts with fully undressing the child, a full skin exam including around the ears, and careful inspection of the oropharynx for a torn frenulum or other hidden trauma.
• Skeletal survey yield: Skeletal survey is a core test in suspected abuse, especially in children under 2 years or with developmental delay, because occult fractures are often missed on routine exam.
• Head injury screening: Head CT matters early because abusive head trauma can be clinically subtle; get neuroimaging for altered mental status, unexplained vomiting, facial trauma, and any concerned infant under 7 months. We walk through the imaging triggers in the episode.
• Abdominal injury labs: AST, ALT, and lipase screen for occult abdominal trauma in younger children, with abnormal results prompting CT imaging, while CBC and coagulation studies help assess bleeding and important mimics.

Reporting and Family Interaction

• Partner with the caretaker: Start from the shared goal of the child’s safety and health; the adult who brought the child in may not be the perpetrator, so avoid turning the bedside interview into an investigation.
• Trust your concern signal: If the story, exam, or injury pattern feels off, acknowledge that instinct and act on it; early concern is often what prevents missed abuse in preverbal children.
• Mandated reporting threshold: The safest approach is to report any reasonable suspicion of abuse or neglect, and transfer to another hospital does not remove that obligation. We get into the reporting nuances in the episode.
• Law enforcement involvement: Involve law enforcement urgently when a parent or guardian refuses transport or evaluation despite safety concerns, because immediate scene control may be necessary to protect the child.
• Reporting practicalities: Know your local statute, report promptly, and answer unknowns honestly; “I do not know” is appropriate when details are unclear and should not delay contacting child protective services.
• Discipline versus abuse: Physical discipline that leaves a mark is abuse and reportable; distinguishing accepted discipline from abuse becomes straightforward once there is visible injury.

References:

1. Christian, Committee on Child Abuse and Neglect. The Evaluation of Suspected Child Physical Abuse. Pediatrics. 2015;135(5):e1337-e1354. Pediatrics. 2015;136(3):583. PMID: 26398954.