SEPTEMBER 2023 | VOLUME 20 | ISSUE 9

PEDIATRIC

Emergency Medicine Practice Evidence-Based Education • Practical Application

CLINICAL CHALLENGES
• What are risk factors for
nonaccidental trauma?

• What historical and physical

examination findings are indicative of
nonaccidental trauma?

• Which children with suspected

nonaccidental trauma need a skeletal
survey?

• Which specialty services should

be involved to help determine
appropriate disposition?

Authors
Gwendolyn Hooley, MD
Fellow, Emergency Department, Children’s Hospital
Los Angeles, Los Angeles, CA

Sylvia E. Garcia, MD

Assistant Professor, Pediatric Emergency Medicine,
Icahn School of Medicine at Mount Sinai, New York,
NY
Peer Reviewers
Andrea G. Asnes, MD, MSW
Professor of Pediatrics, Yale School of Medicine,
New Haven, CT
Melissa Siccama, MD
Assistant Professor, Child Abuse Pediatrics, Loma
Linda University Children’s Hospital, Loma Linda, CA
Prior to beginning this activity, see the
“CME Information” on page 2.
Emergency Department
Evaluation and Management
of Nonaccidental Trauma in
Pediatric Patients
n Abstract
Children who have suffered physical abuse may present to the
healthcare setting multiple times before a diagnosis is made.
Emergency clinicians must be able to recognize sentinel and se-
vere signs of nonaccidental trauma and pursue an appropriate
evaluation to prevent further injury. This issue offers evidence-
based recommendations for the identification and manage-
ment of nonaccidental trauma in children. Key historical and
physical examination findings that should trigger an evaluation
for physical abuse are reviewed. Recommendations are given
for obtaining diagnostic studies and consulting with specialists.
Guidance is provided for documenting and reporting findings
when nonaccidental trauma is suspected.

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This issue is eligible for 4 CME credits. See page 2. EBMEDICINE.NET

 CME Information
Date of Original Release: September 1, 2023. Date of most recent review: August 1, 2023. Termination date: September 1, 2026.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing
medical education for physicians.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should
claim only the credit commensurate with the extent of their participation in the activity.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional approval.
ACEP Accreditation: Pediatric Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category
I credit per annual subscription.
AAP Accreditation: This continuing medical education activity has been reviewed by the American Academy of Pediatrics and is acceptable for a maximum
of 48 AAP credits. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Members of the American Academy
of Pediatrics.
AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to 4 American Osteopathic Association Category 2-B credit hours per issue.
Needs Assessment: The need for this educational activity was determined by a practice gap analysis; a survey of medical staff, including the editorial board of
this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation responses from prior educational activities for
emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) identify areas in practice that require modification to be consistent with current evidence
in order to improve competence and performance; (2) develop strategies to accurately diagnose and treat both common and critical ED presentations; and
(3) demonstrate informed medical decision-making based on the strongest clinical evidence.
CME Objectives: Upon completion of this activity, you should be able to: (1) describe injury patterns suggestive of nonaccidental trauma; (2) conduct a
thorough history and physical examination to identify findings that are suspicious for nonaccidental trauma; and (3) apply principles of correct management
and safe disposition for victims of nonaccidental trauma.
Discussion of Investigational Information: As part of the activity, faculty may be presenting investigational information about pharmaceutical products that
is outside Food and Drug Administration-approved labeling. Information presented as part of this activity is intended solely as continuing medical educa-
tion and is not intended to promote off-label use of any pharmaceutical product.
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 Case Presentations
A 2-month-old boy is brought to the ED by his mother for lethargy and a seizure at home…
• The mother states that earlier that day the child had been fussier than usual, then he had a seizure last-
CASE 1

ing about 3 minutes. Since the seizure, the child has been very sleepy.
• The boy’s temperature and vital signs are normal. On examination, the infant appears lethargic, with
poor tone. He vomits once in the ED.
• What is on your differential for this patient? What are the next steps in management?

A 13-month-old boy is brought to the ED by his grandmother for 3 days of fever and runny nose...
CASE 2

• On examination, the child has a fever of 38.2°C, rhinorrhea, bilateral tympanic membrane erythema,
and a 1-cm bruise to the pinna of the left ear.
• What other workup is indicated at this time? Is the bruise likely an accident? Does this warrant a Child
Protective Services referral?

A 5-month-old girl is brought to the ED by her babysitter after falling earlier in the day…
• The babysitter says the child was pulling to stand on a coffee table then fell down and has been incon-
CASE 3

solable since.
• On examination, the child cries when you palpate her right lower extremity.
• You wonder whether this injury make sense for the child’s age...

n Introduction ten underreported and children may present to the

Every year, nonaccidental trauma (NAT) causes sig-
nificant morbidity and mortality in pediatric patients.
In 2020, there were approximately 618,000 victims
of child abuse in the United States, which is approxi-
mately 8.4 victims/1000 children. Younger children
are often most vulnerable. For infants aged <1 year,
there were 25.1 victims/1000 children. Approximately
1750 children died from child abuse in 2020, with
younger children having the highest fatality rates.1
The most common manifestations of NAT include
bruising, burns, fractures, and abusive head trauma.
When assessing an injured child, clinicians should
always consider whether the history is suspicious for
abuse, while remaining cognizant of personal biases
that may cause them to overevaluate or underevaluate
injured children. Evidence-based screening tools can
assist clinicians in deciding whether further workup for
NAT is indicated. If there is suspicion for abuse, clini-
cians are mandated reporters and must notify Child
Protective Services. When faced with an injury sug-
gestive of abuse, clinicians should initiate a workup
for both occult injury as well as reasonable medical
problems that could explain the injury. For example,
children aged <2 years with a highly concerning injury
for abuse should undergo a skeletal survey, as well as
follow-up for evaluation of risks for bony fragility, and
a repeat skeletal survey in 10 to 14 days. Disposition
of these patients will depend on multiple factors, in-
cluding the severity of injuries, need for further medi-
cal intervention, and the safety of the child at home,
usually determined by a multidisciplinary team.
Despite the prevalence of NAT, cases are of-
healthcare setting multiple times before receiving a
diagnosis.2 Within the healthcare setting, victims tend
to interface most frequently with emergency depart-
ment (ED) clinicians, and initial signs of child abuse
can often be missed.2,3 It is imperative that emer-
gency clinicians recognize and appropriately treat
suspected NAT to prevent associated morbidity and
mortality. This issue of Pediatric Emergency Medicine
Practice focuses on identifying and managing sus-
pected NAT in the emergency setting, based on the
latest evidence.
n Critical Appraisal of the Literature
A literature search was conducted using PubMed and
Ovid®. Key search terms included child abuse, child
mistreatment, child maltreatment, and non-accidental
trauma in various combinations with emergency medi-
cine, emergency department, sentinel injuries, child
abuse in COVID-19, screening tools for child abuse,
bias in child abuse reporting, social determinants of
child abuse, abusive head trauma, abusive head in-
jury, occult fracture, non-accidental fracture patterns,
prediction rule for child abuse, screening tool for child
abuse, and racial disparities in child abuse reporting.
The majority of articles were retrospective studies,
literature reviews, and review articles, although some
case series, textbooks, and prospective cohort studies
were identified. Many studies focused on frequently
missed signs of child abuse and ways to improve
detection. Since the focus of this review is on NAT,
studies of sexual abuse in children were excluded.

SEPTEMBER 2023 • www.ebmedicine.net 3 © 2023 EB MEDICINE

n Etiology and Pathophysiology
Risk Factors
NAT affects children of all ages, ethnicities, and socio-
economic backgrounds. Certain characteristics place
some children more at risk than others. For example,
boys tend to have slightly higher rates of abuse than
girls. Additionally, younger children are at risk for
abuse and at higher risk for mortality related to the
abuse.1,4 Additional risk factors associated with NAT
can be divided into 3 categories: (1) child factors, (2)
perpetrator factors, and (3) environmental factors.
Child Risk Factors
Child risk factors for NAT include physical disabili-
ties, emotional/behavioral problems, developmental
disabilities, chronic illness, birth related to an un-
planned/unwanted pregnancy, low birthweight, and
preterm birth.
Perpetrator Risk Factors
According to 2020 federal data evaluating character-
istics of perpetrators of abuse, the majority of per-
petrators (77.2%) were the victim’s parents. The next
largest percentage of perpetrators were other rela-
tives or the parent’s partner. When looking at individu-
al age groups, older children have a higher incidence
of abuse by nonparental perpetrators. Several factors
increase the risk for perpetrating child abuse, includ-
ing substance abuse, lower educational level, his-
tory of antisocial or criminal behavior, having been a
victim of child abuse themself, and caregiver disability
including physical and psychiatric health problems.1,5
Additional parental risk factors for child maltreat-
ment include young age, low self-esteem, maternal
smoking, poor impulse control, mental health issues,
and negative perceptions/poor education/unrealistic
expectations of normal child behavior.
Environmental Risk Factors
Some elements of a family’s home situation can in-
crease the risk for child abuse. Environmental risk fac-
tors include social isolation, unemployment, single-
parent homes, financial hardship, housing insecurity,
domestic violence, military families (particularly in
times of deployment), and a nonbiologically related
adult male in the home.4 While studies frequently cite
historically marginalized ethnicities and poverty as
risk factors for child abuse, newer studies show that
suspected abuse is reported more frequently in these
groups due to provider bias.4,6,7 Nonminority children
of high socioeconomic status presenting with findings
concerning for abuse are frequently underreported
and underinvestigated for NAT.6-8
Injuries Suggestive of Abuse
Sentinel Injuries
Given that younger children are particularly vulner-
able and may have subtle presentations of NAT, even
SEPTEMBER 2023 • www.ebmedicine.net
seemingly minor trauma in a preambulatory child
should raise suspicion and be investigated further.4,9
Victims of NAT often present to the emergency
setting several times prior to the diagnosis of NAT,
emphasizing the importance of recognition of sen-
tinel injuries in these patients. A sentinel injury is an
appreciable minor injury that is suspicious for NAT.10
Examples of sentinel injuries include unusual bruising
in infants and toddlers, and intraoral injuries such as
a torn frenulum in infants. Inadequately explained or
patterned burns (eg, cigarette burns), and fractures in
premobile children, can also be signs of NAT.10,11 (See
Figure 1, page 5.) Early identification of high-risk chil-
dren can prevent significant morbidity and mortality,
since between 11% and 50% of children returned to
an abusive environment undergo further abuse.9,10
Bruises
Bruising is the most common sentinel injury. Bruising
is rarely accidental in precruising-age children, occur-
ring <2% of the time, and should raise suspicion for
abuse. Often, these seemingly minor injuries occur
concurrently with more severe injuries from NAT or
precede more clinically significant NAT. Recognizing
these injuries as hallmarks of abuse and interven-
ing early can prevent more serious trauma later.12
As children learn to walk, bruising can be common
on certain areas of the body due to frequent falls. Dis-
tinguishing routine accidental bruising of childhood
from abusive bruising patterns is important when
evaluating an injured child. (See Figure 2, page 6.)
The TEN-4-FACESp is a validated tool that can be
used to remember which bruises are higher risk for
possible NAT in children aged <4 years of age. (See
the “Physical Examination” section on page 8 and
Figure 3, page 6.)
Fractures
After soft-tissue injury and burns, fractures are the
next most common manifestation of NAT.13 Fractures
can occur from normal falls and injuries that children
may sustain while playing. However, certain fracture
types and sites are more specific for NAT. Any fracture
in a nonambulatory child should raise suspicion for
NAT.13-15 Fracture sites that are highly concerning for
NAT include the rib, femur, sternum, spinous process,
scapula, and humerus for children aged <36 months.
Multiple fractures or fractures in different stages of
healing are also red flags for NAT.16 (See Figure 4,
page 7.)
Children have more elastic bones with softer cor-
tices, allowing them to develop unique fracture pat-
terns. An example of a unique fracture pattern associ-
ated with abuse is a metaphyseal corner or “bucket
handle” fracture, which is highly specific for inflicted
injury. (See Figure 5, page 7.) These fractures are
usually due to torsional or tensile force such as grab-
bing an extremity and shaking it or shaking the child
4 © 2023 EB MEDICINE
while the extremities flail, causing detachment of the
periosteum with accompanying bony fragments.14,17
Spiral fractures are another unique fracture pattern
that may indicate abuse, specifically in preambulatory
children. (See Figure 6, page 7.) These fractures can
be caused by grabbing an extremity and twisting it.14
Nonetheless, it is important to correlate the history to
the specific fracture, as certain spiral fractures, such
as the tibial or “toddler fracture” (a spiral fracture in
an ambulatory child who falls in a twisting motion),
can be common in ambulatory children who trip and
fall. For preambulatory patients or patients with a
suspicious history, further workup for these fractures
should be pursued.
Head Trauma
Abusive head trauma is the leading cause of death
due to NAT and can lead to lifelong disability in
survivors.18 The mechanisms of injury can include
direct striking of the head against a surface or
object, and acceleration-deceleration of the skull
by rapidly shaking the infant.19-21 Injuries caused
by direct contact can cause skull fractures, epidural
hematomas, scalp hematomas, and brain contu-
sions. Acceleration-deceleration injuries can cause
tearing of the bridging veins, which are more fragile
in infants, leading to subdural hematomas. Rapid,
violent shaking of infants also can lead to traumatic
axonal injury.19,21 Infants are particularly vulnerable
to this type of injury due to their proportionately
larger head and the increased laxity of their neck
muscles, ligaments, and cervical spine compared to
older children.21 Victims of abusive head trauma can
have a variety of manifestations including isolated
scalp hematomas, lethargy, altered mental status,
seizures, vomiting, decreased tone, decreased feed-

Figure 1. Injuries Suggestive of Nonaccidental Trauma in Children

A B

C D
A. Torn frenulum. Reprinted from Journal of Pediatric Health Care. Volume 26, Issue 3. Gail Hornor. Medical evaluation for child physical abuse: what the
PNP needs to know. Pages 163-170. Copyright 2012, with permission from the National Association of Pediatric Nurse Practitioners.
https://www.sciencedirect.com/journal/journal-of-pediatric-health-care
B. Pinna bruising. Reprinted from Clinics in Dermatology, Volume 35, Issue 6. Sphoorthi Jinna, Nina Livingston, Rebecca Moles. Cutaneous sign of
abuse: kids are not just little people. Pages, 504-511. Copyright 2017, with permission from the International Academy of Cosmetic Dermatology.
https://www.sciencedirect.com/journal/clinics-in-dermatology
C. Bite mark. Reprinted from Judy Hinchliffe. British Dental Journal. Forensic odontology, part 5. Child abuse issues. Volume 210, Pages 423-428.
Copyright 2011, with permission from Springer Nature. https://www.nature.com/bdj/
D. Cigarette burns. Reprinted from Annals of Emergency Medicine. Volume 51, Issue 5. Itai Shavit, Hadas Knaani-Levinz. Images in Emergency
Medicine. Pages 579-582, Copyright 2008, with permission from the American College of Emergency Physicians.
https://www.sciencedirect.com/journal/annals-of-emergency-medicine

SEPTEMBER 2023 • www.ebmedicine.net 5 © 2023 EB MEDICINE

ing, and abnormal breathing.18,19 Given the wide
range of nonspecific symptoms, it is crucial for clini-
cians to always consider nonaccidental head trauma
for infants presenting to the ED.
n Differential Diagnosis
NAT will typically be part of a larger differential for
children presenting to the ED. Children may present
for traumatic injuries, or injuries may be incidentally
found on a visit for a different complaint. It is impor-

Figure 2. Accidental Versus Abusive Bruising Patterns in Children

A B
A. Accidental bruising patterns.
B. Abusive bruising patterns.
Reproduced from Archives of Disease in Childhood: Education & Practice. S Maguire. Volume 95, Issue 6. Pages 170-177, Copyright 2010, with
permission from BMJ Publishing Group Ltd. https://ep.bmj.com/

Figure 3. TEN-4-FACESp Bruising Clinical Decision Rule for Children Aged <4 Years

Material provided courtesy of Ann & Robert H. Lurie Children’s Hospital of Chicago. © 2022 Ann & Robert H. Lurie Children’s Hospital of Chicago. All
rights reserved. Contact for permission to use.

SEPTEMBER 2023 • www.ebmedicine.net 6 © 2023 EB MEDICINE

tant to consider the possibility that some traumatic
injuries are consistent with accidental causes, such
as toddler fractures.14 Additionally, hematologic
disorders that increase propensity for bruising and
bleeding should also be considered.11 Congenital
dermal melanocytosis (previously known as Mon-
golian spots), phytophotodermatitis, and disorders
characterized by a purpuric rash (such as Henoch-
Schönlein purpura) can look like bruises, depending
on skin type. Additionally, cultural practices such as
coining and cupping are not considered abusive, but
can create lesions that look like bruises. For skin that
Figure 4. Multiple Rib Fractures
Reprinted from Stevan Kriss, Angela Thompson, Gina Bertocci, et al.
Pediatric Radiology. Characteristics of rib fractures in young abused
children. Volume 50, Pages 726-733. Copyright 2020, with permission
from Springer Nature. https://www.springer.com/journal/247
Figure 5. Metaphyseal Corner Fracture
Reprinted from Tal Laor, Diego Jaramillo. Pediatric Radiology. It’s time
to recognize the perichondrium. Volume 50, Pages 153-160. Copyright
2020, with permission from Springer Nature.
https://www.springer.com/journal/247
SEPTEMBER 2023 • www.ebmedicine.net
appears burned, consider staphylococcal scalded skin
syndrome and bullous impetigo in young children.
Bone disorders such as osteogenesis imperfecta can
cause pathological fractures and can present with
multiple fractures in different stages of healing. For
infants with intracranial hemorrhage, consider coagu-
lopathies as a possible cause, such as hemophilia,
metabolic disorders, and vitamin K deficiency, since
more parents are now declining vitamin K injections
at birth.22 Given the broad differential, many of these
children will not have a definitive diagnosis in the ED.
Once safety is ensured, patients should be referred to
child abuse pediatricians and other specialists, as ap-
propriate, to identify the underlying etiology of their
presentation and ensure appropriate treatment.
n Prehospital Care
The prehospital setting is valuable in the evaluation
of suspected NAT. Emergency medical services (EMS)
has the unique advantage of being able to assess
the home and family dynamics on-scene. EMS can
coordinate with law enforcement and Child Protec-
tive Services, when possible, prior to transfer to the
ED, streamlining patient care. Prehospital providers
should be judicious in how to approach situations
of suspected NAT on-scene, due to safety concerns
when confronting caregivers, choosing to defer inter-
ventions such as police involvement to the ED on a
case-by-case basis.23
Figure 6. Spiral Fracture in a
Nonambulatory Child
Copyright 2023 Dr. Andrew Dixon. Image courtesy of Dr. Andrew Dixon
and Radiopaedia.org. Used under license. Radiopaedia.org, rID: 10321
7 © 2023 EB MEDICINE
 EMS systems should focus on both educating and
providing resources to prehospital providers, so they
are prepared to care for victims of NAT, since EMS
providers are mandated reporters in most states.23,24
Emergency department clinicians should clarify with
EMS whether a report has been initiated, to ensure
children receive appropriate, timely care and suspi-
cions of abuse are properly investigated.
n Emergency Department Evaluation
History
The first step in evaluation of NAT in the ED is obtain-
ing a thorough history. Determining how a specific
injury occurred, when it occurred, and how long it
took the family to seek medical attention are impor-
tant details to obtain. Clinicians should ask open-
ended questions and allow caregivers/parents to give
their full side of the story so as not to influence the
narrative with leading questions. Clarifying questions
should be posed in a nonaccusatory manner. If pos-
sible and appropriate, interviewing verbal children
separately from parents may help determine whether
abuse occurred. However, there are some potential
issues with interviewing children. Some children may
not be forthcoming on how their injuries were sus-
tained, due to possible repercussions. Additionally,
children may not always be reliable historians and it
may require a trained forensic team to evaluate if clini-
cian suspicion is high. It is generally advised to avoid
having multiple clinicians ask a child the same ques-
tions repeatedly. Routine elements of medical history,
including developmental and social history, should be
obtained. Ask open-ended questions about familial
stressors, child temperament, parental substance
abuse, familial discipline patterns, pregnancy history,
and familial abuse history.4
There are several historical red flags for NAT that
clinicians should assess for. A poor explanation or
even a denial of trauma for a clinically significant injury
should raise suspicion for NAT. Parents and/or caregiv-
ers may change key details of the story to different cli-
nicians, and different witnesses may provide different
accounts of how the injuries occurred. Explanations
that are inconsistent with the child’s development,
age, injury pattern, or injury severity should also raise
concern for NAT. Delays in seeking care that are not
clearly attributable to another cause (eg, transporta-
tion, fear of repercussions of undocumented status)
are another red flag for possible child abuse.4 Clini-
cians should be familiar with developmental mile-
stones (see Table 1) to better assess whether a history
is consistent with the child’s age, as children become
more injury-prone as they become more mobile.
Physical Examination
A thorough, disrobed physical examination of any pa-
tient arriving at the ED, regardless of complaint, is key
SEPTEMBER 2023 • www.ebmedicine.net
to identifying NAT and sentinel injuries. Fully undress-
ing children and inspecting the skin may identify senti-
nel injuries otherwise missed (eg, bruising in abnormal
locations). Any poorly explained injury to a young,
preambulatory infant is highly suspicious. Unexplained
injuries or injuries that do not seem consistent with
the story should also raise suspicion. Additionally,
injuries to multiple organ systems or injuries in differ-
ent stages of healing are indicative of NAT. Injuries to
nonbony or unusual locations (eg, the ear or neck) are
suspicious for abuse, as well as oral and ocular injuries
in infants. Signs of child neglect can also be associ-
ated with abuse.4 A neurologic examination should be
performed, especially for children aged <2 years, who
have a higher risk for NAT.
Injury Patterns Suggestive of Nonaccidental
Trauma
Certain injury types and patterns should raise suspi-
cion for NAT.22
Bruises
Bruising from NAT follows a distribution pattern
that is different from accidental trauma. Specifically,
bruising to the torso, ears, cheek, or neck are
high-risk areas for NAT.26 (See Figure 2, page 6.)
Clinical decision rules can be helpful and objective
in deciding which children need further workup
to evaluate for NAT. The TEN-4-FACESp rule
developed by Mary Clyde Pierce and colleagues
can be applied in young children with superficial
injuries to evaluate for possible NAT. (See Figure 3,
page 6.) TEN-4-FACESp is a mnemonic device that
serves as a reminder of red flags that could suggest
NAT, including bruising of the torso, ear, neck; any
bruising in infants aged up to 4 months; frenulum
injury in nonambulatory infants; bruising of the angle
Table 1. Motor Developmental
Milestones, by Age25
Age Motor Developmental Milestones
2 months Holds head up when placed prone
2-4 months Holds head steady without support, swings at
objects, pushes up onto elbows when prone
4-6 months Rolls from prone to supine, leans on hands to
support self when sitting (starts at 4 months)
6-9 months Sits on their own, moves things from 1 hand to
another (typically 6 months)
9-12 months Pulls to stand, cruises (typically 9-10 months,
including crawling)
10-14 months Takes a few steps independently (typically starts
at 12 months)
12-18 months Walks independently, climbs on/off chair without
help, drinks from cup without lid
www.ebmedicine.net
8 © 2023 EB MEDICINE
of the jaw, cheeks, and eyelids; subconjunctival exception of isolated, unilateral, nondiastatic, linear,
hemorrhage; and patterned bruising. The tool is 95% or parietal skull fracture. While the PediBIRN4 uses all
sensitive and 87% specific, so a child with any TEN-4- 4 of these criteria, the PediBIRN3 excludes the criteria
FACESp injury has a high risk for abuse26 and should regarding skull fractures. The PediBIRN4 has a higher
be further worked up for NAT. The Lurie Children’s sensitivity at 96%.29,30 The PediBIRN3 still has a high
Child Injury Plausibility Assessment Support Tool sensitivity at 93% and results in fewer workups of
(LCAST) is a freely available interactive app that is patients who do not have abusive head trauma, and
based on the TEN-4-FACESp tool. thus seems to be preferred by clinicians.31,32 (See
Figure 8, page 10.)
Burns
Burns are another skin manifestation of child abuse.
Clinicians should take note of the depth, shape, and
pattern of burns. Intentional
burns tend to be deeper
because children are less able Figure 7. Burn Risk of Neglect and Maltreatment in Children
to use protective reflexes in Tool (BuRN-Tool)
abusive situations, though
some deep burns can also
be accidental. Specific burn
appearance, such as with
cigarette burns, are more
specific for NAT. Burns that
occur to the posterior trunk,
bilaterally, or in a clear
immersion pattern are also
very specific for NAT.27
Another externally
validated decision tool is the
BuRN-Tool, which scores both
scald and nonscald burns in
children. The tool takes into
consideration the child’s age,
burn severity, interactions
with social work, explanation
of the burn, concerns about
parental supervision during
the event, and burn pattern, to
screen burns for potential NAT.
(See Figure 7.) A score ≥3
is concerning for NAT, with a
sensitivity and specificity close
to 80%.28

Abusive Head Trauma

The PediBIRN screening tool
was developed to identify
children at risk for abusive
head trauma. The tool is
validated in children aged ≤3
years and uses the presence
of respiratory compromise
at any point during the
child’s interaction with the
medical system; bruising
along the torso, ears, or neck;
Reprinted from Child Abuse Review, Volume 30, Issue 6. Eleanor J. Evans, C. Verity Bennett, Linda Hollén,
bilateral or interhemispheric
et al. Does the BuRN-Tool score correctly predict cases of maltreatment in children referred for a child
hemorrhages on imaging; protection medical assessment? Pages 565-575, © 2021 John Wiley & Sons, Ltd. https://onlinelibrary.
and any skull fracture with the wiley.com/journal/10990852

SEPTEMBER 2023 • www.ebmedicine.net 9 © 2023 EB MEDICINE

n Diagnostic Studies
Laboratory Testing
The appropriate diagnostic studies will depend on
the type of injury, the extent of injuries, and the age
of the child. Most children for whom child abuse is
on the differential should be screened with a com-
plete blood cell count (CBC), coagulation studies,
liver function tests, and lipase test.4,33,34 Specific
testing for alternative etiologies of the injury should
be considered. It is recommended to order these
tests in conjunction with specialists and child abuse
pediatricians, as many of these tests will not result in
the emergency setting and will require follow-up. For
children with nonpatterned bruises as well as intra-
cranial hemorrhage, hematologic studies including
CBC, coagulation studies, and testing for bleeding
diathesis (eg, hemophilia and von Willebrand) should
be considered.4,35 Rarely, certain metabolic disorders
increase the risk for spontaneous bleeds, but this is
beyond the scope of ED care.
For children presenting with fractures, laboratory
testing to evaluate bone health, including calcium,
phosphorus, and alkaline phosphorous should be
ordered, and depending on presentation, parathyroid
hormone and 25-hydroxyvitamin D. DNA analysis for
genetic disorders such as osteogenesis imperfecta
can also be considered.4,33 The more-specific testing
is reasonable to defer to primary care providers or
appropriate specialists.
For children with signs of abdominal trauma,
transaminases and lipase should be ordered to evalu-
ate for abdominal injury. If suspicion is high or labora-
tory studies are abnormal with transaminases >80
IU/L, a computed tomography (CT) abdomen with
intravenous (IV) contrast should be obtained from the
ED to assess for actionable abdominal trauma.4,34
Figure 8. Pediatric Brain Injury Research Network (PediBIRN) Abusive Head Trauma
Screening Tools
Used with permission from Kent Hymel, MD. Screening tools available at: https://www.pedibirn.com/home.php
SEPTEMBER 2023 • www.ebmedicine.net
Imaging Studies
For children aged <2 years for whom NAT is sus-
pected, a skeletal survey should be performed.36,37
For nonambulatory children, a skeletal survey can
identify additional occult fractures in up to 7% to 10%
of children.4,36,37 The yield of this study decreases
with age, with the most value in children aged up to
2 years, and limited value in children aged >3 years.38
The skeletal survey is a series of x-rays of multiple
views of every bone in the body, with additional
views obtained if occult fractures are discovered.39
These x-rays include anterior-posterior and posterior-
anterior views of all 4 extremities and the chest,
including oblique views of the ribs, abdomen, pelvis,
spine, and skull.40 Acute fractures may not be visible
on the initial skeletal survey, so clinicians should not
be reassured by a negative study, as it does not rule
out NAT. Thus, for all children for whom a skeletal
survey is being obtained to evaluate for NAT, a refer-
ral is needed for a repeat skeletal survey in 10 to 14
days from the original study; this potentially increases
fracture identification by up to 25%.41
It is important to consider the possibility of abu-
sive head trauma for children aged <2 years who are
being evaluated for NAT. Abusive head trauma can
have high associated morbidity and mortality but may
have subtle presentations. For children with obvious
signs of head trauma or a story concerning for abu-
sive head trauma, head imaging should be obtained.
The decision to image is difficult for children without
obvious signs of head injury. For children presenting
with other findings suggestive of abuse, the preva-
lence of occult head trauma varies among studies.
Some studies find that occult head trauma can have a
prevalence as high as 30% in children presenting with
other findings. Given the high risk, current recom-
mendations suggest a low threshold for head imaging
in children aged <2 years for whom NAT is on the dif-
10 © 2023 EB MEDICINE
ferential, particularly those aged <6 months. The test
of choice has been a CT of the head without contrast,
but a specific protocol of fast magnetic resonance
imaging (MRI) is effective in identifying intracranial
blood and offers a non–radiation-based alternative to
screening for occult head trauma.4,42
Ophthalmic Evaluation
For children aged <2 years with evidence of head
trauma, ophthalmic evaluation for retinal hemor-
rhages should be obtained, as certain patterns of
retinal hemorrhages can be highly indicative of NAT.
Because this requires a dilated pupillary examination
by an ophthalmologist and may be uncomfortable
for the child, new data suggest deferring this exami-
nation until after neuroimaging confirms intracranial
pathology, due to the costs and resources associated
with this examination.43 Waiting to confirm intracra-
nial pathology increases the yield of the pupillary
examination and limits the amount of unnecessary
testing. This does not typically occur in the ED, as the
recommendation is within 72 hours of presentation.
Of note, for children aged <14 days, retinal hemor-
rhages may be seen on examination due to birth
trauma and may be a normal finding.43
Additional Testing
Further testing for alternative etiologies can be consid-
ered, based on injury type, in consultation with child
abuse pediatricians and specialists. (See Table 2.)
Table 2. Additional Diagnostic Studies to
Consider, by Injury Type
Injury Diagnostic Studies (Emergency Department
and Outpatient)
Bruising • Bleeding diathesis testing
• Skeletal survey if patient aged <2 years
• Neuroimaging (CT/MRI) if patient aged <6
months
Head trauma • Bleeding diathesis testing
• Metabolic testing
• Skeletal survey if patient aged <2 years
• Head CT
• Retinal examination
• Consider CT/MRI spine
Fractures • Calcium, phosphorus, alkaline phosphorous
testing
• Consider parathyroid hormone and
25-hydroxyvitamin D and DNA testing for
disorders such as osteogenesis imperfecta
• Skeletal survey
• Repeat skeletal survey in 10-14 days
Abbreviations: CT, computed tomography; MRI, magnetic resonance
imaging.
www.ebmedicine.net
SEPTEMBER 2023 • www.ebmedicine.net
n Treatment
The treatment for NAT will depend largely on the
types of injuries sustained. Medical treatment should
proceed as it would for any patient presenting with
traumatic injuries. Appropriate immobilization and/
or consultation with orthopedics for fractures, neu-
rosurgery for abusive head trauma, burn manage-
ment and burn center referral when appropriate,
and possibly trauma surgery should be initiated as
necessary based on the child’s medical needs. For
patients with identified intracranial or intra-abdominal
injuries, trauma activation is appropriate, as multisys-
tem trauma is possible. Children may require hos-
pitalization based on the severity of injury and even
operative management in certain cases.16 Consulta-
tion with psychiatry or social work to provide mental
health resources can help children process and cope
with the emotional aspects of child abuse, but may
not be required in the ED.4
n Documentation and Reporting
Clinicians should be detailed in their documentation,
since Child Protective Services and law enforcement
use the medical record for their proceedings. Notes
should include the clinician’s level of concern and
photographs, if relevant. However, because most
emergency clinicians are not trained forensic child
abuse specialists, it is not the duty of the clinician to
determine exactly how the injury occurred, to identify
a perpetrator, or to say definitively whether NAT is
present. Clinicians are obligated to report any sus-
picion to the appropriate services and allow them to
conduct an investigation with trained forensic experts.
For children for whom abuse is suspected,
emergency clinicians, as well as all members of the
healthcare team, are mandated reporters in all 50
states. In conjunction with social work colleagues (a
very valuable resource in these situations) clinicians
should alert Child Protective Services as well as law
enforcement, if necessary. The duty is to report child
abuse to Child Protective Services and to collect data
if there is a reasonable suspicion; clinicians who fail
to report suspicion of abuse may face legal action.
Child Protective Services will conduct an investigation
to determine whether abuse is occurring. If a child
abuse pediatrician is available, contacting them early
or arranging follow-up can be helpful and may be
required by law enforcement. Allowing the specialists
the opportunity to interview the patient and family
early and visualize findings in real time can facilitate
their participation in legal proceedings in the fu-
ture.5,44 Clinicians should notify parents in a nonjudg-
mental manner that they will be speaking with social
work and Child Protective Services regarding their
child’s injuries.4
11 © 2023 EB MEDICINE
n Special Circumstances
Domestic Violence
Though emergency clinicians are mandated report-
ers for suspected child abuse, they are not mandated
reporters for domestic violence between adults unless
the abuse is affecting the child to the point of qualify-
ing as abuse or neglect or the abuse involves a vul-
nerable adult (eg, elderly, disabled). In questionable
situations, consultation with Child Protective Services
over the phone may be helpful in determining next
steps and whether further evaluation is needed.
COVID-19 Pandemic
The COVID-19 pandemic impacted the recogni-
tion and reporting of child abuse. While overall ED
volumes decreased across the country, the proportion
and severity of NAT cases relative to the number of
patients increased at some centers. It is thought that
pandemic stressors and children spending more time
at home increased the risk for NAT.45,46 Despite the
increase in proportion, the overall number of children
presenting with NAT decreased. Researchers have
attributed this to underreporting, with less-severe
injuries failing to present to the ED and because NAT
is frequently identified in the educational system.45-47
Data from the pandemic suggest clinicians should
have heightened vigilance during natural disasters
and incidents in which children will be spending
more time at home.45 Data are still emerging from
the COVID-19 pandemic, and the overall impact the
pandemic had on NAT is still being determined.
n Controversies and Cutting Edge
Bias
New research is impacting the ways clinicians think
about risk factors for NAT. Prior thinking suggested
that non-White children were at high risk for suf-
fering NAT. However, mitigating factors include
socioeconomic status, cultural differences in disci-
pline practices, as well as reporting bias.1,3,5 Newer
research identifies the role clinician bias has on
screening for and reporting of suspected NAT. Bias
has been shown to be associated with overreporting
in non-White communities and may lead to under-
reporting in White communities.7,8,48 Some stud-
ies show overreporting of NAT for non-White and
low-socioeconomic-status communities has led to
misdiagnosis of NAT. This is detrimental to children,
as families can be occasionally separated as a result,
leading to emotional and psychological consequenc-
es.49 While environmental risk factors play a role
in NAT, it is important to fully evaluate all children,
regardless of ethnic background, who present to the
ED, since children from high socioeconomic back-
grounds still suffer from NAT.7,48
SEPTEMBER 2023 • www.ebmedicine.net
Clinical Decision Tools
The use of clinical decision rules in the evaluation
of NAT has provided an objective way to assess for
NAT. When findings suggestive of abuse are subtle,
evaluation for suspected abuse can feel subjective
when based on elements of history and interactions
with parents. The emergence of validated decision
tools such as the TEN-4-FACESp, BuRN-Tool, and
PediBIRN tools can make evaluation and reporting of
these cases more objective and help decrease implicit
bias.26,27 Further research can help develop more de-
cision tools to aid clinicians in making this diagnosis.
Follow-Up Skeletal Surveys
There is some debate in the literature about the risks
and benefits of obtaining follow-up skeletal surveys.
When working up children for suspected NAT, a
skeletal survey can help identify occult fractures and
should be obtained at the time of presentation and
then repeated 10 to 14 days later.41 Some contro-
versy in the literature exists in regard to the radiation
risk of these studies, and some advocate for limited
follow-up surveys.50 Newer data show the radia-
tion risk of the skeletal survey is minimal, and the
benefit likely outweighs the risk in identifying which
children are unsafe at home, given that fractures are
often sentinel injuries.51 Thus, full follow-up skeletal
surveys should be arranged for children when there
is suspicion for NAT and an initial skeletal survey was
performed, even if negative.
n Disposition
When evaluating children for NAT, deciding who
is safe to send home is a critical decision. Some
children will have to be admitted due to medical
reasons. Those with severe traumatic injuries should
be admitted to a pediatric trauma center to receive
appropriate subspecialist care.44 For children who
do not have injuries severe enough to necessitate
medical admission, the disposition should be de-
cided by a multidisciplinary team consisting of the
clinician, social workers, and Child Protective Ser-
vices. Some children may be safe to go home and
have Child Protective Services visit them at home a
few days later. For these children, follow-up with a
child abuse pediatrician and mental health services
should be arranged, along with other specialty
services as needed. Occasionally, admission for
the protection and extended evaluation of a child
who is not safe to send home may be warranted.4,44
Children who the multidisciplinary team believe to
be in immediate danger will require a safe disposi-
tion outside of the home; preferably foster place-
ment if there are no ongoing medical needs requir-
ing admission.
12 © 2023 EB MEDICINE
 Management Pitfalls for Nonaccidental Trauma
in Pediatric Patients
1. “I was not sure if I had enough evidence from
my evaluation to make a diagnosis of nonac-
cidental trauma.” Emergency clinicians are
required to report findings and suspicion but
not necessarily diagnose child abuse. Dedicated
forensic experts with specialized training will
ultimately make the diagnosis, but it is important
that clinicians document their findings thor-
oughly in the chart and take photographs when
appropriate. Clinicians should report suspicion
of abuse to Child Protective Services so special-
ists can conduct an investigation and potentially
diagnose abuse.
2. “I thought this child might have an injury that
was nonaccidental, but I wasn’t sure. I didn’t
want to report in case I was wrong.” If clini-
cians see an injury suspicious for abuse, there is a
duty to report, keeping in mind the laws specific
to the clinician’s state where they practice. When
available, child abuse pediatricians can offer guid-
ance about whether a child should or should not
be reported to Child Protective Services.
3. “This child was in for ear pain, so I didn’t
undress him or do a full skin examination.”
Fully undress all children presenting to the ED
and conduct a thorough head-to-toe assessment,
looking for superficial injuries. Many children
present to the healthcare setting multiple times
prior to finally being evaluated for abuse, and
failure to disrobe and conduct a thorough exami-
nation is one reason for this.
4. “Children frequently bruise. I didn’t think
a bruised cheek required further workup.”
Clinicians should be familiar with and able to
recognize sentinel injuries in children, since they
require further evaluation, given their high risk
for future abuse.
5. “The mom said her 2-month-old infant rolled
off the bed. I thought that was a reasonable
explanation for the injury.” Review develop-
mental milestones and determine whether the
history for a traumatic injury in a child is consis-
tent with what is expected for that child’s devel-
opmental age. Since children do not start rolling
over until approximately 4 months of age, the
explanation for this child is not feasible.
SEPTEMBER 2023 • www.ebmedicine.net
6. “The family seemed nice, and I thought the
injury was probably just an accident. I didn’t
think it needed to be reported.” Be aware of
personal biases when evaluating patients for
abuse and examine reasons why you do or do
not suspect abuse in a particular patient present-
ing with a traumatic injury. Also, remember the
presenting parent(s) may not be the perpetrator
or be aware of the abuse.
7. “I wasn’t sure whether I needed to work
up this child with bruising for nonaccidental
trauma.” Use clinical decision tools (eg, TEN-
4-FACESp, BuRN-Tool, PediBIRN) as well as his-
torical features to identify patients with potential
NAT who need further workup.
8. “I suppose the 3-month-old could have sus-
tained a bruise to the ear from his mom trip-
ping while carrying him.” Review injury patterns
that are highly concerning for abuse such as
bruising, intraoral injuries, and fractures in pream-
bulatory infants.
9. “I decided to just call Child Protective Services
for this patient, and I arranged follow-up after
discussing it with them.” For cases of suspected
abuse, include a multidisciplinary team early on,
including a social worker and child abuse pedia-
trician, if available.
10. “The skeletal survey was negative, so I ruled
out child abuse.” Order skeletal surveys in chil-
dren aged <2 years for whom NAT is suspected.
Remember these children will need a repeat
survey in 10 to 14 days from presentation, so
arrange appropriate follow-up. Even if the repeat
skeletal survey is negative, it is possible a child is
still experiencing abuse, so appropriate reporting
and follow-up with child abuse specialists is para-
mount. Because most emergency clinicians are
not trained forensic child abuse specialists, it is
not the duty of the clinician to determine exactly
how the injury occurred, identify a perpetrator, or
to say definitively whether NAT is present.
13 © 2023 EB MEDICINE
 Case Conclusions
For the 2-month-old boy who was brought to the ED by his mother for lethargy and a seizure at
home…
CASE 1

Given the new-onset seizure and lethargy, a CT scan and bloodwork were ordered. The bloodwork returned
within normal limits. The CT showed bilateral subdural hemorrhages. A retinal examination was performed,
which showed retinal hemorrhages. Social work, neurosurgery, and Child Protective Services were alerted.
The child was admitted to the pediatric intensive care unit for further management.

For the 13-month-old boy who was brought to the ED by his grandmother for 3 days of fever and
runny nose...
Further examination showed bruising to the calves and buttocks. Laboratory studies, including hematologic
CASE 2

studies, were conducted, and all returned within normal limits. A skeletal survey was performed, which
showed multiple old fractures in various stages of healing. Social work and Child Protective Services were
alerted. Upon further evaluation, it was determined the child was not safe to go home, given the multiple
injuries, and he was admitted to the hospital for further workup while awaiting temporary placement by
Child Protective Services, as they continued their investigation.

For the 5-month-old girl who was brought to the emergency department by her babysitter after fall-
ing earlier in the day...
X-rays showed a spiral femur fracture. Because the story and fracture were inconsistent with the injury, a
CASE 3

skeletal survey was obtained, but no additional fractures were identified. Bloodwork was ordered and re-
turned within normal limits. Social work and Child Protective Services were notified. The child was deemed
safe to go home with the parents, who were not home at the time of the child’s injury. A follow-up skeletal
survey with a child abuse pediatrician 2 weeks later showed only the isolated femur fracture. The babysitter
was investigated and ultimately found guilty of child abuse.

5 Recommendations
To Apply in Practice
5 Things That Will
5 Recommendations
Change To
Your Practice
Apply in Practice
1. In children with traumatic injuries, apply clini-
cal decision tools such as the TEN-4-FACESp,
BuRN-Tool,5
andRecommendations
PediBIRN to screen for NAT
To Apply
and pursue further workupinwhen
Practice
indicated.
2. When considering whether to pursue a
workup for NAT in a child, evaluate whether
your own personal biases are shaping your
perspective of the situation.
3. Learn to conduct a thorough history and
physical examination and look for sentinel
injuries in all children presenting to the ED,
in order to identify NAT early on and prevent
morbidity and mortality.
4. Review state laws regarding NAT where you
practice and familiarize yourself with when
and how to report.
5. Understand which specialists and organiza-
tions are available in your practice setting
and when to alert them about NAT.
n Summary
NAT is a significant cause of pediatric morbidity and
mortality. Given many abused children will present to
the ED prior to being diagnosed, emergency clini-
cians should familiarize themselves with signs of NAT
and appropriate management. It is important to con-
duct a thorough history and physical examination on
all children presenting to the ED to screen for NAT.
Injuries that seem inconsistent with the child’s devel-
opmental age, certain injury patterns, traumatic inju-
ries in preambulatory children, or delays in seeking
care should prompt clinicians to move NAT further
up the differential. A complete physical examination
should be performed, including undressing the child
to look for occult sentinel injuries that may otherwise
be missed. Clinicians should familiarize themselves
with injury patterns highly suggestive of NAT. Multiple
injuries at various stages of healing, injuries to pream-
bulatory infants, or injuries in unusual locations such
as the ears, torso, or mouth should raise suspicion
for abuse. The use of clinical decision tools for injury
patterns can help clinicians determine which children
need further evaluation.
Once suspicion of abuse exists, clinicians, as
mandated reporters, are required to report that suspi-
cion but not to diagnose or conduct a forensic inves-
tigation. Emergency clinicians have a responsibility
to report concerns but often do not have the exper-

SEPTEMBER 2023 • www.ebmedicine.net 14 © 2023 EB MEDICINE


tise and resources available to definitively conclude
whether NAT occurred. Clinicians should thoroughly
document historical and physical examination find-
ings as well as order medically appropriate tests.
Even if the ED workup is negative, clinicians with
suspicion should still report and allow Child Protec-
tive Services to conduct an investigation, especially
since some studies such as a skeletal survey may be
negative initially. Involvement of a multidisciplinary
team including social work, Child Protective Services,
and child abuse pediatricians can help ensure these
children receive appropriate care, suspicions are
properly investigated, and follow-up with the ap-
propriate services is initiated. These multidisciplinary
teams can also help clinicians in determining the
safest disposition for patients from the ED. Child
Protective Services and child abuse pediatricians have
the resources and forensic expertise to definitively
conclude whether child abuse occurred and will alert
law enforcement when appropriate.
n Time and Cost-Effective Strategies
Involvement of a multidisciplinary team, including a
social worker and a child abuse specialist, can save
time and provide a safe disposition for patients.
Their involvement can be cost-effective by helping
to streamline care for patients. These teams can help
arrange follow-up and interface with law enforce-
ment, which can alleviate clinician burden. Addition-
ally, their expertise can help aid in the diagnosis
and avoid unnecessary testing in cases in which the
suspicion for NAT is low.
n References
Evidence-based medicine requires a critical appraisal
of the literature based upon study methodology and
number of subjects. Not all references are equally
robust. The findings of a large, prospective, random-
ized, and blinded trial should carry more weight than
a case report.
To help the reader judge the strength of each refer-
ence, pertinent information about the study, such as the
type of study and the number of patients in the study is
included in bold type following the references, where
available. The most informative references cited in this
paper, as determined by the authors, are noted by an
asterisk (*) next to the number of the reference.
1. Children’s Bureau -- An Office of the Administration for Children
& Families. Child maltreatment 2020. 2022. Accessed August 1,
2023. Available at: https://www.acf.hhs.gov/cb/data-research/
child-maltreatment (Federal data report)
2. Rosenfeld EH, Johnson B, Wesson DE, et al. Understanding
non-accidental trauma in the United States: a national trauma
databank study. J Pediatr Surg. 2020;55(4):693-697. (Prognos-
tic and epidemiological review)
3. Leetch AN, Woolridge D. Emergency department evaluation of
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child abuse. Emerg Med Clin North Am. 2013;31(3):853-873.
(Review)
4.* Christian CW. The evaluation of suspected child physical
abuse. Pediatrics. 2015;135(5):e1337-e1354. (Clinical report)
DOI: 10.1542/peds.2015-0356
5. Mulder TM, Kuiper KC, van der Put CE, et al. Risk factors
for child neglect: a meta-analytic review. Child Abuse Negl.
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6. Rodriguez CM, Lee SJ, Ward KP. Underlying mechanisms
for racial disparities in parent-child physical and psycho-
logical aggression and child abuse risk. Child Abuse Negl.
2021;117:105089. (Prospective analysis; 292 patients)
7. Hymel KP, Laskey AL, Crowell KR, et al. Racial and ethnic
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analysis; 500 patients)
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9. Eismann EA, Shapiro RA, Makoroff KL, et al. Identifying
predictors of physical abuse evaluation of injured infants:
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12. Henry MK, Wood JN. What’s in a name? Sentinel injuries in
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14. Berthold O, Frericks B, John T, et al. Abuse as a cause of
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(Review)
15. Bataenjer R, Grotzer M, Seiler M. For infants with fractures:
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21.* Deutsch SA. Understanding abusive head trauma: a primer for
the general pediatrician. Pediatr Ann. 2020;49(8):e347-e353.
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22. Pomeranz ES. Child abuse and conditions that mimic it. Pediatr
Clin North Am. 2018;65(6):1135-1150. (Review)
23. Tiyyagura G, Beucher M, Bechtel K. Nonaccidental injury in
pediatric patients: detection, evaluation, and treatment. Pediatr
Emerg Med Pract. 2017;14(7):1-32. (Review)
24. Alphonso A, Auerbach M, Bechtel K, et al. Development of a
child abuse checklist to evaluate prehospital provider perfor-
mance. Prehosp Emerg Care. 2017;21(2):222-232. (Delphi
study)
25. Zubler JM, Wiggins LD, Macias MM, et al. Evidence-informed
milestones for developmental surveillance tool. Pediatrics.
2022;149(3):e2021052138. (Review)
26.* Pierce MC, Kaczor K, Lorenz DJ, et al. Validation of a
clinical decision rule to predict abuse in young children
based on bruising characteristics. JAMA Netw Open.
2021;4(4):e215832. (Observational study; 2161 patients)
DOI: 10.1001/jamanetworkopen.2021.5832
27. Loos MHJ, Almekinders CAM, Heymans MW, et al. Incidence
and characteristics of non-accidental burns in children: a
systematic review. Burns. 2020;46(6):1243-1253. (Systematic
review; 17 studies)
28. Kemp AM, Hollén L, Emond AM, et al. Raising suspicion of
maltreatment from burns: derivation and validation of the
BuRN-Tool. Burns. 2018;44(2):335-343. (Prospective study;
1327 patients)
29. Hymel KP, Willson DF, Boos SC, et al. Derivation of a clinical
prediction rule for pediatric abusive head trauma. Pediatr Crit
Care Med. 2013;14(2):210-220. (Prospective, multicenter,
observational, cross-sectional study; 209 patients)
30. Hymel KP, Armijo-Garcia V, Foster R, et al. Validation of a clini-
cal prediction rule for pediatric abusive head trauma. Pediatrics.
2014;134(6):e1537-e1544. (Prospective, multicenter, observa-
tional, cross-sectional study; 291 patients)
31. Hymel KP, Fingarson AK, Pierce MC, et al. External validation
of the PediBIRN screening tool for abusive head trauma in
pediatric emergency department settings. Pediatr Emerg Care.
2022;38(6):269-272. (Retrospective secondary analysis; 117
patients)
32. Hymel KP, Karst W, Marinello M, et al. Screening for pediatric
abusive head trauma: are three variables enough? Child Abuse
Negl. 2022;125:105518. (Retrospective secondary analysis;
973 patients)
33. Flaherty EG, Perez-Rossello JM, Levine MA, et al. Evaluat-
ing children with fractures for child physical abuse. Pediatrics.
2014;133(2):e477-e489. (Practice guidelines)
34. Lindberg DM, Shapiro RA, Blood EA, et al. Utility of hepatic
transaminases in children with concern for abuse. Pediatrics.
2013;131(2):268-275. (Retrospective secondary analysis; 2890
patients)
35. Anderst J, Carpenter SL, Abshire TC, et al. Evaluation for
bleeding disorders in suspected child abuse. Pediatrics.
2022;150(4):e2022059276. (Clinical report)
36. Cornell EM, Powell EC. Skeletal survey yield in young children
with femur fractures. J Emerg Med. 2018;55(6):758-763. (Retro-
spective chart review; 22 patients)
37. Wood JN, Henry MK, Berger RP, et al. Use and utility of skeletal
surveys to evaluate for occult fractures in young injured chil-
dren. Acad Pediatr. 2019;19(4):428-437. (Retrospective chart
review; 1769 patients)
SEPTEMBER 2023 • www.ebmedicine.net
38. Lindberg DM, Berger RP, Reynolds MS, et al. Yield of skel-
etal survey by age in children referred to abuse specialists. J
Pediatr. 2014;164(6):1268-1273. (Retrospective analysis; 2609
patients)
39. Offiah A, van Rijn RR, Perez-Rossello JM, et al. Skeletal imag-
ing of child abuse (non-accidental injury). Pediatr Radiol.
2009;39(5):461-470. (Reivew)
40. American College of Radiology, the Society for Pediatric Radi-
ology. ACR–SPR practice parameter for the performance and
interpretation of skeletal surveys in children. 2021. Accessed
August 1, 2023. Available at: https://www.acr.org/-/media/ACR/
Files/Practice-Parameters/Skeletal-Survey.pdf (Guideline)
41.* Harper NS, Lewis T, Eddleman S, et al. Follow-up skeletal
survey use by child abuse pediatricians. Child Abuse Negl.
2016;51:336-342. (Observational study; 2890 patients)
DOI: 10.1016/j.chiabu.2015.08.015
42. Boehnke M, Mirsky D, Stence N, et al. Occult head injury is
common in children with concern for physical abuse. Pediatr
Radiol. 2018;48(8):1123-1129. (Observational study; 1143
patients)
43. Ip SS, Zafar S, Liu TYA, et al. Nonaccidental trauma in pediatric
patients: evidence-based screening criteria for ophthalmologic
examination. J AAPOS. 2020;24(4):226.E1-E226. (Retrospec-
tive chart review; 190 patients)
44. Committee on Hospital Care and Committee on Child Abuse
and Neglect. Medical necessity for the hospitalization of the
abused and neglected child. Pediatrics. 1998;101(4 Pt 1):715-
716. (Review)
45. Bullinger LR, Boy A, Messner S, et al. Pediatric emergency
department visits due to child abuse and neglect following CO-
VID-19 public health emergency declaration in the Southeast-
ern United States. BMC Pediatr. 2021;21(1):401. (Retrospective
chart review)
46. Kovler ML, Ziegfeld S, Ryan LM, et al. Increased proportion
of physical child abuse injuries at a Level I pediatric trauma
center during the COVID-19 pandemic. Child Abuse Negl.
2021;116(Pt 2):104756. (Retrospective chart review)
47. Kaiser SV, Kornblith AE, Richardson T, et al. Emergency visits and
hospitalizations for child abuse during the COVID-19 pandemic.
Pediatrics. 2021;147(4):e2020038489. (Retrospective cohort)
48. Laskey AL, Stump TE, Perkins SM, et al. Influence of race
and socioeconomic status on the diagnosis of child abuse: a
randomized study. J Pediatr. 2012;160(6):1003-1008. (Random-
ized control trial; 2109 subjects)
49. Najdowski CJ, Bernstein KM. Race, social class, and child
abuse: content and strength of medical professionals’ ste-
reotypes. Child Abuse Negl. 2018;86:217-222. (Randomized
control trial; 53 subjects)
50. Sonik A, Stein-Wexler R, Rogers KK, et al. Follow-up skeletal
surveys for suspected non-accidental trauma: can a more
limited survey be performed without compromising diagnostic
information? Child Abuse Negl. 2010;34(10):804-806. (Retro-
spective study; 22 patients)
51. Sait S, Havariyoun G, Newman H, et al. Effective radiation dose
of skeletal surveys performed for suspected physical abuse.
Pediatr Radiol. 2023;53(1):69-77. (Retrospective study; 68
children)
16 © 2023 EB MEDICINE
 Clinical Pathway for Emergency Department Management
of Nonaccidental Trauma in Pediatric Patients

Child presents to the emergency department

• Obtain full history and head-to-toe physical examination

• Apply decision tools for bruising and other injuries identified (Class I)

Suspicion for abuse?

YES NO

Alert Child Protective Services and social work (Class I) Continue medical workup as indicated

Child aged <2 years?

YES NO

Order skeletal survey (Class I) Initiate workup based on suspected injury. Order CBC, coagulation studies, LFTs, lipase (Class I)

Suspicion for skin/soft-tissue
injury:
• Test for bleeding diathesis
as indicated (Class II)
Suspicion for fracture: Head trauma is suspected or nonaccidental Lipase or AST/
• Test vitamin D, vitamin C, trauma is suspected in a patient aged <6 ALT elevated:
calcium, phosphorus levels months: • Obtain CT
(Class II) • Obtain CT or MRI abdomen
• Test for osteogenesis
imperfecta (Class III)
• Consult orthopedics (Class I)
CT positive for intracranial hemorrhage?

YES NO
Abbreviations: AST, aspartate transaminase; ALT,
alanine transaminase; CBC, complete blood
cell count; CT computed tomography; LFTs, • Consult neurosurgery (Class I)
No need for retinal
liver function tests; MRI, magnetic resonance • Order retinal examination
examination (Class II)
imaging. (Class II)

Class of Evidence Definitions

Each action in the clinical pathways section of Pediatric Emergency Medicine Practice receives a score based on the following definitions.
Class I Class II Class III Indeterminate
• Always acceptable, safe • Safe, acceptable • May be acceptable • Continuing area of research
• Definitely useful • Probably useful • Possibly useful • No recommendations until further
• Proven in both efficacy and effectiveness • Considered optional or alternative research
Level of Evidence: treatments
Level of Evidence: • Generally higher levels of evidence Level of Evidence:
• One or more large prospective studies • Nonrandomized or retrospective stud- Level of Evidence: • Evidence not available
are present (with rare exceptions) ies: historic, cohort, or case control • Generally lower or intermediate levels • Higher studies in progress
• High-quality meta-analyses studies of evidence • Results inconsistent, contradictory
• Study results consistently positive and • Less robust randomized controlled trials • Case series, animal studies, • Results not compelling
compelling • Results consistently positive consensus panels
• Occasionally positive results

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2023 EB Medicine. www.ebmedicine.net. No part of this publication may be reproduced in any format without written consent of EB Medicine.

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6. Which of the following patients needs a skel-
etal survey?
a. A 2-year-old girl presenting with a tibial spiral
fracture after running and falling
b. A 5-year-old boy presenting with a humerus
fracture with patterned bruising to the lower
leg after a fall
c. An 18-month-old boy presenting with upper
respiratory infection symptoms who is found
to have bilateral knee bruising
d. A 4-month-old girl presenting with fever who
is found to have bruising to the torso

7. A 7-month-old boy presents with incessant cry-

ing and is found to have a tibial spiral fracture.
The initial skeletal survey is remarkable for
only the tibial fracture. When should a follow-
up skeletal survey be performed?
a. No follow-up survey is needed, as a fracture
1. Which of the following is NOT a risk factor for has already been found.
nonaccidental trauma (NAT)? b. A follow-up survey should be performed in 5
a. Single mother to 7 days.
b. Military family c. A follow-up survey should be performed in 10
c. Ethnic background to 14 days.
d. Financial instability d. A follow-up survey should be performed in 3
to 4 weeks.
2. Which of the following is a risk factor for NAT?
a. Female sex 8. A 3-month-old girl presents with seizures and
b. School age lethargy and is found to have a subdural he-
c. Full-term birth matoma. The initial skeletal survey is negative.
d. Autism diagnosis Which is the next step?
a. Retinal examination
3. What is the most common type of sentinel b. Repeat skeletal survey in 1 week
injury? c. Repeat head computed tomography in 6
a. Burns hours
b. Bruises d. Focused assessment with sonography in
c. Bites trauma examination
d. Torn frenulum
9. Which of the following tests is NOT needed
4. Which of the following is the least concerning for a child with an intracranial hemorrhage?
historical finding for NAT? a. Coagulation studies
a. An injury that occurred 24 hours prior to b. Vitamin levels
presentation c. Metabolic studies
b. An injury to a 2-month-old boy after rolling d. Hemophilia studies
off the bed
c. Parents who did not witness the injury 10. Which of the following is a mandated reporter
d. Intracranial hemorrhage caused by a fall from for suspected abuse?
standing a. Paramedic
b. Physician
5. Which of the following sites of bruising, if inci- c. Social worker
dentally found, requires further workup? d. All of the above
a. Forearm
b. Forehead
c. Ear
d. Knee

SEPTEMBER 2023 • www.ebmedicine.net 18 © 2023 EB MEDICINE

The Pediatric Emergency Medicine Practice Editorial Board
EDITORS-IN-CHIEF
Ilene Claudius, MD
Professor; Director, Process &
Quality Improvement Program,
Harbor-UCLA Medical Center,
Torrance, CA
Tim Horeczko, MD, MSCR,
FACEP, FAAP
Associate Professor of Clinical
Emergency Medicine, David
Geffen School of Medicine,
UCLA; Core Faculty and Senior
Physician, Los Angeles County-
Harbor-UCLA Medical Center,
Torrance, CA
EDITORIAL BOARD
Jeffrey R. Avner, MD, FAAP
Chairman, Department of
Pediatrics, Professor of Clinical
Pediatrics, Maimonides
Children's Hospital of
Brooklyn, Brooklyn, NY
Steven Bin, MD
Associate Clinical Professor,
UCSF School of Medicine;
Medical Director, Pediatric
Emergency Medicine, UCSF
Benioff Children's Hospital, San
Francisco, CA
Richard M. Cantor, MD, FAAP,
FACEP
Professor of Emergency
Medicine and Pediatrics; Section
Chief, Pediatric Emergency
Medicine; Medical Director,
Upstate Poison Control Center,
Golisano Children's Hospital,
Syracuse, NY
Steven Choi, MD, FAAP
Chief Quality Officer and
Associate Dean for Clinical
Quality, Yale Medicine/Yale
School of Medicine; Vice
President, Chief Quality Officer,
Yale New Haven Health System,
New Haven, CT
Ari Cohen, MD, FAAP
Chief of Pediatric Emergency
Medicine, Massachusetts
General Hospital; Instructor
in Pediatrics, Harvard Medical
School, Boston, MA
SEPTEMBER 2023 • www.ebmedicine.net
Jay D. Fisher, MD, FAAP, FACEP
Associate Professor of Emergency
Medicine; Program Director,
Pediatric Emergency Medicine
Fellowship, Kirk Kerkorian School
of Medicine at UNLV; Medical
Director, Pediatric Emergency
Services, UMC Children's
Hospital, Las Vegas, NV
Marianne Gausche-Hill, MD,
FACEP, FAAP, FAEMS
Medical Director, Los Angeles
County EMS Agency; Professor
of Clinical Emergency Medicine
and Pediatrics, David Geffen
School of Medicine at UCLA;
Clinical Faculty, Harbor-UCLA
Medical Center, Departments
of Emergency Medicine and
Pediatrics, Los Angeles, CA
Michael J. Gerardi, MD, FAAP,
FACEP, President
Associate Professor of
Emergency Medicine, Icahn
School of Medicine at Mount
Sinai; Director, Pediatric
Emergency Medicine, Goryeb
Children's Hospital, Morristown
Medical Center, Morristown, NJ
Sandip Godambe, MD, PhD,
MBA
Chief Medical Officer, SVP
Medical Affairs, Attending
Physician, Pediatric Emergency
Medicine, Children’s Health of
California (CHOC) Children’s
Hospital, Orange, CA
Ran D. Goldman, MD
Professor, University of British
Columbia, Pediatric Emergency
Physician, BC Children’s
Hospital, Vancouver, BC, Canada
Alson S. Inaba, MD, FAAP
Pediatric Emergency Medicine
Specialist, Kapiolani Medical
Center for Women & Children;
Associate Professor of Pediatrics,
University of Hawaii John A.
Burns School of Medicine,
Honolulu, HI
Madeline Matar Joseph, MD,
FACEP, FAAP
Professor of Emergency
Medicine and Pediatrics,
Associate Dean for Inclusion and
Equity, Emergency Medicine
Department, University of
Florida College of Medicine-
Jacksonville, Jacksonville, FL
19
Anupam Kharbanda, MD, MSc
Chief, Critical Care Services,
Children's Hospital Minnesota,
Minneapolis, MN
Tommy Y. Kim, MD
Health Sciences Clinical
Professor of Pediatric Emergency
Medicine, University of California
Riverside School of Medicine,
Riverside Community Hospital,
Department of Emergency
Medicine, Riverside, CA
Melissa Langhan, MD, MHS
Associate Professor, Departments
of Pediatrics and Emergency
Medicine, Section of Emergency
Medicine, Yale University School
of Medicine, New Haven, CT
Robert Luten, MD
Professor, Pediatrics and
Emergency Medicine, University
of Florida, Jacksonville, FL
Garth Meckler, MD, MSHS
Associate Professor of Pediatrics,
University of British Columbia;
Division Head, Pediatric
Emergency Medicine, BC
Children's Hospital, Vancouver,
BC, Canada
Joshua Nagler, MD, MHPEd
Associate Division Chief and
Fellowship Director, Division of
Emergency Medicine, Boston
Children's Hospital; Associate
Professor of Pediatrics and
Emergency Medicine, Harvard
Medical School, Boston MA
James Naprawa, MD
Attending Physician, Emergency
Department USCF Benioff
Children's Hospital, Oakland, CA
Joshua Rocker, MD, FAAP,
FACEP
Chief, Division of Pediatric
Emergency Medicine, Associate
Professor of Pediatrics and
Emergency Medicine, Cohen
Children's Medical Center of
New York, New Hyde Park, NY
Steven Rogers, MD
Associate Professor, University of
Connecticut School of Medicine,
Attending Emergency Medicine
Physician, Connecticut Children's
Medical Center, Hartford, CT
Jennifer E. Sanders, MD, FAAP,
FACEP
Assistant Professor, Departments
of Pediatrics, Emergency
Medicine, and Education, Icahn
School of Medicine at Mount
Sinai, New York, NY
Christopher Strother, MD
Associate Professor, Emergency
Medicine, Pediatrics, and
Medical Education; Director,
Pediatric Emergency Medicine;
Director, Simulation; Icahn
School of Medicine at Mount
Sinai, New York, NY
Adam E. Vella, MD, FAAP
Associate Professor of
Emergency Medicine and
Pediatrics, Associate Chief
Quality Officer, New York-
Presbyterian/Weill Cornell
Medicine, New York, NY
David M. Walker, MD, FACEP,
FAAP
Chief, Pediatric Emergency
Medicine, Joseph M. Sanzari
Children's Hospital, Hackensack
University Medical Center;
Associate Professor of Pediatrics,
Hackensack Meridian School of
Medicine, Hackensack, NJ
Vincent J. Wang, MD, MHA
Professor of Pediatrics and
Emergency Medicine; Division
Chief, Pediatric Emergency
Medicine, UT Southwestern
Medical Center; Director of
Emergency Services, Children's
Health, Dallas, TX
INTERNATIONAL EDITOR
Lara Zibners, MD, FAAP, FACEP,
MMEd
Honorary Consultant, Paediatric
Emergency Medicine, St. Mary's
Hospital Imperial College
Trust, London, UK; Nonclinical
Instructor of Emergency
Medicine, Icahn School of
Medicine at Mount Sinai, New
York, NY
PHARMACOLOGY EDITOR
Aimee Mishler, PharmD, BCPS
Emergency Medicine Pharmacist,
St. Luke's Health System, Boise, ID
© 2023 EB MEDICINE
 Points & Pearls
QUICK READ
SEPTEMBER 2023 | VOLUME 20 | ISSUE 9
Points
• Examples of sentinel injuries include unusual
bruising in infants and toddlers, and intraoral
injuries such as a torn frenulum in infants. In-
adequately explained or patterned burns (eg,
cigarette burns), and fractures in premobile chil-
dren can also be signs of nonaccidental trauma
(NAT).10,11 (See Figure 1.)
• Distinguishing routine accidental bruising from
abusive bruising patterns is important when evalu-
ating an injured child. (See Figure 2.)
• When obtaining the history, ask open-ended
questions and allow caregivers/parents to give
their full side of the story, so as not to influence
the narrative with leading questions.
• Injuries that seem inconsistent with the child’s
developmental age, certain injury patterns,
traumatic injuries in preambulatory children, or
delays to seeking care should prompt clinicians
to move NAT further up the differential.
• A thorough, disrobed physical examination of
any patient arriving at the ED, regardless of
complaint, is key to identifying NAT and sentinel
injuries.
• Multiple injuries at various stages of healing,
injuries to preambulatory infants, or injuries to
unusual locations such as the ears, torso, or
mouth should raise suspicion for abuse.
• Clinicians should thoroughly document histori-
cal and physical examination findings as well as
order medically appropriate tests.
• Even if the ED workup is negative, clinicians with
suspicion should still report and allow Child Pro-
tective Services to conduct an investigation.
• Evidence-based clinical decision tools such as
TEN-4-FACESp (see Figure 3), BuRN-Tool (see
Figure 7), and Pedi-BIRN (see Figure 8) can be
used to help identify children at high risk for NAT.
• All children for whom NAT is suspected due to
bruising should have baseline screening labora-
tory studies including a CBC, coagulation studies,
liver function tests, and lipase, with additional test-
ing to evaluate alternative etiologies (eg, bleeding
diathesis) done in consultation with a specialist or
child abuse pediatrician. (See Table 2.)
SEPTEMBER 2023 • www.ebmedicine.net
Emergency Department
Evaluation and Management
of Nonaccidental Trauma in
Pediatric Patients
Pearls
l When assessing an injured child, clinicians
should remaining cognizant of personal biases
that may cause them to overevaluate or under-
evaluate the child.
l Once suspicion of abuse exists, clinicians, as
mandated reporters, are required to report that
suspicion but not to diagnose or conduct a
forensic investigation.
l Involvement of a multidisciplinary team in-
cluding social work, Child Protective Services,
and child abuse pediatricians can help ensure
children for whom there is suspicion of NAT re-
ceive appropriate care, suspicions are properly
investigated, and follow-up with the appropri-
ate services is initiated.
• All children aged <2 years being evaluated for
NAT should have a skeletal survey done in the
ED,36,37 with a follow-up repeat survey 10 to 14
days after the initial visit.41
• Have a low threshold computed tomography (CT)
scan of the head for children aged <2 years, espe-
cially young infants, being evaluated for NAT.
• Routine examination for retinal hemorrhages may
not be necessary unless there is CT evidence of
abusive head trauma,43 and may lead to increased
cost and resource utilization.
• The treatment for NAT will depend largely on
the types of injuries sustained. Medical treatment
should proceed as it would for any patient present-
ing with traumatic injuries.
• Report suspicions of abuse to Child Protective
Services, so a conclusive forensic investigation of
abuse can be conducted.
• For children who do not have injuries severe
enough to necessitate medical admission, the dis-
position should be decided by a multidisciplinary
team consisting of social workers, the clinician, and
Child Protective Services.
20 © 2023 EB MEDICINE