Non-Accidental Trauma (NAT, Child
Maltreatment)
UK HealthCare Pediatric
Trauma Service Child
Protection Team Subcommittee
Quick Reference
Non-Accidental
Trauma Clinical Practice
Guideline
Section I
A. Recognizing Child Physical
Abuse
Child physical abuse is non-accidental physical injury as a result of punching,
beating, kicking, biting, shaking,
throwing, stabbing, choking, hitting, burning, or otherwise
harming a child
that is inflicted
by a parent, caregiver, or other person who
has responsibility for the child.
Such injury is considered
abuse regardless of whether
the caregiver intended to hurt the
child.
B.
Risk Factors for Physical
Abuse
•
Parent or Caregiver Factors
•
Personality characteristics
•
Psychological well-being (untreated/inadequately treated mental illness)
•
History of maltreatment
•
Substance abuse
•
Attitudes and knowledge
• Immaturity
• History
of law enforcement or child protective services involvement
•
Family Factors
•
Non-biological parental male living
in the home
•
Marital conflict/domestic violence
•
Lower economic status
•
High stress level/lack of social support
•
Child Factors
•
Age
≤ 3 years
have the highest risk
•
Disability (physical/cognitive/emotional)
•
Prematurity
•
Long-awaited child
•
The absence
of risk factors
is not the absence of risk!!!
C. Bruising concerning
for NAT
•
TEN/4 FACESp
Bruising Rule
o Bruising anywhere on a child 4 months of age or younger
o Bruising to the torso, ears, or neck in a child less
than 4 yrs of age.
o Injury
or bruising to the frenulae, angle of the jaw, cheek (buccal aspect), eyelid,
or subconjunctival hemorrhage
o Patterned
bruises
•
Bruising incompatible with child’s age and/or
development.
•
Extensive, poorly explained or unexplained
bruising
The
above findings should warrant further child
abuse evaluation for occult trauma as per below protocol. Consultation with PFM
advised.
NOTE:
Photography with measurement/scale is important
•
Bite marks
•
Measurement of diameter can be helpful
determination of adult vs. child
but
can still be difficult.
•
Inflicted adult bite
marks are very worrisome
– typically indicate a more sadistic abuser.
•
Swabbing fresh bite marks
can help identify perpetrator by DNA analysis. This can
be accomplished
by moistening a swab,
swipe over bite mark several times,
allow to dry and put in evidence collection
kit.
•
Most common perpetrator is TODDLER
NOTE: Photography with
measurement/scale is important
D. Burns
•
Characteristics of inflicted
burns:
§ Sharply demarcated edges
§
Paucity of splash marks
§
Burns in the
genital area
§
Predominance of partial
and full thickness burns
§
Relative uniformity of burn depth
over larger surface areas
§
Patterned burns, including but not
limited to stocking glove pattern
NOTE: Photography with
measurement/scale is important
o The appearance of burns can
change rapidly (in a matter of hours). Photo
documentation should
be done IMMEDIATELY if the child is
otherwise stable.
o Abuse work-up
should be performed as per protocol below and would also strongly consider
skeletal survey in children 2-3 years of age
E.
Abusive Head Trauma (AHT)
•
#1 cause of death in
child physical abuse
•
Global brain injury
caused by rotational forces
•
Involves shaking, impact,
or both
•
Subdural hematomas, +/- retinal hemorrhage,
bruising, fractures
•
Previously
known as “Shaken baby syndrome”
•
Often triggered by crying
•
Typically, not a one-time
event
•
Frequently, these children present with
NO history of trauma
•
Beware
of
vomiting without diarrhea – this is a
commonly missed presentation for abusive
head injury.
•
AHT and young age
are significant risk factors
for seizures in children with TBI and
up to 77% of victims
of AHT have
been report to have
either clinical or subclinical seizures.
•
Beware of rapid increase
in head circumference.
1.
Consider head CT in
any child who has crossed
two major percentile lines in head circumference
over a short time
(a few months).
2.
Head ultrasound is known to miss
subdural especially as child
gets older and fontanelle gets
smaller and, as such is NOT recommended for this evaluation
concern..
F. Abdominal Trauma
•
Any bruise or injury on the
abdominal area should prompt labs
•
If labs are
abnormal, then imaging should be obtained
•
In
cases of abdominal trauma, liver enzymes > 80 has been associated with forensically significant abdominal trauma (i.e., liver contusion) that may not necessarily require surgical intervention.
•
Hollow organ injury could still be
a concern
with otherwise normal labs, so
if significant abdominal bruising or concerning abdominal exam,
would still obtain
imaging despite
normal screening labs.
•
FAST scan/ultrasound is not sufficient.
•
CT imaging of the abdomen/pelvis with IV and PO
contrast is gold standard to evaluate for abusive abdominal trauma (if oral contrast
unable to be utilized due to patient condition, IV contrast must be used at
minimum)
G. Skeletal Trauma
•
When evaluating skeletal injuries, the physician
should consider the
location of the fracture, the mechanism
given, the child’s chronologic
age and developmental status.
•
Certain radiographic
findings in infants and toddlers carry a level of specificity for abuse.
•
Age/development of child
should also be considered, as infant fractures or fractures in non-mobile
children raise clinical concern for abuse.
•
Additional fracture
information:
o
Buckle fractures
in any child
under 9 months of age are
of concern due to
a lack of mobility
and underdeveloped protective
reflexes that might lead to
an “accidental”
mechanism such as falling on an outstretched
arm.
o
Spiral fractures
can occur from
seemingly innocuous trauma such as
tripping while
running and are not always indicative
of abuse.
o
Transverse fractures
– the mechanism should
reflect the
specific type and magnitude of forces required
to cause
this specific fracture morphology.
o
Metaphyseal corner fractures are highly suspicious for abuse. Often associated with soft tissue injury as well
|
High specificity |
Moderate specificity |
Low specificity, but common |
|
Metaphyseal corner fractures Rib fractures, especially posteromedial Scapularfractures Spinous process fractures Sternal fractures |
Multiple fractures, especially bilateral Fractures of different ages Epiphyseal separations Vertebral body fractures and subluxations Digital fractures Complex skull fractures |
Subperiosteal new bone formation Clavicular fractures Long-bone shaft fractures Linear skull fractures |
Section II
A.
Admission to
the Children’s Hospital
a.
If the child’s condition/presentation/injuries
meet Pediatric Trauma Activation Criteria (Trauma Alert or Trauma Alert Red),
then the patient is to
be evaluated in the trauma
resuscitation area of
the emergency room, and the ED Pediatric Trauma
Process Guidelines must be followed.
b.
Children
with acute injuries should
be admitted to the Pediatric Trauma Service.
c. Children without acute injuries may be admitted to the Pediatric Hospitalist Service.
B.
Documentation
a.
Questions to Ask
•
Who is/are the primary
caregivers?
•
When did the caregivers first notice symptoms/bruises?
•
Does caregiver history
change when they are given new medical information about the child including
newly identified injuries?
•
Do different
witnesses give different accounts?
•
What did they do after they noticed
these symptoms?
•
When was
the last time the child
was
acting normally? Note: in young
infants, it can be difficult to tell.
•
When was the last time the
child was tracking, cooing,
smiling, eating without
vomiting?
•
Have
there been any accidents?
•
Are there other children at
home or not living
with the family?
•
Has the child had any injuries
before?
•
Is
there a history of SIDS or any other unexpected death of a young child?
b.
What to
Document
•
Detailed physical examination documentation with appropriate drawings
•
Be sure the
child is completely unclothed during
examination and the
lights are on in the
room
•
Document location, size, and
shape of all bruising or unusual
markings
•
A careful and well documented
history
•
Use quotes whenever possible
•
Document detailed descriptions of the mechanisms of injury or injuries with inclusion
of
the progression of symptoms
•
Also make
note of what the caregiver did
after these events/symptoms
•
Photo Documentation
•
Photo-documentation as soon
as possible is becoming the standard of care.
§ The pediatric forensic medicine
team or hospital social workers
are typically available
to take photographs
and appropriately store the images.
§
Informed consent
is not required
in open investigations of child abuse
§ Each
injury should be photographed at least 2 times: 1 establishes location of
injury on the body and the second is closer up to obtain detail and
measurement.
§
Photograph injuries:
·
Prior to treatment
·
Turn on the lights in
the room
·
Document the patient’s name, DOB, MRN,
etc. (this can be accomplished by the first picture being of the patient’s
sticker).
·
Should have patient’s face then a full body photo
(with appropriately covered
genitals).
·
Use a ruler or measurement device to give
perspective. A paper measuring tape
used for measuring
head circumference with a patient label attached is a great way to
accomplish this.
C.
Work-up for Child Physical
Abuse
1.
≤
12 months
·
Skeletal survey
·
Consult Orthopedic Surgery if abnormal
findings identified
·
Follow-up skeletal
survey should be performed within 10 to 14
days-to be arrange by Forensics
·
Trauma labs
1.
CBC, CMP, PT, PTT,
lipase, and urinalysis
2.
urinalysis is looking
for blood and preferably a bag specimen
3.
Consider toxicology screen, including BOTH comprehensive urine drug
screening AND pain management quantitative urine drug testing
4.
Consider CK and platelet
function analysis if extensive
bruising
·
CT of head without
IV contrast or MRI of head
o
Obtain for all children <6 months of age with
injuries concerning for child maltreatment
o
Highly consider obtaining in children 6-12
months of age with injuries concerning for child maltreatment
§ If head/neck/ear/face bruising or swelling
(however if present
for >3 days, admission
for
MRI)
§
If signs or symptoms
of neurological impairment present
§
Extensive injuries
o If CT head obtained
at outlying hospital, speak with radiologist for an
official UK over-read: requires outside images AND
report if available, as well as direct consult
with.
§ Once over-read is approved, contact imaging records (3-2131) for accession number to be assigned
to OSH study.
o
Immediate Neurosurgery consult if abnormal finding identified
o If concerns for AHT, due to high risk of subclinical
seizures, Neurology consult for continuous EEG for at least 24 hours or until
evaluated by Neurology. (If continuous EEG not available, obtain routine EEG).
o Antiepileptic drugs to
be given for positive findings of seizure activity or for positive
EEG
o Admit to PICU if GCS <13
or
concerning
findings identified on head imaging
o Immediate Forensic Medicine
consult if findings
identified on head imaging
·
MRI of head
o If evidence of trauma on physical exam
o If head CT is abnormal at all
including enlarged extra-axial spaces, a MRI should be
obtained
o This often
requires sedation and can be performed
after the child is admitted
·
Dilated fundoscopic exam – when indicated based upon clinical exam,
head CT, and/or PFM recommendations
· CT of abdomen/pelvis with IV and po contrast – if trauma labs
abnormal OR significant abdominal injury on
physical exam
· Consult Pediatric Forensic Medicine Team for any of the following:
o Any concerning skin findings
o Abnormal trauma
labs
o Abnormal skeletal survey
o Abnormal head
imaging
o To arrange
follow-up skeletal survey
o Any questions/concerns regarding evaluation,
including psychosocial concerns, medical work-up
·
Consult Pediatric Surgery
for any of the following:
o Abnormal trauma
labs
o Bruising on abdomen/trunk
o Bilious vomiting
2. 13
to 24 months
· Skeletal survey
1.
Consult Orthopedic Surgery if abnormal
findings identified
2.
Follow-up skeletal
survey should be performed within 10 to 14
days
·
Trauma labs
1.
CBC, CMP, PT, PTT,
lipase, and urinalysis
2.
The urinalysis is looking
for blood and preferably a bag specimen
3.
Consider toxicology
screen, including BOTH comprehensive urine drug
screening AND pain management quantitative urine drug testing
4.
Consider CK and platelet
function analysis if extensive
bruising
·
CT of head without
IV contrast
1.
If head/neck/ear/face bruising
or swelling
2.
If signs or symptoms
of neurological impairment present
3.
Consult Neurosurgery if abnormal
finding identified
4.
Immediate Neurology
consult if abnormal findings
identified
•
Consider immediate EEG per
Neurology, but recommend
EEG during admission
•
Antiepileptic drugs if seizure activity present or EEG abnormal
•
Consider admission to PICU
5.
If head CT is
abnormal at all, a MRI should be
obtained
·
Dilated fundoscopic exam – when
indicated based upon clinical exam, head CT, and/or PFM recommendations
·
CT of abdomen/pelvis
with IV contrast and PO contrast – if trauma labs elevated
or significant abdominal injury on physical exam
·
Consult Pediatric Forensic
Medicine Team for any
of the following:
o Any concerning skin findings
o Abnormal trauma
labs
o Abnormal skeletal survey
o Abnormal head
imaging
o To arrange
follow-up skeletal survey
o Any questions/concerns regarding evaluation,
including psychosocial concerns, medical work-up
·
Consult Pediatric Surgery
for any of the following:
o
Abnormal trauma
labs
o Bruising on abdomen/trunk
o Bilious vomiting
3. 2 to 5 years
·
Consider skeletal survey
1.
If severe trauma
2.
If child is
non-verbal, unresponsive, or developmentally delayed
3.
If patient has experienced burns
4.
Consult Orthopedic Surgery if abnormal
findings identified
5.
Follow-up skeletal
survey should be performed within 10 to 14
days
·
Trauma labs
1.
CBC, CMP, PT, PTT,
lipase, and urinalysis
2.
The urinalysis is looking
for blood and can be
a bag specimen
3.
Consider toxicology screen including BOTH comprehensive urine drug
screening AND pain management quantitative urine drug testing
4.
Consider CK and platelet
function analysis if extensive
bruising
·
CT of head without
IV contrast
1.
If signs or symptoms
of neurological impairment present
2.
Consider for head/neck/ear/face bruising or swelling
3.
Consult Neurosurgery if abnormal
finding identified
4.
Consult Neurology
•
Consider EEG
•
Antiepileptic drugs if seizure activity present or EEG abnormal
5.
If head CT is
abnormal at all, a MRI should be
obtained
·
Dilated fundoscopic exam – when
indicated based upon clinical exam, head CT, and/or PFM recommendations
·
CT of abdomen/pelvis
with IV contrast and PO contrast – if trauma labs elevated
or significant abdominal injury on physical exam.
·
Consult Pediatric Forensic
Medicine Team for any
of the following:
o Any concerning skin findings
o Abnormal trauma
labs
o Abnormal skeletal survey
o Abnormal head
imaging
o To arrange
follow-up skeletal survey
o Any questions/concerns regarding evaluation,
including psychosocial concerns, medical work-up
·
Consult Pediatric Surgery
for any of the following:
1. Abnormal trauma labs
2.
Bruising on abdomen/trunk
3.
Bilious vomiting
4. Follow-up
skeletal survey
·
Should be
performed at least 10 to 14 days
after the initial
skeletal survey.
·
Pediatric Forensic Medicine team will schedule
follow-up skeletal survey and clinic visit in Pediatric Forensic Medicine
Clinic.
|
Suggested Guidelines for Evaluation of Suspected Child Physical
Abuse |
||||||
|
|
Head CT or MRI |
Skeletal Survey |
Labs* |
Abdominal CT |
Fundoscopic
Exam |
Social Work
Consult |
|
0-1 year |
Yes |
Yes |
Yes |
If abdominal bruising
or elevated transaminases |
If positive neuroimaging or
evidence of head trauma † |
Yes |
|
1-2 years |
Consider† |
Yes |
Yes |
If abdominal bruising
or elevated transaminases |
If positive neuroimaging or evidence of head trauma† |
Yes |
|
2-5 years |
Consider† |
If extensive injury
or developmental delay |
Yes |
If elevated transaminases or suggested by physical exam |
Not typically
recommended |
Yes |
|
Above 5 years |
No |
No |
No |
If suggested by
physical exam |
Not typically
recommended |
Yes |
|
*
Labs include
CBC, CMP, Lipase, PT, PTT and UA † Indicated if decreased mental status,
skull fracture, or head injury |
||||||
D.
Reporting
a.
All healthcare
providers are mandated reporters.
b.
First call should always be to the
hospital social worker (in-house or on call)
·
The social worker will interview the family
·
They can help
facilitate communication with DCBS
and the police
·
Pager: 330-0331
·
Phone: 218-5587
c.
In Fayette County:
·
Protection and Permanency
Phone(859)245-5258
d. Child Protection Hot Line
·
They will send to appropriate
county or give you
the phone number.
·
Phone: (800) 752-6200
e. If
outside the county, may
go to the following address:
·
https://apps.chfs.ky.gov/Office_Phone/index.aspx
f.
University of Kentucky Pediatric
Forensic Medicine Team
·
Phone: (859) 218-6727
·
Call UK•MDs at 1-800-888-5533 and ask for clinician
on call
g. Remember:
the DCBS
report must be made in
the county where the
event occurred!!
Section III
Kentucky Unified Juvenile Code
A.
KRS Chapters 600 to 645
a.
Laws
that declare a child’s
right to be free
from abuse and neglect.
b.
Requires the reporting
of neglect, physical, sexual or emotional abuse,
and dependency of children.
c.
Requires that reports will be
assessed and investigated.
d.
Requires that social services will be provided to victims of children maltreatment.
B.
KRS 620.030(1)
a.
The law states
that it is the duty of everyone
who has reasonable cause to believe that a child is dependent, abused
or
neglected to report this information.
b.
Any
person who knows or
has reasonable cause to
believe that a
child is dependent, neglected or abused
shall immediately cause
an oral or written
report to be made to a local law
enforcement agency or the
Kentucky State Police; the Cabinet or
its
designated representative; the commonwealth’s attorney or the county
attorney; by telephone
or otherwise…
C.
KRS 620.040 (5)(b)
a.
Medical personnel have the right to hold
a child
whom they feel is in
imminent danger.
b.
If a child who is in the hospital or under the
immediate care of a physician
appears to be in imminent
danger if he is
returned to the persons having
custody of him, the physician or hospital administrator may
hold a child without court order, provided
that a request
is made to the court for
an emergency custody
order at the earliest practicable time, not to exceed
seventy-two (72) hours.
D.
KRS 620.050(1)
a.
Immunity from prosecution is given to any person making a report or assisting
legal authorities or the child protection
program in making an assessment.
b.
Anyone acting upon
reasonable cause in the making
of a report or acting
under KRS 620.030 to KRS
620.050 in good
faith shall have immunity
from any liability, civil or criminal, that might otherwise
be incurred or imposed.
Any such participant shall have
the same immunity
with respect to participation in any judicial
proceeding or resulting from such
report or action.
E.
KRS
620.050 (14)
a. Medical
evaluation can be performed without parental consent in the context of an
investigation for abuse/neglect concerns.
b. As
a result of any report of suspected child abuse or neglect, photographs and
X-rays or other appropriate medical diagnostic procedures may be taken or
caused to be taken, without the consent of the parent or other person
exercising custodial control or supervision of the child, as a part of the
medical evaluation or investigation of these reports.
F.
KRS 620.990(1)
a.
The failure
to report or falsely reporting child
abuse or neglect can result in criminal charges.
b.
Any person
intentionally violating
the provisions of this
chapter shall be
guilty of a Class B misdemeanor.
A class
B misdemeanor carries a
penalty of up to 90 days
in jail and/or
a fine
of
up to
$250.
G. KRS 214.185(4)
a. allows
a professional to provide
medical, dental, and other health
services to minors without a parent
or guardian’s consent if (1) requiring consent would lead
to a delay in or the denial or treatment and
(2)
the risk to the minor’s
life requires treatment without delay.
H. KRS 214.185(7)
a. notes that except as
otherwise provided in KRS 214.185,
CHFS or a custodian or guardian of a
minor will not be financially responsible for services
rendered to a minor without
consent unless
such services were essential to preserve
the minor’s health.
UK HealthCare Reference Contact: In the event any UK HealthCare employee
has a question regarding
legal or risk management they may contact:
Paula J. Holbrook,
RN,
BHS, JD, CPHRM Associate
General Counsel, University of Kentucky
Clinical Risk Manager, Assoc. Director,
Risk Management 800 Rose Street,
Room HG 608
Lexington, Kentucky 40536
859-257-6212 859-257-2498 facsimile
Revisions: February 19, 2016; July 15, 2016; July
2017, April 2024
Disclaimer
These guidelines are not intended as
a directive or to present a definitive statement of the applicable standard of
patient care. They are offered as an approach for quality assurance and
risk management and are subject to (1) revision as warranted by the continuing
evaluation of technology and practice; (2) the overall individual professional
discretion and judgment of the treating provider in a given patient
circumstance; and (3) the patient’s willingness to follow the recommended
treatment.
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