Non-accidental Trauma in Infants: a Review of Evidence-Based Strategies for Diagnosis, Management, and Prevention

Purpose of Review To provide a resource for providers that may be involved in the diagnosis and management of infant non-accidental trauma (NAT). Recent Findings Infants are more likely to both suffer from physical abuse and die from their subsequent injuries. There are missed opportunities among providers for recognizing sentinel injuries. Minority children are overrepresented in the reporting of child maltreatment, and there is systemic bias in the evaluation and treatment of minority victims of child abuse. Summary Unfortunately, no single, primary preventative intervention has been conclusively shown to reduce the incidence of child maltreatment. Standardized algorithms for NAT screening have been shown to increase the bias-free utilization of NAT evaluations. Every healthcare provider that interacts with children has a responsibility to recognize warning signs of NAT, be able to initiate the evaluation for suspected NAT, and understand their role as a mandatory reporter.

Improving the Diagnosis of Abusive Abdominal Trauma

Background/Objective: Abusive abdominal trauma (AAT) in children when missed can be fatal. In addition, differentiating from accidental trauma is essential in evaluating for other injuries and protecting from continued inflicted injuries. Abdominal CT remains the gold standard study to evaluate for abdominal injuries. Our purpose is to identify findings in presentation, clinical evaluation, the abdominal CT, and other imaging that can improve the diagnosis of abusive abdominal trauma. Methods: A retrospective (2011-2020) study compared children younger than 3 years that had abdominal CT scans for abusive trauma to those with accidental blunt abdominal trauma. Demographic information, clinical presentation, physical exam findings, final diagnoses, lab values, and imaging studies were collected. Descriptive analysis and Fisher’s exact test were used to determine significance of findings. Results: 226 (125 male, average age 11 months) patients had AAT and 90 (48 male, average age 18 months) patients had accidental trauma. 30 patients in the abusive group and 19 patients in the accidental group had positive CT. Most (70%) children with AAT and positive CT had no explanation for the trauma. Fall injury was reported in 27% of abusive (88.9% younger than 1 years) and 32% (83.3% older than 1 year) of accidental trauma. Retinal hemorrhage, abdominal bruising, subdural hematoma, and rib fractures were significantly (p<0.05) more common in the abusive group. In addition, 13 (43%) of patients with AAT and positive CT had rib fractures while none were detected on CT in the accidental group. Conclusions: In children younger than 3 years with abdominal trauma that present with a history of a fall or unknown injury, abusive abdominal trauma should be suspected. These children should subsequently be evaluated for other injuries. Children should be evaluated for nonaccidental trauma if rib fractures are visualized on abdominal CT, as these were only seen in AAT.

Indicators of Non-accidental Trauma in Patients Under 24 Months of Age

Emergency department medical staff should be cautious of trauma patients who present with any of thesevariables found to be associated with NAT. Identification of NAT on the first presentation by medical staff may prevent victims of NAT from facing subsequent abuse, fatality, or lifelong complications

High prevalence of non-accidental trauma among deceased children presenting at Level I trauma centers in the Netherlands

Purpose Between 0.1—3% of injured children who present at a hospital emergency department ultimately die as a result of their injuries. These events are typically reported as unnatural causes of death and may result from either accidental or non-accidental trauma (NAT). Examples of the latter include trauma that is inflicted directly or resulting from neglect. Although consultation with a forensic physician is mandatory for all deceased children, the prevalence of fatal inflicted trauma or neglect among children is currently unclear. Methods This is a retrospective study that included children (0–18 years) who presented and died at one of the 11 Level I trauma centers in the Netherlands between January 1, 2014, and January 1, 2019. Outcomes were classified based on the conclusions of the Child Abuse and Neglect team or those of forensic pathologists and/or the court in cases referred for legally mandated autopsies. Cases in which conclusions were unavailable and there was no clear accidental cause of death were reviewed by an expert panel. Results The study included 175 cases of childhood death. Seventeen (9.7%) of these children died due to inflicted trauma (9.7%), 18 (10.3%) due to neglect, and 140 (80%) due to accidents. Preschool children (< 5 years old) were significantly more likely to present with injuries due to inflicted trauma and neglect compared to older children (44% versus 6%, p < 0.001, odds ratio [OR] 5.80, 95% confidence interval [CI] 2.66–12.65). Drowning accounted for 14 of the 18 (78%) pediatric deaths due to neglect, representing 8% of the total cases. Postmortem radiological studies and autopsies were performed on 37 (21%) of all cases of childhood death. Conclusion One of every five pediatric deaths in our nationwide Level I trauma center study was attributed to NAT; 44% of these deaths were the result of trauma experienced by preschool-aged children. A remarkable number of fatal drownings were due to neglect. Postmortem radiological studies and autopsies were performed in only one-fifth of all deceased children. The limited use of postmortem investigations may have resulted in missed cases of NAT, which will result in an overall underestimation of fatal NAT experienced by children.

Distribuição de óbitos por causas externas entre crianças menores de um ano, 2004-2019 / Distribution of deaths from external causes among children under one year during the period of 2004-2019

Resumo: O objetivo foi analisar a distribuição de óbitos por acidentes e violências em crianças menores de 1 ano. Métodos: o número de óbitos foi obtido no site do Departamento de Informática do Sistema Único de Saúde considerando o período de 2004-2019. Resultados: No período ocorreram 16.274 mortes de bebês devido aos acidentes (n=12.984) e violências (n=3.290), configurando a quinta causa de morte no primeiro ano de vida. A maior parte dos óbitos por acidentes foi devida a “outras causas de traumatismos acidentais” (n=11.300), e mais de 75% deles foi devido à aspiração de objeto, alimento, conteúdo gástrico. As agressões (n=1450) apresentaram tendência de aumento no período de estudo. Conclusão: Os acidentes e violências ocupam a quinta causa de morte de crianças menores de 1 ano. Tendo em vista a evitabilidade desses óbitos é crucial a proposição de intervenções que antecedam o nascimento da criança, preferencialmente envolvendo a atenção pré-natal. Abstract:The objective was to analyze the distribution of deaths due to accidents and violence in children under 1 year of age. Methods: the number of deaths was obtained from the website of the Informatics Department of the Unified Health System considering the period 2004-2019. Results: In the period there were 16,274 deaths of babies due to accidents (n=12,984) and violence (n=3,290), making up the fifth cause of death in the first year of life. Most of the deaths from accidents were due to “other causes of accidental trauma” (n=11,300), and more than 75% of them were due to aspiration of objects, food, gastric contents. Aggression (n=1450) tended to increase during the study period. Conclusion: Accidents and violence are the fifth leading cause of death for children under 1 year of age. In view of the preventability of these deaths, it is crucial to propose interventions that precede the child's birth, preferably involving prenatal care.Keywords: Children. External Causes. Accidents. Violence. Mortality. Child mortality.

A clinical study of traumatic tympanic membrane perforation

<p><strong>Background:</strong> Tympanic membrane (TM) which forms the partition between external auditory canal and middle ear may be ruptured by trauma. Traumatic TM perforation is a commonly observed condition. Though, several therapeutic interventions have been described, conservative follow-up until spontaneous complete recovery is the most common choice.</p><p><strong>Methods:</strong> It was a prospective cohort study conducted during a period of 10 months from July 2020 to April 2021, carried out in 30 patients who presented to outpatient department of ENT and casualty of Hassan institute of medical sciences hospital with traumatic TM perforation. After taking informed consent, detailed history was taken, thorough examination of ear was performed and characteristics of perforation were noted. Pure tone audiometry (PTA) was conducted, data was statistically analysed.</p><p><strong>Results:</strong> Mean age group was 33.1 years and 73.3% were males. Ear pain was the commonest symptom with accidental trauma being the most common cause. 70% of them had left TM perforation and posteroinferior quadrant was mostly involved.</p><p><strong>Conclusions:</strong> Traumatic TM perforation is commonly seen in young adults following accidental trauma and assault. Earache, sudden hearing loss and tinnitus are the common symptoms. Most of the cases heal spontaneously with conservative management.</p>