A comparison of accidental and nonaccidental trauma: it is worse than you think

Child abuse, or nonaccidental trauma (NAT), is a major cause of pediatric morbidity and mortality, and is often unrecognized. Our hypothesis was that injuries due to accidental trauma (AT) and NAT are significantly different in incidence, injury, severity, and outcome, and are often unrecognized.

Our aim was to carry out an examination of the differences between pediatric injuries due to AT and NAT regarding incidence, demographics, injury severity, and outcomes.

A 4-year retrospective review of the Trauma Registry at Children's Medical Center Dallas, a large Level I pediatric trauma center, comparing incidence, age, race, trauma activation, intensive care unit (ICU) need, Injury Severity Score (ISS), and mortality between AT and NAT patients was carried out.

There were 5948 admissions, 92.5% were AT and 7.5% were NAT victims. The NAT patients were younger (1.8 ± 3.3 years vs. 6.8 ± 4.2 years for AT patients; p < 0.01), more often required an ICU stay (NAT 36.5% vs. 13.8% for AT patients; p < 0.0001), and had a higher ISS 14.0 ± 9.7 vs. 7.5 ± 7.2; p < 0.0001). The mortality rate in NAT was 8.9% vs. 1.4% for AT (p < 0.001). Of the 40 NAT patients who ultimately died, 17.5% were not initially diagnosed as NAT.

NAT victims differ significantly from the AT patients, with a greater severity of injury and a 6-fold higher mortality rate. Delayed recognition of NAT occurred in almost 20% of the cases. It is generally accepted that NAT is underestimated. Its increased mortality rate and severity of injury are also not well recognized compared to the typical pediatric trauma child.