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High prevalence of non-accidental trauma among deceased children presenting at Level I trauma centers in the
Marie-Louise H J Loos1, Roel Bakx2, Wilma L J M Duijst3,4
1Amsterdam UMC, Department of Paediatric Surgery, Emma Children's Hospital, Paediatric Surgical Centre Amsterdam, University of Amsterdam & Vrije Universiteit Amsterdam, Amsterdam, the Netherlands. m.h.loos@amsterdamumc.nl.
Insights
One in five child deaths in Dutch trauma centers resulted from non-accidental trauma (NAT). Preschoolers were most vulnerable, and many neglect deaths involved drowning. Limited autopsies may underestimate fatal NAT.
Area of Science:
- Pediatric Traumatology
- Forensic Pathology
- Child Abuse and Neglect Studies
Background:
- Childhood deaths from injuries are often classified as unnatural causes.
- Non-accidental trauma (NAT), including inflicted injuries and neglect, is a significant concern.
- The precise prevalence of fatal NAT in children remains unclear despite mandatory forensic consultations.
Purpose of the Study:
- To determine the prevalence of fatal non-accidental trauma (NAT) in children presenting to Level I trauma centers.
- To identify demographic factors associated with NAT, particularly in preschool-aged children.
- To assess the role of neglect, including drowning, in pediatric deaths.
Main Methods:
- Retrospective analysis of 175 child deaths (0-18 years) at 11 Dutch Level I trauma centers (2014-2019).
- Classification of death causes based on Child Abuse and Neglect teams, forensic pathologists, court findings, or expert panel review.
- Review of postmortem radiological studies and autopsies performed.
Main Results:
- 17.1% of deaths were attributed to inflicted trauma (9.7%) or neglect (10.3%), while 80% were accidental.
- Preschool children (<5 years) were significantly more likely to die from inflicted trauma or neglect (44% vs. 6%).
- Drowning accounted for 78% of neglect-related pediatric deaths; postmortem investigations were performed in only 21% of cases.
Conclusions:
- Approximately one in five pediatric deaths in this cohort was linked to NAT.
- Preschool-aged children represent a disproportionately high percentage of NAT fatalities.
- Underutilization of postmortem investigations may lead to underestimation of fatal NAT in children.
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.
