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Nonaccidental Pediatric Trauma: Which Traditional Clues Predict Abuse?
Shad Masters Baab1, James Fuller Lawsing2, Cassandra Sarmiento Macalino3
1From the Wake Forest School of Medicine.
Insights
A history inconsistent with injuries is the strongest predictor of nonaccidental trauma (NAT) in children. Early recognition of potential child abuse through prior visits was rare, highlighting the importance of incongruent histories in identifying abuse.
Area of Science:
- Pediatric Emergency Medicine
- Child Abuse Pediatrics
- Forensic Pediatrics
Background:
- Identifying nonaccidental trauma (NAT) in children is crucial for timely intervention.
- Numerous historical and physical clues have been proposed to predict NAT, but their diagnostic utility varies.
- Accurate identification of NAT relies on distinguishing between accidental injuries and those resulting from abuse.
Purpose of the Study:
- To determine which specific clinical indicators from the literature are predictive of nonaccidental trauma (NAT) in suspected cases.
- To evaluate the effectiveness of various historical and physical findings in identifying child abuse.
- To assess the potential for early recognition of NAT through prior medical evaluations.
Main Methods:
- A 4-year retrospective study analyzed 109 suspected NAT cases referred to a medical center.
- Medical records were reviewed for historical and physical findings suggestive of NAT, including prior visits.
- Chi-square and logistic regression analyses were used to assess the association between diagnostic clues and the outcome of likely abuse.
Main Results:
- Of 109 suspected NAT cases, 79.3% were confirmed as likely abuse after expert investigation.
- Univariate analysis identified incongruent history, old injuries, denied trauma, changed history, and retinal hemorrhage as associated with likely abuse.
- Multivariate logistic regression revealed that only a history incongruent with injuries independently predicted likely abuse (OR, 8.65; P = 0.0151).
- Early recognition of NAT from prior visits occurred in only 1.8% of cases.
Conclusions:
- A history incongruent with the observed injuries is the most significant predictor of nonaccidental trauma (NAT) in children.
- The potential for early detection of child abuse through prior emergency department visits is very low.
- Clinical evaluation focusing on the congruence between injury and history is paramount in diagnosing NAT.
Objectives:
The objective of this study is to determine which of the child abuse clues quoted in the literature predict nonaccidental trauma (NAT): history incongruent with injuries found on examination or imaging, old injuries present, history of trauma denied by caregivers, multiple fractures present, changing history, fractures of varied duration, metaphyseal fracture, ear bruise, neck bruise, different history (second historian), and metaphyseal fracture.
Methods:
This is a 4-year retrospective study of all suspected NAT cases referred to our medical center. In addition to the index visit, medical records were searched for visits before the index visit with patient historical or physical findings that might have suggested NAT but were not investigated. The association of diagnostic clues and the outcome were assessed by chi-square and logistic regression analysis.
Results:
For 48 months, there were 109 cases of suspected NAT referred for evaluation (age range, 1 week to 15 years). After formal investigation by an abuse specialist, 79.3% of the cases were considered "likely abuse". Those historical or physical findings with a univariate association with a final conclusion of likely abuse included history incongruent with injuries, old injuries present, trauma history denied, changed history, and retinal hemorrhage. In multivariate logistic regression, only a history incongruent with injures remained an independent predictor of likely abuse (odds ratio, 8.65; 95% confidence interval, 1.74-43.07; P = 0.0151). After review of prior records, in only 2 of 109 cases (1.8%) was there a prior visit where NAT could have been suspected; however, history was thought to be congruent with the injury at the original visits.
Conclusion:
In this 4-year study of NAT, the clinical clue that best predicted likely abuse after expert investigation was a history that was incongruent with the injuries found on emergency department evaluation. The incidence of possible early recognition from a prior emergency department visit in this group was very low, <2% of cases.
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