The Identification and Work-Up of Nonaccidental Trauma: Practice Variation Across US Children's Hospitals

Nonaccidental trauma (NAT) in children is associated with several warning signs. Since fractures are the second-most common injury caused by NAT, pediatric orthopaedic surgeons are positioned to help identify and treat at-risk children. However, no standardized tools for identifying NAT exist, resulting in national practice variation. The purpose of this study was to compare NAT protocols from Children's Hospitals across the US to understand how institutions vary in screening and treatment.

We used treatment and identification recommendations for suspected child abuse from the American Academy of Pediatrics (AAP) as our preferred reference. Sixteen protocols were obtained from CORTICES study group representatives and analyzed across the following categories: medical history, general physical exam, skin findings, abdominal/head trauma, orthopaedic findings, orthopaedic workup, and general workflow. Each category contained 2 to 6 AAP-generated recommendations that were searched for within protocols. Additional variables, including age for protocol activation, admission service, and social work availability, were collected.

General workflow recommendations for consultations and treatment were comprehensive across all study sites. Each hospital used a specialized Child Abuse Team on call 24/7 with additional in-person clinic hours. Variations arose in what service at-risk patients were admitted to (Trauma, Pediatrics, and General Surgery) and whether protocols were age-based (25%), injury-based (18.75%), or a combination of both (56.25%). Multiple organ system injuries (Physical Exam) and retinal hemorrhage (Abdominal/Head Trauma) were mentioned as red flags in the fewest number of protocols (25%). Only 50% of sites described midshaft humerus/femur fractures (Orthopaedic Findings) as a source of concern in infants/toddlers. Seven sites (43.8%) did not suggest a repeat skeletal survey (Orthopaedic Workup) 2 to 3 weeks after a high-risk patient's initial presentation.

Despite widespread adoption of institutional NAT protocols and specialized Child Abuse Teams, variation across major pediatric centers exists regarding which criteria providers use to identify, treat, escalate, and follow potential child abuse cases. This indicates an opportunity to standardize screening tools and practices across hospitals and providers, decreasing variation and ultimately improving care delivery for children.

Level IV.