#71: Non-Accidental Trauma (NAT) with Dr. Kristine Fortin

November 16, 2022 | By Justin Berk

Summary

Take a deep dive into a difficult topic with our expert guest, Dr. Kristine Fortin! In this episode, we learn the nuances of history-taking in the setting of concern for non-accidental trauma, signs to look out for on physical exam, and the importance of having a clinical pathway in place to minimize bias. Dr. Fortin also shares how pediatricians play a critical role in providing anticipatory guidance to prevent future trauma.

Credits

• Producer: Audra Iness MD, PhD
• Executive Producer: Max Cruz MD
• Showrunner: Sam Masur MD
• Writer: Audra Iness MD, PhD
• Infographic: Audra Iness MD, PhD
• Cover Art: Chris Chiu MD
• Hosts: Justin Berk MD, Chris Chiu MD, Audra Iness MD, PhD
• Editor:Justin Berk MD; Clair Morgan of nodderly.com
• Guest(s): Kristine Fortin MD, MPH

NAT Pearls

1. The diagnostic approach to NAT is the same as for other chief concerns with reliance on a strong H&P.
2. It is important to consider a workup for occult injury. 
3. Remember to ask about other children that might be at risk in the home or daycare.
4. Documentation with photographs is critical because the appearance of injuries can change over time.

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Approach to patient history

General considerations

• “Non-accidental trauma” (NAT) is also referred to as “physical abuse”or “inflicted injury”.
• Generally defined as injury inflicted on a child but has specific legal definitions that can vary across states.
• Objectively assess if the type of injury can be explained by an accidental mechanism.
• Take into account the child’s developmental level: those who do not cruise rarely bruise, because they are not mobile.
• There are special training courses and considerations for taking a history from the patient in the case of suspected NAT: Children can undergo a forensic interview with a trained interviewer usually starting around age 4.
• Let medical decision-making be your guide: Ask questions that help inform your medical care for the patient, but avoid asking patients the same questions over and over again. 
• Ask questions of the child in a way that is not suggestible (children up to age 8 or 9 are often more suggestible); consider asking someone with training (e.g. social work) to assist you with your interview. 
• Ask your questions of the child alone without family present.

Assessment for delay in care

• When assessing for potential delay in care, ask how the child initially presented, if care was previously sought at an outside institution, and compare the symptom/findings expected for the type of injury to the actual history and presentation
• Example using fractures: if less severe symptoms are expected for the type of fracture (e.g. buckle fracture), then it may take time for symptoms to appear and caregivers to notice/seek medical care when compared to a more obvious and/or painful fracture (e.g. transverse displaced fracture, etc) where you would not expect a delay in presenting for evaluation/care.
• Ask about the symptoms at the time of injury: “What did you do in response to the symptoms?” 
  • Sometimes patients may have already sought care elsewhere, and been sent home from PCP or urgent care; for some patients it can also be difficult to access any care. 

NAT patient presentations

• Bruising is a common chief concern.
• Infants with head trauma: non-specific findings such as apnea, vomiting, and seizures. 
  • Always remember to check growth charts, specifically looking for any sudden increase in head circumference!
• Limb disuse: also consider osteomyelitis or transient synovitis.
• Ask when the child was last well, get very specific about the timing.
• Elicit details about the mechanism of injury; you should be able to picture it in your mind.
• Ask: When and where did it happen? Who was involved? Who witnessed it (visually or by hearing)?
• Social hx: *IMPORTANT* ask if the child has a sibling, since risk of injury is high for siblings and siblings may need medical evaluations.
• Document who lives at home, who is involved in the care of the child, and other children in daycare or home.

Risk factors

• Risk factors/social determinants: important to note your own biases, but also want to link families to needed resources. 
• Ask about CPS involvement in the past, concerns for violence in the home (ask each parent separately), financial stressors, barriers to medical care, mental health, and substance use in the family.
• Remember that NAT can happen without risk factors.
• Must rule out medical disorders: history of unexplained fracture(s) in the family, dental issues, short stature (think about osteogenesis imperfecta), exclusively breastfed (think of rickets).
• Get birth hx for young patients: subdural hemorrhage from birth, clavicle fracture 
• Head trauma: most common in infants, peak incidence correlates with peak timing of colic in infants.
• Abdominal trauma: most common in toddlers.

Key considerations on physical exam 

Fractures

• Cannot always say that a fracture is pathognomonic, most take into account bone type/location and fracture morphology.
• Long bone fractures: Mary Clyde Pierce et al.
• Relate the mechanism to morphology:
  • Buckle: low energy compression force (older child falls on an outstretched hand).
  • Transverse: across the bone. Higher energy, bending force, or direct blow
  • Spiral and oblique: twisting force. Young children who are old enough to walk can get a spiral femur fracture accidentally by “slipping on something wet and did the splits or twisted”. NOT pathognomonic for NAT.
  • Certain bone types have a higher specificity for NAT and should raise suspicion: Sternum, Ribs, CML (Classic Metaphyseal Lesions)/bucket handle/corner fracture with chip around the metaphysis in a growing child since it is the weakest part of the bone.

Summary of categories of specificity of fractures in infants and toddlers

Adapted from Flaherty et al. Pediatrics. 2014 Feb;133(2):e477-489

Bruising

• Multiple injuries at the same time is also a red flag for intentional injury.
• Look for dysmorphic features, signs of underlying medical cause.
• TEN-4-FACES-P: Bruising clinical decision rule of skin findings that alerts you that there could be abuse and you need to do more evaluation– NOT diagnostic but high specificity.
• Rule is validated in children <4 years old but is still applicable to older ages
• T: Thorax – trunk and abdomen- accidents tend to affect bony areas so unusual to bruise these areas, do a thorough abdominal exam.
• E: Ears- look inside and behind the ears, mechanism is usually direct blow or twisting, uncommon for accidental injuries. 
• N: Neck- lift head to view under chin.
• 4: Age of <4.99 months- “Those who do no cruise rarely bruise” because not mobile
• F: Frenulum- look where it connects the lip to gums and look under the tongue.
• A: Angle of the jaw
• C: Cheeks- Fleshy part of the cheeks on the face.
• E: Eyelids
• S: Subconjunctival hemorrhage
• P: Patterned bruising- Silhouette of object that was used to strike the patient, e.g. 2 parallel lines or loop from a belt.
• Important to recognize these findings out of context, such as at a well child visit.
• Head circumference: Obtain if non-specific concerns like fusiness or vomiting in infants, if large increase then concern for an acute bleed.

Workup for NAT and occult injury

• Use clinical pathways and be systematic in your approach to NAT to mitigate bias; focus on objective findings.
• Approach families in a way that explains objective findings. Being open and honest with families is important. Express concerns.
• Work up weight loss objectively, evaluate growth parameters; rule out medical condition or concerns for neglect.
• Next steps in NAT workup per AAP guidelines: Rule out underlying medical condition mimicking injury and other occult injuries. 
• Skeletal survey: Must be performed according to American College of Radiology guidelines.
• Might need to re-do some imaging if obtained from an outside facility, e.g.  a babygram is not enough, need dedicated imaging.
• Skeletal survey recommended for kids < age 2.
• Age 2-5: skeletal survey is at the discretion of physician (exam and hx more reliable if pt verbal).
• Skeletal survey in age >5 is of limited yield. 
• Bleeding disorders: Obtain PT/PTT,  review guidelines which are specific about the workup based on presenting findings. 
• Rickets/metabolic bone disease: Obtain vitamin D, x-rays, alk phos, genetic testing.
• Occult abdominal trauma: Liver enzymes, AST/ALT, amylase, lipase.
• Screening for occult head injury: Not as clear when to do occult screening for head trauma, but screen symptomatic patients. Cnsider CT scan to rule out subdural hemorrhage in infants < 6 months – 1 year Ultrasounds and eye exams are not a good screening tool to rule out head trauma. 

Documentation of findings concerning for NAT

• It is not the role of the medical professional to determine who is the abuser.
• State findings objectively.
• Use simple language.
• Example script for talking with parents: “Every time we see this exam finding, we are worried that someone hurt the child. As a physician, it is the law that I have to report this to Child Protective Services (CPS)  and, as a physician, I am going to do a medical work up.”
• Attribute reports in your documentation so it is clear who stated what: “Mother reported that the patient…”, etc.
• It is important to document how the history was elicited, e.g. “The examiner stated X. In response, the patient stated Y” to document if it may have been a suggestible question.
• *IMPORTANT* Take pictures to document skin findings and injuries since their appearances can change over time.

Anticipatory guidance

• A secondary analysis of a study of children with bruising: An expert panel reviewed the medical objective findings of children with bruising to determine if they were concerning for abuse or accidental injury. A secondary aspect of the study was asking parents to describe attributes of their children. In the abuse group, more answers suggested lack of understanding of child development, e.g. parents describing their children as “needy, greedy, crying all the time, a diva, or always hungry”. 
• Pediatricians can help prevent violence by describing normal childhood development.
• Newborn nursery anticipatory guidance: expectations and coping mechanisms for a crying infant to prevent abusive head trauma.
• Crying is not dangerous to the child, and is not a reflection on the parent’s parenting skills, stress with parents that it is okay to leave the child in a safe place and take a break.
• Social supports: Pediatrics article in June, 2022- earned income tax credits were associated with decreased child maltreatment reports. 
• Patients who have experienced trauma can benefit from anticipatory guidance as they heal from trauma: “Rainbow” by Kacey Musgraves is a song about healing from trauma: Kacey Musgraves – Rainbow (Official Music Video).

Citations and other resources

• Example child physical abuse workup pathway  
• Book on forensic interviewing of children 
• TEN-4-FACESp resources website        Young A, Pierce MC, Kaczor K, Lorenz DJ, Hickey S, Berger SP, et al. Are negative/unrealistic parent descriptors of infant attributes associated with physical abuse? Child Abuse Negl. 2018 Jun;80:41–51. 

1.         Flaherty EG, Perez-Rossello JM, Levine MA, Hennrikus WL, American Academy of Pediatrics Committee on Child Abuse and Neglect, Section on Radiology, American Academy of Pediatrics, et al. Evaluating children with fractures for child physical abuse. Pediatrics. 2014 Feb;133(2):e477-489. 
2.         Pierce MC, Bertocci GE, Vogeley E, Moreland MS. Evaluating long bone fractures in children: a biomechanical approach with illustrative cases. Child Abuse Negl. 2004 May;28(5):505–24. 
3.         Anderst JD, Carpenter SL, Abshire TC, the SECTION ON HEMATOLOGY/ONCOLOGY and COMMITTEE ON CHILD ABUSE AND NEGLECT, Anderst JD, Carpenter SL, et al. Evaluation for Bleeding Disorders in Suspected Child Abuse. Pediatrics. 2013 Apr 1;131(4):e1314–22. 
4.         Christian CW, COMMITTEE ON CHILD ABUSE AND NEGLECT. The Evaluation of Suspected Child Physical Abuse. Pediatrics. 2015 May 1;135(5):e20150356. 
5.         Pierce MC, Kaczor K, Lorenz DJ, Bertocci G, Fingarson AK, Makoroff K, et al. Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics. JAMA Netw Open. 2021 Apr 1;4(4):e215832. 

Goal

Listeners will explain findings on history and physical exam that are concerning for non-accidental trauma, the initial workup for occult injury, and important considerations for appropriately documenting findings in cases suspicious for non-accidental trauma. 

Learning objectives

After listening to this episode listeners will be able to…

1. Recognize clinical exam findings concerning for non-accidental trauma.
2. Facilitate patient and family safety by inquiring about other potential victims in cases of suspected NAT.
3. Provide appropriate anticipatory guidance for trauma prevention.
4. Develop a differential diagnosis for medical conditions that may mimic non-accidental trauma.
5. Implement a systematic approach when evaluating the presence of occult injury.

Disclosures

Dr. Fortin reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Iness AN, Fortin K, Cruz M, Masur S, Chiu C, Berk J. “Non-Accidental Trauma”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ November 15, 2022.