Non-Accidental Trauma in Pediatrics

Authors: Tamir Zitelny, MD, Blake Briggs, MD

Rapid recognition, evidence‑based evaluation, meticulous documentation, and confident reporting – so kids don’t fall through the cracks.

The ED as the Inflection Point

Non-accidental trauma (NAT) remains one of the most preventable causes of morbidity and mortality in children. The ED is often the first – and sometimes only – opportunity to intervene and your suspicion may be the child’s only protection (1,2). Missing NAT carries staggering consequences (recurrent visits, more injuries, even death). That’s why in the ED we don’t necessarily need certainty; we act on reasonable suspicion and lean on protocols and teams downstream (1,19).

The First Five Minutes: Stabilize, then Zoom Out

Stabilize ABCs, then completely undress the child for a head-to-toe exam: scalp, posterior pinna, mouth/frenula, trunk, buttocks, genitalia, palms/soles. Photograph patterned injuries with scale and body-map them in your documentation (1). Vital sign abnormalities (tachycardia, hypertension, hypotension) may be subtle clues of occult injury (1,18). 

History Features that Should Ping your Radar

Mechanism inconsistent with developmental age (“he just rolled off the couch” doesn’t explain a spiral femur fracture in a 4-month-old who can’t roll). Conflicting caregiver accounts, and prior “sentinel injuries” (minor bruises, frenulum tears, subconjunctival hemorrhage) all raise suspicion (4). Document caregiver statements verbatim. A delay in seeking care is just as important as the explanation itself – if a parent waited 24 hours for a seizure, that’s absolutely a red flag (4, 5).

Skin and Bruising: Pattern Recognition

Bruising is the single most common finding of NAT – “those who don’t cruise rarely bruise” (9). Any bruise in a non-mobile child is abuse until proven otherwise (11). Concerning patterns include bruising in the TEN‑4‑FACESp regions – Torso, Ears, Neck; any bruise in infants <4 months; and on Frenulum, Angle of jaw, Cheeks, Eyelids, Subconjunctivae; patterned marks (hand, loop, belt) (3,10,11). These do not happen from “rough play.” 

More on the frenulum: this can be easily torn when the mouth is hit, or the lip is pulled/stretched. A frenulum tear is NOT pathognomonic for abuse, but intra-oral injuries are seen in a significant number of abuse cases. In short, non-ambulatory children with facial injuries should raise your level of concern for abuse.

Abusive Head Trauma (AHT)

AHT is the leading cause of mortality from abuse. Think AHT in infants with lethargy, vomiting, seizures, apnea, bulging fontanelle, scalp hematomas, or any bruising without a plausible mechanism (2). Head CT is the ED test of choice; MRI follows in stable patients for parenchymal detail. Multilayer retinal hemorrhages are strongly supportive – obtain an ophthalmology exam (8,12).

Fractures That Should Worry You

You’ll see broken bones in the ED all the time. Nearly all rib fractures in infants are abusive (7). Posterior ribs and metaphyseal lesions are highly specific; scapular, sternal, and spinous process fractures are equally worrisome. Multiple fractures at different stages of healing are classic and concerning for abuse. Context matters – long-bone or isolated skull fractures may be accidental in the right age group, but never dismiss them. All kids <24 months with concerning injuries need a skeletal survey, repeated at ~2 weeks (7,13).

If you’re not sure, err on the side of imaging: order the skeletal survey in all children <24 months with suspicious injuries. Your ED x-rays may be the first and only chance to catch multiple occult fractures.

Abdominal Injuries: the Silent Killers

Blunt abdominal trauma from abuse is insidious and deadly, often with few external clues. Screen high-risk children (<5 years, bruising, AHT suspicion, abnormal exam) with AST/ALT, lipase, UA. AST/ALT ≥80 IU/L should prompt CT abdomen with IV contrast (5,6). An ultrasound/FAST is not sensitive enough! Abuse is the most common cause of duodenal injury in young children (6).

This threshold of 80 IU/L has been found to be 77% sensitive and 82% specific for intra‑abdominal injury (5,6).

Oral and Dental Clues

Oral injuries are small but mighty in their diagnostic power. Torn frenulum, unexplained mucosal lacerations, or patterned bite marks in a non-mobile infant should immediately trigger concern (14). Always look in the mouth – these are easily missed in a rushed ED exam, so take an extra 30 seconds to inspect carefully. For boards and clinical practice, remember: frenulum tears, in the wrong developmental context, fully warrant a NAT workup.

Documentation That Holds Up

Write objective facts, not conclusions: “Posterior rib fractures inconsistent with history.” Use quotes for caregiver words. Photograph with scale/ID, upload per policy (1). You are a mandated reporter – reasonable suspicion is enough, and good-faith reporters are legally protected (15,16).

Final Bombs

Non-accidental trauma in children is a diagnosis you cannot afford to miss. When the possibility of abuse crosses your mind, treat it like any other high‑stakes diagnosis: stabilize the child, then widen your aperture. While I hope this is something you never have to deal with as a clinician, this is a very real and very disturbing reality that rears its ugly head in the ED. This is a dense, difficult to digest topic, so remember the following key pearls:

• Any bruise in a non-mobile infant = abuse (9)
• Nearly all rib fractures in infants are abuse (7)
• Posterior pinna, frenulum, or subconjunctival injuries are red flags (3,10,14)
• Abuse is the most common cause of duodenal injury in <5 yrs (6)
• Multilayer retinal hemorrhages strongly suggest AHT (8,12)
• Document facts; reporting is mandatory (1,15)
• Childhelp National Child Abuse Hotline: 24/7 call/text/chat at 1‑800‑422‑4453

References

1. Christian CW; AAP Committee on Child Abuse and Neglect. The evaluation of suspected child physical abuse. Pediatrics. 2015;135(5):e1337‑e1354. 
2. Raval D, et al. Abusive Head Trauma in Infants and Children: Technical Report. Pediatrics. 2025;155(3):e2024070457. 
3. Pierce MC, et al. Validation of the TEN‑4‑FACESp decision rule. JAMA Network Open. 2021;4(4):e215832.
4. Sheets LK, et al. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics. 2013;131(4):701‑707. 
5. Lindberg DM, et al. Utility of hepatic transaminases to recognize abuse in children. Pediatrics. 2009;124(2):509‑516.
6. Lane WG, et al. Screening for occult abdominal trauma in children with suspected abuse. Pediatrics. 2009;124(6):1595‑1602. 
7. Flaherty EG, et al. Evaluating children with fractures for child physical abuse. Pediatrics. 2014;133(2):e477‑e489.
8. Levin AV. Retinal hemorrhage in abusive head trauma. Pediatrics. 2010;126(5):961‑970.
9. Sugar NF, et al. Bruises in infants and toddlers: those who don’t cruise rarely bruise. Arch Pediatr Adolesc Med. 1999;153(4):399-403.
10. Kemp AM, et al. Patterns of bruising—systematic review. Arch Dis Child. 2005;90(2):182-186.
11. Petska HW, et al. High incidence of occult serious injury in infants with apparently isolated bruises. J Pediatr. 2014;165(2):383-388.e1.
12. Choudhary AK, et al. Consensus on ophthalmic evaluation in suspected abusive head trauma. JAMA Ophthalmology. 2021;139(5):540-548.
13. Mankad K, et al. International consensus on screening siblings/contact children in suspected physical abuse. JAMA Pediatrics. 2023;177(6):611-618.
14. American Academy of Pediatrics; American Academy of Pediatric Dentistry. Oral and dental aspects of child abuse and neglect. Pediatrics. 2017;140(2):e20171487.
15. Child Welfare Information Gateway. Making and Screening Reports of Child Abuse and Neglect. 2025 update.