Non-Accidental Trauma Tips


By Erin Wade







Child physical abuse is a serious health problem that affects many children in Georgia and the United States. Along with the potentially devastating trauma of physical abuse, we now know that adverse childhood experiences can cause other issues that can affect a child’s health and well being throughout their lives. Appropriate identification of non-accidental trauma is of paramount importance for all pediatric healthcare providers. Thus, as April is National Child Abuse Prevention month this article gives you a few tips to utilize.

Research has shown that a large number of infants who present with severe injuries secondary to abuse had recently been evaluated by a healthcare provider and had demonstrated subtle injuries during those initial evaluations[i]. These subtle injuries, or sentinel injuries, when detected, give healthcare providers an opportunity to intervene and prevent more serious harm from befalling the child, and should warrant a trip to the Emergency Room for further evaluation.

The Ten-4 rule is a great guide when evaluating small children for possible non accidental trauma[ii].

  • Any bruising to the Torso, Ears, or Neck is highly concerning for abuse and requires further evaluation
  • Bruising anywhere on a child 4-months of age or younger is highly concerning for abuse and requires further evaluation. This is true of any child that is not yet cruising, regardless of their age.

In addition to the TEN-4 rule, other highly concerning physical exam findings include[iii]:

  • Fractures with a high specificity for abuse[iv]
    • Classic metaphyseal lesions (bucket handle fractures, corner fractures)
    • Rib fractures, especially posterior
    • Scapula fractures
    • Spinous process fractures
    • Sternal fractures
  • Multiple fractures at various stages of healing
  • Patterned injuries (burns, bruises, healed skin injuries, etc.)
  • Loop marks
  • Bite marks
  • Immersion burns
  • Significant injury without a plausible reported history to account for the injury

The identification of sentinel injuries in children of any age requires further evaluation for non-accidental trauma. A thorough history, physical exam, and photographic documentation, along with appropriate radiographic and laboratory analysis are of utmost importance. If a provider is unable to complete such a work up, the child should be evaluated in the Emergency Room as soon as possible in order to complete the necessary non-accidental trauma work-up.

For further non-emergent questions contact us at 404-785-3820; for emergent questions call the Children’s Transfer center at 404-785-7778

[i]Sheets, L. K., et al. “Sentinel Injuries in Infants Evaluated for Child Physical Abuse.” Pediatrics, vol. 131, no. 4, 2013, pp. 701–707., doi:10.1542/peds.2012-2780.

[ii]Pierce, M. C., et al. “Bruising Characteristics Discriminating Physical Child Abuse From Accidental Trauma.” Pediatrics, vol. 125, no. 1, 2009, pp. 67–74., doi:10.1542/peds.2008-3632.

[iii]Christian, C. W. “The Evaluation of Suspected Child Physical Abuse.” Pediatrics, vol. 135, no. 5, 2015, doi:10.1542/peds.2015-0356.

[iv]Kleinman PK ed. Diagnostic imaging of child abuse 2nd ed Mosby 1998

CME Credit

ED Guidelines on Child Sex Trafficking and Exploitation

Greenbaum 2014

by Jordan Greenbaum, MD

The number of cases of suspected sex trafficking seen in Children’s emergency departments (ED) is steadily rising.  This is largely due to improved recognition by law enforcement and the implementation of a community protocol that directs authorities to bring newly identified victims to a Children’s emergency department for immediate medical evaluation.  Between 2014 and 2015, 92 medical exams were completed in the 3 EDs.  In response to the increased awareness of this vulnerable group of youth, Children’s has implemented guidelines for recognizing and responding to suspected cases of child sex trafficking and exploitation.  The guidelines are the product of a multidisciplinary collaboration between providers at the Stephanie Blank Center for Safe and Healthy Children (SVB), and staff from a variety of Children’s departments, including the multiple EDs. Along with a comprehensive overview of sex trafficking, including definitions, potential indicators and detailed instructions on making reports to authorities, the guidelines provide flow diagrams for recognizing and responding to suspected cases.

In the Emergency Departments, providers are asked to consider the possibility of sex trafficking if a child > 11 years old presents with chief complaints of:

  • Vaginal or penile discharge
  • Requests for STI or pregnancy testing
  • Intoxication or ingestion
  • Suicide attempt
  • Clearance exam for the Division of Family and Children’s Services (DFCS)
  • Acute sexual assault

OR, child has

  • History of running away from home
  • An injury that is suspicious for being inflicted

If these or other concerns are noted, staff should request a social work consult.  The social worker will use the Short Screen for Child Sex Trafficking (also included in guidelines) to further assess for possible victimization.  If staff continues to have concerns, they should contact the Child Protection team by calling the Transfer Center.  A trained nurse practitioner from the SVB Center is available anytime of day to come to the ED to conduct a medical evaluation.  Social work will contact law enforcement, DFCS and Georgia Cares.  The latter is an organization that serves as the entry point for services for child trafficking victims.  Upon notification, staff from Georgia Cares will begin an evaluation and work with authorities to determine post-discharge housing, and further referrals.

Should a child protection on-call nurse practitioner not be available, the guidelines include detailed discussions related to issues of confidentiality and assent, obtaining a medical history and prepping interpreters.  The medical exam protocol is also included, as are STI prophylaxis and HIV PEP guidelines. In addition, the on-call child protection team physician is available for phone consultation at anytime at 404-785-DOCS.