AAP 2016 Top 10 #5: Testing for abuse in children with sentinel injuries of NAT

The Bottom Line

Despite the importance of having a high index of suspicion for non accidental trauma tests like the skeletal series that can identify occult injuries are not always ordered when they should be.

What They Did

• This was a retrospective review of multiple hospitals in the PHIS database
• The authors identified key sentinel injuries from the relevant literature and classified by age at which they are more likely associated with NAT. MVC patients were excluded.
  • Less than 6 months: bruising, burns and oropharyngeal injuries
  • Less than 12 months: upper and lower extremity long bone fractures, isolated skull fracture, intracranial hemorrhage
  • Less than 24 months: rib fracture(s), abdominal trauma, genital injury, subconjunctival hemorrhage
• They then determined the frequency of skeletal series, neuroimaging (CT/MRI), AST/ALT and the ultimate diagnosis of NAT with each of the aforementioned injuries
• The study cohort eventually was comprised of over 30,000 children with sentinel NAT injuries
• Rates of testing varied widely as seen in the figure below

What You Can Do

• This study indicates that there is definitely variability in ordering of tests like skeletal series in suspected NAT. Skeletal series is basically only ordered when there is a clinical suspicion for NAT.
• This study suggests that the rate of ordering skeletal series should be increased for “abdominal injury, subconjunctival hemorrhage, or genital injury”
• The authors also noted that “Children who were noted to have been transferred from another institution were significantly more likely to undergo skeletal series and to be diagnosed with abuse. This is consistent with the hypothesis that children with traumatic injuries are more likely to be transferred to the pediatric referral centers.” This means that if you are working at a tertiary care center your index of suspicion is already high – if not, well, then you need to be worried in the first place about the patients with the most worrisome injuries (see the “What They Did” section).
• Overall, since NAT can be easily missed, and since there is variability between centers we should spend time developing standardized protocols. My institution has one, does yours?