Signs of Abuse

An estimated 3.6 million reports of possible child abuse or neglect, also known as nonaccidental trauma (NAT) or nonaccidental injury, involving approximately 6.6 million children were made to child protective services in the United States in 2014. The annual societal cost of child abuse and neglect is estimated conservatively to be over $103 billion. Understanding the history and physical findings specific to NAT will allow physicians to identify those children at risk and avoid missed injuries and recurrent child abuse. Bruising in particular is a cardinal physical finding for NAT. Certain diagnostic tools, such as skeletal surveys and retinal examinations, are used in evaluating for NAT. Abusive head trauma is the most common and deadliest injury. Although less common, abdominal injuries have a high mortality due to nonspecific symptoms and delayed presentation. Solid-organ abdominal injuries and duodenal hematomas can be managed nonoperatively, with a low failure rate. Up to 25% of skeletal fractures for children less than 1 year old are due to NAT. Tools to help medical personnel identify NAT are vitally important because children with recurrent NAT have a higher mortality compared with those identified at the initial episode. In Europe and the United States, checklists and algorithms have been established to standardize management of children with NAT. NAT carries significant morbidity, mortality, and cost to families and hospital resources. The key to prevention is early identification of children with NAT and early involvement of general or pediatric surgeons. Key words: abusive head trauma, ATOMAC guidelines, bruising, child abuse, children, nonaccidental injury, nonaccidental trauma, pediatric surgery, skeletal survey