Pediatrics (System-Integrated)

Non-accidental trauma: recognition and reporting

Clinical Overview and When to Suspect Non-Accidental Trauma

— ~1,800 US child maltreatment deaths annually; ~75% involve children <3 years

— Highest mortality in infants <1 year; AHT is the leading cause of abuse death

— Recurrence of abuse approaches 35–50% if first episode is missed

— Injury inconsistent with developmental stage (e.g., femur fracture in a non-ambulatory infant)

— History changes between providers or between caregivers

— Delay in seeking care without plausible explanation

— Mechanism inadequate for injury severity (short fall causing skull fracture + subdural)

— "Magical injury" — no history offered at all

— Prior ED visits for unexplained injuries, sentinel injuries (frenulum tear, ear bruise in a pre-cruiser)

— Children <3 years, especially <6 months

— Prematurity, disability, chronic medical conditions

— Caregiver risk: substance use, intimate partner violence, social isolation, unrelated adult in home, young or stressed parents

Board pearl: "Those who don't cruise rarely bruise" — any bruise in a pre-ambulatory infant (<~6 months) is a sentinel injury until proven otherwise and warrants full workup plus a report. Missing a sentinel injury is the classic Step 3 distractor where the resident reassures the family and discharges — the next visit is in the PICU with abusive head trauma.

Definition: Non-accidental trauma (NAT), or physical child abuse, refers to inflicted injury in a child caused by a caregiver or other individual, ranging from bruises and fractures to abusive head trauma (AHT) and visceral injury.

Epidemiology and stakes:

When to suspect — "red flag" triggers:

High-risk demographics (risk-stratify, do NOT use to rule out):

TEN-4-FACES-p bruising rule (high specificity): Bruising of the Torso, Ear, Neck in any child <4 years, any bruising in infants ≤4 months, or bruises to Frenulum, Angle of jaw, Cheeks, Eyelids, Sclera, or patterned bruising → mandates abuse workup.

Presentation Patterns and Key History

— "Fell off the couch/bed" with disproportionate injury

— Unexplained fussiness, vomiting, lethargy, apnea, or seizure in an infant (think AHT)

— Refusal to bear weight, swollen extremity "noticed today"

— Burn in a "tidy" stocking-glove or buttocks distribution

— Apparent life-threatening event (BRUE) — consider AHT in differential

— Discrepant histories between caregivers or over time

— Mechanism developmentally implausible (rolling at 2 weeks, climbing at 4 months)

— Blaming a sibling, especially a young one, or the family pet

— Delay in seeking care

— Hostility, evasiveness, or excessive detail/rehearsed quality

— Caregiver focus on self rather than the child

— Exact mechanism, time, witnesses, position of child, surface struck

— Developmental milestones (rolling, sitting, cruising, walking)

— Prior injuries, ED visits, hospitalizations — request prior records

— Birth history, prematurity, bleeding disorders, bone disease

— Family history: bleeding diathesis, osteogenesis imperfecta, metabolic bone disease

— Social: who lives in the home, primary caregivers, IPV screen, substance use, prior CPS involvement

— Frenulum tear, intraoral injury, subconjunctival hemorrhage

— Small bruise on ear, cheek, or torso in non-mobile infant

— Up to 25% of abused infants with serious injuries had a prior documented sentinel injury that was missed

Key distinction: A developmentally implausible mechanism is more concerning than an inconsistent one. A 3-month-old cannot "roll off the changing table and break a femur" — the femur fracture itself is the alarm. Document the child's actual milestones in the chart; this becomes critical legal evidence and anchors your clinical reasoning.

Common chief complaints masking NAT:

History red flags — interview caregivers separately:

Targeted history elements (document verbatim quotes):

Sentinel injuries (minor injuries in young infants that often precede severe abuse):

Physical Exam Findings and Hemodynamic Assessment

— Document with body diagrams and photographs (with consent per institutional policy)

— Measure bruises/burns; note color, pattern, location

— Patterned bruises: loop (cord), linear (belt), hand slap outline, bite marks

— Bruises over soft/protected areas: cheeks, ears, neck, torso, buttocks, genitals

— Multiple bruises in clusters or various stages (dating bruises by color is unreliable — do not rely on it)

— Burns: stocking-glove (forced immersion), doughnut sparing (buttocks held in hot water), cigarette (round, punched-out, deep)

— Bulging fontanelle, increased head circumference, retinal hemorrhages (require dilated ophtho exam)

— Frenulum tear, dental trauma, traumatic alopecia

— Pseudoparalysis of a limb, point tenderness, swelling, deformity

— Rib tenderness, crepitus

— Vitals including accurate weight, HR, BP with appropriate cuff, RR, SpO₂, GCS/AVPU

— Infant in shock from abuse may have head injury (Cushing triad), abdominal hemorrhage, or sepsis from delayed presentation

— Address ABCs first — stabilize before extensive forensic workup

CCS pearl: On the CCS case, order "complete skin exam, document with photos," "fundoscopic exam by ophthalmology," and "measure head circumference" as discrete orders. These appear on the order list and demonstrate appropriate workup. Stabilize airway, IV access, fluids, and type & screen before skeletal survey if the child is unstable.

Complete head-to-toe exam, fully undressed, including diaper area and scalp:

Skin findings concerning for abuse:

Head and face:

Musculoskeletal:

Abdomen: distension, bruising, tenderness — concern for solid-organ or hollow-viscus injury (duodenal hematoma classic)

Hemodynamic assessment (CCS priority):

Diagnostic Workup — Initial Labs and Imaging

— CBC with platelets, PT/INR/aPTT, fibrinogen

— vWF antigen, vWF activity (ristocetin cofactor), factor VIII and IX levels — rule out bleeding diathesis (medicolegally essential before attributing bruising to abuse)

— CMP including AST/ALT, lipase, amylase — screen for occult abdominal injury (AST or ALT >80 U/L → CT abdomen)

— UA with micro — screen for renal trauma (hematuria) and rhabdomyolysis

— Consider tox screen in altered/seizing child

— Indicated in all children <2 years with suspected physical abuse, any child <2 with sibling who is abused, or any nonverbal child with concerning injury

— Not a "babygram" — requires ~21 dedicated views per ACR

— Repeat in 2 weeks to detect healing fractures not initially visible

— Non-contrast head CT for any infant <6 months with bruising, suspected AHT, altered mental status, seizures, apnea, or unexplained vomiting

— MRI brain and cervical spine within days for detail, ligamentous injury, and timing

— CT abdomen/pelvis with IV contrast if AST/ALT >80, lipase elevated, abdominal bruising, or unstable vitals

— Dilated fundoscopic exam by ophthalmologist for any concern for AHT — multilayered, multifocal retinal hemorrhages extending to ora serrata are highly specific for AHT

Board pearl: In children 2–5 years, skeletal survey is selective based on clinical suspicion. In children >5 years, targeted imaging of areas of concern only — skeletal survey rarely yields. Always image before the child leaves your care; do not "send home and follow up."

Universal initial labs in suspected NAT (especially <2 years or with bruising/bleeding):

Skeletal survey (gold standard for occult fracture in children <2 years):

Neuroimaging:

Abdominal imaging:

Ophthalmology:

Diagnostic Workup — Advanced and Confirmatory Studies

— Increases sensitivity by ~20%; detects callus formation on previously missed rib or metaphyseal fractures

— Standard of care per AAP — order before discharge planning

— Detects subdural hematoma age/staging, diffuse axonal injury, hypoxic-ischemic injury, parenchymal contusion, spinal ligamentous injury

— Cervical spine MRI critical in AHT — high rate of occult ligamentous injury

— Calcium, phosphorus, magnesium, alkaline phosphatase, 25-OH vitamin D, PTH

— Consider copper, ceruloplasmin (Menkes), urine organic acids if metabolic concern

— Genetic testing for COL1A1/COL1A2 if osteogenesis imperfecta suspected (blue sclerae, family history, bone density, dentinogenesis imperfecta)

— Factor XIII, platelet function testing, factor levels — sometimes obtained even when initial CBC/PT/PTT normal to preempt defense arguments

— Classic metaphyseal lesions (CML / "bucket-handle" or "corner" fractures) from shaking/yanking

— Posterior rib fractures (from anterior-posterior squeezing of thorax)

— Scapular, sternal, and spinous process fractures

— Multiple fractures of different ages

— Femur fracture in non-ambulatory child

Step 3 management: When the workup is complete, the child abuse pediatrics consult service should formally adjudicate "diagnostic of abuse," "concerning for abuse," or "consistent with stated history." This consultation is now standard at academic centers and strengthens both clinical and legal pathways.

Repeat skeletal survey at 10–14 days:

MRI brain ± cervical spine:

Bone health workup (rule out mimics — medicolegally essential):

Coagulation deep dive if bruising predominant:

Pathognomonic fracture patterns for abuse (high specificity):

Photographs: standardized forensic photography of all injuries with scale ruler

Risk Stratification and First-Line Management Logic

— Admit to hospital even if medically able to go home — "social admission" is appropriate and protective

— Place the child on a unit with appropriate supervision; restrict visitors per institutional protocol

— Make CPS report based on reasonable suspicion — not proof

— All 50 states designate physicians as mandated reporters

— Report by phone immediately and follow with written documentation within 24–48 hours (varies by state)

— Notify hospital social work and risk management

— Child abuse pediatrics (or equivalent), social work, pediatric trauma/surgery, neurosurgery, ophthalmology, child life

— Forensic interviewer for verbal children — clinicians should not conduct repeated interrogations

— Verbatim quotes in quotation marks, attributed to the speaker

— Objective findings with measurements, diagrams, photos

— Avoid conclusions like "the child was abused" — instead "injuries are inconsistent with the reported mechanism and concerning for non-accidental trauma"

— All children <2 years in same household: skeletal survey

— All children <5 years: thorough exam and history

— Older children: targeted exam and interview

Board pearl: You do not need to inform the parents that you are reporting before making the call, but most centers recommend doing so respectfully and factually for transparency and safety. You are immune from civil/criminal liability for good-faith reports — and liable for failure to report.

Step 1 — Stabilize: ABCs, hemodynamic resuscitation, control of intracranial pressure if AHT, surgical consult if abdominal injury

Step 2 — Ensure safety: the child must not return to a potentially unsafe environment until investigation is underway

Step 3 — Mandatory reporting:

Step 4 — Multidisciplinary team activation:

Step 5 — Document meticulously:

Risk tiers for siblings and household contacts:

Pharmacotherapy — Targeted Medical Management

— Head of bed 30°, normocarbia, normothermia

— Hypertonic saline (3%) bolus 3–5 mL/kg or mannitol 0.5–1 g/kg for impending herniation

— Levetiracetam for seizure prophylaxis if early post-traumatic seizures or significant intracranial hemorrhage

— Fosphenytoin or levetiracetam for active seizures; midazolam for refractory status

— Acetaminophen 15 mg/kg q4–6h, ibuprofen 10 mg/kg q6h (avoid in active bleeding or AKI)

— Morphine 0.05–0.1 mg/kg IV for moderate-severe pain (rib fractures, long-bone fractures); monitor sedation in head injury

— IV fluids per Parkland formula (4 mL/kg/%TBSA over 24h, half in first 8h) if >10% TBSA

— Topical bacitracin or silver sulfadiazine (avoid in <2 months or sulfa allergy)

— Tetanus prophylaxis per immunization status

— Vitamin K 1–10 mg IV/IM if PT prolonged and concern for unrecognized deficiency

— FFP, platelets, cryoprecipitate as indicated

— Indicated for open fractures, infected burns, hollow viscus injury — broad-spectrum coverage (e.g., piperacillin-tazobactam)

Key distinction: Do not withhold needed analgesia out of "muddying the exam" concerns. Untreated pain in injured children is a quality-of-care issue and does not invalidate forensic findings. Document baseline neurologic exam before sedation when possible.

NAT itself has no pharmacotherapy — management is directed at the injuries and at supportive care. Common medication scenarios on Step 3:

Abusive head trauma / elevated ICP:

Pain control:

Burns:

Bleeding/coagulopathy:

Antibiotics:

Sedation for imaging: weight-based midazolam or dexmedetomidine for MRI; ensure safe extubation pathway

Procedures and Invasive Management

— Subdural hematoma evacuation if mass effect, midline shift, or rapid neurologic decline

— External ventricular drain for hydrocephalus or ICP monitoring

— Decompressive craniectomy in refractory intracranial hypertension

— Dilated indirect fundoscopy by ophthalmology with RetCam photography when available — documents retinal hemorrhages forensically

— No therapeutic intervention typically needed for retinal hemorrhages — they resolve, but the photographic record is critical

— Closed reduction and casting for most long-bone fractures

— Spica casting for femur fractures in young children

— Splinting for CMLs (often heal without intervention)

— Exploratory laparotomy for hemodynamically unstable abdominal trauma or hollow viscus injury

— Damage control surgery, splenic or hepatic repair, duodenal hematoma management (often nonoperative with NG decompression and TPN)

— Standardized injury photography with scale

— Bite mark casting/swabbing for DNA if suspected

— Sexual assault forensic exam (SAFE/SANE) by trained provider if concern for sexual abuse — do not perform repeatedly

— Avoid placing IV in injured limb or over bruised areas when possible

— Document any iatrogenic marks clearly to avoid confusion with inflicted injury

CCS pearl: On a CCS case, the typical workflow is: stabilize → labs and imaging → ophthalmology consult → child abuse pediatrics consult → CPS report → admit → social work → repeat skeletal survey at 2 weeks → discharge planning meeting. Each of these is a discrete order. Missing the CPS report or the ophthalmology dilated exam is a high-yield way to lose points.

Neurosurgical interventions for AHT:

Ophthalmologic:

Orthopedic:

General surgery / trauma:

Forensic procedures:

Lines and access:

Special Populations — Children with Disabilities and Medical Complexity

— Communication barriers, dependence on caregivers, caregiver stress, social isolation

— Conditions: cerebral palsy, autism spectrum disorder, intellectual disability, deaf/hard-of-hearing, blind

— Have lower threshold for workup and use of augmentative communication or interpreter

— May present with "medical child abuse" / Munchausen by proxy (factitious disorder imposed on another)

— Red flags: symptoms only in presence of one caregiver, multiple specialists, escalating invasive procedures without clear diagnosis, caregiver enjoying medical attention

— Management: covert video surveillance per institutional policy, multidisciplinary case review, separation from caregiver to observe symptom resolution

— Have higher fracture risk but also can be abused — do not assume all fractures are pathologic

— Document bone health workup carefully; involve metabolic bone disease specialist

— Fracture patterns (CML, posterior rib) still concerning even in OI

— Osteopenia of prematurity can predispose to fractures from routine handling

— Calcium, phosphorus, alkaline phosphatase, vitamin D levels guide assessment

— Interview with appropriate accommodations

— Trained interpreters, not family members

Step 3 management: When a medically complex child presents with recurring unexplained symptoms that resolve in the hospital, admit, observe with structured caregiver-absence protocols, and consult child abuse pediatrics before discharge planning. Premature confrontation jeopardizes investigation.

Disabled children are at 3–4× higher risk of abuse:

Medically complex children (technology dependent, multiple specialists):

Children with known bone disease (OI, rickets, prematurity):

Premature infants:

Renal/hepatic impairment: dose-adjust opioids and contrast carefully; pediatric nephrology consult if AKI from rhabdo or hypovolemia

Hearing- or vision-impaired children:

Special Populations — Infants, Adolescents, and Vulnerable Subgroups

— AHT peak incidence 2–4 months (coincides with peak crying — "Period of PURPLE Crying")

— Any bruise in a non-mobile infant → full NAT workup

— Apnea, seizure, vomiting without GI cause → head CT

— Universal "shaken baby" prevention counseling at well visits and discharge

— Most common age for inflicted burns and patterned bruising

— Toilet training stress is a common trigger — counsel families

— Begin to verbalize — use open-ended, age-appropriate questions; forensic interviewer preferred

— Higher rates of sexual abuse, intimate partner violence, sex trafficking

— Confidentiality nuances: state laws vary on adolescent consent for STI testing, contraception, mental health; abuse reporting still mandatory

— Screen for trafficking: tattoos/branding, controlling adult, inconsistent story, no ID, multiple STIs

— IPV screen for the caregiver; abuse during pregnancy increases risk of postnatal child abuse

— Connect to prenatal care and home-visiting programs (Nurse-Family Partnership)

— Higher baseline trauma; document prior medical and abuse history through caseworker

— Behavior changes after visits with biological family may warrant evaluation

Board pearl: Always consider sexual abuse in the differential for unexplained genital, anal, or oral findings; recurrent UTIs; sexualized behavior; or new behavioral regression. A normal anogenital exam does not rule out sexual abuse — most cases have normal exams.

Infants (<1 year) — highest-risk group:

Toddlers and preschoolers:

Adolescents:

Pregnant adolescents or caregivers:

Foster care and adopted children:

LGBTQ+ youth: higher risk of family rejection, homelessness, and victimization — screen sensitively

Complications and Adverse Outcomes

— AHT: increased ICP, cerebral herniation, seizures, hypoxic-ischemic injury, death

— Abdominal trauma: hemorrhagic shock, hollow viscus perforation, peritonitis, duodenal hematoma with obstruction

— Fractures: compartment syndrome, fat embolism (rare in young children), nonunion

— Burns: hypovolemic shock, sepsis, scarring, contractures

— AHT survivors: ~⅓ severe disability, ~⅓ moderate disability, ~⅓ near-normal; cognitive, motor, visual impairment, epilepsy

— Growth failure, failure to thrive

— Chronic pain, post-traumatic dystonia

— PTSD, anxiety, depression, conduct disorder, attachment disorders

— Higher rates of substance use, suicide, teen pregnancy in adolescence

— Adverse Childhood Experiences (ACEs) score correlates dose-dependently with adult cardiovascular disease, COPD, depression, and early mortality

— Without intervention, 35–50% experience repeat abuse

— ~5–10% risk of fatal recurrence in unrecognized severe abuse

— Sibling abuse risk: ~20% of siblings have occult injury on screening

— Caregiver incarceration, family disruption, foster placement

— Missed diagnosis lawsuits

— False positives — distress and family disruption when bone disease or bleeding disorder is later confirmed

— Provider secondary traumatic stress — institutional support is appropriate

Key distinction: ACEs are not equivalent to a diagnosis of NAT, but the same population overlaps. On Step 3, recognize the longitudinal trajectory: today's missed sentinel injury is tomorrow's ACE score of 6 and adult chronic disease. Reporting is a long-term preventive intervention.

Acute medical complications:

Long-term medical sequelae:

Mental health and developmental sequelae (ACEs literature):

Recurrence:

Family-level outcomes:

System and provider complications:

When to Escalate — ICU, Consults, and Inpatient Triage

— Any AHT with altered mental status, seizures, or ICP concerns

— Hemodynamic instability from abdominal or thoracic injury

— Respiratory failure (rib fractures with pulmonary contusion)

— Severe burns (>15% TBSA, airway involvement, electrical/chemical)

— Need for continuous neurologic monitoring or post-op care

— Allows completion of workup, safety planning, social services

— Even medically minor injuries warrant admission if home is unsafe — "social admission" is medically and ethically appropriate

— Child abuse pediatrics (or hospital child protection team)

— Social work — every case

— Ophthalmology for any infant with possible AHT

— Pediatric trauma surgery for abdominal/thoracic injury

— Neurosurgery for intracranial injury

— Orthopedics for fractures

— Forensic interviewer for verbal children with possible sexual or physical abuse

— Psychiatry / psychology for verbal children with trauma symptoms

— Lack of pediatric trauma capability

— Lack of child abuse pediatrics

— Need for PICU or pediatric neurosurgery

— Use pediatric-capable transport team

— Medical stability

— CPS investigation underway with confirmed safe disposition plan

— All consults completed

— Repeat skeletal survey scheduled

— Follow-up appointments arranged

CCS pearl: On CCS, "admit to pediatric ward" plus "social work consult" plus "child abuse pediatrics consult" plus "CPS report" are four separate orders. Order all of them. Do not "observe in ED and discharge home" — this is the wrong-answer trap.

PICU admission criteria:

General pediatric ward admission (essentially all suspected NAT cases):

Mandatory consultations:

Transfer to tertiary center:

Discharge readiness checklist:

Key Differentials — Mimics Within the Trauma/Injury Category

— Bruising over bony prominences (shins, forehead, knees) in ambulatory child — typical

— Mechanism plausible and consistent across tellers

— Single injury, developmentally consistent

— Clavicle fracture, cephalohematoma, skull fracture from instrumented delivery — usually evident in first weeks

— Should resolve/heal by 2–4 weeks; new findings beyond this are not birth-related

— Cao gio (coining), cupping, moxibustion → linear erythema or circular ecchymoses on back

— Recognize as cultural, not abusive, but educate family on safer alternatives if injurious

— Blue-gray macules on buttocks, sacrum, back — present from birth, do not change color over days

— Document carefully at first newborn exam to avoid future misattribution

— Bite marks from siblings (intercanine distance <3 cm suggests child, >3 cm adult)

— Toddler "bumper bruises" on forehead

— Mechanism plausible; corroborated by coach/team

— Heel stick bruising in neonates

— IV infiltration

— Cardiac massage rib fractures (usually anterior/lateral, not posterior; rare in children)

Board pearl: Posterior rib fractures are virtually never from CPR in children — they remain highly specific for abuse even if CPR was performed. This is a classic distractor on Step 3 stems where the parent claims "the rib broke when I did CPR."

Accidental injury (the most important differential):

Birth trauma:

Cultural practices:

Mongolian spots (congenital dermal melanocytosis):

Self-inflicted injury / play injury:

Sports injuries in older children:

Iatrogenic findings:

Key Differentials — Medical Mimics of NAT

— Hemophilia A/B, von Willebrand disease, ITP, vitamin K deficiency (especially in exclusively breastfed infant who missed vitamin K shot — can present with intracranial hemorrhage at 2–8 weeks)

— Workup: CBC, PT/PTT, vWF panel, factor levels

— Osteogenesis imperfecta — blue sclerae, dentinogenesis imperfecta, family history, low bone density, COL1A1/2 mutation

— Rickets — vitamin D deficiency, widened metaphyses, rachitic rosary, low Ca/Phos, elevated ALP

— Menkes disease — copper deficiency, kinky hair, neurodegeneration

— Osteopenia of prematurity

— Mongolian spots, hemangiomas, contact dermatitis, phytophotodermatitis (lime juice + sun → linear hyperpigmentation, "margarita burn")

— Henoch-Schönlein purpura — palpable purpura on lower extremities/buttocks

— Benign enlargement of subarachnoid spaces (BESS) — increased extra-axial space, can predispose to subdural with minor trauma

— Glutaric aciduria type 1 — frontotemporal atrophy, subdural collections, dystonia; newborn screen often catches

— Aneurysm, AVM rupture

— Cellulitis vs bruise

— Osteomyelitis vs fracture

— Congenital syphilis with metaphyseal changes

Key distinction: A medical mimic does not rule out concurrent abuse, and abuse does not rule out a mimic. Pursue both workups when ambiguous. Document the differential explicitly to demonstrate sound clinical reasoning.

Bleeding disorders (mimic bruising-predominant abuse):

Bone fragility disorders (mimic fracture-predominant abuse):

Skin findings mimicking bruises:

Intracranial findings mimicking AHT:

Infections:

Sexual abuse mimics: lichen sclerosus, straddle injury, urethral prolapse, perianal strep

Secondary Prevention and Long-Term Plan

— CPS must confirm safety plan and disposition (home with non-offending caregiver, kinship placement, foster care)

— Document specifically who the child is discharged to and contact information

— Pain control per injury

— Antiepileptics if post-traumatic seizures

— Casts, splints, ortho follow-up

— DME (helmets, walkers, wheelchairs) for AHT survivors

— Pediatric primary care within 1–2 weeks

— Child abuse pediatrics follow-up

— Repeat skeletal survey at 2 weeks if not done inpatient

— Subspecialty follow-up (neurology, ophthalmology, ortho, neurosurgery, PT/OT, rehab)

— Early intervention referral for any child <3 with AHT — automatically eligible under IDEA Part C in many states

— Parenting support, home visiting (Nurse-Family Partnership, Healthy Families America)

— Substance use treatment, mental health treatment, IPV resources for caregivers

— Period of PURPLE Crying education to prevent shaken baby

— Trauma-focused CBT for verbal children

— Attachment-based therapies for younger children

— Ensure siblings have completed evaluation and have ongoing pediatric care

Step 3 management: Early intervention referral, trauma-focused therapy, and home visiting are evidence-based reductions in re-abuse and developmental impact. On Step 3, choosing "refer to Early Intervention services" is the correct longitudinal answer for a child with AHT and developmental delay rather than "reassess in 6 months."

Discharge planning is a multidisciplinary determination — not a single-clinician call:

Discharge medications and equipment:

Mandatory follow-ups:

Family/caregiver interventions:

Child mental health:

Sibling follow-up:

Follow-Up, Monitoring, and Rehab/Counseling

— 1–2 weeks post-discharge, then monthly for first 6 months

— Weight, growth, development at each visit (Denver II, ASQ, M-CHAT-R)

— Re-screen for signs of re-injury at every visit

— Neurology: 1–3 months, then per AED management

— Ophthalmology: 1–3 months for retinal hemorrhage follow-up and visual development

— Orthopedics: 2–4 weeks for fracture healing, then per protocol

— PT/OT: weekly to start, taper as goals met

— Audiology if AHT — sensorineural hearing loss can occur

— Head circumference at each visit in infants

— Developmental milestones — refer to early intervention if delays

— Behavioral/emotional screening (PSC-17, SDQ) at follow-up visits

— Medication levels for AEDs if used

— Period of PURPLE Crying — normal infant crying peaks at 6–8 weeks, can last hours, soothing strategies, "it is okay to put the baby down safely and walk away"

— Safe sleep, never shake a baby

— Stress management, respite care, mental health resources

— Establish a "crying plan" — who to call before frustration peaks

— Discipline strategies (positive parenting, time-outs, never physical punishment per AAP 2018 policy)

— Recognition of caregiver burnout

Board pearl: AAP recommends against any corporal punishment, including spanking — evidence links it to behavioral problems and escalation to abuse. Use well-visit time to coach positive discipline and screen for caregiver depression with EPDS or PHQ-2.

Primary care visits:

Subspecialty cadence:

Monitoring parameters:

Caregiver counseling:

Universal anticipatory guidance at all well visits:

Ethical, Legal, and Patient Safety Considerations

— All US clinicians are mandated reporters in all 50 states

— Threshold is reasonable suspicion, not certainty — you are not the investigator

— Reports made in good faith carry civil and criminal immunity

— Failure to report is a misdemeanor in most states and grounds for medical board action and civil liability

— You do not need parental consent or even notification to report

— HIPAA permits disclosure to CPS and law enforcement in mandated reporting situations without authorization

— Disclose only the minimum necessary information

— Forensic exam (e.g., sexual assault exam) generally requires consent from caregiver or court; in emergencies and to preserve evidence, exam may proceed

— Photography for forensic documentation — follow institutional consent policy; in most states implied medical consent covers documentation

— Adolescent patients may consent to certain confidential services per state law, but abuse reporting overrides confidentiality

— Verbatim quotes in quotation marks

— Objective findings, measurements, photos

— Avoid pejorative language about caregivers

— Use precise medical terminology

— Sign-out must include "this is a suspected NAT case — do not discharge without social work and CPS clearance"

— Restrict visitors per safety plan

— Identify the safe caregiver — band/identify carefully

— Maintain non-judgmental clinical demeanor with families

— Recognize implicit bias — abuse occurs across all socioeconomic and racial groups, but minority families are over-reported; calibrate threshold by clinical findings, not demographics

Step 3 management: When in doubt, report. The threshold is suspicion. "I'll wait until I'm sure" is the wrong answer.

Mandatory reporting law:

Confidentiality and HIPAA:

Informed consent edge cases:

Documentation as legal record:

Transition-of-care safety:

Provider ethics:

Court testimony: be prepared to testify; stick to clinical observations and avoid speculation

High-Yield Associations and Rapid-Fire Clinical Facts

Board pearl: When the stem mentions a non-mobile infant with any bruise, a posterior rib fracture, or a classic metaphyseal lesion — the answer is workup + CPS report + admit. There is no scenario where "reassure and follow up in clinic" is correct.

Sentinel injuries: any bruise in pre-cruiser, frenulum tear, ear bruise, subconjunctival hemorrhage — full NAT workup

TEN-4-FACES-p: Torso, Ear, Neck bruising in <4yo, any bruise <4 months, Frenulum/Angle of jaw/Cheeks/Eyelids/Sclera, patterned

Pathognomonic fractures: classic metaphyseal lesions, posterior rib fractures, scapular, sternal, spinous process

Abusive head trauma triad: subdural hemorrhage + retinal hemorrhages + encephalopathy — but each individually nonspecific; constellation strongly suggests AHT

Retinal hemorrhages in AHT: multilayered, multifocal, extending to ora serrata

Burn patterns suggesting abuse: stocking-glove, doughnut sparing of buttocks, cigarette burns (round, deep, ~8mm)

Skeletal survey indication: all children <2 years with suspected abuse; repeat at 2 weeks

Liver enzyme screen: AST or ALT >80 → CT abdomen

Vitamin K deficiency bleeding: 2–8 weeks in exclusively breastfed infant who missed injection — can mimic AHT

Glutaric aciduria type 1: subdural collections + macrocephaly + dystonia — mimics AHT

Mongolian spots: present at birth, blue-gray, do not evolve in color

Period of PURPLE Crying: Peak around 2 months, Unpredictable, Resistant to soothing, Pain-like face, Long-lasting, Evening

ACEs: 10 categories, dose-dependent association with adult disease; abuse counts as 3 (physical, emotional, sexual)

Munchausen by proxy = factitious disorder imposed on another (DSM-5)

Mandated reporter: reasonable suspicion threshold; immunity if good-faith

AAP: no corporal punishment; positive parenting

High-risk age for abuse death: <1 year, especially infants

Board Question Stem Patterns

Key distinction: Step 3 stems often hinge on choosing active intervention (admit, image, report) over passive observation. Default to action when the stem includes any sentinel feature.

Stem 1 — The sentinel bruise: 4-month-old brought in for fussiness; exam reveals a 1-cm bruise on the cheek. Mother says baby "rolled into the crib rail." Next step? → Skeletal survey, head CT, ophtho exam, labs, admit, CPS report. Distractor: "reassure and discharge."

Stem 2 — Inconsistent history: 6-month-old with spiral femur fracture; father reports "fell from couch." Next step? → Full NAT workup; CPS report. Distractor: orthopedics consult alone.

Stem 3 — AHT presentation: 3-month-old with vomiting, lethargy, bulging fontanelle. CT shows subdural hematoma. Next step? → Ophtho dilated fundoscopy + skeletal survey + CPS + neurosurgery + admit PICU. Distractor: "send home with reflux precautions."

Stem 4 — Burn pattern: 2-year-old with sharply demarcated stocking-distribution burns on both feet during toilet training. Next step? → Admit, NAT workup, CPS report. Distractor: "topical bacitracin and follow up."

Stem 5 — Bleeding disorder mimic: Child with extensive bruising and prolonged PTT. Workup reveals hemophilia A. Action? → Diagnose and treat hemophilia, but still complete full NAT workup if any features remain concerning; document differential.

Stem 6 — Mandated reporter ethics: Resident suspects abuse; attending says "let's wait for the full workup." Correct action? → Report based on reasonable suspicion; do not delay.

Stem 7 — Sibling at home: Index child diagnosed with abuse. 18-month-old sibling at home. Next step? → Skeletal survey + exam of sibling; coordinate with CPS.

Stem 8 — Cultural mimic: Vietnamese grandmother coined a febrile child; linear erythema on back. Action? → Recognize as coining (cao gio), document, educate family; not abuse.

Stem 9 — Medical child abuse: Multiple ED visits for "apnea" only with mother present; symptoms resolve inpatient. → Munchausen by proxy; admit, observe, multidisciplinary review, CPS.

One-Line Recap

Non-accidental trauma is recognized by injuries that do not fit the developmental stage, mechanism, or timing of the reported history — and managed by simultaneous medical stabilization, full forensic workup (skeletal survey, head CT, ophtho, labs), child abuse pediatrics consult, mandatory CPS report on reasonable suspicion, and hospital admission with safety planning before any disposition.

— Any bruise in a non-mobile infant ("those who don't cruise rarely bruise")

— TEN-4-FACES-p bruising distribution

— Classic metaphyseal lesion, posterior rib fracture, multiple fractures of differing ages

— Subdural + retinal hemorrhages + encephalopathy = AHT

— Sentinel injuries (frenulum tear, ear bruise, subconjunctival hemorrhage in young infants)

— CBC, coags, vWF panel, LFTs, lipase, UA

— Skeletal survey now and repeat in 2 weeks

— Head CT and/or MRI brain and C-spine

— Dilated fundoscopic exam

— CT abdomen if AST/ALT >80 or abdominal signs

— File CPS report on reasonable suspicion, not certainty

— Admit to hospital regardless of medical severity if safety is uncertain

— Consult child abuse pediatrics, social work, and relevant subspecialists

— Document verbatim history and objective findings; use photos and diagrams

— Evaluate siblings <2 years with skeletal survey

Board pearl: When in doubt, the Step 3 answer is workup + admit + report, not reassure and discharge — and the wrong-answer trap is always "follow up in clinic."

High-yield recognition triggers:

Workup essentials in any suspected NAT case <2 years:

Mandatory actions — never optional:

Longitudinal lens: the recognized sentinel injury today prevents the PICU admission, lifelong disability, or fatality tomorrow — and reduces an entire ACE cascade across the lifespan.