It is 0715 hours, and you have just come onto shift when EMS calls that they are bringing in an 11-month-old female who won’t stop crying. They do not have any additional information except that she is healthy, with no past medical history, and has stable vital signs. As they wheel past the desk, you observe the child lying on her mother’s chest fast asleep. Mom states that the child just started screaming and crying and she could not get her to stop. She has no idea what happened. On physical exam, you notice what appears to be a blister from a burn on her right palm (see photo on cover). The remainder of your physical exam is unremarkable. When you are done, you tell the mother what you found and ask her if there is any way the child could have been burned. She tells you that she was getting ready to go to school and was sitting in front of the mirror with her daughter on her lap while she was doing her hair with an electric straightening device. She states that her daughter was fidgety and was pulling herself up onto the table. It was after doing so that the child began screaming.

Discussion

Minor injuries in children are extremely common, and most do not require medical attention. Emergency department (ED) visits for pediatric injuries are common, and millions of children are seen each year. Fortunately, most injuries are not the result of abuse or neglect. When it does occur, the identification of physical abuse can be difficult. Witnesses are often not present, victims are often nonverbal, perpetrators often do not admit to actions, children may be too frightened or injured to disclose their abuse, and injuries can be nonspecific.

Physicians are taught to rely on parents for accurate information about the child’s history and may not be critical or skeptical of the information provided. Another confounding factor is that many accidental injuries sustained by ambulatory, active children are unwitnessed by caregivers. In these cases, parents can describe events surrounding the injury but are unable to describe the exact mechanism of trauma. The emergency physician must maintain a high index of suspicion for the possibility of non-accidental trauma (NAT). Certain histories should raise a concern for abusive trauma:

• No explanation or vague explanation for a significant injury;
• Explicit denial of trauma in a child with obvious injury;
• Important detail of the explanation changes in a substantiative way;
• Explanation provided is inconsistent with the pattern, age, or severity of the injury or injuries;
• Explanation provided is inconsistent with the child’s physical and/or developmental capabilities;
• Unexplained or unexpected notable delay in seeking care; or
• Different witnesses provide markedly different explanation for the injury or injuries.^1,2

Some suggestions to aid in getting a better history to guide your decision making include: