• Standard history, including medical, developmental, and social history;
• Family history, especially of bleeding, bone disorders, and metabolic or genetic disorders;
• Pregnancy history: desired/undesired; planned/unplanned, prenatal care, postnatal complications, postpartum depression;
• Familial patterns of discipline;
• Child temperament, including whether child is easy or difficult to care for; excessive crying in an infant; patents’ expectations of the child’s behaviors and development;
• History of abuse to child, siblings, or parents;
• Substance abuse by any caregivers or people living in the home; parental mental health problems, law enforcement interactions, and domestic violence history; and
• Social and financial stressors and resources.^1,2

If there is a concern for NAT, a complete and thorough physical exam should be performed on the child. The child should be undressed, and the exam conducted in a well-lit room. The ED physician should pay attention to areas of bruising, both acute and chronic, patterned injuries, areas of pain or tenderness, and areas of scarring.¹ A helpful mnemonic when NAT is suspected is TEN 4-FACES:

• Torso
• Ear
• Neck; and
• In children younger than 4 years of age, and in ANY infant younger than than 4 months old
• Face
• Auricular area
• Cheek
• Eyes
• Sclera^1,3,4

If abusive trauma is being considered, a skeletal survey and laboratory investigation may be warranted.^1,5 If there is still a concern, child protective services (CPS) should be notified.

Remember, physicians are mandated reporters in all 50 states.

Case Resolution

Given the location of the burn, pediatric burn surgery was consulted. They evaluated the child and debrided the burn. Even though the explanation for the injury was very plausible, because it was not given initially to EMS and ED staff, CPS was contacted. A skeletal survey was performed and did not reveal any findings. A CPS case worker visited the ED and spoke to the patient’s mother. The case worker determined that there was no concern for NAT. The child was discharged with a bacitracin dressing, oral pain medications, and followup in the pediatric burn clinic.

Dr. Rozzi is an emergency physician, medical director of the Forensic Examiner Team at WellSpan York Hospital in York, Pennsylvania, and secretary of ACEP’s Forensic Section.

Dr. Riviello is chair and professor of emergency medicine at the University of Texas Health Science Center at San Antonio.

References

1. Christian CW, Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse. Updated 2021. Pediatrics. 2015;135(5):e1337-1354.
2. Perkins A. The red flags of child abuse. Nursing Made Incredibly Easy! 2018;16(2):34-41.
3. Hinton C, Trop A. ACEP Now. TEN-4 FACES P: a mnemonic to help you spot signs of child abuse. Published August 19, 2020. Accessed September 15, 2024.
4. Pierce MC, Kaczor K, Lorenz DJ, et al. Validation of a clinical decision rule to predict abuse in young children based on bruising characteristics. JAMA Netw Open. 2021;4(4):e215832.
5. Riviello RJ, Rozzi HV. Scan for these potential signs of non-accidental trauma. ACEP Now. Published March 6, 2024. Accessed September 15, 2024.
6. Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers: those who don’t cruise rarely bruise. Arch Pediatr Adolesc Med. 1999;153(4):399-403.