Consensus Guidelines for Management of Suspected Non-Accidental Trauma (NAT)

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Northern California Pediatric Hospital Medicine Consortium

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Table of Contents

• Executive summary
• Introduction
• Evaluation
• Management
• References
• APPENDIX 1
• APPENDIX 2

Executive summary

Objectives

To outline an evidence-based, stepwise consensus approach in order to assist providers in the assessment and management of children with concerns for Non-Accidental Trauma (NAT).

Recommendations

• Be knowledgeable about how to report child abuse in your local area

• Be aware of implicit bias when considering child abuse

• Have a systematic approach for evaluating for and documenting physical abuse

• If reporting child abuse, best practice is to disclose reporting to family in most cases

Methods

This guideline was developed through local consensus based on published evidence and expert opinion as part of the UCSF Northern California Pediatric Hospital Medicine Consortium.

Metrics Plan

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Consensus Guidelines for Management of Suspected Non-Accidental Trauma (NAT):
UCSF Northern California Pediatric Hospital Medicine Consortium

Introduction

Background

Definitions

• Non-accidental trauma (NAT): A life threatening condition that should be considered in all cases of significant trauma in which mechanism of injury cannot be verified or explained.

  Note: Judgment regarding consistency of mechanism of injury, appropriateness of parental behavior and other such considerations can be helpful, but do not rule in or out NAT.

• Child abuse and neglect: “Any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm”

• Mandated Reporting: Child abuse must be reported when anyone who is a legally mandated reporter has knowledge of or observes a child in his or her professional capacity, or within the scope of his or her employment whom he or she knows or reasonably suspects has been the victim of child abuse or neglect.

• Mandated Reporter: Includes (but is not limited to) any person who in their professional capacity is responsible for caring for children and specifically in the medical/hospital setting includes nurses, paramedics, EMTs, physicians, dentists, chiropractors, alternative health practitioners, physical therapists, and mental health professionals including clinical social workers, mental health trainees and interns, marriage, family and child counselors, school counselors; psychologists, psychological assistants and interns and drug counselors). A complete list of mandated reporters is provided in the California Penal Code (PC) section 11165.7

• Implicit bias: the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner. These biases, which encompass both favorable and unfavorable assessments, are activated involuntarily and without an individual’s awareness or intentional control.

  • Some brief data on implicit bias:

    • Jenny et al 1999: Abusive head trauma is missed more often in white families and in families in which both parents lived with the child

    • Drake et al 2010: Systemic discrimination may lead minoritized families to have more risk factors associated with child abuse and neglect, namely poverty.

Criteria for use of guideline
This guideline applies to any child for whom there is a suspicion for physical abuse.

Note: This document does NOT cover concerns regarding sexual abuse: If you have concerns for sexual abuse, please call the local CPS hotline or local police where incident happened to refer you to the sexual assault response team hotline before proceeding with history or exam.

• If there is a disclosure or allegation of sexual abuse, or suspicion for any reason including from exam (genital trauma, positive STI in pre-teenager) or history, then address acute medical concerns, and contact local CPS hotline in the county where the child resides and local police in the jurisdiction where the alleged abuse incident occurred to coordinate referral to the sexual assault response team.

• If clear physical abuse, but concern for concurrent sexual abuse, consultation with Child Abuse Pediatrician or local sexual assault response team is warranted

Considerations: a single report is not without consequence, especially for Black, Indigenous, and people of color (BIPOC) families. If you are unsure whether to make a report (i.e., borderline case), consider a multi-disciplinary discussion to balance biases, and/or consult a child abuse expert before making a report.

When considering initiation of work up for NAT think about:

• Child age and development- Injury not consistent with the child’s developmental ability i.e. “Those who don’t cruise don’t bruise”, or injuries in a non-verbal child. This also applies to diseases that are not typical for age group, e.g., pancreatitis or elevated transaminases in young child without alternate explanation.

• Type of injury- different stages of healing (unless over shins, or areas commonly bruised in typical play), multiple injuries, patterned cutaneous lesions (i.e., bruising in the shape of a belt buckle), pattern of increasing frequency or severity of injury over time, bruises to torso, ear or neck, buttock in a child

• History- unwitnessed injury, implausible mechanism, inconsistent with developmental ability, statement of harm from verbal child, care taker response not appropriate, caretaker does not show concern for injury, poorly explained delay in seeking care, timeline inconsistent with presenting injuries, inconsistencies/discrepancies in histories, injury attributed to sibling/another child/pet.

• Special consideration: Medical child abuse

  • Medical Child Abuse (MCA): A form of child abuse in which a child receives unnecessary and harmful or potentially harmful medical care due to a caregiver’s overt actions including exaggeration of symptoms, lying about the history or simulating physical findings (fabrication), or intentionally inducing illness in their child.

    • All of the following terms have been used to describe MCA: Munchausen by proxy syndrome, Fabricated or induced illness in a child by a caretaker, Child abuse in the medical setting, Meadow syndrome, Doctor shopping, Caregiver fabricated illness in a child, Pediatric condition falsification, Factitious disorder by proxy.

    • The term “medical child abuse” is preferred because it focuses on the potential or real harm being done to the child regardless of the perpetrator’s motivation.

  • MCA should be considered within the differential diagnosis whenever a child presents with a persistent, recurrent, unexplainable illness. There are several indicators and risk factors associated with MCA, including:

    • Symptoms and signs described are incongruous with patient’s appearance or are seen only when the caregiver is present.

    • Diagnostic tests fail to confirm the diagnosis.

    • Usual medical treatment is ineffective in alleviating the presenting symptom(s).

    • Puzzling symptom clusters, leading experienced MD to say, "never seen this before".

    • Additional “red flags”:

      • Frequent housing location changes

      • Siblings who have either died or had unusual medical illnesses

      • Seeking care at a variety of facilities

      • Multiple: office visits/exams, tests, interventions/procedures, specialists involved

      • Reluctance to accept less severe diagnoses

      • Signs and symptoms only begin in the presence of the caregiver.

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Evaluation (see Appendix 1 for pathway)

• History and Physical Exam: Of note, the history, physical, and documentation for patients with suspicion of NAT likely requires more attending oversight than for another pediatrics patient; the way this is done in practice may be site-specific.

  • Conduct separate interviews with each caregiver, other witnesses, child if age-appropriate and possible.

  • Avoid leading questions and interruptions, redirecting, or suggestive questioning.

  • Use caregivers’ own words.

  • Obtain details about the mechanism of injury:

    • Events leading to injury, was it witnessed? Recreate scene as much as possible: Where was the child? Presence of objects/furniture? Type of floor surface? Height of fall? Who was caring for the child at the time of the injury? If there is a delay in seeking care, inquire about the reason for the delay.

  • Additional history:

    • Birth history, developmental history, medical history (note failure to thrive, head circumference, percentile changes), social history (substance abuse, social stressors, prior abuse, CPS involvement), family history (bleeding disorders, bone disorders, metabolic/genetic disorders, apneas, seizures, epilepsy, siblings/family members with developmental delays.)

  • Physical Exam- Should be performed with the patient fully undressed.

    • General: Mental status, affect, level of activity

    • Skin surfaces: pinnae (bruising), behind ears (bruising), oral cavity (teeth, frenulum for tears), soles of palms and feet (bruising or marks), buttocks (bruising), EXTERNAL inspection of genitals and anus (if concern for sexual abuse, medically stabilize patient and do not perform ANY unnecessary examination prior to contacting a Sexual Assault Response Team).

    • Take photos of traumatic findings. See below for tips.

    • Musculoskeletal: Limitations in range of movement or asymmetry, evaluate for extremity swelling and injury

    • Perform a complete neurologic examination

• Labs and Imaging

  • Age-based mandatory work-up

    • • Skeletal survey (19 separate x-rays, NOT a single babygram. Composed of frontal and lateral views of the skull, lateral views of the cervical spine and thoracolumbosacral spine, and single frontal views of the long bones, hands, feet, chest, and abdomen. Oblique views of the ribs should be obtained to increase the accuracy of diagnosing rib fractures, which are strong positive predictors and may be the only skeletal manifestation of abuse).

      • Ophthalmologic exam (recommendation: retinal camera read by pediatric ophthalmology acceptable but if positive should be seen by in-person ophthalmologist)

      • Head imaging (MRI/CT without contrast – not a FAST MRI. Head US not recommended due to lack of sensitivity)

      • Labs: LFTs, lipase, UA.

    • 6-12 months of age:

      • Skeletal survey (NOT a babygram, views as above).

      • Head imaging (MRI/CT without contrast - not a FAST MRI) should be considered if: seizure, AMS, or neurologic signs and symptoms, head circumference (OFC) >95% or large change from baseline, history of head trauma

      • Labs: AST/ALT/Lipase/UA

      • Consider ophtho exam

    • 12-24 months of age:

      • Skeletal survey (NOT a babygram, views as above).

      • Head imaging should be considered if (MRI/CT without contrast - not a FAST MRI): seizure, AMS, or neurologic signs and symptoms, head circumference (OFC) >95% or large change from baseline, history of head trauma

      • Labs: AST/ALT/Lipase/UAo

    • Up to 5 years of age:

      • Labs: AST/ALT/Lipase/UA (strongly consider for all ages)

    • Drug screening should be performed at any age with a concern for drug ingestion, exposure or altered mental status.

    • Special consideration: Patients with developmental delay/non-verbal

      • Medically complex patients are at higher risk for NAT; however, their injuries may also be explained by their underlying pathophysiology (e.g., a TPN-dependent bed bound child is certainly at higher risk for decreased bone density/fractures)

      • In general, follow age-based workup as above, consider using the 12–24 month workup for developmentally delayed children on case-by-case basis

  • By injury

    • Bruise/Hematoma/suspicious skin marks: CBC w/differential, PT/PTT/INR, coagulation storage specimen (blue top drawn for hold), vWF antigen. Factor VIII and IV levels if patient requires blood products. Consider hematology consult.

    • Burns/Bites: See age-based mandatory work-up above.

    • Fracture: Calcium, magnesium, phosphorus, alk phos, 25-OH vitamin D, intact PTH. Consider genetics consult for osteogenesis imperfecta testing if the injuries are solely fractures (no other signs of abuse) or if abuse is strongly suspected and the case is likely to go to court.

      • If possible, consulting a child abuse expert can help in deciding when/if to consult genetics

      • If no child abuse expert is able to be involved, carefully consider what testing to send as the general practitioner could be called on to interpret that testing in court

    • Suspected head trauma: CT vs MRI based on stability. If symptomatic, do most rapidly available test emergently. If applicable, activate as “Trauma Activation” per hospital guidelines. If strong suspicion for abusive head trauma, consider cervical and/or spinal MRI. If intracranial injury, get labs from “bruise/hematoma/suspicious skin marks” above. In general, if there are multiple injuries in addition to subdural hematomas, a genetics consult for glutaric aciduria I is not necessary, but if this is the sole finding and the case may go to court, recommend genetics consult.

      • If possible, consulting a child abuse expert can help in deciding when/if to consult genetics, endocrine, hematology, etc

      • If no child abuse expert is able to be involved, carefully consider what testing to send as the general practitioner could be called on to interpret that testing in court

    • Suspected abdominal trauma: LFTs, lipase, UA, CT Abdomen-pelvis with contrast.

    • Consider troponin I for infants >=3 months of age if: AST or ALT >=80, signs of chest trauma, or ill appearance.

    • If severe tissue injury, add CPK, myoglobin, aldolase.

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Management

• Reporting/Notification

  • CPS- Any mandated reporter who suspects child abuse must report by phone immediately, or as soon as practically possible. Ensure that written report form has been sent within 36 hours. On-call social worker can be of help.

    • CPS Emergency response hotline numbers by county:

      • https://www.cdss.ca.gov/reporting/report-abuse/child-protective-services/report-child-abuse

    • Who should notify the family that CPS is being notified? See Appendix 2: Resources for How to Talk to Parents about NAT concerns.

      • First point of contact with suspicion for NAT should make the report (Social worker versus MD/provider is institution dependent). If there are extenuating circumstances, communication regarding status of making the CPS report is paramount.

      • Ideally, the family should be notified by the providers who make the report, but it may be reasonable to delay for a short time in order to have social work present assuming CPS will not intervene in the meantime

      • Providers CAN make report anonymously but for maintaining provider-caregiver trust, recommended to disclose report to parents as soon as feasible.

      • Use specific language: “I suspect abuse” rather than “the child has an injury and I’m not sure what caused it”

    • Where and how should the CPS notification be documented?

      • Document in the medical record that CPS was notified

      • Be aware of the 21st Century Cures Act i.e., “Open Notes” that went into effect in 2021. This Federal mandate allows patients to have free electronic access to certain types of clinical notes. Follow hospital practices to determine if documentation about concerns for abuse meets criteria for blocking.

      • Use caution in language (ex. “open CPS case” versus “report made”); contact SW if unclear

    • Strategies for discussing suspicions with patient’s family: See Appendix 2

  • Law enforcement- CPS is supposed to cross report to law enforcement (and vice versa), but this does not always occur in a timely manner. In cases where there is concern/risk for homicide, imminent threat to life, or if CPS is not taking the case, a report to law enforcement should be made as well. It is always reasonable to ask CPS regarding the status of cross reporting to the police.

    • In situations where there is a concern for escalation/flight risk, please contact security and law enforcement and state that a CPS hold is being placed and that law enforcement assistance is needed.

    • Medical staff are mandated reporters and need to cooperate with CPS and disclose appropriate information. The same is true for police. Information provided should avoid speculation or stigmatizing language to minimize infusion of bias.

  • If further consultation needed, consult on-call pediatrician or consider transfer if evaluation by child abuse pediatrician is needed.

  • If concern for sexual abuse, consult local Sexual Assault Response Team (SART or SARC depending on hospital site).

• Documentation

  • Photography-

    • Each institution may have its own system for secure photo documentation (most places have digital camera or other method for linking to patient chart)

      • Epic – use Haiku to upload into chart

      • SD card on secure camera – CPS uploads photos – start and end with an identifying photo

      • Regardless of how you are obtaining photos, method should be uniform

    • Method:

      • Use ruler

      • Color white balance

      • Close up and medium distance

      • Anatomic identifier

      • 3 pictures per injury

      • It is helpful to have identifying features in the photos

      • Take pictures prior to dressing injuries (esp. burns, lacerations, etc)

      • Check picture quality (e.g., can you tell what the injury is, like a bruise – comment in chart in if blurry or unclear)

      • If extensive injuries, can be helpful to get whole body shot or image that show the full extent of the injuries

      • Child life can be a helpful resource for facilitating good photos; explaining to the whole team why this is important can be helpful

    • Consent to take pictures – photo documentation for physical abuse does not require consent (sexual abuse does require consent)

      • Language consenting to photography is in most general admission paperwork

  • Paper documentation

    • General rules:

      • Document using patient’s own words rather than paraphrasing. Use quotations as much as possible.

      • Document any injuries present PRIOR to interventions (i.e. if the patient is going to the OR, document if frenulum injury or facial bruising was present at the time of presentation)

      • Be as descriptive as possible in documenting the injuries

        • Include measurements, patterns

        • Objective findings

        • Note tenderness and edema

      • Include any sibling or children in the home on the CPS form.

      • Consult CPS on whether to examine/register/admit other children/siblings

    • Fill out the following form (statewide, ask SW if county-specific forms): https://oag.ca.gov/sites/all/files/agweb/pdfs/childabuse/ss_8572.pdf

      • Fill out form as accurately as possible. If elements of the history are unknown, avoid guessing and just note that they are “unknown.”

      • Be as specific as possible in localizing and describing marks.

      • Use descriptors rather than diagnoses (e.g., “linear semicircular marks” rather than “bite marks” or add phrase such as “suspicious for” or “suggestive of”)

    • Ensure the form is reviewed by the attending of record, signed, and faxed.

• Inpatient Considerations

  • Patient Safety

    • Need for Sitter

      • Sitters do not watch the parent; they watch the patient. As a temporary measure when CPS has not yet determined the perpetrator of the injuries or whether the injuries are consistent with NAT, and a sitter is available, sitters are a reasonable option. The goal is not to collect data on parental interaction or behavior but to ensure patient safety. If a sitter is not available, it is the responsibility of CPS, in consultation with the medical team and social work, to determine whether parents can stay.

      • If parents or relative are determined by CPS to be unsafe to stay with the child, it is appropriate to admit the child to a secure unit. Consider using pseudonym for admission.

    • Can parents receive information about their child/stay at bedside?

      • CPS decides who can stay at bedside and how/whether parents/caregivers may receive medical information. This is further reason to notify CPS ASAP.

    • How to transfer if transfer is necessary?

      • Medical transport (rather than private vehicle) between medical facilities is almost always appropriate

  • Consults – Mandatory

    • Social work

  • Consults - Consider

    • Child Abuse Specialist (may be able to confer over phone with local expert to decide if transfer is necessary for in person consult)

    • Psychiatry

    • Orthopedics

    • Ophthalmology

    • Surgery/Neurosurgery

    • Genetics

    • Dermatology

    • Hematology

• Disposition/Criteria for transfer

  • Discharge- if patient is sent home before you have completed work-up and/or the patient is cleared by CPS, you must be convinced of the child’s safety.

    • If CPS is taking custody, the child must be discharged to CPS (must be present to sign paperwork) versus the foster family.

    • Ensure follow up studies or appointments have been ordered/arranged (eg. Genetics appointment or follow up skeletal survey).

  • Admission- If suspecting NAT, you should PLAN to admit unless you have a good reason to do otherwise.

    • Criteria:

      • Not safe for discharge home as determined by any one of the following: ED attending and/or pediatric attending of record, child abuse expert, CPS, social work, law enforcement.

      • Patient not medically stable.

      • Work-up requires inpatient admission: exam under anesthesia, ophthalmology evaluation, MRI with sedation. In rare cases, with consultation from CPS and child abuse expert, some of the workup may be deferred to outpatient, but generally should be done at the time of presentation.

  • Transfer

    • If required work-up not available at community site including but not limited to: skeletal survey (preference to be read by pediatric radiologist), exam under anesthesia, ophthalmology evaluation, MRI with sedation.

    • If pediatric sub-specialist consultation is needed including but not limited to: child abuse pediatrician, hematology, pediatric radiology, surgery/neurosurgery, genetics

• Caring for the Caregiver – support resources for team members (nurses, social workers, physicians, trainees)

  • Important to debrief – social work team available to talk through gray areas of CPS

  • Local wellness resources

  • Chaplain

  • SCAN Committee

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References

Atigapramoj, Cooch, Gilbreth, Kodali, Laves, Osborn, Stewart (2017). “Zuckerberg San Francisco General Hospital Guidelines for Evaluation and Management of Suspected Non-Accidental Trauma (NAT).”

Christian C, COMMITTEE ON CHILD ABUSE AND NEGLECT (2015). “The Evaluation of Suspected Child Physical Abuse”. Pediatrics May 2015; 135 (5): e20150356. 10.1542/peds.2015-0356

Drake et al (2011). “Racial Bias in Child Protection? A Comparison of Competing Explanations.” Pediatrics. 127(3): 471-478.

Jenny et al (1999). “Analysis of Missed Cases of Abusive Head Trauma.” JAMA. 281(7):621-626.

Riney et al (2018). “Standardizing the Evaluation of Nonaccidental Trauma in a Large Pediatric Emergency Department.” Pediatrics. 141(1): e20171994.

Wooten-Gorges et al (2017). “Appropriate Use Recommendations for Suspected Child Abuse.” Journal of the American College of Radiology. S338-S349. Published Children’s Hospital Guidelines / Pathways

• Children’s Hospital of Philadelphia (CHOP) – Emergency Department Clinical Pathway for Evaluation/Treatment of Children with Concern for Physical Abuse

  • https://www.chop.edu/clinical-pathway/abuse-physical-clinical-pathway

• Seattle Children’s Hospital – ED Bruising

  • https://www.seattlechildrens.org/globalassets/documents/healthcare-professionals/clinical-standard-work/ed-bruising-org-pathway.pdf

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Appendix 1: NAT Workflow

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Appendix 2: Resources for How to Talk to Parents about NAT concerns

From the AAP Clinical Report “the Evaluation of Suspected Child Physical Abuse”, Pediatrics, May 2015:
Once the decision has been made to report a concern of physical abuse to CPS, it is important to discuss the report with the child’s parent(s). This is one of the most difficult discussions a pediatrician may have in clinical practice, but an honest conversation will allow for more open communication during and after the ensuing investigation. In this conversation, it can be helpful to raise concern about an injury, while not apportioning blame, and inform the parent that because of the nature and circumstances of the injury, a report for further investigation is mandated by law. Although some families may abandon the pediatrician’s practice after a report is made, it is important not to abandon the family at the time of the report. An investigation of possible abuse is a time of crisis for a family, and a supportive physician can be of great assistance to the child and nonoffending parent(s) and family members. In addition, most cases of child physical abuse result from family stress, and state CPS agencies typically provide useful family support in these cases. These supports may range from day care vouchers to in-home therapy. Only a minority of children reported to CPS enter the foster care system, and these cases are carefully overseen by the court system. Thus, it is rare that a physician report alone leads to removal of children from their biological parents.

The physician’s cooperation with CPS investigations is necessary to improve decision-making by investigators. Health Insurance Portability and Accountability Act (HIPAA) rules allow disclosure of protected health information to CPS without legal guardian authorization when the physician has made a mandatory report, but state laws differ regarding the release of health information to investigators under other circumstances and after investigations are complete.154 Because CPS and law enforcement investigators do not typically have a medical background or training, the pediatrician’s interpretation of the child’s injuries in straightforward language that allows for a meaningful conversation with the investigators is needed for proper investigation, decision-making, and protection of the child. The physician may be required to write a summary statement of his or her findings and to testify in civil or criminal trial proceedings. Additional information on testifying in civil and criminal legal proceedings can be found in an AAP policy statement on the subject.¹⁵⁵

Phrases to use:
“My role is not to assess blame or responsibility, only to assess your child’s injur-y/-ies.”

“I am not the person who determines whether your child will be able to go home with you or not; that is CPS’s role. My role is to provide them accurate medical information and to take care of your child’s injuries.”

“I am required by law to report any incident like this.”

“With the injuries your child has, this is our standard work up/protocol.”

“I am worried that someone has hurt your child. We need to [admit them, do x study, etc.] in order to further investigate.”

“Based on the injury your child has, he is at high risk for other injuries that may not be obvious so we need to do further testing to make sure he is not hurt elsewhere.”

“I believe someone injured your child so my focus is to make sure he is safe and healthy.”

“The injuries that we’re seeing can be consistent with child abuse. In the same way that we investigate other illnesses, we want to investigate this in order to keep your child safe.”

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Disclaimer

These clinical practice guidelines are based upon the evidence-based consensus opinions of consortium members affiliated with UCSF Benioff Children's Hospitals. They are intended to guide pediatric/neonatal providers, but do not substitute for individual clinical judgment. Evaluation and treatment of specific patients should be adapted based upon the unique conditions of each patient, family and clinical environment.

 

UCSF Northern California Pediatric Hospital Medicine Consortium. Originated 08/2018. Updated 11/2022
*Adapted from “Zuckerberg San Francisco General Hospital Guidelines for Evaluation and Management of Suspected Non-Accidental Trauma (NAT)” 2017. Atigapramoj, Cooch, Gilbreth, Kodali, Laves, Osborn, Stewart.

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