In this lecture, we’ll discuss
non accidental trauma and child neglect.
This is a huge topic, but I’ll try and
drill down on the important aspects of it.
So non accidental trauma by definition
is an act or failure to act
that results in imminent
risk of serious
physical or emotional harm or death of
a child, anyone under 18 years of age,
by the parent or caregiver
responsible for the child’s welfare.
So there are four general
types of non accidental trauma.
We talked about neglect, physical abuse,
sexual abuse, and emotional abuse.
And all four of
those are illegal.
So let’s talk about what are
risk factors for non accidental trauma.
Colicky infants are at increased
risk for non accidental trauma.
They’re so fussy, they
drive their parents crazy
and the parents act out in
ways they later regret.
Children with disability are at
increased risk for non accidental trauma.
Children with emotional problems are
at increased risk for non accidental trauma.
Children of parents who were abused
are more likely to abuse themselves.
And children in foster care are at
increased risk for non accidental trauma.
So how do we tell if a child’s
injury is a result of abuse?
Probably the most important aspect of it is
a changing story or an inconsistent story.
It’s important for people
to document thoroughly
exactly the story that the
parent relays to them
and that parent, we should then follow
how their story changes overtime.
If that story is changing
in terms of what they
perceived of the event
around that child’s injury,
this is a strong indicator for
the possibility of non accidental trauma.
Any history of repeated injuries or hospitalization
to that child should be of concern
and the unexplained
delay in seeking care.
If a child got burned, but it was yesterday,
why didn’t they come in yesterday?
Any inconsistent injury with the story
that’s told by the care provider.
If a child fell off the couch
and has four broken bones,
that’s not consistent
with the story.
And likewise, any story
of injury inconsistent
abilities of the child.
“My child reached out and grabbed
some coins and swallowed them,”
but this child’s only six months of age
or maybe even three months of age,
it’s really unlikely this child
could’ve gotten access to those coins
or actually physically swallow them.
Some few things that we find that
are consistent with non accidental trauma
is extensive bruising.
Also, certain bruising patterns may be
concerning such as hand marks or belt marks
or linear marks could
indicate some sort of abuse.
Something we’re seeing frequently now is
phone charging cords being
And also bite marks can be concerning.
Also, unusual bruise patterns.
For example, here, you can see
the actual areas of the finger
where the parent was holding
the child by the head.
Flexor surfaces are usually more
concerning for non accidental trauma.
It’s unusual to bruise yourself from
the inside of your elbow for example.
Anywhere around the ears is usually
concerning for possible non accidental trauma
or bruising around the neck,
torso or abdomen as well.
Certainly, bruising of the genitalia
will be extremely unusual in an accident.
So here’s an example of
an injury from a whip.
Oftentimes, people will use electrical
cords or phone chargers, this is abusive.
And what’s useful perhaps
about this picture is
you can see how those
marks change over time.
The first picture is an acute event
and the second one’s after
those marks have healed.
But you can see that these are of
linear excoriations or linear marks
and they scar linearly,
that’s highly indicative
of a case of non accidental trauma.
Here’s an example of a belt mark and you
can see the actual head of the belt
and how it slapped against the
skin with the small pin in it.
So we can often see the shape of
the object that caused the mark
and that’s a sign that this is non accidental trauma
and this has gone above and beyond what we
would expect in terms of normal parenting.
This is a difficult image to view, but
this is an example of intraoral injury.
So we will sometimes see torn frenulum,
which is that tag underneath the tongue
that adheres the tongue to
the bottom of the mouth.
If that’s torn, it could
be evidence of something
being forced into
the child’s mouth.
In this child’s case, the father
was raping this child’s mouth
and you can also see
bruising around the lips.
But we can see frenulum tears also with
things like forced bottle feeding,
which may be a sign.
So it’s important to inspect
the internal oral cavity.
Patient’s burns can be very
concerning for potential non accidental trauma
and certainly when we see unusually burn
patterns, we have to worry about this.
One of the classic ones that you’ll see
on exam is sparing of the creases.
So if you look at this drawing, this
child was immersed into hot water
and you can see that the creases
of the skin are spared.
This is because as they’re going
into the water, the legs come up
and you can sort of see that the
creases are against each other,
so the water isn’t injuring
that part of the skin.
So sparing of the creases is highly
concerning for non-accidental trauma.
Certainly any burn in a stocking or
glove-like pattern is suspicious.
And round burns may be a result of
stamping out cigarettes on children.
Also, we may see pattern burns such as
the use of an iron to burn a child.
We’ve definitely seen that in the past.
Here’s an example of a
burn that was concerning
and you can see how
those are linear marks.
Careful history and, eventually,
the parent confessed
that they’d heated up a fork
and then pushed it against the child’s
skin as a way of causing abuse.
So any linear marks like
this are very concerning.