UMEM Educational Pearls

Category: Pediatrics

Title: In NAT, suspicion is key.

Keywords: NAT, non-accidental trauma, abusive head trauma, intra-abdominal injury, burns (PubMed Search)

Posted: 1/6/2018 by Megan Cobb, MD
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In addition to suspicion of NAT with traumatic brain injury and burns, remember these other high risk injuries and features:

- Duodenal injuries in children <4 y/o 

- Frena injuries in non-ambulating children

- Proximal and midshaft humeral fractures > supracondylar fractures 

- Any bruising on the trunk, ears, neck, or with larger size or pattern  

- Delay in seeking care, inconsistent history, mechanism inconsistent with developmental age, and blame of a sibling or other child inflicting harm are all historical features also high risk. 



Non-accidental trauma (NAT) continues to be a sad, but prevelant pathology in the United States. It is estimated that one million children in the US have been victims of maltreatment. As high as one third of children with NAT had the abuse missed on prior medical evaluation. There are several screening tools and clinical prediction rules that have been developed for clinical use, but none are to be used as substitutes for full skeletal survey and CT scan when indicated. 

TEN-4 (clinical prediction rule): 97% sensitivity, 84% specificity with regards to NAT in the setting of bruising by age, location and characteristic. 

PEDIBIRN (clinical prediction rule): 96% sensitive, 43% specificity with regards to abusive head trauma in children less than 3 years old. 

PredAHT (clinical prediction rule): 72% sensitive, 86% specificity, also for abusive head trauma less than 3 years old. 

PIBIS (screening tool): scoring system for well appearing infants presenting with brief resolved unexplained event (BRUE), previously called apparent life threatening event or ALTE. 



Escobar, MA, et al. The association of nonaccidental trauma with historical factors, examination findings, and diagnostic testing during the initial trauma evaluation. Journal Trauma Acute Care Surgery. 2017; 82(6).