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:

• 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.