Understanding non-accidental trauma (NAT) in infants
Non-accidental trauma (NAT) in early life remains a leading cause of morbidity and mortality worldwide. Clinicians must balance vigilance with compassionate communication, acknowledging that many injuries may seem minor or misleading. The goal is to identify sentinel signs, conduct appropriate investigations, and protect the child while supporting the family.
Clinical case: Gabriel’s four-month check
Gabriel, a four-month-old infant, presents for a routine examination. A bruise on his right cheek raises concerns because bruising during infancy is uncommon unless there is a medical or traumatic explanation. The physician recognizes that sentinel injuries can herald occult harm and proceeds with a systematic evaluation, appropriate imaging, and a multidisciplinary plan that prioritizes the child’s safety and family support.
The sentinel injury and its significance
Sentinel injuries are small or seemingly trivial events that may precede more serious harm in NAT. In non-mobile infants, bruising is unusual, so a cheek bruise warrants careful assessment for underlying medical conditions and for additional, possibly occult injuries. Sentinel injuries are not definitive proof of abuse on their own, but they are a crucial trigger for a thorough workup to rule out medical causes and uncover hidden trauma.
Red flags that prompt evaluation
- Unexplained or unusual bruising in a non-mobile infant
- Bruising on protected areas or in multiple, patterned injuries
- Inconsistent or vague injury histories
- Injury mechanism that does not fit the child’s developmental stage
Standardized NAT screening and care pathways
To reduce diagnostic variability and bias, many health systems follow structured protocols for suspected NAT. The evaluation is multidisciplinary, involving pediatricians, radiologists, orthopedists, and child-protection specialists, and aims to identify occult injuries while excluding an underlying medical condition.
Imaging and laboratory work
When NAT is suspected, brain imaging and a skeletal survey are typically performed. Magnetic resonance imaging (MRI) is increasingly used to minimize radiation exposure, especially in infants, while initial skeletal surveys (SS) often occur within 24 hours, with a follow-up SS 11–14 days later to improve fracture detection. An ophthalmologic examination is indicated if intracranial injuries are suspected. Laboratory tests may include assessments for abdominal injury, coagulopathy, or metabolic disorders as indicated by the clinical picture.
Multidisciplinary collaboration
If NAT is confirmed or remains highly suspected, a multidisciplinary team, including child-protection professionals, should guide next steps. In some settings, regional collaboration can help ensure access to experienced radiologists and timely investigations. In all cases, informed consent for investigations should be obtained from a legal guardian, and if consent is refused and the child remains at risk, authorities may need to be involved to ensure safety.
Communication with families
Discussing NAT requires transparent, non-accusatory language. Explain that the injury is unusual for the child’s age and that further evaluation is necessary to distinguish trauma from a medical condition. Emphasize that the goal is to ensure safety and well-being, not to assign blame. Suggested phrases from guidelines help clinicians maintain neutrality and support families while safeguarding the child’s interests.
Managing cases: reporting and next steps
When NAT is suspected or diagnosed, healthcare teams typically consider reporting to child-protection services. This process involves balancing legal duties with patient confidentiality and aims to coordinate protective measures for the child. In cases with confirmed or ongoing risk, authorities may initiate protective actions while the medical team continues to care for the child and involve the family in the plan.
Risk of recurrence and ongoing vigilance
Infants with NAT suspicion have an increased risk of recurrent harm. A structured follow-up and coordinated care plan, including social support and monitoring in the child’s home environment, can reduce recurrence and promote safety for the child as they grow.
Practical guidance for primary care providers
Primary care clinicians should be familiar with their local NAT protocols, document findings meticulously, and arrange timely imaging and specialist referrals. Avoid premature conclusions; use standardized screening tools and involve child-protection teams when indicated. Communicate openly with families, maintain trust, and ensure a clear path to follow-up care.
Conclusion
Standardized NAT screening and multidisciplinary collaboration improve early detection, reduce diagnostic bias, and help prevent ongoing harm. A compassionate, evidence-based approach to evaluation and communication supports families while safeguarding vulnerable infants.
