Introduction
Non-accidental trauma (NAT), also referred to as non-accidental injury, remains a critical concern in pediatric practice. The term NAT encompasses injuries that are likely inflicted by a caregiver or another person, rather than caused by an accidental event. A structured approach to recognition, diagnosis, and family-centered care is essential to safeguard the child and to prevent repeated harm, especially in the first year of life.
Clinical scenario and the challenge of recognition
Consider a fictional case: Gabriel, a 4‑month‑old infant, presents for a routine 4‑month check. A brownish bruise on the right cheek without a clear accidental mechanism raises concern for a sentinel injury—an early sign that may indicate NAT. Primary care physicians often face this dilemma: how to balance the need for a thorough, systematic assessment with the emotional burden of possible child maltreatment, particularly when the physician has a long-standing, trusting relationship with the family.
Sentinel injuries range from minor, seemingly benign findings to more serious injuries. In non-mobile infants, bruises are uncommon, and their appearance should prompt further evaluation. Occult injuries—hidden fractures, brain injuries, or abdominal trauma—may accompany visible bruising, underscoring the need for comprehensive assessment rather than relying on appearances alone.
Sentinel injuries, occult trauma, and risk of escalation
Past research shows that a substantial proportion of NAT cases are missed at initial presentation, and later cases may involve multiple or more severe injuries. Sentinel injuries, even when small, can precede more serious harm, making early detection crucial. Imaging and laboratory studies, guided by age and clinical findings, help identify occult injuries and rule out underlying medical conditions that might mimic NAT triggers.
Occult injuries are not rare: skeletal injuries, intracranial injuries, and abdominal trauma can be present without obvious external signs. Screening studies indicate that a significant subset of NAT-diagnosed infants harbor hidden injuries detectable only through systematic imaging. This evidence supports standardized screening protocols rather than ad hoc testing.
Standardized NAT screening and care protocols
Implementing evidence-based, standardized protocols in pediatrics improves the detection of NAT while helping to minimize missed injuries. Key elements include:
- A multidisciplinary evaluation involving pediatricians with child-protection expertise, radiologists, orthopedists, neurologists, and social services when NAT is suspected.
- Imaging strategies that balance diagnostic yield and safety. For infants under 12 months with suspected NAT, brain imaging (preferably MRI to limit radiation) and a skeletal survey are commonly recommended, with follow-up imaging 11–14 days later when initial results are inconclusive or to detect evolving injuries.
- Ophthalmologic assessment in cases with suspected intracranial injury or retinal hemorrhages, and targeted laboratory testing guided by clinical findings (e.g., coagulation studies when bruising patterns are unusual, abdominal imaging if indicated).
- Documentation and informed consent, with clear communication about radiation exposure and medical necessity. If parental consent is refused but suspicion remains high, child-protection authorities may be involved to ensure the child’s safety.
- Follow-up planning that includes safeguarding the child’s welfare, family support, and, when required, reporting to relevant child-protection services.
These steps align with consensus guidelines from pediatric and radiology groups, including structured decision trees and recommended timelines to minimize delays in diagnosis and care.
Communication with families
Open, empathetic communication is essential when sentinel injuries raise NAT concerns. A transparent, non-accusing language helps families participate in the evaluation and protects the physician-patient relationship. Typical framing includes explaining that the finding is unusual for the child’s age and warrants further assessment to exclude medical causes and identify any additional injuries, followed by a plan for hospitalization if indicated.
Possible dialogue approaches include: describing the injury, stating the need for additional investigations to rule out medical or traumatic causes, expressing concern about the child’s safety, and clarifying that clinicians are not assigning blame but ensuring the child’s well‑being. If legal obligations arise, clinicians should inform families of mandatory reporting procedures and the role of child-protection services.
Care pathways and follow-up
When NAT is suspected or confirmed, early involvement of a specialized team—such as a Child Abuse and Neglect (CAN) unit—facilitates coordinated care, social assessment, and protection planning. The care pathway includes clear diagnostic steps, timely imaging, and appropriate referrals while preserving the child’s safety and continuity of medical care. Siblings and other household contacts may also require evaluation according to established guidelines to prevent recurrent harm.
Conclusions and recommendations
Structured NAT screening protocols reduce variability in care, improve detection of both overt and occult injuries, and help ensure timely protection for at‑risk children. Updating national guidelines to harmonize best practices can support frontline clinicians in recognizing sentinel signs, conducting appropriate investigations, and engaging families with compassion and clarity. Early identification and multidisciplinary management are essential to prevent escalation to more severe forms of trauma and to safeguard the health and development of vulnerable infants.
