The association of non-accidental trauma with historical factors, exam findings and diagnostic testing during the initial trauma evaluation.

Early identification of non-accidental trauma (NAT) is a critical component of pediatric trauma care. Literature searches were conducted related to the association of NAT with seven key areas: history, exam findings (burns, oral trauma, bruising) and imaging (fractures, abdominal and brain injuries). When available, odds ratios (OR) with 95% confidence intervals (CI) for associations with NAT are presented. Systematic reviews have been published in six of the seven key areas and are described. The operational definition of NAT was widely variable across studies, prohibiting meta-analysis. Select highly associated findings included bruising in a pre-mobile child, clustering of bruises (OR 4.0, CI 2.5-6.4), petechiae (OR 9.3, CI 2.9-30.2), chemical burns 24.6 (4.94-135); contact burns 5.2 (1.6-22.9); scald burns 17.4 (6.4-72), burns to hand 1.8 (1.3-2.6), feet 6.3 (4.6-8.6), buttocks 3.1 (2.2-4.5), and perineum 2.5 (1.7-3.7), subdural hematoma (OR 8.2, 6.1-11), hypoxic ischemic injury (OR 4.2, CI 0.6-2.7), and retinal hemorrhages (OR 14.7, CI 6.4 to 33.6) among others. Of note, hollow viscus injuries, particularly duodenal injuries in children < 4 years were indicative of NAT. While there is substantial research on factors associated with NAT, future work is needed to standardize the definition of NAT for investigation and practice, such that evidence-based guidelines can be created to inform trauma providers when a comprehensive NAT evaluation is indicated.