Introduction: Nonaccidental trauma (NAT) is a leading cause of trauma mortality in infants and toddlers. Available data indicate delayed recognition may affect nearly 20% of NAT cases. We hypothesize that unlike critically ill children initially evaluated at a tertiary pediatric center, those requiring secondary transfer may be at higher risk for delayed recognition. We aim to assess patterns of NAT recognition and report patients’ characteristics at our Level 1 Pediatric Trauma Center. Methods: We retrospectively reviewed the charts of children ≤2 years old admitted to our institution’s PICU between 7/1/2016 and 6/30/2023 who had a discharge diagnosis of NAT. We compared characteristics of patients who initially presented to our ED vs transferred from a referring facility. Data pertaining to initial presentation, transport, and hospital course were compared using Mann-Whitney U test post hoc and one-way ANOVA. Results: 83 patients were included: 54 (65.1%) transferred (TX group) vs 29 (34.9%) presented to our ED (ED group). Initial presentation and hospital course did not differ between groups. Compared to the TX group, the ED group included a lower proportion of white (p=0.007) and a higher proportion of African American patients (p< 0.002). Among the ED group, NAT was suspected for 89.7% (26/29) and not suspected for 10.3% (3/29) of patients during their ED evaluation. In contrast, among the TX group, 37% (20/54) had a pretransfer diagnosis of NAT and another 37% (20/54) had documented suspicion in the transfer records, whereas 25.9% (14/54) had no NAT concern pretransfer. Within the TX group, patients without NAT concern pretransfer had higher Pediatric Transport Triage Tool (PT3) scores (median: 6 vs 1 vs 2, p=0.03) and higher rates of pretransfer intubation (50% vs 20% vs 15%, p=0.05) compared to those diagnosed with or suspected of NAT. Conclusions: Among critically ill children with NAT at a Level 1 Pediatric Trauma Center, transferred patients may have had higher rates of delayed recognition compared to those initially evaluated in our ED, despite no difference in severity of illness. Transferred patients without initial NAT concern presented with higher acuity than those where NAT was suspected, questioning whether urgency of medical stabilization may have contributed to delays in recognition.
Hwang et al. (Sun,) studied this question.