High prevalence of non-accidental trauma among deceased children presenting at Level I trauma centers in the Netherlands

Abstract

Purpose: Between 0.1-3% of injured children who present at a hospital emergency department ultimately die as a result of their injuries. These events are typically reported as unnatural causes of death and may result from either accidental or non-accidental trauma (NAT). Examples of the latter include trauma that is inflicted directly or resulting from neglect. Although consultation with a forensic physician is mandatory for all deceased children, the prevalence of fatal inflicted trauma or neglect among children is currently unclear.

Methods: This is a retrospective study that included children (0-18 years) who presented and died at one of the 11 Level I trauma centers in the Netherlands between January 1, 2014, and January 1, 2019. Outcomes were classified based on the conclusions of the Child Abuse and Neglect team or those of forensic pathologists and/or the court in cases referred for legally mandated autopsies. Cases in which conclusions were unavailable and there was no clear accidental cause of death were reviewed by an expert panel.

Results: The study included 175 cases of childhood death. Seventeen (9.7%) of these children died due to inflicted trauma (9.7%), 18 (10.3%) due to neglect, and 140 (80%) due to accidents. Preschool children (< 5 years old) were significantly more likely to present with injuries due to inflicted trauma and neglect compared to older children (44% versus 6%, p < 0.001, odds ratio [OR] 5.80, 95% confidence interval [CI] 2.66-12.65). Drowning accounted for 14 of the 18 (78%) pediatric deaths due to neglect, representing 8% of the total cases. Postmortem radiological studies and autopsies were performed on 37 (21%) of all cases of childhood death.

Conclusion: One of every five pediatric deaths in our nationwide Level I trauma center study was attributed to NAT; 44% of these deaths were the result of trauma experienced by preschool-aged children. A remarkable number of fatal drownings were due to neglect. Postmortem radiological studies and autopsies were performed in only one-fifth of all deceased children. The limited use of postmortem investigations may have resulted in missed cases of NAT, which will result in an overall underestimation of fatal NAT experienced by children.

Keywords: Child; Child abuse; Deceased; Neglect; Non-accidental trauma; Postmortem investigation.

Fig. 1

The Dutch medico-legal system of postmortem investigation in children. In the Netherlands, the DA decides whether postmortem investigations should be performed. This decision is based on information from the police and forensic physician. The forensic physician examines the child externally, collects the clinical history and results of investigations performed at the hospital. Postmortem legal investigations (autopsy, imaging, toxicology) are requested by the DA after consultation of the forensic physician and police and based on their information the cause of death is highly suspected for a crime. The forensic physician is a medical doctor specialized in forensic medicine (duration of forensic medicine specialization is 3 years). The DA has a bachelors and master’s degree in (criminal) law together with an additional training at the public prosecutors office of 4 years. Few DA’s are specialized in child abuse. Cases of pediatric deaths are handled by the DA on call (who may or may not be specialized in child abuse).

Fig. 2

Classification of cases of the total study group.