High prevalence of non-accidental trauma among deceased children presenting at Level I trauma centers in the Netherlands
Authors: Loos Marie-Louise H. J. , Bakx Roel , Duijst Wilma L. J. M. , Aarts Francee , de Blaauw Ivo , Bloemers Frank W. , Ten Bosch Jan A. , Evers Martina , Greeven Alexander P. A. , Hondius Marie-Josée , van Hooren Roland L. J. H. , Huisman Erik , Hulscher Jan B. F. , Keyzer-Dekker Claudia M. G. , Krug Egbert , Menke Jack , Naujocks Tatjana , Reijnders Udo J. L. , de Ridder Victor A. , Spanjersberg W. Richard , Teeuw Arianne H. , Theeuwes Hilco P. , Vervoort-Steenbakkers Will , de Vries Selena , de Wit Ralph , van Rijn Rick R. ,   on behalf of the AsAnTe study group, de Boer Anne , Dorn Tina , Edelenbos Esther , Goslings J. Carel , Kooiker Steven , Michielsen Irma , van Sommeren Lia P. G. W. , Toor Annelies , Affourtit Marjo , van Ditshuizen Jan C. , Wijnen Rene M. H. , Kempink Dagmar R. J. , Bessems Gert J. H. J. M. , Hagenaars Tjebbe , den Hartog Dennis , Jansen M. A. C. , Allema J. H. , Kanters Floris E. P. , Aalbers-Hiemstra Annemieke , Beunder Saskia , Mulder Arnaud , Smiers Frans , Hartendorf Rina C. , Fiddelers Audrey A. A. , Levelink Birgit , Poeze Martijn , de Heus Gisela , Soerdjbalie-Maikoe Vidija , Edwards Michael J. R. , Tromp Tjarda N. , Beuker Benn , Reininga Inge H. F. , Wendt Klaus , Aspers Stasja J. G. , van de Putte Elise M. 
Published: November 2021

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.