Non-accidental injury (NAI) refers to injury caused to abuse or neglect. It is not exclusively a paediatric issue but of course with the dependence and vulnerability of this demographic it is an issue that is highlighted extensively within paediatrics. There has been extensive media coverage with certain cases of children who ultimately died due to recurrent failure of healthcare professionals and authorities to identify the abuse, for example with Victoria Cllimbie (aged 8 years old) and Peter Connelley (Baby P, aged 17 months old)
The NSPCC estimates that approximately 58,000 are in need of abuse protection.
⚠️ Risk factors
- History of intimate partner violence and abuse (IPV) - refers to physical, sexual, psychological, emotional, verbal and financial abuse.
- Substance abuse of caregivers
- Mental health condition in caregivers
- Excessive crying - especially at 0-4 months old has been shown as a trigger for excessive shaking of infants which can lead to injuries.
- Unintended pregnancy - carry a 3x higher odds ratio for maltreatment.
- Developmental problems - 2x likely to have maltreatment.
😷 Presentation
- Bruises - it is important to take note of the shape, pattern and age of bruises. It is important to also take note of bruises in patient’s who are immobile.
- Bites
- Lacerations/abrasions - especially when seen around face, ankles, wrists.
- Thermal injuries - especially in regions where you would not expect to come into contact with hot objects (such as soles of feet, buttocks, back, dorsum of hand).
- Eye trauma - retinal haemorrhage without explanation is suspicious of NAI.
- Intracranial injuries - especially when there is no adequate explanation, child <3 years old, concomitant injuries/ long bone or rib fractures/subdural haemorrhage.
- Fractures - fractures in healthy children should be investigated for NAI. Some more suspicious fractures include:
- Metaphyseal corner fractures (bucket handle fractures) - pathogonomic of NAI. It occurs with back and forth shaking often.
- Occult rib fracture - occult means it is unable to be seen on X-ray. This is common in children who have been grabbed by the chest and squeezed/shaken.
- Spiral fractures - occur as a result of twisting forces and are suspicious of NAI.
🔍 Investigations
The Royal College of Radiologists has guidelines on what imaging to do when NAI is suspected:
- X-ray - for a skeletal survey is to be done initially and repeated within 11-14 days. This should be done for the:
- Head/chest
- Spine/pelvis
- Upper limbs
- Lower limbs
🧠 Neurological imaging:
- Acute presentation - CT head
- Non-acute presentation - MRI head to be done within 1 week of presentation.
👮♀️ Reporting
Child services should be involved very early on when it comes to suspected NAI. The child may need admitting to a paediatric ward while a social worker makes urgent enquiries and pieces together a safety plan.
A senior paediatric review should also be done.
🚨 Complications and errors
There are a few areas where child abuse may slip through the cracks of the system:
- Recognition - if staff are not looking for NAI, or lack the skills and experience, it may easily be missed.
- Communication - as many teams may be involved, a failure to communicate will certainly lead to mismanagement of the case.
- Note keeping - all documentation should be dated, timed with the patient and clinician’s details. Trends should be recognised for recurring themes of suspicious injuries.
It is the responsibility of the medical professional to raise an alarm if a concern is noted. Do not do nothing.