Non-Accidental Injury in Children

Non-accidental injury in children is physical harm inflicted on a child by a carer or other person. Recognition requires that the clinician judge whether the injury is explained by the history and the child's developmental stage.

Infants are at highest risk, and most fatal cases occur in children under 2 years. Risk factors include young carers, parental substance misuse, domestic violence, mental illness, social isolation, disability in the child and previous maltreatment.

Injuries include bruises, burns, fractures, head trauma, abdominal trauma and poisoning. Sentinel injuries, such as a minor bruise or intraoral injury in an infant who does not yet cruise, often precede severe abuse.

Pathophysiology.

Injury arises from direct blows, shaking, squeezing, throwing, burning or scalding. Fractures reflect forces such as grabbing and twisting, and posterior rib fractures reflect chest compression.

Mechanism and developmental ability determine plausibility: a child cannot injure themselves in ways that exceed their motor skills.

• History: delay in seeking care, no explanation, vague or changing accounts, an explanation incompatible with the injury or child's development, or blame placed on a sibling.
• Bruising: in non-mobile infants, on the ears, neck, face, trunk, buttocks or genitalia, patterned or multiple bruises, and petechiae.
• Fractures: rib (especially posterior), metaphyseal corner fractures, multiple fractures in different stages of healing, long bone fractures in non-ambulant infants, skull and scapular fractures.
• Burns and scalds: immersion with clear demarcation and symmetry, cigarette burns, and contact burns showing the shape of an object.
• Intraoral injuries, abdominal injury with vomiting or shock, and poisoning.

Red flags.

• Injury in a child who is not mobile.
• Injuries in multiple sites or of different ages, or in the regions rarely injured accidentally.
• Unexplained neurological signs, apnoea, or encephalopathy in infants.
• A previous child protection concern or sibling death.

• Document history verbatim, with times and who gave it, and examine fully including skin, mouth, frenulum, genitals and fundi. Use body maps and consented photographs.
• Skeletal survey in all children under 2 years with suspected abuse, and in older children with indicated concerns, with a repeat limited survey at 11 to 14 days. Radiological expertise is needed to interpret.
• Neuroimaging (CT head urgently, MRI brain and spine) for infants with suspected head injury or neurological signs. Ophthalmology for retinal haemorrhage.
• Blood tests: full blood count, coagulation screen, von Willebrand and factor assays where bruising or bleeding is significant, bone profile, vitamin D, liver enzymes and amylase, and urine toxicology as indicated.
• Genetic or metabolic testing if a bone disease is suspected.

Differential diagnosis. Accidental injury, osteogenesis imperfecta, rickets and metabolic bone disease, bleeding disorders (haemophilia, von Willebrand disease, vitamin K deficiency, thrombocytopenia), Mongolian blue spots, birth injury, infantile cortical hyperostosis, Menkes disease, glutaric aciduria type 1, and skin conditions that mimic bruising or burns.

• Treat each injury on its merits. Resuscitate and stabilise first, and do not delay treatment for safeguarding procedures.
• Where abuse is suspected, inform the senior clinician and the local child protection team on the same day, in line with local procedures. Do not discharge a child with unexplained injury without a protection plan.
• Admit the child if safety at home cannot be assured. Parents should be told of the concern unless doing so places the child at risk.
• Hold a multi-agency strategy discussion involving children's social care, the police and health professionals. Record all findings, decisions and discussions carefully in the notes.
• Examine and screen siblings and other children in the household.
• Seek the opinion of a senior paediatrician with experience in child protection before concluding that the injury was non-accidental or accidental.

Monitoring. Follow up of injuries (fracture healing, scars), development, mental health and social circumstances.

Referral and escalation. Immediate referral for any child with suspected abuse. In emergencies, contact the police if the child is in immediate danger.

Special groups. Infants and children with disabilities are at higher risk and may have more subtle presentations. Fractures in non-ambulant infants are highly suspicious.