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Non-Accidental Injury

Non-accidental injury (NAI) is common, and potentially life-threatening. It can present with musculoskeletal problems, such as pain, swelling or limping, and all healthcare professionals who have contact with children should be alert to the possibility of abuse. Early intervention is crucial, and any concerns about neglect or abuse should be discussed with senior clinical staff or the designated child protection lead, to protect vulnerable children. Ensure that you are familiar with your local procedures and protocols for child protection.

Priority is to place the child in a safe environment (i.e., admit the child to the ward). It is important that the child is assessed by a paediatrician to exclude life threatening injuries. The child needs assessment for nutritional status and social circumstances to address their safety. Remember that abuse can be of various types - physical, emotional, sexual and neglect.

Points to consider in detecting NAI:

  • Is the history variable or inconsistent with the injuries seen?
  • Was there a delay in seeking attention following an injury? 
  • In a limping child – could this be due to a fracture or soft tissue injury? Is there a history of trauma, and is it consistent with the injury? 
  • Are there multiple injuries? 
  • Are there multiple attendances to the Emergency department, primary care or other healthcare services? 
  • Are there signs of neglect, such as an unkempt, persistently dirty or smelly child - and especially in a child with learning difficulties or chronic illness?
  • Are the findings consistent with the developmental age of the child?

Certain patterns of injury are suggestive of NAI:

  • Bruising in a non-mobile child.
  • Bruising over soft tissues, multiple bruises, clusters of bruises, bruises in the shape of a hand or implement or instrument.
  • Burns in particular shapes e.g., cigarette burns, burns suggestive of forced immersion.
  • Exclude bruising or soft tissue swelling due to medical causes – e.g., vasculitis, coagulation disorders. 
  • Exclude metabolic bone disease with recurrent fractures (e.g., osteogenesis imperfecta or osteoporosis secondary to chronic corticosteroids).
  • Remember a child with an organic diagnosis and especially chronic illness or disability may still be at risk of abuse or neglect.
  • Certain types of fractures are more suggestive of abuse than others (although none are pathognomonic) e.g., classic metaphyseal lesions, usually caused by twisting/shearing forces, posterior rib fractures (from squeezing), skull fractures, any fracture before walking age.
  • Any fracture in a non-mobile child should raise concern about NAI.

Further information

NICE Guideline: When to suspect child maltreatment. 

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