Suspected Non-Accidental Injury
Points to consider in detecting non-accidental injury (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 eg cigarette burns, burns suggestive of forced immersion.
- Exclude bruising or soft tissue swelling due to medical causes – eg 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 in a non-mobile child should raise concern about NAI.
Investigations to consider in a child with fracture and suspected NAI
- Skeletal survey to exclude fractures elsewhere [or multiple fractures from more than one occasion] – it is important to consider repeat X-rays after 11-14 days if there are concerns about possible fractures, as early changes can be missed.
- CT scan head followed later by MRI scan.
- Ophthalmology opinion (evidence from shaking / trauma may be evident).
- Full [Complete] Blood count (to exclude thrombocytopenia) and coagulation screen.
Conditions that may mimic NAI
- Metabolic bone disease (primary osteoporosis - osteogenesis imperfecta or ‘brittle bone disease’). The type commonly involved with unexplained fractures is Type I (Autosomal Dominant, so there may be a family history. Blue sclerae are a clinical finding and there may be generalized osteoporosis and wormian bones in the skull on skeletal survey). Secondary osteoporosis (e.g. from chronic corticosteroid exposure, immobility or malabsorption).
- Copper deficiency – very rare to present with fractures as there is adequate copper in breast milk and milk formula. It can occur in preterm or malnourished babies.
- Scalds and cigarette burns – may be missed if the observed changes are ascribed to bullous impetigo or scalded skin syndrome.
- Bruising tendency e.g coagulation disorders, Idiopathic thrombocytopenic purpura.
See Further Guidance on when to suspect NAI and what actions to take.