Non-Accidental Injury

Non-accidental injury (NAI) is common and potentially life-threatening, and may present with musculoskeletal symptoms such as pain, swelling, reduced limb use or limping. All healthcare professionals who have contact with children should remain alert to the possibility of abuse or neglect. Early recognition and action are essential to protect vulnerable children. Any concerns about possible abuse should be escalated immediately to senior clinical staff and the named/designated safeguarding lead, in line with local child protection procedures.

Immediate priorities

The priority is the child’s safety. Where there is concern about NAI, the child may need to be placed in a safe environment (often admission to hospital) while assessment is undertaken. A child with suspected NAI requires a full paediatric assessment to exclude life-threatening injury, and to consider nutrition, development and social circumstances. Remember that abuse may be physical, emotional, sexual, or related to neglect, and more than one type may be present.

Points to consider when assessing possible NAI

A safeguarding concern should be considered when the history is variable, inconsistent or does not fit the injuries seen; there is delay in seeking medical attention; a child presents with limp or limb pain and there is no clear trauma history or the mechanism does not match the injury; there are multiple injuries or repeated injury presentations; there have been multiple attendances to healthcare services; there are signs of neglect (for example an unkempt or persistently dirty child), particularly in children with learning disability or chronic illness; or the findings are not consistent with the child’s developmental age (for example injuries in a non-mobile infant).

Injury patterns that raise concern

Certain patterns of injury are more suggestive of NAI and should prompt urgent safeguarding review.

Bruising is particularly concerning in a non-mobile child, or when bruising occurs over soft tissues, is multiple or clustered, or has a recognisable pattern (such as hand marks or implement marks). Burns are concerning when they have a clear pattern, for example cigarette burns or burns suggestive of forced immersion.

Certain fracture patterns are also more suggestive of abuse (although none are individually diagnostic), including classic metaphyseal lesions, posterior rib fractures, skull fractures and any fracture in a child who is not yet walking. Any fracture in a non-mobile child should trigger concern and prompt safeguarding escalation.

Important differentials

While safeguarding concerns must be acted upon promptly, it is also important to exclude relevant medical causes where indicated, including bruising due to coagulation disorders or vasculitis, and recurrent fractures due to metabolic bone disease or osteogenesis imperfecta. A child with an established medical diagnosis, particularly a chronic illness or disability, may still be at risk of abuse or neglect.

Further guidance

NICE Guideline: When to suspect child maltreatment.