Non-Accidental Injury

Children should be protected from violence. 

Non-Accidental Injury (NAI) or Violence Against Children - otherwise known as Child Abuse - is common, potentially life-threatening and often presents with musculoskeletal problems, such as pain, swelling, limping, or non-weight bearing.

All healthcare professionals who have contact with children should be alert to the possibility of abuse whether physical, emotional or sexual. Early intervention is crucial and can be life saving. Any concerns about neglect or abuse should be discussed (with senior clinical staff or the designated child protection lead), to protect vulnerable children. It is important to be familiar with your local procedures and protocols for child protection.

Points to consider in detecting Non-Accidental Injury:

• 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? These may include signs of malnutrition, a child who presents as uncared for (e.g., dirty clothes or poor personal hygiene)
• Are the findings consistent with the developmental age of the child?

Certain patterns of injury are suggestive of Non-Accidental Injury:

• 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.
• Bruises at different stages of resolution (often different colours).
• Burns in particular shapes e.g., cigarette burns, burns suggestive of forced immersion in hot water and may be accompanied by bruises and other signs of injury.
• Certain types of fractures are more suggestive of abuse than others (although none are pathognomonic) e.g., classic metaphyseal lesions or spiral fractures, usually caused by twisting/shearing forces.
• 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 that a child with an organic diagnosis and especially chronic illness or disability may still be at risk of abuse or neglect.

Important policy and resources are listed below:

World Health Organisation  https://www.who.int/news-room/fact-sheets/detail/violence-against-children

The Right to be Safe from Violence (Article 19) Article 19 of the UNCRC 

United Nations https://www.un.org/en/site-search?query=child+abuse

United Nations Children's Fund https://www.unicef.org/sites/default/files/2020-06/Global-status-report-on-preventing-violence-against-children-2020.pdf

International Society for the Prevention of Child Abuse https://www.ispcan.org/wp-content/uploads/2018/10/World-Perspectives-on-Child-Abuse-2018_13th-Edition_Interactive.pdf