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, with poor hygiene?
• 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.
• Bruises at different stages of resolution as suggested by bruises of different colours.
• Burns in particular shapes or distributions (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 corticosteroid use).
• 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 (e.g., classic metaphyseal lesions which are usually caused by twisting/shearing forces, posterior rib fractures [from squeezing] and 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 (and detect old fractures). It is important to consider repeating 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 assessment (evidence from shaking / trauma may be evident e.g., retinal haemorrhages).
• Full [Complete] Blood count (to exclude thrombocytopenia) and coagulation screen.

Conditions that may mimic NAI:

• Metabolic bone disease - primary osteoporosis (osteogenesis imperfecta [OI] or ‘brittle bone disease’) or secondary osteoporosis (e.g., from chronic corticosteroid exposure, immobility or malabsorption). The OI type commonly involved with unexplained fractures is Type I (Autosomal Dominant and often with a family history); blue sclerae are a clinical finding and there may be generalized osteoporosis and wormian bones in the skull on skeletal survey.
• 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.