17.9 Non Accidental Injury

Question 1

You have anaesthetised a 5-year-old boy for manipulation of a forearm fracture. During the operation, you
notice that he has multiple bruises on his upper arms and body that you think may indicate child abuse.

a) Which other types of physical injury should raise concerns of abuse in a child of this age? (6 marks)

Answer 1

> > Unusual or excessive bruising.

> > Cigarette burns,
other thermal injury.

> > Bite marks.

> > Injuries in inaccessible places:
neck, ear, feet, buttocks.

> > Unexplained intra-oral injury.

> > Ano-genital trauma or
unusual ano-genital appearance.

> > Trauma without adequate history,
delayed presentation,
inconsistent explanations,
e.g. intra-abdominal, rib fractures.

Question 2

b) What timely actions must be taken as a result of your concerns? (7 marks)

Answer 2

1. > > Act in the best interests of the child.
2. > > Respect child’s right to confidentiality,
   although this is not always possible
   in cases concerning actual or possible abuse.
3. > > Check hospital notes for known
   safeguarding issues,
   details regarding
   other members of family.
4. > > Inform:

• Anaesthetic consultant on call.

• Child’s paediatrician,
on-call paediatric consultant if out of hours,
or Safeguarding Team within hours.

• Theatre team: surgeon, senior scrub, ODP.

5. > > Ask the paediatrician to look
   at injuries as long as this does not
   excessively prolong anaesthesia –
   brief visual assessment only.
6. > > Full documentation of findings and actions.
7. > > Consultant paediatrician and anaesthetist
   to discuss the issue with
   parents and child after surgery
   (except in unusual circumstances
   where this may increase risk to child).

• If there is a fully reasonable explanation,
then no further action is taken.

• If there is continued concern,
then the consultant paediatrician should
refer to social care,
possibly involve police
if there is risk to other
children at home,

take full history from child and
carer and consider
need for forensic examination,

and decide whether
it is appropriate for
the child to go home

Question 3

c) List parental factors (5 marks) that are
known to increase the risk of child abuse.

Answer 3

Parent-related factors:
» Step parents.

> > Teenage parents.

> > Substance abuse.

> > Parent abused as a child.

> > Disabled parent.

> > Mental health problems.

> > Single parent.

> > Domestic violence.

> > Social isolation.

> > Unemployment.

> > Poverty.

Question 4

List features of a child’s past medical history (2 marks) that are known to increase the risk of child abuse.

Answer 4

Child-related factors:

> > Chronic physical or mental disability or illness.

> > Prematurity or low birth weight.

> > Unplanned or unwanted child.