Non-accidental injury

Question 1

A 2 month old boy is brought into the ED by his mother following a fall from the change table at home. According to the mother he had an unwitnessed fall off the change table onto a carpeted floor whilst in the care of her new partner. The baby reportedly cried straight away following the fall and quickly settled. When she got home, he was asleep, however since waking he has been inconsolable with a high-pitched cry. You find the patient to be irritable and drowsy with bruising to the left ear and neck.

Answer 1

Impression
In this child presenting with an unwitnessed fall and bruising to the ear and neck, I am concerned about the cause of the patient’s injuries being of a non-accidental nature given the historical report inconsistent with the developmental capabilities of the baby. There are other considerations in this presentation pertaining to the injuries sustained by the baby including;

Rule out initially;

• Head: brain injury, C-spine and facial/base of skull fractures
• Bruising: bleeding diathesis (haemophilia, , coagulopathy, platelet disorders birth marks

Goals

• implement a SCAN protocol (suspected child abuse and neglect) to assess possibility of NAI
• targeted Hx/Ex/Ix to determine extent of injuries sustained/underlying medical cause of injuries
• provide appropriate management in consultation with the child protection unit (CPU)
• initial assessment for HD stability, evidence of facial/intracranial injuries with raised ICP, base of skull fractures

Question 2

NAI - SCAN protocol + history

Answer 2

SCAN protocol -
Suspected child abuse and neglect;
- record a detailed history of the incident and document it verbatim (to then check for changing of story etc)
o ask around the
- REDS: injuries despite no significant trauma, implausible history for degree of injury, delay in seeking care, caregiver history changes with retelling, severe injuries blamed on child etc

• Paediatric history, developmental milestones
• O&G history
• family history of easy bruising etc

Question 3

NAI - Examination

Answer 3

Examination
- Observe behaviour of carer with child (quality, manner towards staff, affect, etc)
- Physical examination of the child
   0 Examine without the carer around
   0 growth parameters
   0 Top to toe for additional injuries
       - ENT
       -  Fundoscopy
       - cardio, resp, MSK
       - other signs of neglect (malnourished)
- Neuro exam: focal neurology, 
- Medical photography of the injuries

Question 4

NAI - Investigations

Answer 4

Investigations
Key
- MRI Brain + C Spine for injuries
- CT head (senior consult given radiation exposure)

• bloods: FBC, peripheral smear, coags, UEC, LFT
• other imaging (X-Rays) for other injuries sustained
• skeletal survey: fractures at different stages of healing

Question 5

NAI - Management

Answer 5

Management
1- Injuries sustained
2- social situation

1- Depending on nature and degree of injuries
o immobilisation
o other supportive
o peads/neuro input for any cranial injuries
o admission to ICU

2 - Social situation

• Admission to hospital if concerns over Childs safety, or for medical issues
• Discuss with seniors + CPU
• mandatory reporting of suspected child abuse, check the mandatory reporters guide for next steps, involvement of FACS
• Good to be forward and up front with parents about concerns and need for input from CPU
• Clear documentation of all assessments and consultations
• call security and not allow boyfriend onto the hospital premises

Question 6

NAI - What to be suspicious of NAI

Answer 6

NAI
< 6 months
- any bruise
- any fracture
- any burn
- frenulum injuries

Shaken baby

• sub-dural Hb
• metaphyseal injuries
• retinal Hb
• rib fractures
• diffuse axonal injuries