Non accidental injury Flashcards
How many children die a week of child abuse
1-2 c
One in four young adults have experienced severe child abuse
General signs of neglect
Dirty skin, nappy rash, dirty and tangled hair, uncut nails, etc
How many children a year in the uk need child protection
50,000
Physicla ecicenc
Evidence old injuries
Multiple bruising
Xray - old and new fractures
Tearing of frenulum behind upper lip
Cigarette burns, bite marks
Indications of bleeding insice skull/brain
Child may well be withdrawn facial appearacnec fear - frozen watchfulness
STI/pregnancy
What is frozen watchfulness
Physcial abuse themselves
Witness domestic abuse
Watch everything thats happening around them
When are sus of NAI raised
Delay in presenation
Vague, elusive or changing history
Angry or abusive parents even when gently questioned
Discrepancy between witnesses, history and findings
Injuries in very ypung pre-mobile children
Risk factors child abuse
Prev episodes
Abuse in sibling
Single poorly supported parent
Domestic abuse
Substancve misuse in parent
Parent mental ill health
Child with disability
Long time in NICU
Toxic trio
Substance misuse
Domestic abuse
Parental mental ill health
What do not mention to parents about safeguarding?
Fabricated illness
What can do when concerned about safeguarding
Ring social services for advice - dont have to refer
Infrom parents
Speak to multiple seniors
Investigations fo rNAI
Blood test - FBC, coag screen
Skeletal survey
CT head
Opthalmoscopy
What is a askeletal survey
Radiographs skull, thorax, long bones, hands, feet, pelvis and spine
Repeat 7-10 dyas - can see healing fractures that may ahve been missed
Indications for skeletal survey
<2 any evidenve abuse
<5 suspicious fracture
Older child unable to communicate pain
NAI classical injuries
Classical metpahysal lesions
Posterior rib fractures
Scapular fractures
Spinous process fractures
Sternal fractures
Moderate specificity lesions
Multiple fractures
Fractures different afes
Epipjysea seperatuns
VERTEbral bodu fractures and subluxations
Digital fractures
Low specifity lesions
Clavicular
Long bone
Subperticular fractures
What see on X ray in calssic metaphyseal fractures
Bucket handle - metaphysis gets sepreated
Corner fracture - corner sliced off by tendon - avulsion fracture
CT hea dscan indications
All children under 1 if sus NAI
Any child with neurological symptoms
What look for on CT head NAI
Subdrual bleeding
Diffuse axonal injury
Differential diagnosis
Accidental injury
Osteogensis imperfecta
Clotting disorders
Mongolian blue spot
Scalded skin syndrome
Osteogensis imperefecta
Autosomal dominant
Variable everity
Mongolian blue spot
Scalded skin syndrome
Groin and armpits staph infeciton
Treat with antibiotics
Unclear demarcation lines
Referal to social care
Telephone-> in writing
Arrange assessment incl police
Child protection investigation if appropriate
Case conference - write report on child
Sus abuse outcomes
Removal to place of safety - emergency foster carer
Case caonference
Child protection plan
Allow home with supervision and support
care by other relative
Foster care
How much more likely is physical abuse when intimate partner violence occurs in first 6 months of life?
3.4 times as likely
Indirect questions to ask in a history around NAI
Is everything ok at home
Is your partner supportive
If woman is preganant - looked after properly? partner taking care of you>
Direct questions for NAI
Do you ever feel frightened of your partner
Have you ever been in a relationship where you have been hit or hurt in some way
Are you currently in a relationshup where thats happening to you
Risk factors
Exceddive crying
Unintended pregnancy
Developmental problems
What to not about bruises in NAI
Shape - hands, linear, ligatures
Pattern - non bony parts of body
Multiple brusies or clusteres bruises
Age - if cant mobilise - cant cruise dont bruise
When should suspicions be high in lacerations or abrasions?
In non-mobile children
Symmetrically
Around face
Around ankles or wrists in position of ligature
Where do thermal injuries raise sus of NAI?
Soles of feet
Buttocks/back
Back of hands
Shape - concerivbale implement eg cigarette or iron
Sharply delineated borders - immersion injury 0 donut (where bottom in contact with bottom of bath and rest is burned by water)
Fractures when to investgiate for NAI
Single or mulitple ni those without medical condition predisposing
Different age fractures esp when no documentation
Metaphyseal corner fractures
Occult rib fractures - shaken
Spiral fractures
When to suspect NAI with intracranial injuries
Without adequate explanation
< 3
In presence of:
Retinal haemorrhage
Rib o rlong bone fracture
Ass injuries
Multiple subdural haemorrhgae
Differentials for NIA
Coagulopathy - excessive bruising and haemarthrosis
FH present - coag screen
Osteogensis imperfecta - FH + X ray
When should a skeletal survey be repeated
11-14 days - periosteal reaction
Acute vs non acute head presentation
Acute - CT
Non acute - MRI within a week
What cna US be used for
can be used to diagnose metaphyseal and rib fractures as well as identifying subperiosteal fluid.
What happens when sus NAI?
- The child may be admitted to a paediatric ward as a place of safety whilst a social worker makes urgent enquiries and puts a safety plan in place.
- Senior paediatric/child protection review should be undertaken.
- A skeletal survey should be considered.
- If abusive head trauma is suspected, the child should be referred for ophthalmology review to identify possible retinal haemorrhages.13
