Non-accidental injury

Question 1

What are RF’s for non-accidental injury (NAI)?

Answer 1

Hx of Intimate Partner Violence and Abuse

Substance Abuse or Mental Health Condition in one or both caregivers

Excessive crying

Unintended pregnancy

Developmental problems

Child: disability, “wrong gender”, result of non-consensual sex

Parent: Mental health problems, substance misuse, indifference

Family: domestic violence, social isolation, young age, multiple births, step rather than biological parent

Environment: poverty, poor housing

Question 2

Hx of Intimate Partner Violence (IPC) and Abuse as a RF?

Answer 2

• Physical, Sexual, Psychological, Emotional, Verbal, Financial, Neglect, Fabricated induced illness
• Study showed that if IPV occurred w/in child’s first 6 months, physical abuse is ~ 3 times more likely
• If IPV is suspected, but not documents, discuss immediately with senior

Question 3

What questions can you ask to elicit hx of IPV?

Answer 3

Indirect questions:
- Is everything ok at home?
- Is your partner supportive?
- If the woman is pregnant:
– Are you being looked after properly?
– Is your partner taking care of you?

Direct questions:
- 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 relationship where this is happening to you?

Question 4

How can substance abuse or Mental health condition in one or both caregivers increase NAI risk?

Answer 4

through increased burden on the caregiver/caregivers

Question 5

How is excessive crying a RF for NAI?

Answer 5

Excessive crying, especially aged 0-4 months old, has been identified as a trigger for shaking of infants.

This is a common cause of NAI

Question 6

How is unintended pregnancy a RF for NAI?

Answer 6

Study found that unintended pregnancy carried an odds ratio of 2.92 for maltreatment/NAI

Question 7

How are developmental problems a RF for NAI?

Answer 7

Children with developmental concerns were twice as likely to suffer maltreatment during a study within the UK.

This may be due to the increased burden on caregivers, caused by these children’s complex health needs.

Question 8

What should raise suspicion about NAI?

Answer 8

Presentation
Hx
Timeframe
Pt presenting late with obvious injury
Implausible hx for the presenting complaint

Question 9

What different sx may present?

Answer 9

Bruises
Bites
Lacerations/Abrasions
Thermal Injuries
Fractures
Intracranial injuries
Eye trauma
Other

Question 10

What features should you look at in bruises?

Answer 10

Shape
- Worrying: shaped like hands, linear brushes, ligatures, identifiable implement

Pattern
- Bruises on non-bony parts of the body or face/ears
- Multiple (of uniform shape) or clustered bruises
- Bruises a/w petechiae

Age
- Be suspicious of bruises in a child who cannot mobilise
- Remember “if they can’t cruise they don’t bruise”
- Bruising in babies

Question 11

What features of bites should you look at?

Answer 11

• Any bit which appears to be human should be treated as suspicious - can be caused by other children but must get an adequate explanation
• Animal bights not classical NAI but may be sign of poorly supervised child

Question 12

What features should you look at in lacerations?

Answer 12

High suspicion if laceration seen:
- In non-mobile children
- Symmetrically
- Around the face
- Around the ankles or wrists, in the position a ligature could be applied

Always get an adequate explanation!

Question 13

When should you suspect NAI in terms of thermal injuries?

Answer 13

Affected area:
Suspect NAI where thermal injuries are in locations you would not expect to come into contact with a hot object:
- Soles of the feet
- Buttocks/back
- Backs of hands

Shape of the burn/scald
- Suspect NAI where an injury is in the shape of a conceivable implement such as a cigarette or iron
Scalds with sharply delineated borders should arouse suspicion (consider immersion injury)

Question 14

What features should you assess in a fracture?

Answer 14

• Fractures, single or multiple, in children WIHTOUT a medical condition predisposing them to fragile bones, should be investigated for NAI.
• Fractures of different ages, especially where there is no documentation of caregivers seeking medical attention, are highly suspicious of NAI.
• Metaphyseal corner fractures – reported as almost pathognomonic of NAI.
• Evidence of occult rib fractures is also a common finding in infants/children who have been grabbed by the chest and squeezed/shaken.
• Spiral fractures are a result of twisting forces so cannot be caused by simple falling, and are highly suspicious of NAI

Question 15

When should you suspect NAI with intracranial injuries?

Answer 15

Suspect NAI where intracranial injury presents:
- Without an adequate explanation
- In a child < 3 y/o
- In the presence of:
– Retinal haemorrhage
– Rib or long bone fractures
– Other associated injuries
- With multiple subdural haemorrhages

Question 16

What eye trauma is suspicious of NAI?

Answer 16

Retinal haemorrhages with no medical explanation

Question 17

What other injuries raise suspicion for NAI?

Answer 17

Spinal injuries or visceral injuries without a history of major trauma should be thoroughly investigated for suspected NAI.

Question 18

What are DD’s of NAI?

Answer 18

Coagulopathy
- May lead to excessive bruising and haemarthrosis.
- FHx most likely present, but coagulation screening should be undertaken to rule this out.

Osteogenesis Imperfecta
- FHx may be present, and the condition would typically be detected early in life.
- X-ray findings typically show decreased bone density, so a skeletal survey would rule this out.

Question 19

How should abuse be assessed for?

Answer 19

General hx
Family setup
Siblings
Parents - work, health, drugs
Social care involvement
Police involvement
Examination - body, map, observation

Question 20

What investigations can be done in cases of child abuse?

Answer 20

Bloods - ?clotting in bruising

Skeletal survey - Fractures

CT brain - Intracranial haemorrhages

Ophthalmology - Retinal haemorrhages

Forensic
- Child death
- Sexual abuse

Question 21

What imaging is required in suspected NAI?

Answer 21

Skeletal survey

Follow up imaging

Neurological imaging

Alternative Skeletal imaging

Question 22

What does a skeletal survey entail?

Answer 22

Head/chest (including AP and lateral skull)
Spine/pelvis
Upper limbs
Lower limbs

Question 23

What does follow up imaging entail?

Answer 23

Skeletal survey repeated at 11-14 days - to ensure that injuries too new to appear on the initial skeletal survey are detected.

11-14 days is used as this is the maximal time take for the periosteal reaction to occur, allowing fractures to be visualised on X-ray.

Question 24

What does neurological imaging entail?

Answer 24

Depends on timing of presentation

Acute presentation:
- CT head as soon as pt is stabilised on the day of the presentation

Non-acute presentation
- MRI head performed as soon as possible, within a week of presentation

Question 25

What alternative skeletal imaging may be done?

Answer 25

CT more sensitive in diagnosing rib fractures, but has higher radiation dose and so may be used if rib fractures are suspected, but CT Chest is not currently routine.

USS can be used to diagnose metaphyseal and rib fractures as well as identifying subperiosteal fluid.

Question 26

How should suspected NAI cases be reported?

Answer 26

• All suspected cases: involve children’s services from an early stage
• May be admitted to paed ward as a place of safety while 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.

Question 27

What must be done in terms of other children?

Answer 27

identify any other related/associated children as they may also be at risk

Duty of Child Protection, Social Services and Police colleagues

But must establish who else is in the home and if the child has siblings when taking any paediatric history.

Question 28

How should a child presenting with clinical features a/w NAI be managed?

Answer 28

Carefully assess:
- Hx
- Appearance, behaviour or demeanour
- Interaction b/ween child and parent/carers
- Physical signs and sx
- Report of maltreatment from anywhere
- Results of investgiatiosn

Seek explanation for any injury/presentation
- Unsuitable if implausible, inadequate, or inconsistent with presentation

Document
- What was observed/hear from whom and when
- Any concerns (incl. minor concerns)
- Decisions or actions relating to those concerns
- Any outcomes

Escalate
- Concerns to in-charge
- To other agencies using designated paperwork (eg. MARF)
- Contribute to safeguarding process (meetings)

Consider
- Safe place - admit?

Question 30

How should a pt be managed if there are injuries/features that have led you to suspect child maltreatment?

Answer 30

• Manage individual injuries: admit if required, inform paeds
• If pt in immediate danger: refer to social care or police, consider safety of other children as relevant
• If child not in immediate danger: contact social care and consider referral to them, using multi-agency safeguarding procedures

Question 31

How should a pt be managed if sexual abuse is suspected?

Answer 31

• do NOT do examination unless urgent health need to do so
• Open-ended questions to enquire about causes and circumstances
• Refer urgently for collection of forensic evidence (where appropriate)
• Assess need for emergency contraception
• Assess need for STI prophylaxis

Question 32

What are the timescales for DNA gathering in terms of forensics and suspected sexual abuse?

Answer 32

Up to 7 days after vaginal penetration
Up to 2 days after oral penetration
Up to 3 days after anal/penile presentation

Question 33

Whom should child maltreatment be discussed with?

Answer 33

Any concerns about a child’s or young person’s safety or welfare should ideally be discussed with their parents.

Sometimes, a child/young person may request that information is not shared with a parent, or you may decide that discussion with the parents may increase their risk of harm.

If there is uncertainty, seek advice from named or designated colleagues, and/or your practice safeguarding lead/deputy lead.

Question 34

When and how should one seek consent to share information?

Answer 34

1. Always obtain consent before sharing confidential information unless there is reason to believe that this will increase the risk of harm to the child/young person.
   - Don’t let this delay disclosure of important info
   - Ideally, consent should be in writing
   - Confidential info may be shared without consent if required by the law or directed by a court, of it the benefits to the pt outweigh the risks
2. Discuss the following when requesting consent:
   - The reason for sharing the information and how it will benefit the child or young person.
   - The information that will be shared.
   - Who the information will be shared with.
   - How the information will be used.
   - The consequences of their information not being shared.
3. If the pt refuses consent
   - Consider reasons for refusal
   - Remember safety is paramount
4. If info is shared without consent
   - Explain the reason to the child or young person (unless doing so will cause more harm)
5. Document all actions on clinical record

Question 35

What does the care act 2014 do?

Answer 35

Sets out in one place, local authorities’ duties in relation to assessing people’s needs and their eligibility for publicly funded care and support.

Question 36

What are the principles of the care act?

Answer 36

Empowerment
Protection
Prevention
Proportionality
Partnership
Accountability

Question 37

What MSK signs may NAI have?

Answer 37

pain, swelling, limping, or non-weight bearing.

Question 38

What is the most common type of NAI?

Answer 38

Head injury – sometimes referred to as Shaken Baby Syndrome.

Skin injuries, such as; bruising, blistered, burns, and bites.

Bone injuries, such as fractures including greenstick, skull and depressed.

Question 39

What are the criteria for immediate CT Head in paediatrics?

Answer 39

• LOC > 5 minutes (witnessed)
• Amnesia (antegrade or retrograde) lasting > 5 minutes
• Abnormal drowsiness
• 3+ discrete episodes of vomiting
• Clinical suspicion of NAI
• Post-traumatic seizure but no hx of epilepsy
• GCS < 14, or for a baby under 1 year GCS (paediatric) < 15, on assessment in the emergency department
• Suspicion of open or depressed skull injury or tense fontanelle
• Any sign of basal skull fracture (haemotympanum, panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
• Focal neurological deficit
• If < 1 y/o, presence of bruise, swelling or laceration of more than 5 cm on the head
• Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 m, high-speed injury from a projectile or an object)