Non Accidental Injury and Child Protection

Question 1

What are some suspicious features of bruises

Answer 1

Location - head, ears, neck, soft areas (upper arm, thigh) , defensive areas (arm, back of hands etc)
Any bruises in non-mobile infants
Bruises in the shape of pattern or object
Bruise pattern not matching the explanation

Question 2

What is a tramline bruise

Answer 2

Occurs when a linear object hits the skin
Blood vessels either side of impact tear but ones at site are compressed
Bruise forms with central clearing (2 lines)

Question 3

What is the difference between a burn and a scald

Answer 3

Burns are caused by dry heat - e.g. flame

Scalds are caused by moist heat - oil or steam

Question 4

What are suspicious features of burns

Answer 4

In a child that isn’t mobile
Areas that wouldn’t normally be exposed to heat - buttocks etc
In a shape or pattern ]
Glove or stocking distribution suggesting immersion

Question 5

What is a skeletal survey

Answer 5

A series of X-rays taken from a child with suspected NAI

It detects previous fractures

Question 6

List suspicious features of a fracture

Answer 6

Rib fractures in kids
Posterior rib fractures are highly specific to abuse - caused by a crush injury to chest
Metaphyseal fracture -caused by pulling or swinging
C spine fracture - caused by shaking
Skull fractures - if fell less than 3ft or associated with brain injury
Any fracture in a non-mobile child
Femoral fracture in a child who doesn’t yet walk
Multiple fractures or fractures of different ages
Fracture that doesn’t fit the story

Question 7

What can cause NAI of the head in a child

Answer 7

Shaking
Hitting
Throwing the child

Question 8

What are the classic triad of symptoms of a shaken child

Answer 8

Bilateral retinal haemorrhages
Subdural haemorrhage
Encephalopathy

Question 9

List symptoms of NAHI

Answer 9

Skull fracture
Extradural haemorrhage
Confusion and decreased consciousness
(also retinal, subdural haemorrhages and encephalopathy if shaken)

Question 10

What are abrasions

Answer 10

Areas where the epidermis has been crushed or scraped due to contact with a blunt object
Tend to be superficial and heal quickly

Question 11

How can crush abrasions identify mechanism of injury

Answer 11

May leave a pattern, identifying the object used

Question 12

How can scrape abrasions identify mechanism of injury

Answer 12

Leave skin tags and lines showing direction of injury

Question 13

What are some suspicious features of abrasions

Answer 13

Present on non-mobile child
Symmetrical arrangement
On areas usually covered e.g. back, axilla
On areas unlikely to be hit when playing - ears etc
Around the ankles/wrists - ligature marks
Shape or pattern

Question 14

List the different types of abuse

Answer 14

Physical 
Sexual 
Emotional 
Neglect 
Special cases - non-organic failure to thrive, fabricated or induced illness and child trafficking

Question 15

List risks of abuse

Answer 15

Domestic abuse
Parental drug and alcohol misuse 
Parent's being abused as children
Mental health problems 
Lack of support - e.g single parent
Disabilities or additional needs 
Non-engaging families
Poverty 
Harmful or problematic sexual behaviour

Question 16

What are the main child protection guidelines/principles in Scotland

Answer 16

GIRFEC and the SHANNARI

Question 17

What is the threshold for interfering in a patient’s private family life

Answer 17

If you believe they are at risk of significant harm

Question 18

The psychological impact of abuse is often related to the severity of the injury - true or false

Answer 18

False
It doesn’t have to be a severe injury to cause a big psychological effect
Often more related to chronicity - how frequently it happens

Question 19

List some possible signs of emotional abuse in a child

Answer 19

Over-reaction to mistakes
Sudden speech disorders
Neurotic behaviour e.g. rocking, hair-twisting, thumb sucking
Self mutilation
Extremes of passivity or aggression

Question 20

List some possible signs of neglect in a child

Answer 20

poor growth/ faltering growth
inappropriate clothing 
frequent injuries
ingrained dirt 
developmental delay
withdrawn or attention seeking behaviour
failure to respond to a known significant medical/ dental problem
Irregular attendance and repeatedly failed appointments
Failure to complete planned treatment

Question 21

List some possible signs of sexual abuse in a child

Answer 21

Disclosure/ direct allegation
Sexually explicit behaviour, drawings, etc
Pregnancy
Emotional and behavioural signs e.g. anxiety and depression, self-harm, drug, solvent or alcohol abuse
Major changes in behaviour

Question 22

What investigations would you do on a child < 1 year old with suspected NAI

Answer 22

CT Brain
Skeletal survey - with repeat x-rays 2 weeks later
Ophthalmology exam
Plus any others which are clinically indicated

Question 23

What investigations would you do on a child < 2 year old with suspected NAI

Answer 23

Skeletal survey - with repeat x-rays 2 weeks later

Plus any others which are clinically indicated

Question 24

What investigations should be performed on a child with suspicious fractures

Answer 24

Bone profile
Skeletal survey - with repeat x-rays 2 weeks later
Phosphate, PTH, Vit D
Copper and caeruloplasmin - rule out Menke’s disease

Question 25

What investigations should be performed on a child with suspicious bruises

Answer 25

FBC 
Coag screen 
Blood films 
VWF
Factor XII and VIII levels 
Fibrinogen

To rule out medical causes of easy bleeding