Non-Accidental Injury (NAI)/Safeguarding

Question 1

An 8-year-old boy is brought to the GP by his father for 3 days of painful bowel motions. He has recently switched GPs and, in his previous records, he has not been brought in to any of his routine appointments. The child is not very forthcoming with information, but states he has been opening his bowels once per day, with no change in frequency or consistency. His father states it started when he fell down onto one of his toys while playing with his sister. On further questioning, he states there has been some fresh red blood on the toilet paper on wiping. He explains he has been afraid to open his bowels as, for the last three days, he has found it very painful to go, but still has managed without straining. He denies abdominal pain, recent change in diet, or loss of appetite.

On examination, observations are unremarkable and his abdomen is soft and non-tender. An attempt at PR exam is abandoned as he finds it incredibly painful.

Which of the following is the best next step in the management of this patient?

A. Recommend a high-fibre diet

B. Prescribe 7 days of laxatives

C. Topical glyceryl trinitrate per rectum

D. Referral to the GPs safeguarding lead

E. Send a faecal calprotectin

Answer 1

D. Referral to the GPs safeguarding lead

In this scenario, the child’s injuries are not consistent with the father’s explanation of events. His symptoms fit with an anal fissure/laceration. This can occur commonly with constipation in children, although a low threshold to suspect sexual abuse is required in a child who has an anal laceration where constipation, Crohn’s disease, and passing hard stool have been excluded as the cause. He states he is passing stools normally and regularly, but with fresh red PR bleeding and so an anal fissure is the most likely cause and constipation less likely

Not C: Topical glyceryl trinitrate (GTN)

Topical glyceryl trinitrate (GTN) is given to treat chronic anal fissures in adults, but not children, as it is unlicensed. It is used to relieve pain caused by the fissure and help the external anal sphincter relax, allowing more blood flow to the mucosa, which may further aid the healing process.

In children, anal fissures are initially managed by reducing constipation with high-fibre diets, considering use of laxatives, warm baths, and encouragement of drinking plenty of fluids. In this case, the more pressing issue is the inconsistency of the story and the child’s injury, raising suspicion of possible sexual abuse. In this case, referral to the safeguarding lead is more pressing

Question 2

History clues for NAI diagnosis:

Answer 2

-Most often occurs in children <2 years old
-Often delayed presentation with injury
a)Caregiver history may be inconsistent in terms of:
b) Changing narratives
-Narrative not matching up with the severity/type of injury shown
-Injury is unwitnessed
-Evidence of drug or alcohol use in the household

Question 3

Examination findings in NAI:

Answer 3

Examination - findings will vary based on type of injury inflicted
1. Injuries of varying ages
2. Presence of burns or scalds
3, Bruises on arms, legs or face consistent with gripping
4. Subconjunctival haemorrhage
5. Retinal haemorrhage
6. Human bite marks

Question 4

Investigations for NAI:

Answer 4

1. Radiology - a full skeletal survey may be required
   a) Rib fractures
   b) Skull fractures / cranial bleeds
   c) Metaphyseal corner fractures (occur due to a twisting/pulling motion on a limb)
   d) Finger fractures
   e) Clavicle fractures

Bloods to exclude organic causes such as clotting disorders or haematological malignancy

Question 5

Management of NAI:

Answer 5

1. Always inform a senior if you suspect non-accidental injury. Every workplace will additionally have a named safeguarding lead you can contact
2. Admit the child for safeguarding while investigations continue.
3. Ensure other children at home are also safe.
4. Management of injuries
5. Clear and thorough documentation is vitally important
6. Contact social care to see if the child/caregiver is known to them already

Question 6

A 4-month-old baby girl is brought to the paediatric emergency department in the evening by her father. Her father is worried as she rolled off the bed in the morning while he was in the bathroom brushing his teeth, and has been crying ever since.

On examination, there are bruises of varying ages on her arms and legs.

Which of the following is the next best step in management?

A. Inform a senior

B. Contact social services

C. Contact the police

D. Skeletal survey

E. Blood tests, including full blood count and clotting

Answer 6

A. Inform a senior

This case is highly suspicious of non-accidental injury. There are a number of red flags:

1. 4-month-old babies cannot roll over yet; therefore the history is implausible
2. The mechanism of injury does not match the clinical presentation of injuries
3. There is a delayed presentation
   Unwitnessed injury
4. Bruises of varying ages
   This case should be immediately discussed with a senior and/or safeguarding lead. They will then recommend skeletal survey/blood tests to exclude organic causes eg clotting disorders

Once more information is ascertained, social services will need to be contacted to identify if this family is known to them already. Social services will then decide whether to inform police