11/14/24, 10\:53 AM Non-Accidental Injury (NAI)

Non-Accidental Injury (NAI)

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Non-accidental injury (NAI)\: recurring issue in paediatrics, requires vigilance from healthcare professionals.
Prevalence\: 14 million children in the UK; over 58,000 need protection from abuse; nearly 6% of children under 11 and 19%
of 11-17-year-olds report maltreatment.
Risk factors\:
Intimate Partner Violence (IPV)\: 750,000 children witness IPV annually; IPV in
by 3.4 times.
Substance abuse or mental health condition in caregivers increases NAI risk.
Excessive crying\: especially in infants aged 0-4 months, can trigger shaking, a common cause of NAI.
Unintended pregnancy\: associated with higher odds of NAI (OR 2.92).
Developmental problems\: children with developmental concerns are twice as likely to su
Presentation\: consider safeguarding in every paediatric consultation; suspicious injuries include\:
Bruises\: shaped like hands, linear, ligatures, or implements; non-bony parts of body or face/ears; multiple or clustered
bruises.
Bites\: human bites are suspicious; animal bites indicate poor supervision.
Lacerations/abrasions\: in non-mobile children, symmetrically, on face, ankles, wrists.
Thermal injuries\: on soles, buttocks, backs of hands; shaped like an implement; scalds with sharp borders.
Fractures\: multiple or di
Intracranial injuries\: without adequate explanation, in children under 3, with retinal haemorrhage, rib/long bone fractures,
multiple subdural haemorrhages.
Eye trauma\: unexplained retinal haemorrhages.
Other injuries\: unexplained spinal or visceral injuries.
Di
imperfecta.
Imaging\:
Skeletal survey\: head, chest, spine, pelvis, upper and lower limbs; repeat at 11-14 days.
Neurological imaging\: CT head for acute presentation, MRI head for non-acute.
Alternative skeletal imaging\: CT for rib fractures, ultrasound for metaphyseal/rib fractures.
Reporting\: involve children's services early; admit to paediatric ward for safety; senior paediatric/child protection review;
consider skeletal survey and ophthalmology review if abusive head trauma suspected.
Identify other children at risk\: assess siblings and other children in the home to ensure their safety.
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A comprehensive topic overview
Although several cases of non-accidental injury have appeared in the media recently, from Victoria Climbié who died in
2000 at 8 years old to ‘Baby P’ who died aged 17 months old in 2007, these are merely the tip of the iceberg. Non-
accidental injury (NAI) is a recurring problem within paediatrics and it is our duty as healthcare professionals to be as
vigilant as possible.
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Prevalence

Nearly 14 million children live in the UK. The NSPCC estimates that of these, over 58,000 are in need of protection from
abuse. However, for every child identi1,2
The
prevalence of identi
these in 2019 being due to abuse or neglect. 3
It is not possible to accurately identify the prevalence of non-accidental injury
because abuse is both under-recognised and under-recorded. However, nearly 6% of under 11-year-old children and 19% of
11-17-year-olds reported experiences of maltreatment or neglect in one survey. 4
Nearly 10% of children reported in this
same survey that they had been sexually abused in the last year.

Risk factors

History of Intimate Partner Violence and Abuse (IPV)
This abusive behaviour can be physical, sexual, psychological, emotional, verbal,
control.
IPV is common – at least 750,000 children per year witness IPV at home
5
One large study found that where IPV occurs in the home within the
times more likely than if IPV was not present.
6
This may be an issue highlighted in the child’s notes, or signs may be present at a consultation.
Questions that can be asked are shown below (based on the RCPCH child protection companion).
7
If IPV is suspected but not documented discuss immediately with a senior colleague.
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?
Substance Abuse or Mental Health Condition in One or Both Caregivers
This can increase the risk of NAI through increased burden on the caregiver/caregivers.
7,8
Excessive Crying
Excessive crying, especially aged 0-4 months old, has been identi
common cause of NAI, hence excessive crying is a risk factor for NAI within the infant population.
9
Unintended Pregnancy
Although the majority of children whose conception was not planned are not subject to abuse, a large-scale study found
that unintended pregnancy carried an odds ratio of 2.92 for maltreatment/NAI.
10
Developmental Problems
Children with developmental concerns were twice as likely to su
within the UK. 10
This may be due to the increased burden on caregivers, caused by these children’s complex health
needs.

Presentation

Safeguarding should form part of every paediatric consultation, and below are a series of injuries which the most current
set of NICE guidelines identi
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be taken in to account. A patient who presents late with an obvious injury should arouse suspicion as should an implausible
history for the presenting complaint.
11 Bruises
Shape of bruises
Worrying bruises are those shaped like hands, linear bruises, ligatures or an identi
Pattern of bruises
Bruises on non-bony parts of the body or face/ears.
Multiple bruises or clustered bruises.
Age of bruises
Always be suspicious of bruises in a child who cannot mobilise
Remember “ i f t h e y c a n’ t c r u i s e t h e y d o n’ t b r u i s e”
Bites
Any bite which appears to be human should be treated as suspicious.
Bites may be caused by other children but even when bite marks are small, an adequate explanation should be sought.
Animal bites may not be classical NAI but can be a sign of a poorly supervised child.
Lacerations/Abrasions
A high index of suspicion should be present when lacerations or abrasions are seen\:
In non-mobile children
Symmetrically
Around the face
Around the ankles or wrists, in the position a ligature could be applied
An adequate explanation should always be sought for the injuries described above.
Thermal Injuries
A
Soles of the feet
Suspect NAI where thermal injuries are in locations you would not expect to come into contact with a hot object\:
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)
Fractures
Fractures, single or multiple, in children w i t h o u t a medical condition predisposing them to fragile bones, should be
investigated for NAI.
Fractures of di
highly suspicious of NAI.
Metaphyseal corner fractures - reported as almost pathognomonic of NAI.
Evidence of occult rib fractures is also a common
squeezed/shaken.
Spiral fractures are a result of twisting forces so cannot be caused by simple falling, and are highly suspicious of NAI
Intracranial Injuries
Suspect NAI where intracranial injury presents\:
Without an adequate explanation
In a child under 3 years old
In the presence of\:
Retinal haemorrhage
Rib or long bone fractures
Other associated injuries
With multiple subdural haemorrhages
Eye Trauma
Retinal haemorrhages with no medical explanation are highly suspicious for NAI.
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Other
Spinal injuries or visceral injuries without a history of major trauma should be thoroughly investigated for suspected NAI.

Di

Although it is our job to protect the children in our care, by identifying NAI where it is present, we must still consider that
children are generally prone to injury. Infants, children and adolescents can often be injured perfectly innocently and so
di
8 Coagulopathy
This may lead to excessive bruising and haemarthrosis.
A family history would most likely be present, but coagulation screening should be undertaken to rule this out.
Osteogenesis Imperfecta
A family history may be present, and the condition would typically be detected early in life.
X-ray

Imaging

The Royal College of Radiologists (RCR) has produced professional guidance on the imaging requirements when NAI is
suspected, laying out which investigations should be performed and when in relation to initial presentation.
12
Skeletal Survey
Head/chest (including AP and lateral skull)
Spine/pelvis
Upper limbs
Lower limbs
Follow-up Imaging
Skeletal survey should be repeated at 11-14 days.
This is 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.
Neurological Imaging
found in the RCR guidance document.
Imaging modality depends on the timing of the presentation, and a full algorithm can be
Acute presentation
CT head should be performed as soon as the patient has been stabilised, on the day of presentation.
Non-acute presentation
MRI head should be performed as soon as possible, within a week of presentation.
Alternative Skeletal Imaging
CT is more sensitive in diagnosing rib fractures, but carries a higher radiation dose and so may be used if rib fractures are
suspected, but CT Chest is not currently routine.
Ultrasound can be used to diagnose metaphyseal and rib fractures as well as identifying subperiosteal

Reporting

In all cases of suspected NAI, children's services should be involved from a very early stage and will coordinate with other
agencies\:
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.
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If abusive head trauma is suspected, the child should be referred for ophthalmology review to identify possible retinal
haemorrhages.
13
Other Children at Risk
You MUST identify any other related/associated children as they may also be at risk. Child
Protection, Social Services and Police colleagues will play a key role in this, but it is vital to protect any other children who
may be at risk. Hence it is always best to establish who else is in the home and if the child has siblings when taking any
paediatric history.

References

Rao, S. and Lux, A.L. 2012. The epidemiology of child maltreatment. Paediatrics and Child Health. Vol22(11) pp459-464.
Available from\: [LINK]
NSPCC. How safe are our children? 2013. 2013. Available from [LINK]
Department of Education. Children looked after in England (including adoption) ending 31st March 2019. Available from\:
[LINK]
Radford LCS, Bradley C, Fisher H, Bassett C, Howat N, Collishaw S, Child abuse and neglect in the UK today. 2011.
Department of Health (2005). Responding to Domestic Violence\: a Handbook for Health Professionals. Available from\:
[LINK]
Thackeray, J. D., Hibbard, R., Dowd, M. D. et al. 2010. Intimate Partner Violence\: The Role of the Pediatrician. Pediatrics. 125(5)
pp1094-1100; DOI\: 10.1542/peds.2010-0451
Royal College of Paediatrics and Child Health. 2013 Child protection companion - 2nd edition. Available from\: [LINK]
Gavril, A. R. Child Abuse. BMJ Best Practice. Updated February 2018. Available from\: [LINK].
Lee, C., Barr, R., Catherine, N. et al. 2007. Age-Related Incidence of Publicly Reported Shaken Baby Syndrome Cases\: Is
Crying a Trigger for Shaking? Journal of Developmental & Behavioral Pediatrics. 28(4) pp288-293. DOI\:
10.1097/DBP.0b013e3180327b55
Sidebotham, P., Heron, J. and ALSPAC Study Team. 2003. Child maltreatment in the “Children of the Nineties\:
” the role of the
child. Child Abuse Neglect 27. pp337-352
National Institute for Clinical Excellence. 2009 (updated 2017). Child maltreatment\: when to suspect maltreatment in under
18s Clinical guideline [CG89]. Available from\: [LINK]
Society and College of Radiographers and The Royal College of Radiologists. 2018. The radiological investigation of
suspected physical abuse in children, revised
The Royal College of Paediatrics and Child Health and The Royal College of Ophthalmologists. 2013. Abusive Head Trauma
and the Eye in Infancy. Scienti

Reviewer

Dr Sunil Bhopal
Senior Paediatric Registrar
Editor
Dr Thomas Finnerty
Paediatric Lead

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Contents

Prevalence
Risk factors
Presentation
Di
Imaging
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