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Suspected Non-Accidental Injury

Points to consider in detecting non-accidental injury (NAI):

  • Is the history variable or inconsistent with the injuries seen?
  • Was there a delay in seeking attention following an injury? 
  • In a limping child – could this be due to a fracture or soft tissue injury? Is there a history of trauma, and is it consistent with the injury? 
  • Are there multiple injuries? 
  • Are there multiple attendances to the Emergency department, primary care or other healthcare services? 
  • Are there signs of neglect, such as an unkempt, persistently dirty or smelly child - and especially in a child with learning difficulties or chronic illness?
  • Are the findings consistent with the developmental age of the child?

Certain patterns of injury are suggestive of NAI:

  • Bruising in a non-mobile child.
  • Bruising over soft tissues, multiple bruises, clusters of bruises, bruises in the shape of a hand or implement or instrument.
  • Burns in particular shapes eg cigarette burns, burns suggestive of forced immersion.
  • Exclude bruising or soft tissue swelling due to medical causes – eg vasculitis, coagulation disorders. 
  • Exclude metabolic bone disease with recurrent fractures (e.g osteogenesis imperfecta or osteoporosis secondary to chronic corticosteroids).
  • Remember a child with an organic diagnosis and especially chronic illness or disability may still be at risk of abuse or neglect.
  • Certain types of fractures are more suggestive of abuse than others (although none are pathognomonic) e.g. classic metaphyseal lesions, usually caused by twisting/shearing forces, posterior rib fractures (from squeezing), skull fractures.
  • Any fracture in a non-mobile child should raise concern about NAI.

Investigations to consider in a child with fracture and suspected NAI

  • Skeletal survey to exclude fractures elsewhere [or multiple fractures from more than one occasion] – it is important to consider repeat X-rays after 11-14 days if there are concerns about possible fractures, as early changes can be missed.
  • CT scan head followed later by MRI scan.
  • Ophthalmology opinion (evidence from shaking / trauma may be evident).
  • Full [Complete] Blood count (to exclude thrombocytopenia) and coagulation screen.

Conditions that may mimic NAI

  • Metabolic bone disease (primary osteoporosis - osteogenesis imperfecta or ‘brittle bone disease’). The type commonly involved with unexplained fractures is Type I (Autosomal Dominant, so there may be a family history. Blue sclerae are a clinical finding and there may be generalized osteoporosis and wormian bones in the skull on skeletal survey). Secondary osteoporosis (e.g. from chronic corticosteroid exposure, immobility or malabsorption).
  • Copper deficiency – very rare to present with fractures as there is adequate copper in breast milk and milk formula. It can occur in preterm or malnourished babies.
  • Scalds and cigarette burns – may be missed if the observed changes are ascribed to bullous impetigo or scalded skin syndrome.
  • Bruising tendency e.g coagulation disorders, Idiopathic thrombocytopenic purpura.

See Further NICE Guidance on when to suspect NAI and what actions to take.

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