Non-Accidental Injury

Definition

• Physical harm inflicted deliberately on a child or resulting from neglect

• Involves injuries inconsistent with accidental mechanisms

• Requires comprehensive evaluation of medical, social, and family history

____________________________________

Red Flags

• Bruising in non-mobile children or infants under 9 months

• Bruises on protected areas such as ears, face, abdomen, back, buttocks, arms, and hands

• Patterned bruising suggestive of object use (e.g. belt marks, rope injuries)

• Fractures highly suspicious for abuse such as metaphyseal ("bucket handle") fractures, posterior rib fractures, scapular, sternal, vertebral, digital, and complex skull fractures

• Multiple fractures at different stages of healing

• Inconsistent or evolving explanations for injury not matching developmental capabilities

• Delayed presentation for medical care and history of repeated injuries or neglect

____________________________________

History

• Detailed account of injury mechanism, timeline, and circumstances from caregivers

• Inconsistencies or conflicting reports between different caregivers

• Assess caregiver capacity, including mental health issues, substance misuse, and domestic violence

• Previous history of unexplained injuries or sibling abuse

• Social factors such as missed appointments and inadequate supervision

____________________________________

Examination

• Comprehensive physical examination documenting all bruises, lacerations, and fractures using body diagrams

• Evaluate for signs of neglect, including poor hygiene, malnutrition, and developmental delay

• Assess for retinal haemorrhages with ophthalmologic examination in suspected abusive head trauma

• Check for other signs of abuse such as burns, patterned injuries, and injuries in atypical locations

____________________________________

Investigations

• Skeletal survey to identify occult fractures and determine stages of healing

• CT or MRI of the head if neurological signs or suspected abusive head trauma are present

• Ophthalmologic examination to assess for retinal haemorrhages

• Laboratory tests including coagulation studies to exclude bleeding disorders

• Multidisciplinary assessment if injury patterns remain unexplained

____________________________________

Management

• Provide immediate care to address acute injuries and ensure the child's safety

• Meticulously document clinical findings and caregiver statements, using photographs and body diagrams where possible

• Mandatory reporting to child protection services as per local legislation

• Consult with forensic specialists or child abuse paediatricians in cases of uncertainty

• Arrange multidisciplinary follow-up involving social workers, psychologists, and allied health professionals for ongoing support

____________________________________

Additional Notes

• Non-accidental injury is often a diagnosis of exclusion and must be considered in the context of overlapping features with neglect or failure to thrive

• Legal obligations for reporting vary by jurisdiction; ensure compliance with local guidelines

• Parental and caregiver education on injury prevention and supervision is vital to safeguarding child welfare

• Regular team training and clear documentation practices are essential for early recognition and appropriate response to suspected abuse