Non-accidental injury
🚨 Non-Accidental Injury (NAI) refers to physical harm deliberately inflicted on a child or vulnerable adult.
Although often associated with child abuse, it can also occur in the elderly or dependent adults in cases of elder abuse.
👩⚕️ Healthcare professionals have a duty to identify, manage, and escalate suspected cases to safeguard life and well-being.
⚡ Causes
- 👊 Physical abuse: Hitting, shaking, burning, suffocation, or deliberate bodily harm.
- ⚠️ Sexual abuse: Any non-consensual sexual activity, particularly in children or vulnerable adults.
- 🧠 Emotional / Psychological abuse: Persistent verbal, emotional, or psychological maltreatment causing fear, withdrawal, or developmental delay.
- 🚫 Neglect: Failure to meet basic needs (food, shelter, medical care, hygiene, supervision).
📉 Risk Factors
- 🏚️ Domestic violence in the household
- 🍷 Parental/caregiver substance misuse (alcohol, drugs)
- 🧬 Family history of abuse / intergenerational trauma
- 🧠 Caregiver mental illness (e.g., depression, psychosis)
- 🙅 Social isolation or lack of community support
- 💰 Low socioeconomic status or financial strain
🔎 Clinical Signs
- ❌ Inconsistent or changing history, or delay in seeking help
- 🤕 Unexplained or poorly explained injuries
- 🌈 Bruises in different stages of healing → recurrent trauma
- 🖐️ Patterned injuries (belt marks, handprints, bite marks)
- 🦴 Fractures in non-ambulatory infants, or multiple fractures of varying ages
- 🔥 Burns (cigarette burns, immersion burns)
- 🫀 Abdominal trauma (e.g., liver/spleen injury)
- 🚼 Neglect: malnutrition, poor hygiene, developmental delay
🧪 Diagnostic Approach
- 📝 History: Collect full medical, social, and injury history from caregiver + child (if possible).
- 👩⚕️ Examination: Skin, fractures, developmental status, nutritional state.
- 🩻 Imaging: Skeletal survey, head CT/MRI, abdominal US for internal injury.
- 🧪 Bloods: FBC, coagulation screen (exclude bleeding disorders mimicking bruising).
- 🤝 MDT involvement: Safeguarding team, social workers, paediatrics, and (if adult) adult protection services.
💊 Management
- 🛡️ Ensure safety: Admit child/adult if needed to prevent further harm.
- 📞 Involve safeguarding services: Immediate referral to social services/child protection.
- 📝 Document meticulously: Clear notes + injury diagrams. Photographs (with consent) may be required for legal purposes.
- 🚔 Report: Inform statutory agencies (child protection teams, police if criminal concerns).
- ❤️ Medical & psychological care: Treat injuries, provide analgesia, and arrange trauma-informed psychological support.
- 🔄 Follow-up: Regular reviews, safeguarding meetings, social service updates.
🚨 Red Flags
- History inconsistent with injury pattern/severity
- Repeated A&E visits with new injuries
- Patterned marks (belts, cords, bites, burns)
- Signs of chronic neglect (malnutrition, faltering growth, poor hygiene)
- Child appears fearful, withdrawn, or excessively watchful (“frozen watchfulness”)
⚖️ Key Considerations
- Always consider NAI in unexplained or suspicious injuries.
- NAI is both a medical emergency and a safeguarding emergency.
- Confidentiality has limits → clinicians have a duty to share concerns to protect life.
- Work within a multidisciplinary team (MDT) for assessment, treatment, and legal procedures.
👩⚕️ Role of the Healthcare Professional
- 👀 Early recognition of suspicious injuries and patterns
- 🛡️ Prioritise immediate safety of the child or vulnerable adult
- 📢 Report suspicions to safeguarding leads and statutory agencies
- 🤝 Provide holistic care: medical, psychological, and social support
- 📚 Maintain awareness of local safeguarding protocols (e.g., “Working Together to Safeguard Children” in the UK)
Additional related clinical topics
Non-accidental injury (children)
🧒 Types of Non-Accidental Injury (NAI)
- 👊 Physical Abuse: Deliberate harm such as hitting, shaking, burning, or biting.
- Visible injuries: bruises, fractures, burns, lacerations, head trauma.
- Red flag: injuries not consistent with developmental stage (e.g., bruises in a non-mobile infant).
- 💔 Emotional Abuse: Persistent non-physical harm damaging a child’s emotional health.
- Signs: withdrawal, low self-esteem, anxiety, depression, excessive compliance or aggression.
- 🚫 Neglect: Failure to meet a child’s basic needs (nutrition, hygiene, healthcare, supervision).
- Physical signs: malnutrition, poor growth (failure to thrive), unkempt appearance, untreated illness.
- ⚠️ Sexual Abuse: Engaging a child in sexual activities, exploitation, or exposure.
- Signs: genital injuries, sexually transmitted infections, pregnancy, inappropriate sexualised behaviour.
🩸 Common Injuries Associated with NAI
- Bruising:
- Unusual sites → ears, neck, trunk, buttocks, abdomen.
- Bruises of different ages/shapes (e.g., belt marks, handprints).
- Bruising in non-mobile infants is particularly suspicious.
- Fractures:
- Spiral/oblique fractures of long bones (twisting injury).
- Posterior rib fractures (classical for NAI, squeezing mechanism).
- Metaphyseal corner (bucket handle) fractures in infants.
- Multiple fractures at different healing stages → repeated trauma.
- Burns:
- Immersion burns (stocking/glove pattern), sharply demarcated edges.
- Cigarette burns → round, well-defined.
- Explanations inconsistent with injury pattern are a red flag.
- Head Injuries:
- Shaken Baby Syndrome (Abusive Head Trauma): Subdural haemorrhage, retinal haemorrhages, cerebral oedema.
- Clinical signs: irritability, vomiting, seizures, reduced consciousness, bulging fontanelle.
- Bite Marks:
- Human bite marks → oval/round bruises, often multiple, sometimes patterned.
- Abdominal Trauma:
- May cause splenic, hepatic, or bowel injury.
- Often minimal external signs despite severe internal damage.
🧠 Behavioural & Psychological Indicators
- ❓ Inconsistent explanations: History doesn’t match injury pattern or severity.
- ⏱️ Delay in presentation: Significant injuries presented late to hospital.
- 😟 Fear of caregivers: Child may be anxious, withdrawn, or excessively compliant around abuser.
- 🔙 Regression: Bedwetting, thumb-sucking, clinginess, new separation anxiety.
🔎 Assessment & Approach in Suspected NAI
- History: Take careful, separate accounts from caregiver and child (if age-appropriate). Avoid leading questions.
- Examination: Full head-to-toe exam. Document carefully with diagrams and photos (with consent).
- Imaging: Skeletal survey (<2 years) for occult fractures; CT head for suspected intracranial injury.
- Multidisciplinary input: Paediatrics, safeguarding team, radiology, ophthalmology (retinal haemorrhage assessment).
⚖️ Management & Reporting
- Immediate Safety: Ensure the child is safe - may require admission or removal from caregivers.
- Mandatory Reporting: In the UK, clinicians have a professional duty to escalate concerns via local safeguarding procedures (social services, child protection team). Police involvement may be required.
- Medical Care: Treat acute injuries (e.g., fracture stabilization, neurosurgical intervention).
- Psychological Support: Referral to child psychology/mental health services.
- Documentation: Accurate, detailed, objective notes are crucial for medico-legal purposes.
💡 Clinical Pearls:
- Any bruise in a non-mobile baby = suspicious until proven otherwise.
- Posterior rib and metaphyseal corner fractures are highly specific for NAI.
- Always consider safeguarding when the history doesn’t fit the injury.
- Early involvement of the safeguarding team protects both the child and the clinician.
