Paediatrics

Non-Accidental Injury (Safeguarding)

Suspected inflicted injury is a safeguarding and clinical emergency when the injury, account, timing or developmental stage do not fit; act on serious concern without waiting to prove abuse.

In a nutshell

Suspected non-accidental injury is a safeguarding emergency when the injury, account, timing or developmental stage do not fit. Stabilise and protect the child, seek senior safeguarding advice, investigate serious injury and medical mimics, and refer on suspicion rather than waiting for proof.

Classic presentation

A non-independently-mobile infant has unexplained bruising, or an infant has collapse, seizures or abnormal neurology with a history that does not explain the findings.

Key points

A bruise in a child who is not independently mobile is an alerting feature requiring safeguarding assessment.
The explanation must fit the injury, the timing and the child's developmental abilities.
Retinal haemorrhage, intracranial injury, unusual fractures and visceral injury need specialist interpretation and medical differentials; do not rely on an old triad alone.
For suspected physical abuse in infants and young children, discuss urgent skeletal survey and follow-up imaging with the paediatric and radiology teams.
Suspect is not proof: act on serious concern and refer through local safeguarding procedures.
Consider siblings and other children who may also be unsafe.

First-line investigation

A to E assessment, full non-leading history and examination with factual injury documentation, followed by targeted specialist imaging, ophthalmology and medical-mimic testing.

Management

Stabilise and keep safe

Treat life-threatening injury and pain, involve senior paediatrics, and do not discharge while serious injury or immediate safety concerns remain unresolved.^1,2
Record development, accounts and injuries factually; use open, non-leading questions and avoid repeated interviews.^2,4

Investigate occult injury

Discuss skeletal survey, neuroimaging and ophthalmology with the specialist teams according to age, findings and the RCR/RCPCH-endorsed pathway; test targeted medical mimics.^1,3

Refer and coordinate protection

Serious concern is enough to refer. Where significant harm is suspected, a strategy discussion coordinates social care, health, police and other relevant agencies.^1,2,4

Protect recovery

Discharge only after a senior clinical and safeguarding review agrees a safe plan; arrange medical, developmental and psychological follow-up and consider siblings.^2,4

Exam traps

A plausible-sounding account is not reassuring if it is inconsistent with development, injury pattern or other accounts.
Do not call the old subdural-retinal-haemorrhage-encephalopathy triad diagnostic; assess the full differential with specialists.
Do not wait for proof, a skeletal survey result or a confession before making a safeguarding referral.
A normal initial examination or screening blood test does not exclude occult injury or maltreatment.
Do not repeatedly question a child or carer in a leading way; preserve a safe, coordinated assessment.
Think about siblings and other children in the household.

Illustrations

Posterior rib fractures in suspected physical abuseInfant chest radiograph showing posterior rib fractures. Image interpretation must be by an experienced paediatric radiologist within the full clinical and safeguarding assessment.National Institute of Health, Wikimedia Commons · Public domain

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.