Non-accidental injury (NAI) is an uncommon but serious presentation in general practice. Recognition of NAI is an important task for the GP, as unrecognised, it results in serious morbidity and occasionally, mortality.
Case presentation
A 22-month old boy presents urgently with a burn to his hand. He was accompanied by mother, giving a plausible history of the child putting his hand into a pot of boiling water while cooking. Both mother and child were distressed. Following examination, mother was advised by the GP that evaluation at the emergency department (ED) was necessary; ambulance was offered, but she insisted on making her own travel arrangements. The ED was called ahead by the GP. The following day, a call back from ED informed the practice that the mother and child had not attended until 12 hours later.
Examination in hospital revealed a pattern of bruising consistent with NAI.
Literature review
Non-accidental injury is not rare. Young children (predominantly less than three years of age) are most likely to be physically abused, with children younger than one experiencing the highest rate of abuse (21.9 per 1,000 children).1
Prevalence of abuse is increased among immigrant children, asylum seekers and internationally adopted children.3 Lower socio-economic status has a greater association with physical abuse.2 It is helpful to consider NAI under the following categories: bruising, breaks and burns.
Bruising
Bruising is the most co mmon injury inflicted. The pattern of accidental bruising in young children is strongly influenced by their level of independent mobility.
Non-mobile infants are least likely to sustain ‘innocent’ accidental bruises (prevalence < 1%). “Those who don’t cruise rarely bruise.4 Once children move independently (ie. toddlers), bruising increases incrementally (prevalence: crawling/cruising 17%, walking > 50%).
Accidental bruising occurs on the front of the body and over bony prominences. Non-accidental bruises occur on the head, ear, neck and cheeks (see Figure 1). Bruising on forearms, upper limb and adjoining area of trunk, or outside thigh may indicate ‘defensive bruising,’ where the child has tried to protect themselves from blows.
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Petechiae in association with bruises are strongly predictive of abusive injury, with a positive predictive value of 80 (95% CI 64.1 to 90.1) but their absence is of no diagnostic value.5
Many are surprised to hear that the age of bruises cannot be estimated from colour. It has been clearly established that there is no scientific basis for a timeline for the appearance of different colours (red, blue, yellow, green). Different colours appear in the same bruise at the same time, and each of us perceives colour differently. Recent studies show the accuracy with which clinicians correctly age a bruise to within 24 hours of occurrence was less than 40%.6
Breaks (fractures)
It is estimated that a third of abused children have fractures, many of which are not clinically evident. Distinguishing the inflicted from the accidental fracture is challenging. Age is a key factor (80% of abusive fractures occur in children aged less than 18 months).
Rib fractures have the highest probability (71%) for abuse, with 48% for humeral, 28% for femoral and 30% for a skull fracture.7
Burns
Studies give varying estimates (eg. 1-35% of children admitted to burns units have suffered from intentional burns).8 It has been suggested that burns resulting from neglect outnumber intentional burns by 9:1.9 Neglect can result in an accidental-type injury. Accidental scalds in young children are predominantly ‘pull-over’ scalds, where the child pulls down a container of hot liquid on themselves, giving rise to a classical pattern affecting the upper limb, face, anterior trunk, and/or neck. The burn is usually asymmetric with an irregular edge, and irregular burn depth (see Figure 2).
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Intentional burns are predominantly hot water immersion scalds, involving lower limbs, and/or perineum/buttocks or ‘glove and stocking’ burns (see Figure 3). Key distinguishing characteristics are that the burn has clear upper limits, is of consistent depth, and is symmetrical. Other worrying features are skinfold sparing, presence of other unrelated injuries, associated neglect, and a sibling being blamed. In 83% of intentional scald injuries, parents cite tap water as the causative agent. The incidence of true accidental scald injuries being caused by tap water is approximately 16%.10
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Other indicators of non-accidental injury
Other indicators of NAI include delay in seeking help, story of the ‘accident’ is vague or inconsistent, injury is attributed to the actions of siblings, or the account is not compatible with the injury observed. Parental response may be abnormal, eg. preoccupation with their own problems such as when they can return home or becoming inappropriately hostile or evasive. The child’s interaction with parents may be abnormal, eg. withdrawn or frightened.11
Guidance and action
Children First Guidance (2011) was launched to promote protection of children. It states that HSE Children and Family Services should always be informed when a GP has reasonable grounds for concern that a child may have been, is being or is at risk of being abused or neglected.
Parents/carers should be informed if a report is to be submitted to the HSE Children and Family Services, or to An Garda Síochána, unless doing so is likely to endanger the child. A report can be made in person, by phone or in writing. The Standard Report Form12 for reporting child welfare and protection concerns to the HSE should be used. In event of an emergency, if a child is in immediate danger, the Gardai should be informed if the HSE cannot be contacted.
Why does child abuse occur?
While child abuse is uncommon, the perpetrator(s) will often be a patient of the practice, so it is important to understand what factors may anticipate or provoke this situation. The motivations and risk predictors for these acts are often inter-related – acute family stress and lack of external support are powerful precipitants of intense frustration. Single parenthood and low family income are associated with inflicted burns. In up to 70% of cases of inflicted burns, the assault is perpetrated by young women and 50% of these women are the children’s mothers. Previous personal history of abuse of the perpetrator is also a strong risk factor. It is helpful to ask about this, because domestic violence is common in Ireland, and the evidence suggests that patients who have experienced such violence find it acceptable for us to enquire about it.13
A careful history from the abuser may reveal poverty, desperation, substance dependency and their own previous abuse.14 Such socio-emotional problems may overcome the abuser’s emotional reserves, especially when dealing with the care burdens and considerable demands of small children.
The child’s right is becoming more respected in society and this must be balanced with a humane understanding of the offender’s difficulties as a contributor to abusive behaviour. This can enable a GP to initiate holistic treatment. A Cochrane review in 2008 found limited evidence that some parenting programmes may be effective in improving some outcomes that are associated with physically abusive parenting.15 Other studies found benefits for physically abusive parents and abused children using a structured cognitive-behavioural treatment.16
GPs, like society in general, struggle with NAI. An awareness of social risk and prompt recognition of patterns of injury are essential to trigger probing for inconsistencies in the history. It is important to recognise potential risk factors, and to be aware of the options available for intervention.
The child in the introduction (a de-identified, actual case history) suffered a third degree burn to his hand, which fortunately healed well. He is currently with a foster family.
Bullock DP, Koval KJ, Moen KY, et al. Hospitalized cases of child abuse in America: who, what, when, and where. J Pediatr Orthop 2009;29:231–7.
Miller LC, Chan W, Reece RA, et al. Child abuse fatalities among internationally adopted children. Child Maltreat 2007;12:378–80.
Maguire S. Which injuries may indicate child abuse? Arch Dis Child Educ Pract Ed. 2010;95(6):170-7.
Nayak K, Spencer N, Shenoy M, et al. How useful is the presence of petechiae in distinguishing non-accidental from accidental injury? Child Abuse Negl 2006;30:549–55.
Maguire S, Mann MK, Sibert J, et al. Can you age bruises accurately in children? A systematic review. Arch Dis Child 2005;90:187–9.
Kemp AM, Dunstan F, Harrison S, et al. Patterns of skeletal fractures in child abuse: systematic review. BMJ 2008;337:a1518
Maguire S, Moynihan S, Mann M, et al. A systematic review of the features that indicate intentional scalds in children. Burns 2008;34:1072–81.
Chester DL, Jose RM, Aldlyami E, et al. Non-accidental burns in children–are we neglecting neglect? Burns 2006;32:222–8.
Purdue GF, Hunt JL, Prescott PR. Child abuse by burning--an index of suspicion. J Trauma. 1988 Feb; 28(2):221-4.
Munro, E Effective Child protection(2nd edition) 2010
Fiona Bradley, Mary Smith, Jean Long, Tom O’Dowd Reported frequency of domestic violence: cross sectional survey of women attending general practice BMJ 2002;324:1–6
Greenbaum AR, Donne J, Wilson D, Dunn KW. Intentional burn injury: an evidence-based, clinical and forensic review. Burns.2004 Nov;30(7):628-42.
Barlow et al Individual and group-based parenting programmes for the treatment of physical child abuse and neglect 2008 The cochrane library 2008
David Kolko , Individual Cognitive Behavioral Treatment and Family Therapy for Physically Abused Children and their Offending Parents: A Comparison of Clinical Outcomes Child Maltreat November 1996 1: 322-342
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