Makindo Medical Notes

🧒 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• 😟 Fear of caregivers: Child may be anxious, withdrawn, or excessively compliant around abuser.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.