QuestionSBA
QuestionChoice
This would be a reasonable option for a child who has developed constipation and subsequent anal tear/fissure, which is deemed unlikely caused by non-accidental injury. In this case, the more pressing issue is the inconsistency of the story and the child's injury, raising suspicion of possible sexual abuse. In this case, referral to the safeguarding lead is more pressing
33160
c
Recommend a high-fibre diet
QuestionChoice
In this scenario, the child's injuries are not consistent with the father's explanation of events. His symptoms fit with an anal fissure/laceration. This can occur commonly with constipation in children, although a low threshold to suspect sexual abuse is required in a child who has an anal laceration where constipation, Crohn's disease, and passing hard stool have been excluded as the cause. He states he is passing stools normally and regularly, but with fresh red PR bleeding and so an anal fissure is the most likely cause and constipation less likely
33158
a
Referral to the GPs safeguarding lead
QuestionChoice
Topical glyceryl trinitrate (GTN) is given to treat chronic anal fissures in adults, but not children, as it is unlicensed. It is used to relieve pain caused by the fissure and help the external anal sphincter relax, allowing more blood flow to the mucosa, which may further aid the healing process. In children, anal fissures are initially managed by reducing constipation with high-fibre diets, considering use of laxatives, warm baths, and encouragement of drinking plenty of fluids. In this case, the more pressing issue is the inconsistency of the story and the child's injury, raising suspicion of possible sexual abuse. In this case, referral to the safeguarding lead is more pressing
33161
d
Topical glyceryl trinitrate per rectum
QuestionChoice
Constipation may be the first sign of Crohn's disease, where the child is opening their bowels less than three times per week. Constipation can cause anal fissures in children, resulting in the symptoms this child is experiencing. Often in Crohn's disease, however, there are other signs such as bloating, diarrhoea (sometimes with blood and mucus), reduced appetite, weight loss, fatigue, and slow growth. If inflammatory bowel disease is suspected, then a faecal calprotectin would be appropriate. The history, however, does not suggest this child is constipated or has any other systemic issues. In this case, the more pressing issue is the inconsistency of the story and the child's injury, raising suspicion of possible sexual abuse, and raising concern of a sinister cause for his anal fissure. In this case, referral to the safeguarding lead is more pressing
33162
e
Send a faecal calprotectin
QuestionChoice
This would be a reasonable option for a child who has developed constipation and subsequent anal tear/fissure, which is deemed unlikely caused by non-accidental injury. Usually a trial of high fibre diet would be trialled first, followed by laxatives if unsuccessful. In this case, the more pressing issue is the inconsistency of the story and the child's injury, raising suspicion of possible sexual abuse. In this case, referral to the safeguarding lead is more pressing
33159
b
Prescribe 7 days of laxatives
QuestionComment
This is beyond dark
16056
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George
QuestionComment
I honestly would rather not make assumptions about what is truly going on….
24259
QuestionComment
Better to be safe than sorry tho just incase 
24574
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Metabolism Myotonia
QuestionComment
if you don't make assumptions that kid is gonna keep getting abused
27108
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NICU Serotonin
QuestionComment
Welcome to the real world...
29177
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Jaundice Inpatient
QuestionComment
it's not about what you would rather do though, you are obligated by law to raise this with the safeguarding team (or by professional duty if it was an adult)
43119
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Ale
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Anterior Gallbladder
QuestionComment
this kind of question makes it very real. I got goosebumps. 
24278
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canIhave12bottlesofbleachplease
QuestionComment
Refer to safe guarding and give the dad a slap?
28090
QuestionComment
*punch
61543
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Acute Myopathy
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Schizoid Personality Order
Concept
Chapter
# Summary
 

Non-accidental injury refers to any intentional injury inflicted upon a child or harm that occurs due to caregiver neglect. Common signs and symptoms include delayed presentation, inconsistent caregiver narratives, injuries of varying ages, and specific findings such as subconjunctival or retinal haemorrhage. Key investigations include a full skeletal radiographic survey and blood tests to exclude organic causes of presentations. Management involves immediate senior and safeguarding lead notification, admission for safeguarding, treatment of injuries, thorough documentation, and liaison with social care.
 

# Definition
 

Non-accidental injury is a term used to describe any physical harm in a child that is deliberately inflicted or results from the failure of a caregiver to prevent such harm.
 

# Epidemiology

Non-accidental injury predominantly affects children under the age of 2 years. Precise epidemiological data can be challenging to establish due to underreporting and differing definitions of abuse.

The Crime Survey for England and Wales estimates that 7.6% of adults aged 18-74 had experienced physical abuse before the age of 16. Unfortunately, over 100,000 incidents of physical abuse to children were recorded in 2019. In approximately 80% of cases the abuser is the parent or carer. 
 

# Aetiology

Non-accidental injury results from deliberate harm inflicted by a caregiver or due to a caregiver's failure to prevent harm.
 
Risk factors may include:

- Previous child maltreatment or domestic violence in the family 
- Caregiver substance abuse or mental health issues
- History of the caregiver being abused
- Emotional volatility 
- Poverty and poor housing
- Children in the care system 

Children and young people with disabilities are more likely to be the victim of abuse.  
 

# Signs and symptoms
 

In non-accidental injury, key clinical manifestations may include:
 

 -  History
  
  -  Predominantly occurs in children under 2 years old
  -  Often delayed presentation following injury
  -  Inconsistencies in the caregiver's narrative, including:
          -  Changing stories
          -  Severity/type of injury not corresponding to the narrative
          -          Injuries in a child not yet independently mobile 
  -  Unwitnessed injuries
  -  Evidence of drug or alcohol use in the household
 -  Physical Examination Findings
  
  -  Injuries of varying ages
  -  Presence of burns or scalds
  -  Bruises:
          -  To any part of the body in an infant
          -  Bruises on the head and face most common sites of abusive bruising
          -  Consistent with gripping
  -  Subconjunctival haemorrhage
  -  Retinal haemorrhage
  -  Human bite marks
  -  Immersion scalds: most commonly on lower limbs. This may spare the buttocks if they were pressed against the bottom of the bath. 
  -  Torn frenum: Associated with head injuries or force-feeding of an infant.
  -  Cigarette burns  
  -  Female genital mutilation (see below)

  
With investigation, other sites of non-accidental injury may include:

- Subdural haemorrhage 
- Long bone fractures in a child not yet independently mobile 
- Fractures of different ages 
- Rib fractures without a history of major trauma 
 

# Differential diagnosis
 

Differential diagnoses can include accidental injury, bleeding disorders, and certain types of malignancies. Each presents with specific signs and symptoms:
 

 -  **Accidental injury**: Injuries correspond to the history provided and are developmentally appropriate. 
 -  **Bleeding disorders**: May present with easy bruising, nosebleeds, heavy or prolonged menstrual bleeding, and excessive bleeding from minor cuts or after surgery or dental work.
 -  **Haematological malignancy**: May present with fatigue, shortness of breath, recurrent infections, easy bruising or bleeding, and unexplained weight loss.

Other forms of child abuse to consider are:
 
 - **Physical Abuse**: This may include NAI, but also includes female genital mutilation, which is illegal in the UK.
 - **Emotional Abuse**: The psychological ill-treatment or neglect of a child's emotional needs. This may include bullying, corruption, making the child scared or preventing the child from enjoying normal social activity.
 - **Sexual Abuse**: Forcing a child to engage in sexual behaviours ranging from viewing pornography to engaging in sexual activity. 
 - **Neglect**: This is when a child's basic needs are not met. The child may not have adequate food, provision of medical care or housing. 
 

# Investigations
 
 - It is important to record a detailed history and complete a body map. 
 -  Radiology: A comprehensive skeletal survey may be necessary to identify:
  
  -  Rib fractures
  -  Skull fractures or intracranial bleeds
  -  Metaphyseal corner fractures (caused by a twisting or pulling motion on a limb)
  -  Finger fractures
  -  Clavicle fractures
 -  Laboratory testing: Blood tests are important to rule out organic causes such as clotting disorders or haematological malignancies.
 -  Medical photography may also be used. 
 

# Management
 

 -  Report suspicions: Always inform a senior or a named safeguarding lead if non-accidental injury is suspected.
 -  Safeguarding measures: Admit the child for safeguarding while investigations continue. Ensure the safety of other children in the home.
 -  Treatment: Administer appropriate medical management for injuries.
 -  Documentation: Maintain clear and thorough documentation.
 -  Social care liaison: Contact social care to investigate if the child or caregiver is already known to them.

# Complications

- Recurrence or escalation of the NAI
- Psychological distress 
- Poor health outcomes 
- Substance misuse and employment difficulties later in life


# Female Genital Mutilation 

Female Genital Mutilation (FGM) is a term for intentional injuries, cuts and alterations of female genitals without a medical indication. It is illegal in the UK and is considered to be child abuse. It most commonly affects girls between the ages of 0 and 15. It can have serious complications to the physical and mental health of the individual including chronic pain, infection, fertility problems, PTSD and depression. 

It is illegal to perform FGM, assist an individual to perform FGM or fail to protect a girl for whom you're responsible from FGM. 

If you see a patient and are concerned about a patient being at risk of FGM, it is important to contact 999 if the risk is imminent, or if not imminent, to inform the police on 101 and NSPCC on 0800 028 3550. 

 
#  Prognosis 
 
Non-accidental injury is important for any healthcare worker to be aware of. In 2017/2018, almost 100 children were the victim of a homicide and almost 60 died due to assault. Furthermore, there were over 15,000 cases of neglect and over 50,000 sexual offences against children reported to the police. 
 

# NICE Guidelines
 
[NICE Guidance: Child maltreatment: when to suspect maltreatment in under 18s](https://www.nice.org.uk/guidance/cg89)

[NICE Guidance: Child abuse and neglect](https://www.nice.org.uk/guidance/ng76/resources/child-abuse-and-neglect-pdf-1837637587141) 

#  References 
 
[Office for National Statistics Child Physical Abuse](https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/childphysicalabuseinenglandandwales/yearendingmarch2019) 

[Patient Info Safeguarding Children](https://patient.info/doctor/safeguarding-children-referral-and-management-of-an-abused-or-at-risk-child) 

[BMJ Best Practice Child Abuse](https://bestpractice.bmj.com/topics/en-gb/846/epidemiology)

[NHS Female Genital Mutilation](https://www.nhs.uk/conditions/female-genital-mutilation-fgm/)
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Non-accidental Injury
Topic
29
Paediatrics
6632
A low threshold for suspecting sexual abuse is essential in a child with an anal laceration when other potential causes, such as constipation, Crohn's disease, and passing hard stool, have been ruled out.
An 8-year-old boy is brought to the GP by his father for 3 days of painful bowel motions. He has recently switched GPs and in previous records, he has not been brought in to any of his routine appointments. The child is quiet and withdrawn, but states he has been opening his bowels once per day, with no change in frequency or consistency. His father states it started when he fell down onto one of his toys while playing with his sister. On further questioning, he states there has been some fresh red blood on the toilet paper on wiping. He explains he has been afraid to open his bowels as, for the last three days, he has found it very painful to go, but still has managed without straining. He denies abdominal pain, recent change in diet, or loss of appetite.

On examination, observations are unremarkable and his abdomen is soft and non-tender. An attempt at PR exam is abandoned as he finds it incredibly painful.

Which of the following is the best next step in the management of this patient?
a