PAEDIATRICS
NON-ACCIDENTAL INJURY - NAI
documentation and mandatory report are key here
PromptHISTORY features in NAI
ResponseInconsistent mechanism
Inconsistent or incomplete history
Delayed presentation
Inappropriate interaction (Child vs carer)
Age of child vs appropriate injuries
No cause for injury found
Injury in non ambulant infant
Inconsistent or incomplete history
Delayed presentation
Inappropriate interaction (Child vs carer)
Age of child vs appropriate injuries
No cause for injury found
Injury in non ambulant infant
PromptHigh risk groups for NAI
ResponseChronic disease/Developmental delay
Failure to thrive
Socioeconomic status
DV
Single parent
Substance abuse
Foster care
Failure to thrive
Socioeconomic status
DV
Single parent
Substance abuse
Foster care
PromptCommon injuries in NAI
ResponseTEN4FACESp (this mnemonic was a question)
Torso, Ears, Neck, Frenulum, Angle of the jaw, Cheeks, Eyelids or Subconjunctivae
Any bruising child <4 months
P = Pattenrned bruising
Soft tissue
Suffocation
Torso, Ears, Neck, Frenulum, Angle of the jaw, Cheeks, Eyelids or Subconjunctivae
Any bruising child <4 months
P = Pattenrned bruising
Soft tissue
- Any injury in non movile child
- Various bruises of various ages
- Circumferential injuries
- Usually not over bony prominences
- Cigarette, immersion pattern
- Buttocks/hands/genital areas
- ICH - various (Eg: Extradural)
- Retinal haemorrhages
- Unexplained encephalopathy
- Perforated viscous, solid organ injury
- Metaphyseal chip (corner) fracture (bucket handle fracture)
- Femur (any long bone fracture, especially bilateral)
- Skull fractures
- Fractures of different ages
- Sternal, scapular, spinous process
- Posterior rib
Suffocation
Prompt
Spiral fracture of humerus, inconsistent with age (10m)
SDH L parietal 2-3mm, SAH fronotocipital, Diffuse ventricular compression/oedema
Multiple healing rib fractures
Spiral fracture of humerus, inconsistent with age (10m)
SDH L parietal 2-3mm, SAH fronotocipital, Diffuse ventricular compression/oedema
Multiple healing rib fractures
Response
PromptComponents of examination in NAI
ResponseInjuries (above - Fractures burns bruising, bites, ICH/head injury)
Conscious state/neurologic status
Genitalia/sexual abuse
Developmental assessment + milestones, evidence of neglect
Features of primary bone disorder/renal disease, evidence of bleeding disorders
Conscious state/neurologic status
Genitalia/sexual abuse
Developmental assessment + milestones, evidence of neglect
Features of primary bone disorder/renal disease, evidence of bleeding disorders
PromptED management of NAI
ResponseExclude other injuries, full trauma assessment, trauma call activation
Treat identified injuries (Eg analgesia + ortho consult for femoral fracture)
Analgesia
Social work involvement
Offer/allocate support person
Doccumentation - (ensure you document concerns)
Call child protection - Mandatory report (duty of care) and act within the law
Open disclosure vs concerns for abuse vs need to divulge to parents need of reporting.
Admission for further investigation of injury and social circumstances
Treat identified injuries (Eg analgesia + ortho consult for femoral fracture)
Analgesia
Social work involvement
Offer/allocate support person
Doccumentation - (ensure you document concerns)
Call child protection - Mandatory report (duty of care) and act within the law
Open disclosure vs concerns for abuse vs need to divulge to parents need of reporting.
Admission for further investigation of injury and social circumstances
PromptInforming the “other” parent about NAI
ResponseEnsure another person with you (Chaperone, SW)
Consider security presence
Openly disclose suspicion of NAI
Inform legal requirement for mandatory report
Consider security presence
Openly disclose suspicion of NAI
Inform legal requirement for mandatory report
PromptSafe discharge in NAI
ResponseExclude significant injury (Eg: Head injury)
Responsible adult to care for child
Transport home
Risk assessment of home situation - ensure safe for child
Injury specific discharge advice for child (eg: Head injury advice red flags)
Time of day - don’t discharge at 4AM
General appearance of child - neglected = admission
Responsible adult to care for child
Transport home
Risk assessment of home situation - ensure safe for child
Injury specific discharge advice for child (eg: Head injury advice red flags)
Time of day - don’t discharge at 4AM
General appearance of child - neglected = admission
PromptDAMA in NAI
ResponseAttempt to reason with parent/carer to stay
Formal report of child abuse (DCJ in NSW)
Call parent/carer later to check on child
Call police to ensure welfare check occurs
Formal report of child abuse (DCJ in NSW)
Call parent/carer later to check on child
Call police to ensure welfare check occurs