10.3 Non-Accidental Injury & Safeguarding

Recognizing and Responding to Non-Accidental Injury

Non-accidental injury (NAI), a form of child physical abuse, is a diagnosis every pediatrician must be able to consider. The Arab Board exam tests pattern recognition of red-flag histories and injuries, the correct threshold for reporting, and the multidisciplinary response, rather than expecting trainees to "prove" abuse themselves.

Red Flags in the History

A history is suspicious for NAI when it shows:

• Mismatch between the history and the injury — for example, a history of a minor fall from a low sofa given for a child with multiple fractures or a severe head injury.
• Mismatch between the history and the child's developmental stage — for example, "he rolled off the changing table" offered as an explanation for a 6-week-old infant who is not yet able to roll.
• Inconsistent or changing accounts, including different explanations from different caregivers, or a history that changes each time it is retold.
• Unexplained delay in seeking medical care that is disproportionate to the severity of the injury.
• A history of repeated unexplained injuries or frequent, unrelated emergency department visits.
• An implausible mechanism for the specific injury pattern observed — for example, a spiral femur fracture in a non-ambulatory infant attributed to a sibling "falling on" them.

Exam tip: The single most reliable red flag on a written exam is a history that does not fit the child's developmental milestones — always cross-check the stated mechanism against what the child could physically do at that age.

Bruising Patterns That Raise Concern

Bruises are the most common presenting sign of physical abuse, and their location, pattern, and the child's mobility matter more than their number.

• "Those who don't cruise rarely bruise." Bruising in a pre-mobile infant (one who cannot yet roll, crawl, cruise, or walk) is highly concerning and should prompt further evaluation, because accidental bruising generally requires independent mobility.
• The TEN-4-FACESp mnemonic summarizes high-risk bruising:
  • TEN-4: bruising to the Torso, Ears, or Neck in a child under 4 years, or any bruising in an infant under 4 months old.
  • FACESp: bruising to the Frenulum, Angle of the jaw, Cheeks, Eyelids, Subconjunctivae, or any patterned bruise, at any age.
• Patterned bruising that reproduces the shape of an object — a looped cord or belt mark, parallel linear "slap" marks, grip marks with finger-tip-sized ovals encircling a limb, or a bite mark — is strong evidence of an inflicted injury rather than an accidental one.

Fracture Patterns Suspicious for Abuse

A related, exam-favorite entity is abusive head trauma ("shaken baby syndrome"), classically presenting with the triad of subdural hemorrhage, retinal hemorrhage, and encephalopathy in an infant without an adequate history of trauma; any suspected case warrants urgent ophthalmology referral for dilated fundoscopy and neuroimaging.

Worked example: A 4-month-old infant is brought in with a swollen, painful thigh. The caregiver reports the infant "just started crying" while lying in the crib. Imaging shows a spiral fracture of the femur. Because this infant cannot yet roll or bear weight, and no mechanism was offered that could generate this fracture, this combination — an unexplained long-bone fracture in a non-ambulatory infant — is a classic exam vignette for NAI requiring safeguarding referral.

Mandatory Reporting Principles

Every physician has a legal and ethical duty to report suspected child abuse to the relevant child protection or statutory authority. Key principles:

• The threshold for reporting is reasonable suspicion, not proof or certainty — clinicians are not expected to investigate or confirm abuse themselves before reporting.
• Parental consent is not required to make a report; the child's safety overrides usual confidentiality and consent norms.
• Documentation should be objective and factual — record the history verbatim (in quotation marks, noting who gave it), describe injuries precisely using body diagrams or photographs where possible, and avoid writing conclusory or presumptive language such as "abuse" directly in the chart; describe findings and let the safeguarding process draw conclusions.
• Failure to report suspected abuse is itself a safeguarding failure with potential legal consequences for the clinician.

The Multidisciplinary Safeguarding Approach

No single clinician manages a suspected NAI case alone. A coordinated team typically includes:

• The treating pediatrician, who performs a full clinical assessment and arranges a skeletal survey (mandatory in suspected physical abuse under age 2, and considered in older toddlers) to look for occult or healing fractures.
• Ophthalmology, for dilated fundoscopy when abusive head trauma is suspected.
• The hospital's named safeguarding or child protection lead, who coordinates the response and ensures statutory reporting occurs.
• Social work and statutory child protection services, who assess the home environment and the safety of the child and any siblings.
• Police or legal authorities, where a crime may have been committed.
• Radiology, for expert interpretation of skeletal survey and neuroimaging findings.

Any siblings or other children in the same household should also be assessed, since risk to one child in a household often implies risk to others. Until safety can be assured, the child should be admitted or kept in a place of safety while the multidisciplinary assessment proceeds.

Exam Pearls

• A history that does not match the child's developmental stage is the single strongest red flag.
• Bruising in a non-mobile infant, or in the TEN-4-FACESp distribution, warrants further evaluation.
• Metaphyseal corner fractures and posterior rib fractures are highly specific for NAI.
• Reporting requires only reasonable suspicion, not proof, and does not require parental consent.