Child protection and injury assessment

Child Protection & Non-Accidental Injury (NAI)

• Injury interpretation: Certain patterns are highly concerning but no fracture pattern or subdural/retinal/encephalopathy triad independently proves abuse. Integrate the mechanism, developmental ability, medical mimics, complete examination and specialist child-protection assessment.

• TEN-4-FACESp screening: In bruised children younger than four years, concerning sites include torso, ears, neck, frenulum, angle of jaw, fleshy cheeks, eyelids and subconjunctivae; patterned bruising also matters. Any bruising in an infant aged at most 4.99 months qualifies. This is a screening prompt for assessment, not proof of abuse. Bruising is the most common presentation of physical abuse and the most frequently overlooked sentinel injury preceding catastrophic physical trauma or fatality:

• Non-mobile infant bruising: Requires prompt medical and safeguarding assessment, considering developmental ability, history, injury distribution and medical alternatives. Suspicion triggers the local reporting pathway; assessment must not be framed as a presumption of guilt that the family must disprove.

• Accidental vs Non-Accidental Distribution:

  • Accidental Bruises: Predominantly occur over bony prominences (forehead, chin, knees, shins) as toddlers learn to walk and stumble.

• Patterned Bruising: Imprints that match the profile of an implement: parallel linear marks with central clearing (tram-track lines from a cane or stick), loop-shaped contusions (folded electrical cord or telephone wire), buckle marks (belts), or cluster hand/fingerprint grab marks on the upper arms or thorax.

Suspicious Burn Patterns

• Immersion Scald Burns: Produced when an infant is forcibly held in scalding hot water. Hallmark features include:
  • Sharp, abrupt fluid level demarcations (waterlines) without ragged splash marks.
  • Symmetrical stocking or glove scalds of the feet or hands.
  • "Doughnut sign": Scalding of the buttocks with a central sparing of the perineum and mid-buttock skin that was pressed firmly against the cooler porcelain surface of the bathtub.
  • Sparing of the anterior flexural creases of the hips and knees where the child instinctively flexed their limbs away from hot water.
• Contact Burns: Sharp outlines corresponding to heated metallic objects (flat iron, cigarette lighters). Cigarette burns present as deep, uniform, circular punched-out lesions ($8\text{ to }10\text{ mm}$ in diameter) at various stages of healing.

Skeletal Trauma Patterns

Certain fracture types and radiological patterns carry exceptional diagnostic specificity for inflicted physical trauma:

• Posterior Rib Fractures: Biomechanical Mechanism: Direct forceful manual anteroposterior thoracic compression (squeezing chest while shaking); Specificity for Non-Accidental Injury: High Specificity (CPR rarely causes rib fractures in infants)
• Multiple Fractures of Differing Ages: Biomechanical Mechanism: Repeated, chronic abusive trauma over time (callus formation alongside acute fractures); Specificity for Non-Accidental Injury: High Specificity
• Scapular, Sternal, or Spinous Process Fractures: Biomechanical Mechanism: Massive direct focal blunt impact unexplainable by domestic trauma; Specificity for Non-Accidental Injury: High Specificity
• Complex Skull Fractures: Biomechanical Mechanism: Depressed, diastatic ($> 3\text{ mm}$ wide), bilateral, or fractures crossing cranial suture lines; Specificity for Non-Accidental Injury: Moderate to High Specificity
• Spiral Diaphyseal Fractures in Non-Walkers: Biomechanical Mechanism: Torsional twisting of long bones (femur, humerus) in pre-ambulatory infants; Specificity for Non-Accidental Injury: High Specificity

Abusive Head Trauma (AHT / Shaken Baby Syndrome)

• Mechanism: Violent repetitive rotational acceleration-deceleration forces applied to an infant's head when shaken by the chest or extremities, with or without blunt impact against a hard or soft surface. The infant's heavy head, weak cervical neck musculature, and unmyelinated brain render bridging cerebral veins exceptionally vulnerable to traction shearing.
  1. Subdural Haematoma (SDH): Classically thin subdural collections over the cerebral convexities, tentorium, or interhemispheric fissure.
  2. Severe Retinal Haemorrhages: Found in up to 85% of cases. Typically extensive, multilayered (preretinal, intraretinal, and subretinal), extending to the ora serrata periphery, often associated with traumatic retinoschisis (splitting of retinal layers) and circumferential macular folds.
  3. Encephalopathy: Altered conscious state, lethargy, apnoea, seizures, or coma, completely disproportionate to the history provided by caregivers.

Mandatory Reporting and Legal Obligations in Australia

• Child-protection duties: Doctors have reporting duties across Australia, but reportable categories, ages and suspicion/belief thresholds differ by jurisdiction. Check the local Act and child-protection pathway. Proof is not required before reporting at the statutory threshold, and consent is not needed for a lawful mandatory report. Protect immediate safety while seeking specialist advice.
• Legal Threshold: The legal standard is "reasonable grounds to suspect"; medical practitioners are not required to prove abuse before lodging a report. Reports are made to the respective State/Territory statutory child protection department.
• Reporter protections: Good-faith statutory reports generally receive legal protections. Their scope depends on the jurisdiction and lawful reporting conditions; avoid promising absolute immunity from every conceivable liability.
• Emergency Management & Safeguarding Protocol:
• Safeguarding: Arrange a safe disposition with senior paediatrics, social work and child protection. Admission is appropriate when medically required or discharge would be unsafe; statutory and emergency powers are jurisdiction-specific. Explain findings respectfully and document observations without presuming intent. 2. Multidisciplinary Team Activation: Notify hospital social work, the senior consultant paediatrician, and the hospital Child Protection Medical Service (e.g., Child Protection Unit). 3. Complete Forensic Diagnostic Workup:
  • Skeletal survey: Specialist radiology uses an age-appropriate protocol for suspected abuse, often with follow-up around two weeks where indicated. It is not simply two views of every bone; neuroimaging and other tests are selected by age and findings.
  • Non-contrast Cranial CT / MRI: Urgent neuroimaging for any infant with suspected head trauma, altered consciousness, or unexplained seizures.
  • Dilated Fundoscopic Examination: Formal review by a consultant ophthalmologist within 24 to 48 hours to document retinal haemorrhages.
  • Coagulation studies, liver transaminases, amylase/lipase, and metabolic bone disease screening (calcium, phosphate, alkaline phosphatase, vitamin D) to exclude medical mimics (e.g., osteogenesis imperfecta, haemophilia, severe rickets).

Clinical comparison: Accidental versus Non-Accidental Injury (NAI) Patterns in Children

• Thermal Burns: Accidental Trauma Characteristics: Asymmetrical, ragged margins with splash marks; downward liquid trajectory; Suspicious Non-Accidental Injury (Abuse): Sharp waterlines, stocking/glove distribution, bilateral buttocks with doughnut sparing; Mandatory Diagnostic Workup: Inpatient admission; photographic documentation; child protection report
• Skeletal Fractures: Accidental Trauma Characteristics: Isolated linear fractures matching reported low-energy fall (e.g., clavicle, toddler's tibia); Suspicious Non-Accidental Injury (Abuse): Posterior rib fractures, metaphyseal corner fractures, multiple fractures at varying healing stages; Mandatory Diagnostic Workup: Complete skeletal survey (repeat at 14 days); serum calcium, PO4, ALP, vitamin D
• Head & Eye Trauma: Accidental Trauma Characteristics: Small epidural haematoma matching focal impact; absent or mild intraretinal haemorrhages; Suspicious Non-Accidental Injury (Abuse): Multilayered extensive retinal haemorrhages; interhemispheric subdural haematoma; encephalopathy; Mandatory Diagnostic Workup: Non-contrast brain CT; MRI brain/spine; urgent dilated ophthalmology exam
• History & Interaction: Accidental Trauma Characteristics: History consistent across carers and compatible with child's developmental motor milestones; Suspicious Non-Accidental Injury (Abuse): Inconsistent, evolving history; mechanism fails to explain injuries; delayed presentation; carer apathy; Mandatory Diagnostic Workup: Detailed verbatim documentation of carer statements; statutory agency notification

Primary references (checked 7 October 2026): RCH pyloric stenosis.