Clinical Manifestations of NAI:

Types of Non-accidental injury:

Physical
Emotional
Neglect and negligent
Sexual

Physical abuse:
History:

Vague, inconsistent, contradictory, inadequate or implausible story when explaining

the cause of the childs injury
Delay in seeking medical attention
Inappropriate parent or caregiver response/behavior:
o Arguing, roughness or violence
o Lack of interaction between parents and children
Sexual behavior beyond the childs years and supposed knowledge
High Risk Factors:
o Social history:
Signs of abused child
Abusive parents
Family factors:
Employment/financial issues
Marital conflict/domestic violence
Stressful events
Loneliness/isolation of parent
Lack of social support.

Physical Examination:

Failure to thrive with or without developmental delay

Child with poor hygiene, dental and gum disease, untreated sores
Multiple injuries of various type and different ages
Bruises:
o Characteristic bruises:
Oval bruises suggestive of a slap on the face or grasp around a limb
Burns with patterns (cigarettes mark)
Scalds of the lower limbs and abdomen with no splash marks (glove
and stocking distribution/doughnut pattern immersion burns
Belt marks
Loop marks
Bite marks

Location of bruises:
Bruises to padded areas like buttocks, breasts, lower abdomen, or
medial aspects of both thighs
Associated signs:
o Bilateral retinal hemorrhages (shaken baby syndrome)
o Orofacial injuries:

frenulum tears, tongue injuries, gingival lesions, and dental trauma

Peri-orbital hematoma secondary to base of skill #

Ear trauma

Nasal septa deviation

Traumatic alopecia
o
Injuries highly epidemiologic association with abuse:
Bruises in children who cannot cruise
Bruises of the trunk, ear, and neck
Long bone fractures in children who do not walk
Rib fractures in infants younger than one year of age
Hollow viscus injury in children younger than four years old
Subdural hematoma in infants younger than one year old
Behavioral symptoms:
o Fear of parent/caregiver
o Overly compliant, withdrawn, unusual fear of authority
o Wariness of physical contact
o Unusual hunger for affection
o Fear of going home after school/childcare
o Sudden change in behavior
o Wetting/soiling pants inappropriate for age group
o Sleep problems including nightmares
o Constantly watching for possible danger, apphrehensive.
o Aggressive behavior

Investigation:

X-Ray:
o Fractures highly suggestive of NAI:
Metaphyseal corner fractures
Posterior Rib fractures
Fractures of the sternum, scapula, or spinous processes
Multiple fractures in various stages of healing
Bilateral acute long-bone fractures
Vertebral body fractures and subluxations in the absence of a history
of high force trauma
Digital fractures in children younger than 36 months of age or without
a corresponding history
Epiphyseal separations

Complex skull fractures in children younger than 18 months of age,

particularly without a corresponding history
CT- head:
o Subdural hematoma bilateral retinal hemorrhages (shaken baby syndrome)
Bloods (TRO bleeding disorders)
o FBC (Anemia?)
o LFT ALT/AST TRO liver injury (Blunt abdominal trauma)
o Urine analysis and toxicology

Distinguishing NAI physical abuse from accidental injury:

Location of the injury:

o Certain locations on the body are more likely to sustain accidental injury.
o These include the knees, elbows, shins, and forehead.
o Protected body parts and soft tissue areas, such as the back, thighs, genital
area, buttocks, back of legs, or face, are less likely to accidentally come into
contact with objects that could cause injury.

Number and frequency of injuries:

o The greater the number of injuries, the greater the cause for concern. Unless
the person is involved in a serious automobile accident, he/she is not likely to
sustain a number of different injuries accidentally. Multiple injuries in different
stages of healing are also a strong indicator of chronic abuse.
Size and shape of the injury:
o Many non-accidental injuries are inflicted with familiar objects: a stick, a
board, a belt, a hair brush. The marks which result bear a strong
resemblance to the objects used. Accidental marks resulting from bumps and
falls usually have no defined shape.
Description of how the injury occurred:
o If an injury is accidental, there should be a reasonable explanation of how it
happened that is consistent with the appearance of the injury. When the
description of how the injury occurred and the appearance of the injury are
inconsistent, there is cause for concern. For example, it is not likely that a
person's fall from a wheelchair onto a rug would produce bruises all over the
body.
Consistency of injury with the person's developmental capability:
o
As children grow and gain new skills, their ability to engage in activities that
can cause injury increases. A toddler trying to run is likely to suffer bruised
knees and a bump on the head. Toddlers are less likely to suffer a broken
arm than an eight-year-old who has discovered the joy of climbing trees.

Neglect/Negligence:
Physical Examination
Physical signs:

Consistent and regular hunger

Malnutrition
Low weight for age
Gaining weight when hospitalised or placed in alternative care
Poor language skills and coordination
Poor hygiene (child constantly unwashed)
Poor teeth, gum disease, untreated sores, not immunised against illness
Consistent lack of supervision

Behavior symptoms:

Poor bonding with parents

Clings to any adult, goes too easily with strangers
Unusually tired, listless, or motionless
Feeds hungrily or hardly at all
Hungry for adult affection and attention
Habitual school truant or late-comer
Poor school performance, learning difficulties Reluctance to go home Rocking,
sucking, head banging

Emotional abuse:
Physical signs:

Stunted growth: Non-organic failure to thrive

Accelerated growth away from family
Feeding behaviour grossly disturbed
Delayed mental and emotional development
Unusual patterns of urination and defecation
Poor social adjustment, anti-social behaviour, unhappy

Behavior signs:

Changes in behaviour
Lying and stealing
Destructive or violent behaviour
Child rocks, sucks, or bites self
Being very shy, passive, compliant
Being aggressive and constantly seeking attention
Low self-esteem, negative statements about self
Inability to mix with other children

Sexual abuse:
Physical signs:

Pain, itching, discharge, or bleeding in genital area

Bruises to breasts, buttock, lower abdomen or thighs
Vaginal infection with or without associated urinary tract infections
Abdominal pain suggestive of pelvic inflammatory disease
Recurrent headaches which are not neurological in origin
Sexually-transmitted diseases
Painful urination, bedwetting inappropriate for age
Pregnancy, especially teenage pregnancy
Torn, stained, bloody underclothes
Symmetrical bruises over the medial aspects of both thighs which suggest that the
childs hips were forcibly abducted during the act of sexual assault

Behavior signs:

Fear of being hurt during dressing / nappy change

Inappropriate sexual activity
Fear of being alone with a particular adult

Investigation:

Urine analysis for UTIs

Blood tests for STDs
Urethral swab/vagina swab for STDs
UPT for girls