Emergency Medicine

Paediatric Emergencies 373

CHILD ABUSE (NON-ACCIDENTAL INJURY)

• torn upper lip frenulum, or palatal haemorrhage from a
  feeding bottle or even a fist thrust into the mouth to prevent
  the baby crying, or from a direct blow


• human bite marks, and bruising from a fist or slapping,
  which may rupture the tympanic membrane


• deep cigarette burns, or scalds limited to the buttocks and
  genitalia or both feet, suggesting immersion in hot water


• a fractured skull or long bone, particularly in a child not
  yet able to walk. A spiral fracture of a long bone is most
  suspicious, as are other healing fractures of differing ages
  on skeletal survey


• subconjunctival, vitreous or retinal haemorrhage,
  suggesting violent shaking, or from a direct blow


• signs of trauma to the genitalia or anus, perianal warts or
  other sexually transmitted diseases.

MANAGEMENT

1 Inform the senior ED doctor and paediatric team immediately if you have
any suspicion of child abuse, and arrange for admission of the child.

2 Check whether the child is on the Child Protection Register already and
involve the ED social worker early.

3 Do not confront the parents at this stage. Explain that you want a further
opinion from a senior paediatric doctor, which necessitates admitting the
child.

4 Make sure to accurately document in the medical notes the history, physical
examination findings, timing and nature of consultations, and suspicion of
child abuse.

5 Contact the social work department and follow local procedural policy with
respect to the timing and involvement of additional agencies such as the
police and social services, if the parent refuses admission.

6 En l ist t he help of add it iona l suppor t g roups such as t he Nat iona l Associat ion
for Prevention of Child Abuse and Neglect (NAPCAN. http://www.napcan.org.au))
in Australia, or the National Society for Prevention of Cruelty to Children
(NSPCC. http://www.nspcc.org.uk/)) in the UK, if further advice or help is required.

Tip: a similar presentation may be seen in osteogenesis imperfecta

with multiple fractures, and idiopathic thrombocytopaenic purpura and

leukaemia with widespread bruising and bleeding. However, these are

rare compared with genuine cases of child abuse.

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