Children who attend with an injury that might have been inflicted need a full assessment of their physical condition and psychosocial situation.

The priorities in dealing with child physical abuse are to:

1. suspect physical harm / non-accidental injury (NAI)
2. diagnose, treat and document the child's injuries
3. interpret a pattern of injury or findings leading to the suspicion of abuse
4. notify and involve the Victorian Forensic Paediatric Medical Service (VFPMS)
5. assess the child's psychosocial situation
6. provide, when consent is given or legislation requires information sharing in the absence of guardian's consent , a verbal and/or written report to Child Protection and the Police. VFPMS may be responsible for this task
7. plan for the child's safe discharge and ongoing medical / psychological care.

Contact 

Assessment of a child's psychosocial situation may be conducted as a multidisciplinary assessment by professionals within the health service, including social workers and mental health professionals, working in partnership with Child Protection, police and community-based professionals.

Management of suspected NAI

Admission or discharge?

Admission to hospital should be arranged when it is medically necessary (head injury, fractures, failure to thrive etc) or when it is necessary for the child's safety.

A low threshold for admission is appropriate when dealing with an injured child.

Consider NAI in any infant who presents with an unexplained encephalopathy. Any infant with a cerebral injury, from shaking or direct trauma, should be admitted to ICU for monitoring overnight. Delayed deterioration may occur. (At RCH - ICU admission should only be declined following assessment by the ICU consultant).

The safe discharge of the child is the responsibility both of the hospital and Child Protection.

SCAN (Suspected Child Abuse and Neglect) multi-disciplinary professionals' meetings

All admitted patients should be the subject of a SCAN meeting held within 24 hours of admission.
The SCAN protocol is designed to help coordinate early discussions with Paediatric medical staff, Victorian Forensic Paediatric Medical Service, Child Protection and police.

See SCAN meeting resources.

Medical investigation of suspicious injury

Forensic investigation of suspicious bruising

Forensic investigation of suspected intra-abdominal trauma

• Amylase and lipase
• LFT
• FBE
• Fibrinogen
• Dipstick urine (blood)
• Ultrasound
• CT abdomen if significant concerns about paralytic ileus, intra-abdominal haemorrhage and elevated amylase (> 3 hours post trauma)

Forensic investigation of suspected abusive head trauma

• Consider radiological imaging (MRI and/or CT brain scan) of the brains of infants and young children who might have been shaken.
• Consider MRI cervical spine
• Investigate as for fracture
• Consult with an ophthalmologist (and arrange for examination by the ophthalmologist)
• Investigate as for bruising when intracranial haemorrhage exists
• Urine Metabolic screen
• Admission to ICU should be considered  whenever altered conscious state has occurred after suspected shaking because of the high risk of further neurological deterioration caused by progressive brain swelling

Forensic investigation of suspicious fractures

Radiological investigation

Infants and Toddlers aged < 2 years

The optimal method for radiological investigation of occult fracture has not been determined for children aged less than two years. Protocols vary between regions. 

The following guidelines have been developed mindful of the need to minimise a child’s exposure to radiation (ALARA principle) balanced with the need to adequately investigate concerns regarding occult fracture in the context of suspected child abuse.

As a general principle, order investigations only when a positive result might result in intervention that increases a child’s safety or might result in additional action of some sort.

As a general guide we recommend the combination of Skeletal Survey and Bone Scan for children aged less than two years when there is a reasonable suspicion that the child has suffered an occult fracture.

Recommendation: < 2 years old – Skeletal Survey and Bone Scan

Exceptions

However, if one of the following fractures is detected as the only injury then additional radiological investigation is not necessary. 

• Distal radius/ulna fracture in a toddler aged > 9 months AND a history of a fall
• Distal tibia/fibula fracture in a toddler aged > 11 months AND fall while walking. “Toddler fracture” 
• Single linear skull fracture in a child aged > 12 months AND a history of a fall or adult landing on child
  
• Clavicle fracture in the newborn
• Clavicle fracture in 2nd year of life AND a history of a fall

In regions where Bone Scan is not available or when parents refuse consent for Bone Scan then a second Skeletal Survey performed 2 weeks after the first Skeletal Survey may be considered. Note that this process is likely to miss some occult fractures (particularly rib fractures in infants). Strategies will need to be put in place to ensure safe care for the infant between Skeletal Surveys and safe plans to ensure that the second Skeletal Survey is performed and the infant is not lost to follow up.

“Double reporting” of Skeletal Surveys (reporting by two independent radiologists) is encouraged.

Children aged > 2 years

Most children aged > 2 years will develop symptoms and signs of injury when a fracture is present.  We recommend X-rays of the site(s) of suspected fracture with coned views if required.

Recommendation: > 2 years : Radiograph (x-ray) sites of clinically suspected fracture(s).

However, Skeletal Survey might be indicated because of a strong suspicion of occult fracture in a child aged > 2 years. Bone Scan might be considered as an adjunct to Skeletal Survey under such circumstances.

Occasionally MRI or ultrasound might also be considered.

Notes

• Skeletal Surveys must be performed according to recommended protocols.
• X-rays might fail to detect rib fractures and some long bone fractures.
• Bone Scan is not a sensitive tool for the detection of skull fractures. If skull fracture is suspected, obtain a skull radiograph or CT scan. Note that the dose of irradiation must be weighed against the need to determine whether a skull fracture exists. 
• Bone Scan might not detect CML.
• Bone Scan is unlikely to detect most fractures that occurred > 12 months previously.  

Blood tests to investigate suspicious fracture

First line tests:

• Calcium
• Phosphate
• LFT
• U&E Creatinine
• Vit D
• FBE

Second line tests:

• Magnesium
• Copper
• Parathyroid hormone
• Syphilis serology
• Urine Metabolic Screen
• Inflammatory markers

Also consider genetic tests for OI.

Forensic investigation of suspicious burns and scalds

If suspicions exist about intentional thermal injury such as scalds and contact burns in children aged < 3 years, then skeletal survey, bone scan and additional investigations for other forms of child abuse should be considered.

Toxicological tests

Toxicology tests might be considered when ingestion or poisoning is possible as a result of care-giver neglect or intentional exposure/ ingestion. Also consider toxicology tests in children with unexplained altered conscious state, head injury, thermal injury and sexual assault.

• Consult with forensic experts before collecting samples.
• Ensure chain of evidence procedures if sending samples to forensic laboratory
• Collect blood and urine if ingestion or poisoning was within prior 24 hours
• Collect urine if ingestion or poisoning was more than 24 hours previously
• Consult with VFPMS if considering sampling hair for toxicological analysis.

Forensic toxicology laboratories and hospital biochemistry laboratories differ significantly in the analytical techniques used for drug detection and in the way that results are reported. Send samples to the laboratory that can perform the required tests.