Child Safeguarding and Non-Accidental Injury

Introduction

Safeguarding is everyone's responsibility, and it is one of the few areas of medicine where a student or foundation doctor has a direct professional and legal duty regardless of seniority. The GMC is unambiguous: if you believe a child or young person is at risk of, or is suffering, abuse or neglect, you must tell an appropriate agency promptly, and you can share information without consent where it is in the child's best interests.⁴

The threshold for acting is suspicion, not proof. You are not required to diagnose abuse, decide who did it, or exclude every medical mimic before referring. Your job is to recognise the features that should raise concern, examine and document carefully, escalate to someone senior the same day, and make sure the child is safe in the meantime.

Two failures recur in serious case reviews. The first is professionals recording concerns without acting on them, each assuming someone else would. The second is a plausible explanation being accepted because the family seemed articulate, affluent or engaged - abuse occurs in every social group, and the absence of the stereotypical risk factors excludes nothing.

Definitions and legal framework

The four categories

• Physical abuse - hitting, shaking, throwing, poisoning, burning, scalding, drowning, suffocating, or otherwise causing physical harm, including fabricating or deliberately inducing illness
• Emotional abuse - persistent emotional maltreatment causing severe and lasting adverse effects on a child's emotional development: conveying that they are worthless, inadequate or unloved, imposing developmentally inappropriate expectations, silencing, bullying, or making them witness the ill-treatment of another
• Sexual abuse - forcing or enticing a child to take part in sexual activities, whether or not they are aware of what is happening; contact and non-contact, including grooming and online abuse. It is perpetrated by adults and by other children.
• Neglect - persistent failure to meet a child's basic physical or psychological needs, including food, clothing, shelter, supervision, medical care and emotional responsiveness. It begins in pregnancy with maternal substance misuse.

Alongside these sit child sexual exploitation, child criminal exploitation including county lines, female genital mutilation, forced marriage, so-called honour-based abuse, radicalisation, modern slavery, and exposure to domestic abuse - now recognised in law as harm to the child in its own right.

Legal framework

• Children Act 1989 and 2004 - the child's welfare is the paramount consideration⁶
• Section 17 - a child in need, requiring services to achieve a reasonable standard of health and development
• Section 47 - a duty on the local authority to make enquiries where there is reasonable cause to suspect a child is suffering, or is likely to suffer, significant harm
• Working Together to Safeguard Children - the statutory multi-agency guidance describing how organisations must cooperate³
• Emergency Protection Order through the courts, and police protection allowing removal to a place of safety for up to 72 hours
• Mandatory reporting of FGM - regulated health professionals in England and Wales must report known cases in a girl under 18 to the police
• Gillick competence and the Fraser guidelines govern consent and confidentiality in under-16s - but a competent young person's refusal to allow disclosure does not override a duty to protect them from significant harm

Risk factors

Risk factors raise the index of suspicion. They never confirm abuse, and their absence never excludes it.

Child factors

• Age under 1 year - infants carry by far the highest risk of fatal and severe physical abuse
• Prematurity, low birth weight and prolonged neonatal admission, which disrupt early bonding
• Disability, chronic illness or complex needs, which increase both dependency and carer stress
• Excessive crying, particularly in the first months - the single commonest trigger for shaking
• Behavioural difficulties, and a child perceived by the carer as difficult or different
• Multiple birth, or an unwanted or concealed pregnancy

Carer and household factors

• Domestic abuse, parental substance misuse and parental mental illness - often described together as the trilogy of risk, and present in a large proportion of serious case reviews
• Young parental age, and social isolation with little practical support
• A carer who was themselves abused as a child
• Parental learning disability, where support needs may not have been met
• Unrealistic expectations of the child's behaviour or development
• A non-biological adult in the household - a statistically significant risk factor for physical abuse
• Poverty, housing instability and unemployment, which increase stress and reduce protective resources

Features that should raise concern

The history

NICE CG89 places the greatest weight on the account rather than the injury, and this is where most of the discriminating information lies.¹

• No explanation offered for a significant injury
• An explanation that is inconsistent, changes over time, or differs between carers
• An explanation incompatible with the injury - its severity, distribution or mechanism
• An explanation incompatible with the child's developmental stage - a 3-month-old cannot roll off a sofa if they cannot yet roll
• Unexplained delay in seeking help
• Repeated attendances with injuries, or injuries of clearly different ages
• The child's account differs from the carer's, or the child seems frightened, withdrawn or unusually watchful
• An inappropriate carer response - hostility, evasiveness, lack of concern, or a focus on their own needs rather than the child's
• Concerns raised by the child themselves, which must always be taken seriously

Bruising

Fractures

• Any fracture in a child who is not independently mobile
• Multiple fractures, particularly of differing ages
• Posterior rib fractures - produced by antero-posterior compression of the chest when an infant is gripped and squeezed; highly specific for abuse and often occult on early imaging
• Classic metaphyseal lesions (bucket-handle or corner fractures) - shearing injuries at the metaphysis caused by gripping and twisting or by the flailing of limbs during shaking; highly specific
• Scapular, sternal and spinous process fractures, which require considerable force
• Complex, bilateral, wide, depressed or suture-crossing skull fractures
• Femoral fracture in a non-ambulant infant
• A spiral or oblique long bone fracture in a child too young to have generated the twisting force themselves

Burns and scalds

• Immersion scalds - sharply demarcated, symmetrical, with a glove and stocking or buttock-and-lower-limb distribution, sparing of flexures where the limb was held flexed, and an absence of splash marks
• Cigarette burns - circular, roughly 8-10 mm, deep and punched out, often multiple
• Contact burns bearing the shape of an implement - an iron, a radiator grille, a hair straightener
• Burns on normally protected sites - the back, buttocks, perineum, soles
• Delayed presentation of a burn, or an explanation inconsistent with the depth or pattern

Other physical signs

• A torn frenulum in a non-mobile infant, or other oral injury
• Bite marks - an intercanine distance greater than about 3 cm suggests an adult; forensic odontology assessment may be needed
• Anogenital injury, bleeding or discharge
• Unexplained poisoning or ingestion, or an unexplained apparent life-threatening event
• Retinal haemorrhages and unexplained intracranial injury

Neglect, emotional and sexual abuse

• Neglect - poor hygiene, inadequate or inappropriate clothing, untreated dental caries, faltering growth, untreated medical conditions, missed immunisations, repeated non-attendance, poor school attendance, and developmental delay disproportionate to any diagnosis
• Emotional abuse - fearfulness, frozen watchfulness, indiscriminate affection towards strangers, low self-esteem, self-harm, and behavioural or developmental regression
• Sexual abuse - anogenital bleeding, pain or discharge; a sexually transmitted infection or pregnancy in a child; sexualised behaviour or knowledge inappropriate for age; recurrent urinary symptoms or new soiling; sudden behavioural change, running away, or self-harm
• Fabricated or induced illness - symptoms reported only by the carer and never observed independently, symptoms that resolve when the carer is absent, biologically implausible or inconsistent test results, a carer who presses for repeated invasive investigation, and a marked discrepancy between reported and observed function

Differential diagnosis

Medical conditions genuinely mimic abuse, and missing one causes profound harm to a family. Equally, looking for a medical explanation must never delay a safeguarding referral - the two happen in parallel, not in sequence.

Assessment and immediate management

First priorities

1. Treat the child. Resuscitate and manage injuries before anything else - safeguarding never displaces clinical care.
2. Ask whether the child is safe now, and whether there are other children in the household who may not be.
3. Tell a senior colleague immediately - the paediatric registrar or consultant, and the named or designated doctor for safeguarding. Do not sit on a concern until the end of a shift.
4. Take the history from the carer, and separately from the child where age allows. Use open questions, never leading ones, and do not interrogate or repeatedly question the child - forensic interviewing is a specialist skill and premature questioning can compromise both the child and any later investigation.
5. Record verbatim, in quotation marks, exactly what was said and by whom.
6. Examine the child fully undressed, including the whole skin surface, the scalp, behind the ears, the mouth and frenulum, and the growth parameters. Anogenital examination is performed only by a clinician specifically trained to do it.
7. Document on body maps with the site, size, shape and colour of every mark, and arrange medical photography where available.
8. Refer to children's social care the same day, following it up in writing, and consider whether the police need to be involved.

Investigations

• FBC, blood film, clotting screen and, where bruising is unexplained, extended coagulation studies including factor VIII, factor IX and von Willebrand testing
• Bone profile, vitamin D and parathyroid hormone, and consideration of genetic testing for osteogenesis imperfecta
• Skeletal survey - performed in all children under 2 years with suspected physical abuse, to a standard protocol, with a repeat limited survey at 11-14 days to detect healing fractures not visible initially
• CT head in any infant under 1 year with suspected abusive head trauma or unexplained neurological signs, followed by MRI of brain and spine
• Formal ophthalmological examination through dilated pupils for retinal haemorrhages, ideally within 24 hours
• Urine toxicology where poisoning is possible, and urine organic acids if glutaric aciduria is a consideration
• Sexually transmitted infection screening and forensic sampling where sexual abuse is suspected, arranged through the appropriate specialist service
• Assessment of siblings and other children in the household, who are at risk and are often forgotten

What happens next

• Strategy discussion between children's social care, police and health to agree whether a section 47 enquiry is needed
• Child protection medical examination by a paediatrician with safeguarding expertise, producing a formal report
• Initial child protection conference, which may result in a child protection plan under one of the four categories of abuse
• Ongoing multi-agency review, with core groups and review conferences
• Court proceedings where necessary, in which the contemporaneous medical record becomes evidence - which is why the quality of documentation matters so much

Outcomes and prevention

The consequences of child maltreatment extend far beyond the presenting injury. Abusive head trauma carries a mortality of around a fifth and leaves many survivors with cerebral palsy, epilepsy, visual impairment and learning disability. Beyond the physical, maltreatment is one of the strongest known predictors of adverse outcomes across the lifespan.

• Developmental and educational impairment, and reduced attainment
• Mental health consequences - depression, anxiety, post-traumatic stress disorder, self-harm and suicide
• Substance misuse, offending, and difficulties forming relationships
• Adult physical health - the adverse childhood experiences literature links maltreatment to cardiovascular disease, chronic lung disease, diabetes and reduced life expectancy
• Intergenerational transmission, though it is important to be clear with families that this is a raised risk and not an inevitability⁵

Prevention is more effective than detection, and much of it is delivered through services students see in general practice and health visiting: universal health visiting contacts, targeted family support, the Family Nurse Partnership for young first-time mothers, perinatal mental health services, domestic abuse services, and programmes such as ICON, which teaches parents that infant crying is normal, peaks at around 6-8 weeks and always stops - and that it is safe to put the baby down and walk away.⁷

For the individual clinician the practical message is narrow and clear. You are not expected to be certain, to investigate the family, or to identify a perpetrator. You are expected to notice, to examine and document properly, to escalate the same day, and to remember the other children in the house. Recording a concern without acting on it is the failure that appears again and again in serious case reviews, and it is entirely avoidable.²