Joint Trust Guidelines for the Management of: Unexplained Injury in Infants
Clinical Guideline
For Use in:
Children’s Department, Emergency Department
By:
For:
Division responsible for
document:
Paediatric medical and nursing staff, Emergency dept medical and
nursing staff,
Management of infants (under age one year) with an unexplained
injury
Division 3
Key words:
Infant, Injury, Non-accidental injury, child maltreatment
Name of document author:
Dr Richard Reading,
Job title of document author:
Name of document author’s Line
Manager:
Job title of author’s Line
Manager:
Consultant Paediatrician, (NNUH)
David Booth
Consultant Neonatologist
Supported by:
Dr Chris Upton, Dr Kate Armon, Dr Duncan Maciver, Mr Narman
Puvanechandra, Ms Sue McDonnell, Dr Archana Soman, Dr Tim
Daynes, Miss Rachael Hutchinson, (NNUH)
Dr R Stocks, Safeguarding Lead, (JPUH)
Accepted by James Paget University Hospital, (JPUH) on
18/09/2014 under the Tri-Hospital Clinical Guidelines
Assessment Panel (THCGAP)
Assessed and approved by the:
Approved by committee Chair’s Action 05/06/2015
Clinical Guidelines Assessment Panel 17/06/2015
(CGAP)
Date of approval:
05/06/2015
Ratified by or reported as
approved to (if applicable):
Clinical Standards Group and Effectiveness Sub-board
To be reviewed before:
This document remains current after
this date but will be under review
To be reviewed by:
Reference and / or Trust Docs ID
No:
Version No:
05/06/2018
Richard Reading (Named doctor for safeguarding children)
JCG0039 id 7977
2
Description of changes:
Updated
Compliance links:
Version Information
Version No
Updated By
NICE
JCG0039
THCGAP
JCG0039 v2 Richard Reading
Updated On
18/09/2014
06/05/2015
Author/s: Richard Reading
Valid until: 05/06/2018
Document Management of Unexplained Injury in Infants
Copy of complete document available from: Trust Intranet
Description of Changes
Change of header and footer to joint hospital
version
Updated front sheet
Date of issue: 05/06/2015
Guideline Ref No JCG0039 v2 id 7977
Page 1 of 11
Trust Guideline for the Management of: Unexplained Injury in Infants
Algorithm for the management of any infant with unexplained injury
Infant with obvious injury
E.g. bruise, fracture
Infant with presentation indicating possible injury
E.g. encephalopathic, Irritable, Immobile limb
Resuscitate if required
Carry out any urgent investigations required
Immediate management of injury or medical condition
Consider injury in differential diagnosis,
and initial investigations
Injury demonstrated or
possible
Injury excluded.
Manage infant’s
presenting condition
Take history of injury, document this in detail. Record parent’s words.
Examine infant naked, whole body including ENT examination.
Is there an explanation of the injury or clinical presentation
Yes and
credible
No or not compatible with the injury
Suspect child maltreatment
If in Emergency Dept – refer to paediatrics
If in paediatrics – start purple paperwork
Make immediate referral to Children’s services
Consider whether police referral required
Head injury (p3)
Bruising (p4)
Still consider maltreatment as
possible. If in doubt:
In Emergency Dept consider
discussing with on-call paediatrician.
In paediatrics, discuss with
consultant paediatrician
Fracture (p5)
Author/s: Richard Reading
Valid until: 05/06/2018
Document Joint Trust Guidelines - Management of Unexplained Injury in Infants
Copy of complete document available from: Trust Intranet
Thermal injury (p6)
Date of issue: 05/06/2015
Guideline Ref No JCG0039 v2 id 7977
Page 2 of 11
Trust Guideline for the Management of: Unexplained Injury in Infants
Algorithm for infant with head injury
Includes scalp haematoma, skull fracture, intracranial bleeding, brain injury
Child maltreatment needs to be considered in all head injuries in infants unless there is a
clear witnessed injury or other documented explanation
Requiring intensive care
Not requiring intensive care
Ensure police and
children’s services aware
(life threatening injury by
definition)
Ensure:
Consultant paediatrician aware,
children’s services aware, consider if
police need to be informed
Admit
Document relevant history,
communication with other
agencies, child protection
arrangements etc before
transfer to PICU
Immediate investigations
Skull X Ray
CT Head
FBC and clotting studies (if bleeding or
bruising)
Within 24
hours
Investigations within 24 hours (or by
next working day if at weekend)
Skeletal survey
Ophthalmological opinion
Medical photographs if visible injury
Management within 24 hours
Liaise with Children’s services about
strategy meeting
Consider second medical opinion
Subsequently
Investigations
Liaise with radiologist about further
imaging and timing – eg MRI
Consider further medical
investigations after discussion
Management
Liaise with Children’s services about
discharge arrangements, case
conference, reports required.
Ensure consultant has seen child
before considering discharge.
Author/s: Richard Reading
Valid until: 05/06/2018
Document Joint Trust Guidelines - Management of Unexplained Injury in Infants
Copy of complete document available from: Trust Intranet
Date of issue: 05/06/2015
Guideline Ref No JCG0039 v2 id 7977
Page 3 of 11
Trust Guideline for the Management of: Unexplained Injury in Infants
Algorithm for bruising
Is the infant mobile ie
crawling, shuffling, cruising or
walking
No
Suspect child
maltreatment
Yes
Is explanation plausible, and is
the bruising on a site seen in
accidents (ie forehead, nose,
chin, lower legs)
No
Suspect child
maltreatment
Admit.
Inform children’s services
Yes
Still consider maltreatment
as possible. If in doubt:
In Emergency Dept consider
discussing with on-call
paediatrician.
In paediatrics, discuss with
consultant paediatrician
Basic investigations and management within 24 hours:
Clinical photographs (consider police photography if assault possible)
Take a history of bruising, bleeding, response to surgery etc in child and extended family
Haematology – Full Blood count, platelets, clotting screen (PT APPT)
Skeletal survey (by next working day if at weekend)
Consider CT scan (discuss with consultant paediatrician and radiologist)
Ophthalmological examination (bleep ophthalmic SpR on-call)
Specialist assessment in specific cases if indicated:
Extended clotting screen not usually required unless clinical suspicion of possible clotting
disorder (discuss with paediatric haematologist)
If a bite mark, consider forensic dentist opinion
Consider second opinion from another consultant paediatrician
Author/s: Richard Reading
Valid until: 05/06/2018
Document Joint Trust Guidelines - Management of Unexplained Injury in Infants
Copy of complete document available from: Trust Intranet
Date of issue: 05/06/2015
Guideline Ref No JCG0039 v2 id 7977
Page 4 of 11
Trust Guideline for the Management of: Unexplained Injury in Infants
Algorithm for fractures
Not skull fracture – for this see head injury
Is the infant mobile ie
crawling, shuffling, cruising or
walking
No
Suspect child maltreatment
Yes
No
Is explanation plausible,
reasonable, and indicates
appropriate supervision for child’s
age and development.
Yes
Admit.
Inform children’s services.
Still consider maltreatment as
possible.
Discuss with on-call paediatrician,
consultant paediatrician, paediatric
orthopaedic surgeon, or paediatric
radiologist as appropriate
Basic investigations and management within 24 hours:
Take family history for Osteogenesis Imperfecta and examine sclerae etc
Bone chemistry – Ca, Phosphate, Alk Phos, Parathyroid Hormone
Skeletal survey (by next working day if at weekend)
Consider CT scan – discuss with consultant paediatrician and paediatric radiologist
Ophthalmological examination
Seek consultant paediatric orthopaedic surgeon opinion if not already involved.
Specialist assessment in specific cases if indicated:
Assessment for brittle bones rarely necessary in absence of history of prematurity,
neurological disease, or clinical features or family history of OI
Author/s: Richard Reading
Valid until: 05/06/2018
Document Joint Trust Guidelines - Management of Unexplained Injury in Infants
Copy of complete document available from: Trust Intranet
Date of issue: 05/06/2015
Guideline Ref No JCG0039 v2 id 7977
Page 5 of 11
Trust Guideline for the Management of: Unexplained Injury in Infants
Algorithm for thermal injuries
E.g. burns, scalds
Is there a clear, plausible, witnessed explanation, and have the
carers brought the infant for attention immediately
No
Yes
Still consider maltreatment
as possible. If in doubt:
In ED discuss with on-call
paediatrician.
In paediatrics discuss with
consultant paediatrician
Suspect child
maltreatment
Admit
Inform children’s services
If transferred to regional burns
unit, document relevant
history, communication with
other agencies, child
protection arrangements etc
before transfer.
Management
The most important information for subsequent assessment of
thermal injuries is good quality clinical photographs. Ideally at
initial presentation and later at dressing changes.
Full examination of undressed infant including ENT to check for
other injury.
Assessment of home circumstances by social worker, or police
may be indicated to determine whether explanation is plausible.
Author/s: Richard Reading
Valid until: 05/06/2018
Document Joint Trust Guidelines - Management of Unexplained Injury in Infants
Copy of complete document available from: Trust Intranet
Date of issue: 05/06/2015
Guideline Ref No JCG0039 v2 id 7977
Page 6 of 11
Trust Guideline for the Management of: Unexplained Injury in Infants
Objective/s
To enable management of infants with an unexplained injury so that:
 appropriate medical investigations and management can take place
 the infant’s safety can be assured
 safeguarding procedures are carried out in a timely and comprehensive way
 parents are treated with respect, given full information and are clear about
management plans
General Principles







This guideline is for medical management only.
The doctor’s first duty is for the welfare and safety of the child.
Legally there is no duty of care toward parent(s) although they should be treated
with respect, honesty and openness.
This guidance uses terminology introduced in the NICE guideline on “When to
suspect Child Maltreatment” (NICE clinical guideline 89): “Suspect child
maltreatment” implies the response should be to carry out safeguarding
procedures including reporting the case to children’s services; “Consider child
maltreatment” implies an abusive injury remains on the differential diagnosis and
the case is discussed with senior and experienced colleagues; “Exclude child
maltreatment” implies the history, examination findings and other features all point
to an explained non-abusive cause.
Trainees and non-consultant doctors should always discuss any case they have
concerns about with their consultant.
Hospital policy is for any child, regardless of which specialty they were admitted
under, to have access to and the advice of a named consultant paediatrician.
Among other things the paediatrician is responsible for ensuring safeguarding
concerns have been identified and addressed.
Child maltreatment assessment is complex, this guideline covers the basic
principles but there will be many situations when decisions are less clear cut. In
such cases discussion with others is always helpful.
Rationale
Injuries in infants are a safeguarding emergency, with a high risk that they have been
caused by maltreatment. Doctors treating these infants need to take decisive and speedy
action to ensure the safety and welfare of their patients. Failure to take such action has
been identified as a reason for child protection failures in many high profile enquiries into
child death and serious injury. This guideline should aid decision making in these cases in
both the Emergency Department (where these infants frequently present) and in the
Children’s Assessment Unit.
The guidelines are based on evidence collected by the Cardiff Child Protection
Systematic Review Group and follow recommendations including the NICE guideline on
“When to suspect Child Maltreatment” (NICE clinical guideline 89), the RCPCH guidance
Author/s: Richard Reading
Valid until: 05/06/2018
Document Joint Trust Guidelines - Management of Unexplained Injury in Infants
Copy of complete document available from: Trust Intranet
Date of issue: 05/06/2015
Guideline Ref No JCG0039 v2 id 7977
Page 7 of 11
Trust Guideline for the Management of: Unexplained Injury in Infants
in Child Protection Companion (RCPCH, 2013), the Norfolk Children’s Safeguarding
Board Protocol 11, the NNUH guideline on Safeguarding Children, and by reviewing
similar guidelines produced by Addenbrookes Hospital and Queen Elisabeth Hospital
Kings Lynn.
Broad recommendations
Any injury in an infant should raise concerns about maltreatment. The Cardiff Child
Protection Systematic Review Group has shown that the younger the child the greater the
likelihood of maltreatment. Maltreatment is the most common mechanism of severe injury
in non-mobile babies.
Equally though, no injury is pathognomonic for maltreatment – all injuries must be
considered individually in the context of the history, age and development of the infant
and other available information.
On presentation, medical treatment may be the more urgent priority. This includes ABC
assessment, resuscitation and immediate treatment of injury. However, the possibility of
maltreatment should be considered early in the process and appropriate safeguarding
procedures should commence as soon as possible.
Background information from children’s services, community health services or previous
A&E or hospital records is important but should not deflect clinical suspicion of
maltreatment.
Documentation is vital. For all entries clearly write your name, grade, specialty, date and
time. Notes should be accurate, legible, extensive and contemporaneous. Include
verbatim quotes from the parents or caregivers where appropriate. Describe the injuries in
text and on a body map. Once a child is seen in the paediatric department, start using
purple paperwork. This is designed to guide you through the history, examination and
documentation.
Head injury
Head injuries may present occultly – for instance as irritability, apnoea, seizures, or
altered level of consciousness.
CT scan is the investigation of choice to identify intracranial injury acutely.
The risks of CT (ie radiation) need to be taken into account against the relatively high
yield of intracranial pathology in the presence of other injuries.
Estimates vary but the amount of radiation is equivalent to 10 months background
radiation, raising the risk of a childhood brain tumour by one third.
Author/s: Richard Reading
Valid until: 05/06/2018
Document Joint Trust Guidelines - Management of Unexplained Injury in Infants
Copy of complete document available from: Trust Intranet
Date of issue: 05/06/2015
Guideline Ref No JCG0039 v2 id 7977
Page 8 of 11
Trust Guideline for the Management of: Unexplained Injury in Infants
MRI imaging does not always identify acute subdural bleeds but is useful after three or
four days, to characterise and date bleeds more accurately and to identify intra-cerebral
injury. Timing of MRI scanning should be discussed with a paediatric radiologist.
Follow-up MRI scanning may be indicated in some cases.
Rare causes of subdural haemorrhage include some metabolic disorders such as Glutaric
aciduria Type I, Menkes syndrome, Maternal SLE,
Bruising
Any bruise, anywhere, on a non-mobile infant is highly suspicious for maltreatment. There
are many documented cases of babies initially presenting with a few small bruises, who
subsequently present with major abusive trauma.
Thus a full child abuse work-up is justified for any bruises on a non-mobile infant.
Mobile babies tend to have bruises in well defined places – the forehead, nose, chin and
lower legs.
Most major and common clotting abnormalities are excluded by a full blood count and the
standard clotting screen. At the NNUH this includes PT and APTT. National
recommendations suggest that Thrombin time and Fibrinogen should also be measured.
There is debate about von Willebrand factor. Currently we recommend the standard
NNUH clotting screen.
History of easy bruising, bleeding after minor injuries, dental extractions, minor surgery or
post-partum should be elicited about the child and first degree relatives.
Extended clotting screen is rarely necessary unless there is clinical suspicion from the
history or specific features of the injury. Where there is concern, discuss with a paediatric
haematologist.
Fractures
In all cases of fracture in infants, the opinion of a paediatric orthopaedic surgeon should
be sought. Usually the admitting orthopaedic surgeon would arrange for an opinion from a
colleague with paediatric expertise.
Skeletal survey should be done according to the Royal College of Radiologists
recommended schedule – including oblique views of the ribs and separate views of the
thorax and abdomen.
Author/s: Richard Reading
Valid until: 05/06/2018
Document Joint Trust Guidelines - Management of Unexplained Injury in Infants
Copy of complete document available from: Trust Intranet
Date of issue: 05/06/2015
Guideline Ref No JCG0039 v2 id 7977
Page 9 of 11
Trust Guideline for the Management of: Unexplained Injury in Infants
Failure to identify fractures on skeletal survey is common. A standard skeletal survey
should include a follow-up chest X Ray at 10 – 14 days. If there is clinical suspicion,
consider a bone scan or a repeat skeletal survey at 10-14 days.
Brittle bones can occur in: osteopenia of prematurity, copper deficiency (usually
associated with prematurity), rickets, scurvy, as well as any of the different subtypes of
osteogenesis imperfecta. In almost all of these cases there are clues in the history, family
history, clinical findings or in the radiology images. A basic bone chemistry screen
currently should include serum calcium, phosphate, alkaline phosphatase and Parathyroid
Hormone. Vitamin D levels are probably unhelpful. Further assessment for bone disorders
is complex and usually requires discussion with a paediatric bone metabolism specialist.
Thermal injuries
Burns and scalds are worrying injuries in infants, with a high risk of being caused by
maltreatment. In all cases careful consideration should be given to maltreatment or
neglect being either a direct or contributory cause.
However, older mobile infants may be injured by pulling hot liquids on themselves, or by
touching hot objects in the same way as toddlers.
The key is a careful history, careful examination of the injury, consideration of whether the
child’s developmental stage is consistent with the mechanism described. Meticulous
documentation and photography is most important.
Some typical thermal injuries suggestive of maltreatment are:
 Immersion scalds with a glove and stocking distribution, often with a clear upper
demarcation and a uniform depth of scald. They may be associated with scalding
on the buttocks with central sparing (where the child’s bottom is protected by
contact with the bath).
 Multiple unusual burns, which may have an unusual outline or pattern or be in
unusual parts of the body. Abusive burns are often very deep.
 Burns caused by branding – often with a sharp outline
 Cigarette burns which are usually round, 0.5-1cm in diameter, deep, with a central
cratered area and may have raised rolled edges if already healing.
Ophthalmology opinion
In the first instance, seek the opinion of the middle grade ophthalmologist. An
experienced Registrar or Associate Specialist can perform the examination using dilating
drops on the ward. If positive findings are found or examination could not be carried out
adequately then the consultant paediatric ophthalmologist (either Mr Puvanachandra or
Mr Astbury) must be contacted to see the child.
Clinical audit standards
Author/s: Richard Reading
Valid until: 05/06/2018
Document Joint Trust Guidelines - Management of Unexplained Injury in Infants
Copy of complete document available from: Trust Intranet
Date of issue: 05/06/2015
Guideline Ref No JCG0039 v2 id 7977
Page 10 of 11
Trust Guideline for the Management of: Unexplained Injury in Infants
Identify infants with specified injuries (ie head injury, bruises etc)
Measure from purple paperwork whether the relevant investigations and procedures
described in this guideline have been carried out.
Where these have not been carried out, examine paperwork to see whether deviations
from guideline have been documented and reasons given.
Summary of development and consultation process undertaken before registration
and dissemination
Drafted by Richard Reading in consultation with authors listed. Circulated to Paediatric,
Orthopaedic, Plastic Surgery, Ophthalmology and Emergency Departments for
consultation and agreement of final contents.
Distribution list / dissemination method
Paediatric directorate and clinical governance lead. Emergency department directorate
and clinical governance lead. Safeguarding team. Available on trust guidelines page,
copies in ED and CAU.
References / source documents
National Collaborating Centre for Women and Children’s Health. When to Suspect Child
Maltreatment.
NICE
Clinical
guideline
89.
NICE
2009
http://www.nice.org.uk/nicemedia/live/12183/44954/44954.pdf
Royal College of Paediatrics and Child Health. Child Protection Companion. RCPCH
2013
Royal College of Radiologists and Royal College of Paediatrics and Child Health.
Standards for Radiological Investigations of Suspected Non-accidental Injury.
RCR/RCPCH 2008
Cardiff Child Protection Systematic Review Group and NSPCC series:
CORE-INFO: bruises on children
CORE-INFO: thermal injuries on children
CORE-INFO: fractures in children
CORE-INFO: head and spinal injuries in children
All available from www.core-info.cf.ac.uk
Kemp AM. Abusive head trauma: recognition and the essential investigation
Arch Dis Child Educ Pract Ed 2011;96:202-208
Maguire S. Which injuries may indicate child abuse? Arch Dis Child Educ Pract Ed
2010;95:170-177
Author/s: Richard Reading
Valid until: 05/06/2018
Document Joint Trust Guidelines - Management of Unexplained Injury in Infants
Copy of complete document available from: Trust Intranet
Date of issue: 05/06/2015
Guideline Ref No JCG0039 v2 id 7977
Page 11 of 11