Identifying non-accidental injury in children presenting to A&E departments: An overview of the literature

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Summary

Background

The need for an effective system of child protection, which is able to detect children at risk of physical abuse, has never been more urgent. The level of reporting of non-accidental injury (NAI) in young children is lower than would be expected from official statistics, which means that Accident and Emergency (A&E) nurses and clinicians have a special responsibility to improve detection of possible abuse, in what has become a very challenging area of medicine. Aims: In this paper, we review the main issues facing clinicians and nurses in the identification of children at risk of NAI and discuss the policy implications affecting A&E departments. In particular we ask the question: what are the factors that influence the identification and reporting of suspected NAI in young children and how can the under-recognition of NAI be improved?

Conclusion

We conclude that organisational changes, such as the creation of a shared national database and improved training for A&E staff so that they are aware of social as well as clinical risk factors, are needed to address the under-reporting of non-accidental injury in young children.

Introduction

The level of reporting of child physical abuse to child protection agencies is lower than would be expected from local prevalence statistics, indicating that many victims of abuse are not being identified (Sidebotham and Pearce, 1997). The definition of ‘child abuse’ continues to be an area of contention especially when the evidence is not clear and when practitioners do not know how to interpret the evidence, both clinical and social. In addition, the definition of ‘abuse’ has been open to debate in the past, particularly when the cause of the injury is unclear and when the blame does not point towards any particular individual. In recent years, medical practitioners have been made more aware of non-accidental injury in childhood and have started to acknowledge the importance of identifying it on presentation to hospital (Kempe et al., 1962). However, the research evidence suggests that many cases still remain undetected (Jenny et al., 1999, Sundell, 1997, Haeringen et al., 1998). In this paper, we will examine the problems facing clinicians and nurses in Accident and Emergency (A&E) in the identification and reporting of possible non-accidental injury in young children, and offer an analysis of how the detection of non-accidental injury in young children might be improved.

The literature on the under-reporting of NAI in children is extensive and there is a significant overlap between the identification of child abuse by health professionals working within the hospital setting and by professionals from other agencies such as the police and social services. Thus, we acknowledge that child abuse occurs outside of the hospital setting and there is a need to utilise the skills of different agencies as well as health professionals. However, the analysis was restricted to the identification of NAI in A&E departments because there is evidence that potential child abuse is not being detected effectively by clinical and nursing staff (Jenny et al., 1999, Sidebotham and Pearce, 1997). Also, we wanted to focus on A&E departments where the potential for identifying NAI is greater as the injuries are often more severe. Consequently health professionals are the first point of contact for identifying NAI, and the actions they take may have a major impact on the detection of children at risk of abuse. We conclude by offering a set of recommendations for a more effective system of identifying NAI in young children in A&E.

Section snippets

Methods

A comprehensive literature search was conducted to identify papers relevant to the clinical detection of non-accidental injury in children presenting to A&E departments between the years 1980 and the present. The exclusion of earlier papers was intended to focus the review on more recent developments in the identification of NAI. Our search was conducted using the following electronic databases, Medline, BIDS, PsychInfo, and references were also identified from the bibliographies and reference

Discussion: raising awareness of NAI among clinical and nursing staff working in A&E

The research that has been conducted to date on the identification of NAI in young children shows that the procedures in place are limited and many cases of abuse remain undetected. Sidebotham and Pearce (1997) found that only 5.3% of all children attending an A&E department in Bath, who were considered at risk of abuse according to standard risk assessment procedures, were referred on to other child protection professionals for further discussion of the child’s risk of future harm. Following

Conclusion

We recommend that in all cases of ‘serious’ physical injury in children under the age of 24 months, such as a skull fracture, major burns, scalds and related injuries, who present to an A&E department, a full clinical examination should be conducted. In addition, background checks should be made and a social history of the child and the carers should be taken, to maximise the identification of children at risk of serious abuse. A&E doctors should not rely on subjective opinion or on issues of

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