Suspected NAI

Background

Any person, who suspects that a child is being abused, or is at risk of abuse, has a responsibility to report their concerns to the health board. All staff working with children should be familiar with the "Children First" document, the national guidelines for the protection and welfare of children.

A child protection concern is likely to fall within one of four categories of child abuse which are :

(1) Neglect, (2) Sexual Abuse, (3) Physical Abuse and (4) Emotional Abuse.

Assessment

A case of NAI may be: Clear cut or suspected.

Clear cut - a case is clear cut when:

A parent, guardian or other person makes a statement about an injury
To a child that he or another person has inflicted
Clear medical evidence shows that ill-treatment has taken place

In these cases arrangements must be made for the child to be medically examined by a Paediatrician.

Suspected - a case is suspected when there are indications that an injury or other condition (e.g. unexplained failure to thrive) is caused by the ill-treatment or neglect by a parent, guardian or other person but where no clear or medical evidence exists, or where no statement is made, or where the degree or type of injury is at variance with the explanation given.

In such cases it is important to identify the degree of risk to the child and to take any necessary steps to protect the child.

The priorities in dealing with child abuse are:

to diagnose, treat, and document the child's injuries
to interpret the pattern of injury or behaviour leading to the suspicion of abuse
to notify and involve the on-call social worker at the hospital (9-5 pm)
to provide, when parental consent is given, a verbal or written report to the HSE-S

Consent / confidentiality

The doctor must establish that consent (ideally written) has been given (by one of the child's parents / legal guardian) to perform a clinical examination and to provide a report to the Southern Health Board or the Gardaí. If the child is under a protection application then a nominee of the Southern Health Board is the child's guardian. If the family refuse permission to make a report:

Giving information to others for the protection of a child is not a breach of confidentiality
Where the interests of the parent and the child appear to conflict, the child's interest should be paramount. (ref 1)

Please complete proformas for suspected child abuse cases.

General Management

Check the The Child Protection Notification System(ref 2)
Past ED records should be reviewed
NCHD staff who feel unhappy about a child's injuries or the Hx should indicate this to the parent /carer
Language should not be confrontational or challenging "I can see how worried you are about these bruises"
Remember a parent who has possibly injured a child has brought the child because of concern for the child
Record all information given and document the history and findings meticulously
The priority for the all staff is the safety of the child and the treatment of the presenting problem
All cases must be referred to the duty hospital social worker even if a child is discharged home or transferred to another institution for ongoing care
The GP should be notified

Risk factors for NAI

Previous abuse within the family
Unexplained absences from school or nursery
Early mother child separation (incl. SCBU admission)
A handicapped child
Maternal depression or illness
Repeated minor injuries
Odd time of presentation e.g. after children normally in bed
Attitude of parents or carers e.g. inappropriate or mechanical behaviour, delayed presentation, undue anxiety and repeated attendances - cries for help?

Physical Abuse

Physical abuse (non-accidental injury or NAI) refers to the deliberate injury of any child
The Emergency Dept. staff will assess and treat such injuries and involve paediatric staff as necessary
The inpatient care of a child suspected of physical abuse is the responsibility of the paediatric consultant
All events and details surrounding the alleged injury should be carefully recorded by the attending doctor
The record should include the date, time, place and details of the informant and practitioners involved and be legibly signed

Examination

A comprehensive examination of the child should include height and weight measurements
Careful inspection of all surfaces with special attention to the scalp, mouth, gums, eyes and behind the ears
Use of body diagrams
Ensure descriptions are consistent with the following definitions:
- Abrasion- a superficial scraping injury of the body surface with or without bleeding
- Bruise- Leakage of blood from blood vessels discolouring the tissues of the body
- Incision- A cutting type injury that severs tissues in a clean and generally regular fashion
- Laceration- A tear or split in the tissues
Consider an ophthalmologic examination, particularly in the younger child, where a shaken injury is suspected as there may be no external signs of trauma

Conditions suspicious of NAI include:

Inadequate or inconsistent explanations injuries
Retinal haemorrhages
Scalds, burns or poisoning - ? cigarette burns / rope marks
Long bone fractures in a child under 3 years
Repeated injuries
Facial bruising - loose teeth, injuries in the mouth
Perineal injuries
Human bites
Failure to thrive
Delay in seeking medical help
Frozen watchfulness
Excessive crying - may provoke abuse from parents or others responsible for the child

Investigation

Abnormalities of clotting are rare so beware of attributing bruises to this cause (coagulation screen)
Clinically suspected fracture sites should be x-rayed directly
Skeletal surveys (requested by paediatric staff Not CEM staff) may be useful in children < 3 years
Medical photography in the case of suspected abuse should be facilitated as follows:
- A medical doctor to be present
- Include a request for scale (measuring tape held rigid and parallel, never wrapped around contours)
Documentation

Legal implications

Accurate and complete documentation is essential
Clinical photographs are an excellent way of recording visible injuries
Call the hospital photographer/security or person delegated this duty during office hours
The medical report should not be used for any purpose for which explicit permission has not been sought

Child Sexual Abuse (CSA)

Guideline for paediatric forensic medical examinations after disclosure of/concerns for sexual abuse

Acute referrals
- Pre pubertal within 3 days and peri/pubertal within 7day - for forensic sampling
Urgent referrals
- Incident pre pubertal greater than 3days and peri/pubertal greater than 7 days but presenting within 34 days of last potential sexual contact
Non Actue Referrals
- Greater than 34 days since last potential sexual contact

ALL children who have made a disclosure of sexual abuse or for whom sexual abuse is strongly suspected should be referred to TUSLA

If child is aged 14yrs or over the referral should be made to SATU which is based in the South Infirmary: 021 4926297 (Out of hours: 021 4926100). SATU provides 24hr/ 7days a week service
For children under 14yrs of age the family centre provide paediatric medical examinations 9am -5pm, Monday to Friday (Excluding Bank Holiday or Public Holiday). Phone 021 4923302 or Clinical Nurse Manager Mobile 087 2837117
For urgent (between 7-34 days) and child is <14yrs can be referred to family centre that day or next working day if presenting Monday- Friday (consider medical considerations as outlined below). Over Weekends & Bank Holidays consult with on call Paediatric Forensic Examiner, Galway (see below)
If urgent safety needs contact the Gardaí / Tusla Emergency Social Work Services
If the child attends the CED at CUH, a senior clinician should contact An Garda Siochana and the Paediatric Forensic Medical Services, Galway via 091 524222. Urgent health needs and safeguarding take priority

Forensic sampling timeframes:

(these samples will be taken by the forensic examiner)

For pre pubertal children 72hrs since last contact with the alleged perpetrator
Pubertal up to 7days since last contact with the alleged perpetrator
Blood for Toxicology (up to 48hrs)
Urine for Toxicology up to 5 days

Preservation of Forensic Evidence

Garda can do early evidence kit for non-intimate samples (mouth swabs, urine)
Retain clothing including nappies, bedsheets etc.
Advise not to wash, to avoid wiping after toileting

Medical considerations

Detailsed check for inuries
Emergency contraception up to 120 hrs after assault
Hepatitis B exposure (if required Vaccine is available in CUH pharmacy)
Hep B Immunoglobulin considered up to 1 week post exposure
HIV Post Exposure Prophylaxis can be commenced up to 72 hrs post exposure (HIV PEP stocked in CUH pharmacy, ADON can access out of hours)
Prophylaxis for STI – Not routinely given in children and adolescents
Healing injuries may be present for up to 34 days after a sexual assault dictating urgent examination ideally within one working day even if child presenting outside the immediate timeframe for forensic sampling.

Referral information

Referrer's name, address, occupation and contact number
Child's name and date of birth
Details of the report – including timeframe, any immediate medical needs which may need intervention, and immediate child safety concerns;
Confirmation of consent for examination – i.e. parent or legal guardian available for consent or if child in care of TUSLA (Full Care Order), consent must be obtained from Principle Social Worker.
Specific needs child/family may have – e.g. does not speak English and will need an interpreter.
Name, address and telephone number of Garda involved in case
Name and telephone number for person who will be transporting child to the Forensic Medical Examination

SCA algorithm

Neglect and Emotional Abuse

These issues are more difficult to establish because of the lack of physical evidence
They are given equal priority in the definition of abuse
Refer to hospital social worker team

Child Welfare Concerns

Where referral to the Child and Adolescent Psychiatry Team / Adult Psychiatry Team is appropriate, there is currently no agreement that this in itself satisfies the hospital's child protection and welfare duty and therefore one should also make a referral to the hospital social worker.

The emergency department is NOT an appropriate "place of safety" (the paediatric ward is).

Admission to hospital

Admission to hospital should be arranged when it is necessary for further management (fractures, burns, failure to thrive) or when it is necessary for the child's safety
Children should be admitted under the paediatric consultant on call that day unless the child has specific injuries (fractures, burns, and lacerations) where two consultants may jointly care for the child as appropriate
Where transfer to another institution is required the paediatric, specialty and social work teams at that institution need to be informed
Children requiring specialist care in other institutions should still be notified to the duty social worker at the presenting hospital

Useful Contacts

Children First Department - CUH (Block 36, St. Finbarr’s Hospital Douglas Road, Cork). VPN 23220
Child Protection Notification system can be contacted via Tusla
Sexual Assault Unit, South Infirmary/Victoria Hospital (021) 4926297 / 4926100
Family Centre, St Finbars Hospital (021) 4923302

Social Work Department CUH:

Katy Twomey, A/Social Work Team Leader VPN: 65617
Laura Barrett – Bleep 649
Main Office – Ext: 22488

Garda Contact:

The Garda Communications room Anglesea Street (021) 4522000 (24 hours).They will contact the appropriate local Garda station

References:

Children First-National Guidelines For The Protection And Welfare Of Children. DOHC 1999. Government Sales Office, Sun Alliance House, Molesworth House, Dublin 2. Back to text
2. Child Protection and Welfare Process- SHB Guidelines, Abbeycourt House, Georges Quay, Cork. Print version. EMed.ie are NOT responsible for this document! Back to text

Suspected Child Abuse / Neglect