Non-accidental injury in children

Clinical feature by Dr Alice Johnson, FRACP, Paediatrician and Head Of Department, Child Protection Unit, Perth Children’s Hospital.

A 3-month-old baby boy attends your practice for routine immunisations. He is underweight and has three bruises to his left cheek and bruising to his right ear pinna. His mother says he must have rolled on a toy. How would you proceed?

Physical child abuse is common and is a significant cause of paediatric morbidity and mortality. According to the Australian Institute of Health and Welfare, 8.7 per 1000 children under 18 years were substantiated for maltreatment in 2019/2020, with 14 per cent of substantiations for physical abuse.

Physical abuse affects children of all ages and all socioeconomic groups, but infants are at increased risk of severe or fatal abuse due to their small size and vulnerability. Perpetrators of abuse are usually the child’s parents or carers and rarely provide an honest account of causative events.

Doctors have a critical role in the identification of physical abuse, particularly in pre-verbal children, who cannot report what has happened to them. Physical abuse may result in soft tissue injuries (bruises, abrasions and lacerations), fractures, burns or brain injuries (abusive head trauma). Abuse may result in one injury or multiple injuries occurring over time.

Approximately 25 percent of children who are subject to abusive head trauma or other serious forms of physical abuse, have had prior presentations with minor injuries (sentinel injuries) that were not recognised as being suspicious. Detection of sentinel injuries in young children is extremely important, so that interventions can be put in place by the Department of Communities, to prevent further harm.

Children with unexplained or suspicious injuries should be referred to their local hospital or discussed with the Perth Children’s Hospital (PCH) Child Protection Unit (08 6456 4300) or the Emergency Department (08 6456 2222). Young children will need hospital admission to ensure safety whilst a thorough child protection assessment is carried out. Investigations in hospital may include:

  • Children with suspicious bruising – Full blood picture and coagulation screen to exclude a serious bleeding disorder
  • Children under 2 years:
    • Ophthalmology review – to look for retinal haemorrhages
    • Skeletal survey – to look for new or healing fractures
    • Head imaging – to look for evidence of abusive head trauma

What are the red flags for non-accidental injury?

Examples of concerning features in the history:

  • No history provided for the injury:
    • 8 week old with fractured femur. Father reports, ‘I have no idea how it happened, he just woke up and wasn’t moving his leg
  • A history that does not fit with the injury:
    • 3 month old with multiple bruises to his cheek and ear pinna. Mother reports, ‘He must have rolled on a toy’
  • A history that does not fit with the developmental stage of the child:
    • 3 week old with facial bruising and a humeral fracture. Step-father reports, ‘I put him in the middle of the double bed, and he must have rolled off’.
  • A significant delay in presentation:
    • 2 year old with 15 per cent partial thickness scald burns that occurred five days ago. Aunt reports, ‘He has not been in pain at all’.

Concerning features on examination/investigation:

  • Bruising:
    • In babies or non-mobile children
    • Imprint bruising (imprint of an object or a hand) in children of any age
  • Fractures:
    • In babies or non-mobile children
    • Rib or metaphyseal fractures
  • Head injuries:
    • Subdural haematomas in infants
    • Extensive retinal haemorrhages
  • Multiple injuries or injuries of different ages.


Bruising is the most common way that non-accidental injury will present and differentiating accidental bruising from suspicious bruising is very important.

Which bruises suggest an accidental mechanism?

  • Bruises in mobile children
  • Bruises affecting:
    • Bony prominences (shins, knees, elbows and lower back)
    • T-zone of face (forehead, nose and chin)

Which bruises may suggest a non-accidental mechanism?

  • Bruises in babies and non-mobile children
  • Bruises to the soft parts of the body (cheeks, neck, ears, abdomen, buttocks, genitals)
  • Clusters of bruises
  • Imprint bruises

What actions to take if you suspect non-accidental injury

  • Take a detailed injury history:
    • How did it happen?
    • Where did it happen?
    • Who witnessed the injury?
  • Conduct a top to toe examination:
    • Don’t forget the ears, oral frena and buttocks
    • Document your findings
  • Refer to your local hospital or consult with PCH CPU (6456 4300) or PCH ED (6456 2222). Explain to parents that the injury is concerning and needs to be looked into.
  • Refer to the Department of Communities:
    • Central Intake Team – (daytime 1800 273 889)
    • Crisis Care – (after hours and weekends 9223 1111)
  • Refer to the WA Guidelines for Protecting Children 2020


  2. Bennett CE and Christian CW. Clinical evaluation and management of children with suspected physical abuse. Pediatric Radiology (2021) 51:853-860
  3. Henry MK and Wood JN. What’s in a name? Sentinel injuries in abused infants. Pediatric Radiology (2021) 51:861-865
  4. Maguire S and Mann M. Systematic reviews of bruising in relation to child abuse – what have we learnt: an overview of review updates. Evidence-based Child Health: a Cochrane review journal (2013) 8:255-263