By Emily Baird
Royal Hospital for Sick Children Edinburgh

Correspondence to: [email protected]

Published 08 April 2020

Non- accidental injury (NAI) is often considered to be a silent pandemic. Even in the best of times, sadly abuse goes unnoticed and children come to harm. At its most extreme, this leads to the death of the child, and worldwide, there are estimated to be 50,000 deaths each year1. There are of course subtleties to NAI, a spectrum encompassing any act, or failure to act, that results in serious physical or emotional harm, sexual abuse, neglect or exploitation of a child. We have come a long way since Caffey2 first described the phenomenon of parental maleficence associated with multiple fractures, subdural and retinal haemorrhages, in the 1940s. There are whole teams, guidelines, standards and screening tools to safeguard and protect children, which have lowered mortality. However, despite this, the subtle, initial presentations can be missed and COVID-19 presents the perfect storm for the escalation of NAI. The silent pandemic, becoming even more silent and deadly, in the face of this new, viral pandemic.

NAI is more likely to happen

Already departments are reporting an increasing number of NAI cases3, and when the risk factors for NAI are examined, this comes as no surprise.

Social isolation is a risk factor intrinsic to the perpetrator of abuse and intrinsic to the family structure.  As we have all been asked to limit our social contact in the light of COVID-19, the support that normally comes with socialising with friends and wider relatives is lost. The sudden withdrawal of nurseries, schools, youth programmes and time with other relatives takes away not only the respite of childcare, but also the early warning system that these places would normally provide. Children with developmental delay and additional needs are at particular risk of abuse, and the loss of respite and support networks for these families is a particularly cruel blow.

Social isolation to many families means confinement, often with multiple children, in small dwellings with no access to outdoor spaces in which families can relive the stress of lockdown. These conditions make for a tense and volatile environment.

NAI is more prevalent in families with lower incomes, and financial uncertainty has been further associated with increasing this risk. This was seen during the last economic recession, where there was a substantial increase in abuse and mortality from non-accidental head trauma4. Through financial uncertainty, COVID-19 further adds an element of stress to a precarious situation for many children, and this effect will be long lasting.

Another known risk factor for NAI is the lack of access to healthcare. We are actively encouraging patients to stay away from hospitals to minimise the risk of spreading COVID-19, however we may also be inadvertently heightening the risk of NAI in the process. Child abuse and neglect will continue to happen, but behind closed doors; we just won’t know about it. Mental health services are also particularly fragile at this time. Mothers with post-natal depression and psychosis may have less support, and infants are particularly vulnerable in this setting. Any member of the household may have mental health issues, including substance abuse, which may be less well supported in these challenging times, and this poses a risk to the child living with them.

Fig 1. Risk factors heightened by COVID-19

  • Social isolation
  • Lack of early warning system
  • Loss of support systems
  • Low income and financial uncertainty
  • Lack of access to healthcare
  • Healthcare systems under stress

NAI may go unnoticed

Not only are many families under extremely stressful circumstances, but healthcare systems are too. The increasing burden of COVID-19 presents a real challenge to maintain the standards that are normally in place. Staff are working out with their normal roles and may not be as familiar with the presentation of NAI.

Fig. 2 The presentation of NAI



Radiological findings7

Delay in presentation

Inconsistencies in history

Lack of overt trauma

Children <3 years old

Child with additional needs

Lack of medical condition which predisposes to bone fragility


Does the child look well cared for?

Is the child behaving appropriately?

Are the carers behaving appropriately?

Bruising and burns

  • Atypical places
  • Differing ages
  • Differing shapes

Injuries to face, mouth, genitals, perineum, eyes

Signs of underlying pathology

Multiple fractures

Fractures of differing stages of healing

Femoral fractures

  • Midshaft
  • Especially in a non-ambulant child

Humeral fractures

  • Midshaft
  • Especially if child <3 years old

Skull fractures

Rib fractures

Corner fractures

Subdural haemorrhage

Although we are taught that a ‘corner fracture’ is pathognomomic of NAI, any fracture can represent abuse and we should be particularly aware of fractures of differing ages, occult fractures and fractures of long bones in non-ambulant children. It is worth bearing in mind that a third of children subjected to physical abuse have fractures5, and if a child less than 18 months old has a fracture, there is a one in eight chance that this was sustained non-accidentally6. A high index of suspicion, whether in the Emergency Department or Fracture Clinic is paramount, and the involvement of the local Child Protection Team is essential.

The additional challenges of managing NAI

Once recognised, the child should be admitted to the hospital, even with the current risks of viral transmission. It is only in the hospital that the child can be considered in a place of safety. The processes to investigate NAI, such as the discussion between healthcare providers, social work and police may not be as rapidly achievable, and the length of stay may be dictated by this, rather than the orthopaedic treatment.

Discharge planning for the child will be challenging. Under normal circumstances, the child may be discharged with additional supervision, discharged to the care of another member of the family, or into an emergency foster placement, all with increased social work visitation. All of these options are currently compromised by COVID-19 and a longer admission may be required to protect the wellbeing of the child.


Non-accidental injury is the tragic outcome of a complex interplay between the individual, relationship, community and society, and COVID-19 will only to compound this. It must be a diagnosis which we seek to actively dismiss, to safeguard the children under our care, as it is the failure to recognise the abuse that often leads to the child’s demise.


  1. United Nations Children’s Fund, Hidden in Plain Sight: A statistical analysis of violence against children, UNICEF, New York, September 2014. Available at:
  2. Caffey J. Multiple fractures in the long bones of infants suffering from chronic subdural haematoma. Am J Roentgenol Radium Ther. 1946;56(2):163-73.
  3. Cook Children's Newsroom (2020). Available at:
  4. Huang MI, O’Riordan MA, Fitzenrider BA, McDavid L, Cohen AR, Robinson S. Increased incidence of nonaccidental head trauma in infants associated with the economic recession. J Neurosurg Pediatr. 2011;8(2):171-6.
  5. Belfer RA, Klein BL, Orr L. Use of skeletal surveys in the evaluation of child maltreatment. Am J Emerg Med. 2001;19(2):122-4.
  6. Worlock P, Stower M, Barbor P. Patterns of fractures in accidental and non-accidental injury in children: a comparative study. Br Med J (Clin Res Ed). 1986;293(6539):100-2.
  7. Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K, Datta S, Thomas DP, Sibert JR, Maguire S. Patterns of skeletal fractures in child abuse: systematic review. BMJ. 2008;377:a1518.