Features
Non-accidental injury in children in the time of COVID-19 pandemic Emily Baird
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.
T Emily Baird is a Consultant Paediatric Orthopaedic Surgeon at the Royal Hospital for Sick Children in Edinburgh, with an interest in trauma, and the paediatric hip and foot. Emily has been the President of British Orthopaedic Trainees’ Association, and now sits on the Education Committee of the British Society for Children’s Orthopaedic Surgery and is the Head of Education for the South East Scotland T&O ST programme.
here 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 subdural and retinal haemorrhages, and multiple fractures, 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 more deadly in the face a global, viral pandemic.
NAI is more likely to happen Some departments have reported an increasing number of NAI cases3, and when the risk factors for NAI are examined, this comes as no surprise. However, the sad truth is that the abuse will be hidden away, and most departments have in fact seen less referrals to Child Protection recently. 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 and youth programmes takes away not only the
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respite of childcare, but also the early warning system that these institutions 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 families with children with additional needs is a particularly cruel blow. Social isolation for 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 stressful and volatile environment. Domestic abuse has said to have surged amid lockdown, with the number of deaths (including those of children) more than double the average number4. 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, posing a risk to children living with them. NAI is known to be 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 trauma5. Through financial uncertainty, COVID-19 adds yet another element of stress to a precarious situation for many children, and this effect will be long lasting.
