Non-Accidental Injury An Overlooked Threat To Infant Safety
At five months old, Umar was a healthy, active baby who was growing in line with his developmental milestones, and already able to roll over and turn.
Once his mother returned to work after exhausting her maternity leave, Umar was sent to the same childcare centre as his brother.
There was no reason for Umar’s parents to doubt the centre’s ability to care for him as their older son had been there for more than a year. However, one morning about two months ago, Umar’s mother received a phone call informing her that her infant was having difficulty breathing.
“My wife and I rushed to the childcare centre. When we arrived, Umar was weak and unconscious. We took him to a clinic immediately before he was referred to a hospital,” said his father, who asked to be known only as Siddiq.
With no other obvious symptoms, he said doctors initially suspected that Umar had a lung infection. The baby was admitted to the hospital’s paediatric intensive care unit, where further investigations, including an MRI scan, revealed something far more serious. Although there were no visible wounds or bruises on the outside, Umar had suffered a severe internal head injury believed to have been caused by violent shaking.
(Violent shaking in babies means forcefully shaking an infant, causing their fragile brain to move violently within the skull, leading to severe internal injuries like bleeding, bruising and swelling.)
After a police report was lodged, the hospital concerned referred Umar to Universiti Malaya Medical Centre (PPUM), where his case was managed by the SCAN (Suspected Child Abuse and Neglect) team.
EARLY SIGNS OFTEN OVERLOOKED
Umar’s case is not merely a personal tragedy. It reflects a deeply concerning medical reality, particularly among infants: severe injuries that leave no external marks and are only detected when the child’s condition becomes critical. In medical terms, this condition is known as non-accidental injury (NAI).
According to Dr Kong Sik Thien, a clinical specialist in general paediatrics at PPUM’s Department of Paediatrics, the term is used when the injuries sustained do not match the narrative provided, the child’s developmental stage, or the usual mechanisms of accidental injury.
More worrying, she said, is that NAI often involves the head and eyes, two organs that are extremely vulnerable in infants. In such cases, a more specific term is used: Non-Accidental Head Injury or Abusive Head Trauma, an internationally accepted term since 2009 that encompasses injuries caused by violent shaking, blunt impact, or a combination of both.
Based on her clinical experience, Dr Kong said one of the main challenges in identifying NAI is the fact that many infants show no obvious external signs in the early stages. As a result, serious injuries are often only discovered when the baby’s condition has already become critical.
“In cases of head abuse, for example, babies often develop subdural haemorrhage, which is bleeding beneath the lining of the brain. Although the bleeding may not occur directly within the brain tissue, the resulting pressure can cause brain swelling, seizures and breathing difficulties, and, in some cases, require emergency surgery. Sometimes, however, there are subtle early signs that parents may not notice, such as bruises here and there,” she said.
She added that bruising in infants who are not yet able to walk, crawl or move independently is illogical and difficult to explain through normal infant activity. Such bruises should be taken seriously as they are inconsistent with the child’s developmental stage.
“Some examples are bruises on the buttocks or back of the body, or bruises that resemble lines, finger imprints or handprints,” she said.
NOT NEW
Dr Kong also revealed that NAI is not an isolated occurrence. At PPUM alone, more than 200 cases of child abuse and neglect are treated each year. Of these, around 13 cases involve serious injuries to the brain and eyes. Most patients with brain and eye injuries are infants below one year of age.
“All cases involving brain and eye injuries are usually very serious and most require treatment in intensive care units,” she said, adding that some cases have resulted in death.
She also said PPUM conducted an internal study involving more than 70 patients over the past seven to eight years to better understand the patterns and impact of NAI. The study found that approximately 60 to 70 percent of cases occurred while the infants were under the care of individuals other than their own family members, a finding she described as deeply concerning in terms of caregiving and supervision.
Previously, Women, Family and Community Development Minister Datuk Seri Nancy Shukri was reported by the media as saying that 354 cases of child abuse resulting in death were recorded over a five-year period up to 2024.
DIAGNOSING NAI
Dr Kong stressed that a diagnosis of NAI is never made hastily or based on a single examination. It is established only after thorough interviews and detailed medical assessments are conducted, and after other possible medical conditions have been ruled out.
“According to standard procedure, we obtain a full account from the parents, examine the baby’s condition and health status, and then proceed with brain imaging and full-body X-rays,” she said.
Brain imaging, such as a CT scan, is usually used to assess whether there is any bleeding, brain swelling or skull fracture. Full-body X-rays help detect bone fractures, such as rib or limb fractures, that may not show any external signs. If there is no reasonable explanation from the caregiver or parents to account for the injuries, suspicion of NAI becomes stronger.
“The pattern of injury is also important. In NAI cases, bleeding often involves multiple areas of the brain or eyes. Such patterns are rarely seen in ordinary accidents, especially minor ones,” she added.
Even if there is suspicion of NAI, doctors do not jump to conclusions. Dr Kong said information from multiple disciplines must be gathered before a case is identified as suspected NAI, in line with medical and legal ethics.
Parents are also advised to lodge a police report promptly to facilitate investigations, particularly in cases involving alleged abuse at childcare centres, while the hospital continues to provide medical treatment to the infant.
EYES WINDOW INTO BRAIN INJURY
Meanwhile, PPUM consultant ophthalmologist Prof Dr Nurliza Khaliddin said eye examinations play an equally critical role in confirming a diagnosis of NAI. According to her, violent shaking not only damages the infant’s brain but also has a direct impact on the eyes.
“When a baby is shaken, the optic nerves and blood vessels in the eyes are also shaken. This can cause bleeding in the eye, known as retinal haemorrhage, which often mirrors what is happening in the brain. If the eye findings are severe, the brain injury is usually severe as well,” she explained.
She said retinal injuries in NAI cases have distinctive features that are rarely seen in other types of injury. These include bleeding across multiple layers of the retina; the presence of Roth spots, which are red or white spots caused by small haemorrhages; and retinoschisis, a condition in which the retinal layers split due to strong impact or violent shaking.
“These patterns are very important diagnostically. We would not know if we did not examine the eyes as not all cases show clear external signs,” she said.
She added that eye injuries resulting from NAI can be long-lasting and permanent because an infant’s visual system is still developing. Trauma at such an early stage can disrupt normal visual development.
“These injuries can lead to amblyopia, or lazy eye, which cannot be corrected with glasses or surgery. If retinal bleeding is severe, the effects can last a lifetime,” she said.
She also noted that some children may appear to recover physically, but as they grow older and start school, other problems may begin to surface.
“At that stage, they may experience learning difficulties, problems with concentration or delayed cognitive development, all of which stem from brain injuries sustained during infancy.”
AWARENESS AND PREVENTION
On preventing NAI, Dr Kong strongly advised parents to ensure that childcare centres are registered with the relevant authorities, such as the Social Welfare Department, and to check their baby’s condition before and after leaving them with caregivers.
Parents are also advised not to send their babies to centres that lack sufficient staff or do not allow parents access to the premises.
Dr Nurliza, meanwhile, has this advice for caregivers and parents: “If a baby cries continuously and is uncontrollable, place the baby in a safe spot and take time to calm yourself down or seek help from someone else.”
She said there are many ways to soothe a crying baby, such as gentle rocking, changing their position, or playing calming music.
“But if the baby continues to cry, place them somewhere safe for 15 minutes and use that time to calm yourself. No one can function like a robot caring for a baby 24 hours a day. But shaking a baby, even briefly and in a moment of anger, can have devastating consequences.
“We must also remember that NAI is not a minor or isolated issue. Because babies cannot speak or defend themselves, they are most vulnerable to injuries that may go unnoticed. Early detection, close monitoring of caregiving arrangements, and public awareness are the main safeguards to protect infants from tragic injuries that can have lifelong consequences,” she said.
In Umar’s case, the baby now faces the reality of living with a disability due to severe brain injury.
“He’s now like a newborn baby again,” Siddiq said softly.
