Characteristics and Outcomes of Non-accidental Visceral Injuries Among Children: Five Years’ Experience of National Data in Saudi Arabia

Introduction

Figure

Child maltreatment is a major public health concern worldwide. This phenomenon could be defined as any type of abuse for children younger than eighteen years, and consist of physical, sexual, emotional, or neglect 1. The World Health Organization reports that an estimated 1 billion children worldwide experience violence yearly 2. Physical abuse is one of the most prevalent forms of child maltreatment, and it has unwanted consequences. Child maltreatment can result in physical complications, including bruises, cuts, fractures, and internal injuries; or psychological complications, such as anxiety, depression, and post-traumatic stress disorder 3. All these factors increase morbidity and mortality rates, with some studies reporting mortality rates of up to 10% in physically abused patients 4. A study conducted in Saudi Arabia reported that the prevalence of child maltreatment, including physical abuse, emotional abuse, neglect, and sexual abuse, was approximately 38.8%. The prevalence of physical abuse, specifically in Saudi Arabia, ranges from 11.5% to 37.3%, with a mortality rate of 6.2% 5. An examples of NAVI is Abdominal injuries: contusion, laceration, rupture of solid or hollow viscera and Thoracic injuries: lung contusions, chylothoraces, cardiac lacerations, rupture 6. NAVI victims are at risk of severe complications such as organ failure, sepsis, and long-term disability. Therefore, it is a severe form of child abuse associated with a high mortality rate, with up to 50% of the cases resulting in death 7. While no child is blamed for experiences of abuse or neglect, studies have shown that the risk increases in children with special health needs or disabilities, especially in low-income families 8. Accurately estimating the global prevalence of NAVI is challenging; however, studies have reported rates ranging from 2.5% to 8% 9. Moreover, in United Kingdom, the prevalence of Abusive non-accidental visceral is not specified. However, they have highlighted the importance of screening tests to detect abdominal injuries in abused children 10.

Despite the importance of this issue and its profound consequences, there are limited number of international and local studies on NAVI that highlighted this aspect of child maltreatment. The aim of this study is to identify the prevalence of NAVI accidents, clinical traits (demographics and injury patterns), and final health status (morbidities, fatalities, hospitalisations, and dispositions) in children in Saudi Arabia.

Methods:

Study design and participants:

This descriptive cross-sectional study based on the records of registered cases in the National family safety Records (NFSR). The NFSR is a database of child abuse cases presented to health facilities across Saudi Arabia. This design accessed a readily available cohort of cases collected over the past five years, including their characteristics and clinical details. Cases were extracted from 62 child-protection centres representing the governmental health sector in Saudi Arabia.

A total number of 30 cases with NAVIs due to abuse were reviewed and documented in the NFSR from April 2017 to March 2022. All patients under 18 years of age, of both sexes, and registered in the past five years with evidence of NAVIs were included in this study. Through this data we will cover the study objectives by capturing the prevalence of NAVI and describing the characteristics of the victims.

Measures:

After getting approval on the research manuscript from Institute Review Board (IRB), The NFSR authorities were approached through the research coordinator by initiating an electronic request in the NFSP electronic portal. Once reviewing the request by the NFSR team, they will retrieve the requested information officially through correspondence from NFSR department and give them to the researcher. After that the electronic charts were reviewed by the principal investigator (PI) to make sure his request is accomplished.

Data of children with NAVIs were including all variables with primary and secondary outcomes. The data collection instrument included categorical variables, including the victim’s sex, caregiver’s relationship with the victim, parents’ information, abuse information, socio-demographic characteristics of victims and offenders, current health status of the victim, perpetrator’s sex, marital status, employment, education level, health condition, and relationship with the victim; numerical variables, including the victim’s age, length of hospitalisation, and perpetrator’s age; and outcome variables, including the prevalence of NAVIs, organ(s) affected by NAVIs, victim’s disposition, length of hospitalisation, and discharge status.

Statistical Analysis

The data of children with NAVIs were described, including patterns of injuries, socio-demographic characteristics, and abuse outcomes, using frequencies and percentages for categorical data and means and standard deviations for numerical data. An appropriate standardised test was performed using the Statistical Package for the Social Sciences (SPSS) software to determine the co-association from the test of central tendencies. Chi-square or Fisher’s exact test was used to assess the relationship between the injury type and the patient’s characteristics. Confidence intervals were computed, and a p-value < 0.05 was considered statistically significant.

Ethical Considerations

Information obtained from a secure and confidential database was encrypted and was not leaked to any individual; therefore, informed consent was not required. Ethical approval was obtained from the Institutional Review Board of King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (No#NRC22R/155/03).

There is no direct benefit or harm to the researchers or individuals; however, the results of published data will be communicated to the policymakers for the formulation of appropriate rules and regulations. Subjects’ privacy and confidentiality are assured, no identifiers will be collected, and all data will be kept in hard and soft copies in a secure place within the National Guard Health Affairs (NGHA) premises.

Results

Table 1 shows the socio-demographic characteristics of the NAVI victims, including age, sex, living arrangements, previous history of abuse, and final health status. The participant’s mean age was 6.5±4.7 years, and 40% were male. More than three-quarters (80%, n=24) of the participants lived with both parents, while 20% had a single parent. Nearly one-quarter (23.3%, n=7) of the victims reported having experienced previous abuse. Almost half (46.7%, n=14) of the participants were admitted to the hospital ward, (26.7%, n=8) to the emergency room/clinic, and (23.3%, n=7) to the intensive care unit. Regarding final health status, nearly a quarter (23.3%, n=7) of the victims reported deterioration of their health status, and (6.7%, n=2) died.

Table 1: Demographic information on the victims of non-accidental visceral injury (n=30)
	Number (%)
Age
Mean (year)	6.5±4.7
Sex
Male	12 (40.0)
Female	18 (60.0)
Living arrangement
Both parents	24 (80.0)
Single parent	6 (20.0)
Victim’s health before abuse
Healthy	24 (80.0)
Chronic illness	2 (6.7)
Unknown	4 (13.3)
Previous history of abuse
Yes	7 (23.3)
No	14 (46.7)
Unknown	9 (30.0)
Alleged perpetrator known
Yes	24 (80.0)
No	6 (20.0)
Victim’s admission
Ward	14 (46.7)
Emergency room/Clinic	8 (26.7)
Intensive care unit	7 (23.3)
Mortuary	1 (3.3)
Victim’s final health status
Well	15 (50.0)
Deterioration of health status	7 (23.3)
Unknown	6 (20.0)
Dead	2 (6.7)

Percentages may not add up to 100 because of rounding

There was a sharp increase in NAVI cases over the five-year period, particularly after 2020, from two cases per year in 2017 to nine cases in 2021 (Figure 1). Figure 2 shows the year-to-year variation in NAVI rates calculated from child population data ranging from 1.9 to 8.3 per ten million population between 2017 and 2021, indicating that the injury rates varied widely per year. NAVI predominantly affected children aged 5-10 years (40.1%), followed by children aged <5 years (33.3%) and >10 years (16.6%) (Figure 3). Lung injury was the most common form of NAVI, accounting for 23.3% of the cases, followed by injury to the liver (20%), small intestine (13.3%), and pancreas (10%) (Table 2).

Table 2: Anatomical location of non-accidental visceral injury†
Visceral injury	Number (%)
Lung	7 (23.3)
Liver	6 (20.0)
Small intestine	4 (13.3)
Pancreas	3 (10.0)
Stomach	2 (6.7)
Kidney	2 (6.7)
Scrotum	1 (3.3)
Vagina	1 (3.3)
Heart	1 (3.3)
Multiple sites	3 (10.0)

†Percentages may not add up to 100 because of rounding

Among children who had experienced NAVI, siblings were the perpetrators in 25% of the cases, followed by fathers (20.8%), mothers (20.8%), and both parents (8.3%). One-third (33.3%) of the perpetrators were ≤18 years old, followed by the age groups 19-30 years (29.1%), 31-40 years (25%), and 41-50 years (12.5%). More than half (62.5%) were males, and (41.6%) were married. Regarding the perpetrators’ highest level of education, over half (54.1%) had completed high school education, followed by elementary school (16.7%) and intermediate school (12.5%) education. Nearly one-third (29.1%) of the perpetrators were employed, and most (83.3%) were healthy (Table 3).

Table 3: Characteristics of the known perpetrators of non-accidental visceral injury (n=24) †
	Number (%)
Relationship with victim
Both parents	2 (8.3)
Father	5 (20.8)
Mother	5 (20.8)
Sibling	6 (25.0)
Others (e.g., relatives)	6 (25.0)
Age group (year)
≤18 19-30	8 (33.3) 7 (29.1)
31-40	6 (25.0)
41-50	3 (12.5)
Sex
Male	15 (62.5)
Female	9 (37.5)
Marital status
Married	10 (41.6)
Single	10 (41.6)
Divorced	3 (12.5)
Separated	1 (4.2)
Level of education
Illiterate	3 (12.5)
Elementary school	4 (16.7)
Intermediate school	3 (12.5)
High school	13 (54.1)
Higher education	1 (4.2)
Employment status
Employed	7 (29.1)
Unemployed	6 (25.0)
Student	6 (25.0)
Housewife	5 (20.8)
Health condition
Healthy	20 (83.3)
Chronic illness	2 (8.3)
Addict	2 (8.3)

Discussion

Child physical abuse, especially those leading to visceral injuries in victims, is a serious issue that may be easily missed, as not all victims exhibit external signs that indicate physical abuse. Therefore, awareness of the variability in the presentation of visceral injuries would facilitate early diagnosis and better outcomes 11. The incidence of physical abuse in Saudi Arabia has increased, as previously assessed over three periods, 2000-2004, 2005-2006, and 2007-2008, with 14, 16, and 35 reported cases, respectively 12. The present study showed a variable increase in incidence: two cases per year in 2017, rising to nine cases in 2021. This sharp increase in numbers of NAVI cases could be related to multiple reasons; such as increase public awareness and health practitioners toward abuse cases, which in turn increases the reporting practices. Moreover, during this five years, there has been an announcement of “Protection against abuse” law that led people to be more conscious about abuse and as consequence increases the reported cases. Similarly, the rate of NAVI cases has a spike increase after 2017 that might be associated with increased number of child protection centers in the healthcare sectors and increase in public awareness campaigns.

The mean age of the victims was 6.5±4.7 years, which differs from the mean age of 2.1 years and 14±2 months reported in international studies 13. We noticed that visceral injuries tended to show a slight female predominance, whereas other non-accidental injuries were occurred more frequently in males 14. In addition, 54% of NAVI cases presented at Children’s Hospital in Denver, USA, between 1996 and 2002 were females; however, the incidence of non-visceral cases in males was higher (59%) 15. Similar findings in Saudi Arabia showed a male predominance (59%) in non-accidental fracture incidence 16.

Upon analysing the characteristics of the known perpetrators in the NAVI, we found no similar published data for comparisons; therefore, we compared it with the profile and family structure of child abuse and neglect cases in general. Half (49.9%) of the known perpetrators were one or both parents, while the other half were siblings and other relatives. These results likewise those of studies conducted in the United Kingdom 17. In the United States, parents were mostly the offenders 18. In the present study, males comprised the majority of perpetrators (62.5%), and 62.4% of all abusers were less than 30 years old, similar to international data 17. Moreover, more than half (54.1%) of the perpetrators had a high school degree, whereas only one had a higher education level. There are significant variations in the literature regarding the association between the perpetrators’ levels of education and child abuse. Different studies have suggested that child abuse is often perpetrated by those with limited education or no high school degree 19, 20. Another study showed that child abuse is more common among highly educated perpetrators 21. However, one study concluded that there was no definite relationship between these variables 22. Our results showed that 29.1% of the perpetrators were employed, which is consistent with data found in national and international studies 21, 23.

This study revealed that nearly half (46.7%) of the victims were admitted to the hospital ward because of NAVI. A study in 2019 that came to a similar conclusion stated that most children who had experienced current or previous physical or visceral abuse were admitted to wards 24. Regarding clinical and emergency check-ups, only 26.7% of the cases in the present study required such care before discharge. In contrast, a study published in 2012 reported that more than half (57%) of the children with NAVI required only clinical visits or emergency care units 25. Nearly a quarter (23.3%) of the victims in this study experienced a deterioration in their medical status, consistent with the findings of previous studies. A study published in 2012 revealed that two-thirds of the victims had pre-existing chronic health issues, and their secondary health status worsened because of maltreatment and abuse 24. Additionally, this study reported a 6.6% mortality rate due to NAVI, which is significantly lower than that in international records (53%) 14.

Our data showed that the lungs and liver were the most commonly affected organs, accounting for 23% and 20% of the cases, respectively. The high rates of liver injuries were consistent with those of previous studies that reported that liver injuries comprised almost two-thirds of all hospitalisations due to NAVI 26, 27. However, as most of the studies were concerned with intra-abdominal injuries only, the rate and percentage of lung injuries were not assessed, considering the lung as an intra-thoracic organ. Another study reported that the duodenum was the most injured intra-abdominal organ and showed a certain level of variability among the most affected organs 6. Pancreatic injuries were found in 10% of cases in this study, which is lower than the 17% reported in a case series 29. Kidney injuries were less frequently reported, accounting for 6.7% of all cases, although other studies have reported higher percentages of renal injuries in abusive abdominal trauma, ranging from 19% to 25% 26, 29.

This study has some limitations. First, the sample size was relatively small, which may have affected the generalizability of the findings. Second, the investigation was limited to information included in the National Family Safety Registry (NFSR), which may not have provided a complete picture of NAVI among children in Saudi Arabia. Finally, missing data were reported throughout the data collection process, which may have influenced the accuracy and completeness of the results.

Conclusions

This study provides important information on the socio-demographic characteristics, injury patterns, and perpetrators of NAVI in children. The results highlighted that NAVI predominantly affects children aged 5-10 years, with lung and liver injuries being the most common, and that the victims’ siblings and parents were the most common perpetrators. This study provides valuable insights into the characteristics and outcomes of NAVI in children in Saudi Arabia. Moreover, the trend of increasing number of NAVI cases over the five years was significant, which might continue to persist in the coming years. As a results of this study further research to establish a comprehensive understanding of NAVI is demanding. Due to that its essential to develop some effective prevention strategies to address this important public health issue and reduce the incidence of NAVI in children.

Acknowledgements

We want to express our deepest gratitude and appreciation to the Research Department of the National Family Safety Program for its continuous support in extracting and analysing the data and assisting in writing the manuscript.

Declarations

Funding: None

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Review Board of King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (NRC22R/155/03).

References

1. Violence prevention [Internet]. Violence Prevention. 2024. Available from: https://www.cdc.gov/violenceprevention

2. World Health Organization: Violence against children. (2022). Accessed: May 21, 2023: https://www.who.int/news-room/fact-sheets/detail/violence-against-children

3. Sébastien, Orellana., Richard, A., I., Bethlehem., Ivan, L., Simpson-Kent., Anne-Laura, van, Harmelen., Petra, E., Vértes., Edward, T., Bullmore. Childhood maltreatment influences adult brain structure through its effects on immune, metabolic and psychosocial factors. medRxiv, (2023). doi: 10.1101/2023.06.15.23291420

4. John, A.M., Gall., John, A.M., Gall. Physical Child Abuse. (2020). doi: 10.1007/978-3-030-29462-5_5

5. Sarah, Aldharman., Wed, S, Alotaibi., Asma, Alqahtani., Hassan, Saleheen., Maha, Almuneef. Determining the Prevalence of Child Maltreatment Among Young Adults in Saudi Arabia Using ISPCAN Child Abuse Screening Tool. Cureus, (2023). doi: 10.7759/cureus.38531

6. Abdominal Trauma. (2023). doi: 10.5772/intechopen.109615

7. Barbara, L., Knox., Suzanne, P., Starling., Kenneth, W., Feldman., Nancy, D., Kellogg., Lori, D., Frasier., Suzanna, L., Tiapula. Child Torture as a Form of Child Abuse. Journal of Child & Adolescent Trauma, (2014). doi: 10.1007/S40653-016-0108-X

8. Austin AE, Lesak AM, Shanahan ME: Risk and protective factors for child maltreatment: A review. Curr Epidemiol Rep. 2020, 7:334-42. 10.1007/s40471-020-00252-3

9. Piteau SJ, Ward MG, Barrowman NJ, Plint AC: Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review. Pediatrics. 2012, 130:315-23. 10.1542/peds.2011-1545

10. Benan, Shu. Update on Non-accidental Trauma. (2022). doi: 10.1007/978-981-19-4963-0_14

11. Muhammad, Romail, Manan., Sara, Rahman., Leah, Komer., Hamna, Manan., Saadia, Iftikhar. A Multispecialty Approach to the Identification and Diagnosis of Nonaccidental Trauma in Children. Cureus, (2022). doi: 10.7759/cureus.27276

12. Al Eissa M, Almuneef M: Child abuse and neglect in Saudi Arabia: journey of recognition to implementation of national prevention strategies. Child Abuse Negl. 2010, 34:28-33. 10.1016/j.chiabu.2009.08.011

13. Ute, Ziegenhain., Anne, Katrin, Künster., Tanja, Besier. Violence against children. Bundesgesundheitsblatt-gesundheitsforschung-gesundheitsschutz, (2016). doi: 10.1007/S00103-015-2271-X

14. Po-Yuan, Wang., Wei-Chieh, Tseng., Meng-Chang, Lee., Li-Min, Hsu., Sang, Do, Shin., Sabariah, Faizah, Jamaluddin., Hideharu, Tanaka., Do, Ngoc, Son., Ki, Jeong, Hong., Sattha, Riyapan., Ali, Haedar., Wen-Chu, Chiang., Ramana, Rao., George, M., Abraham., Trichur, V., Ramakrishnan., Sabariah, Faiwah, Jamaluddin., Mohd, Amin, Mohidin., Al-Hilmi, Saim., Lim, Chee, Kean., Cecilia, Anthonysamy., Shah, Jahan, Din, Mohd, Yssof., Kang, Ji., Cheah, P, Kheng., Shamila, bt, Mohamad, Ali., Periyanayaki, Ramanathan., Chia, Boon, Yang., H., W., Chia., Hafidahwati, Hamad., Samsu, Ambia, Ismail., Wan, Rasydan, B., Wan, Abdullah., Akio, Kimura., B., Velasco., Carlos, D., Gundran., Pauline, Convocar., Patrick, Tiglao., Kyoung, Jun, Song., Joo, Jeong., Sungbae, Moon., Joo, Yeong, Kim., Won, Chul, Cha., Seung-Chul, Lee., Jae, Yun, Ahn., Ka, Lee., Seok, Ran, Yeom., Hyeong-Ho, Ryu., Su, Jin, Kim., Sang, Chul, Kim., Jen-Tang, Sun., Ruei-Fang, Wang., Shang-Lin, Hsieh., Wei, Fong, Kao., Parinya, Tianwibool., Phudit, Buaprasert., Osaree, Akaraborworn., Omer, Al, Sakaf., Saleh, Fares, Llc., L., Huy., Nguyen, Van, Dai., Pairoj, Khruekarnchana. Characteristics of non-accidental injuries in children and adolescents in Asia: a cross-national, multicenter cohort study. Dental science reports, (2023). doi: 10.1038/s41598-023-33471-x

15. The National Family Safety Program: Hospital Based Child Maltreatment Registry Annual Report. (2016). Accessed: November 18, 2021. https://nfsp.org.sa/ar/projects/NationalRecord/Documents/NFSR%202016_Ar_En.pdf

16. Almuneef MA, Philip W, Almuntaser M: Characteristics of nonaccidental fractures in abused children in Riyadh, Saudi Arabia. Saudi J Med Med Sci. 2019, 7:9-15. 10.4103/sjmms.sjmms_12_18

17. Simon, Kennedy., Susan, Bewley., Jane, Chevous., Concetta, Perot., Marcella, Vigneri., Loraine, J., Bacchus. A systematic review that evaluates the extent and quality of involving childhood abuse survivors in shaping, conducting and disseminating research in the UK. Research for all, (2022). doi: 10.14324/rfa.06.1.03

18. Sedlak A, Mettenburg J, Basena M, Petta I, McPherson K, Greene A, Li S: Fourth National Incidence Study of Child Abuse and Neglect (NIS-4): Report to Congress. (2010). Washington, DC: U.S. Department Of Health And Human Services, Administration for Children and Families. http://www.acf.hhs.gov/programs/opre/abuse_neglect/natl_incid/index.html

19. Masako, Tanaka., Katholiki, Georgiades., Michael, H., Boyle., Harriet, L., MacMillan. Child Maltreatment and Educational Attainment in Young Adulthood Results From the Ontario Child Health Study. Journal of Interpersonal Violence, (2015). doi: 10.1177/0886260514533153 (education level)

20. Malik F: Determinants of child abuse in Pakistani families: parental acceptance-rejection and demographic variables. Int J Bus Soc Sci. 2010, 1:67-80

21. Almuneef MA, Alghamdi LA, Saleheen HN: Family profile of victims of child abuse and neglect in the Kingdom of Saudi Arabia. Saudi Med J. 2016, 37:882-8. 10.15537/smj.2016.8.14654

22. Alokan FB, Kemi B: The correlation between parents’ educational status and child abuse. Hum Soc Sci J. 2010, 5:73-9

23. Andrea, J., Darling., Simon, Hackett., Kimberly, Jamie. Female sex offenders who abuse children whilst working in organisational contexts: offending, conviction and sentencing. Journal of Sexual Aggression, (2018). doi: 10.1080/13552600.2018.1476601

24. Quiroz HJ, Parreco J, Easwaran L, et al.: Identifying populations at risk for child abuse: a nationwide analysis. J Pediatr Surg. 2020, 55:135-9. 10.1016/j.jpedsurg.2019.09.069

25. AlMadani O, Bamousa M, Alsaif D, Kharoshah MAA, Alsowayigh K: Child physical and sexual abuse in Dammam, Saudi Arabia: A descriptive case-series analysis study. Egypt J Forensic Sci. 2012, 2:33-7. 10.1016/j.ejfs.2012.01.001

26. Lane WG, Dubowitz H, Langenberg P, Dischinger P: Epidemiology of abusive abdominal trauma hospitalizations in United States children. Child Abuse Negl. 2012, 36:142-8. 10.1016/j.chiabu.2011.09.010

27. Sheybani EF, Gonzalez-Araiza G, Kousari YM, Hulett RL, Menias CO: Pediatric nonaccidental abdominal trauma: what the radiologist should know. RadioGraphics. 2014, 34:139-53. 10.1148/rg.341135013

28. Narendra, Kumar., Anita, Singh., Yadvendra, Dheer., Sandeep, Tiwari., Samir, Misra., Harshit, Agarwal. Pancreatic Injury—a Case Series Analysis from a Level I Trauma Center. Indian Journal of Surgery, (2021). doi: 10.1007/S12262-020-02664-3

29. Nasser, A, N, Alzerwi. Traumatic injuries to the renal blood vessels and in-hospital renal complications in patients with penetrating or blunt trauma. Frontiers in Surgery, (2023). doi: 10.3389/fsurg.2023.1134945