Child abuse

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  • Infant and children with disabilities are at higher risk
  • In >80% of cases, the parent or primary guardian is the abuser
  • Report suspicion
    • Transparent, frank discussion with caregivers
    • Social work or child protection agency involvement
      • Protect the child first, admit if suspicious
      • Social work may follow-up as outpatient for very low risk cases

Risk Factors

  • Domestic violence
  • Maternal depression
  • Drug and alcohol abuse
  • Premature birth
  • Children with disabilities or children who require significant medical care
  • Unrealistic expectations for the child

Clinical Features

Red flags:

  • History given is inconsistent with the mechanism of injury
  • Changes in caregivers report
  • Significant delays in care
  • Any injury to a young, pre-ambulatory infant
  • Injuries to multiple organ systems
  • Injuries in different stages of healing;
  • Patterned injuries
  • Injuries to nonbony or other unusual locations, (torso, ears, face, neck, or upper arms)
  • Significant injuries that are unexplained
  • Other evidence of child neglect.


  • Bruises, ecchymosis, and soft-tissue injuries on the face, cheeks, back, neck of if the child is not cruising yet
  • Bruises in clusters or patterned marks
  • Bruising of any child under 4 months of age warrants a full child abuse work-up

Oral injuries

  • Torn frenulum in premobile children is highly associated with physical abuse
  • Other reported oral injuries include laceration/bruising to the lips, mucosal lacerations, dental trauma, tongue injuries, and gingival lesions


  • Most commonly immersion injuries of the extremities, buttocks, or perineum
  • More likely symmetrical with clear upper margins
  • Many will also have occult fractures; children <24mo should undergo a skeletal survey


  • Fractures moderately suspicious of abuse:
    • Long-bone transverse or spiral fracture of the diaphysis of the femur, humerus, tibia
    • Multiple bilateral fractures
    • Different stages of healing with multiple fractures
    • Epiphyseal separations
    • Vertebral body separation
    • Complex skull fractures
    • Pelvic fractures

Head Trauma

  • Leading cause of death in abused children <2 years old
  • Shaken Baby Syndrome - Retinal Hemorrhages
    • Present in up to 75% of cases and are virtually pathognomonic
    • Described as “dot and blot” hemorrhages or flame or splinter hemorrhages

Abdominal Trauma

  • Most from a direct blow or from being thrown
  • Any abrasion or bruise on the abdominal area should prompt an evaluation for possible trauma
  • Consider abuse in preschool aged children with any hollow viscus or pancreatic injury

Differential Diagnosis

Crying Infant


  • Skeletal survey for all children < 2 years of age, non-verbal, or severe developmental delay. Note: Follow-up skeletal survey should be performed within 10 to 14 days
    • Skull AP and lateral view (left and right)
    • Chest AP and lateral view
    • Right and left oblique of the chest
    • AP of the abdomen to include pelvis and hips
    • AP and lateral spine to include cervical, thoracic, and lumbar vertebrae
    • AP bilateral humerus
    • AP bilateral forearms
    • AP bilateral femurs
    • AP bilateral tibia and fibula
    • Posterior view of the hands
    • Dorsoplantar view of the feet
  • Head CT without contrast for any child < 1 year with suspicion of abuse or >1 year with concerning signs of head trauma
  • Trauma labs: CBC, CMP, PT, PTT, lipase, and urinalysis (looking for blood; use bag specimen). Consider urine tox screen
    • Consider CPK and platelet function studies if extensive bruising is present
    • If trauma labs are abnormal, obtain a CT of abdomen/pelvis with IV contrast
  • Consider a dilated fundoscopic exam if under 2 years
  • Photograph injuries
  • Obtain a social work consult

Inpatient Workup[1]

  • Ophtho consult for retinal hemorrhages
  • CBC
  • CMP, Mg, phos
  • PT/INR/aPTT, fibrinogen
  • PTH, iCa, 25-hydroxy-Vit D, 1,25-dihydroxy-Vit D
  • vW panel (vW AT, ristocetin cofactors, factor VIII)


  • Treat injuries as indicated
  • Report abuse to the appropriate state child protection authority


  • Admit for medical treatment or if any question of child's safety upon discharge

See Also

External Links

Pediatric Emergency Playbook -- Vomiting in the Young Child: Nothing or Nightmare


  1. Children's Hospital of Georgia NAT Workup Protocol. Medical College of Georgia at Augusta University. Last reviewed 2016.