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Physical child abuse: Recognition

Stephen C Boos, MD, FAAP
Section Editor
Daniel M Lindberg, MD
Deputy Editor
James F Wiley, II, MD, MPH


This topic will discuss the initial recognition of physical child abuse. The clinical findings, diagnosis, and management of physical child abuse, sexual abuse, and child neglect are discussed separately:

(See "Physical child abuse: Diagnostic evaluation and management" and "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children".)

(See "Evaluation of sexual abuse in children and adolescents" and "Management and sequelae of sexual abuse in children and adolescents".)

(See "Child neglect and emotional maltreatment".)


Physical child abuse may be broadly defined as injury inflicted upon a child by a parent or caretaker. Specific definitions can vary widely among countries, as well as among different ethnic and religious groups [1,2].


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Literature review current through: Sep 2016. | This topic last updated: Aug 12, 2016.
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  1. Dubowitz H, Bennett S. Physical abuse and neglect of children. Lancet 2007; 369:1891.
  2. Christian CW, Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse. Pediatrics 2015; 135:e1337.
  3. Administration for Children & Families. Child Maltreatment 2010. Annual Report, US Government Printing Office; US Department of Health and Human Services, Washington, DC 2010. Available from http://www.acf.hhs.gov/programs/cb/pubs/cm10/cm10.pdf. (Accessed April 11, 2012).
  4. Child Maltreatment 2011. Report, Children's Bureau http://www.acf.hhs.gov/sites/default/files/cb/cm11.pdf; U.S. Department of Health and Human Services, Washington, DC, 2011.
  5. Sedlak AJ, Mettenburg J., Basena M, et al. (2010). Fourth National Incidence Study of Child Abuse and Neglect (NIS–4): Report to Congress. Washington, DC: U.S. Department of Health and Human Services, Administration for Children and Families. http://www.acf.hhs.gov/sites/default/files/opre/nis4_report_congress_full_pdf_jan2010.pdf
  6. Gilbert R, Widom CS, Browne K, et al. Burden and consequences of child maltreatment in high-income countries. Lancet 2009; 373:68.
  7. Finkelhor D, Turner HA, Shattuck A, Hamby SL. Prevalence of Childhood Exposure to Violence, Crime, and Abuse: Results From the National Survey of Children's Exposure to Violence. JAMA Pediatr 2015; 169:746.
  8. Gilbert R, Fluke J, O'Donnell M, et al. Child maltreatment: variation in trends and policies in six developed countries. Lancet 2012; 379:758.
  9. Farst K, Ambadwar PB, King AJ, et al. Trends in hospitalization rates and severity of injuries from abuse in young children, 1997-2009. Pediatrics 2013; 131:e1796.
  10. Leventhal JM, Gaither JR. Incidence of serious injuries due to physical abuse in the United States: 1997 to 2009. Pediatrics 2012; 130:e847.
  11. Crume TL, DiGuiseppi C, Byers T, et al. Underascertainment of child maltreatment fatalities by death certificates, 1990-1998. Pediatrics 2002; 110:e18.
  12. Spencer N, Devereux E, Wallace A, et al. Disabling conditions and registration for child abuse and neglect: a population-based study. Pediatrics 2005; 116:609.
  13. Rosenberg LA, Wissow LS. Effects of maltreatment on the child. In: Child Advocacy for the Clinician, Williams & Wilkins, Philadelphia 1990. p.12.
  14. Klein M, Stern L. Low birth weight and the battered child syndrome. Am J Dis Child 1971; 122:15.
  15. Murphy JF, Jenkins J, Newcombe RG, Sibert JR. Objective birth data and the prediction of child abuse. Arch Dis Child 1981; 56:295.
  16. Benedict MI, White RB. Selected perinatal factors and child abuse. Am J Public Health 1985; 75:780.
  17. Gessner BD, Moore M, Hamilton B, Muth PT. The incidence of infant physical abuse in Alaska. Child Abuse Negl 2004; 28:9.
  18. Strathearn L, Gray PH, O'Callaghan MJ, Wood DO. Childhood neglect and cognitive development in extremely low birth weight infants: a prospective study. Pediatrics 2001; 108:142.
  19. Herrenkohl TI, Sousa C, Tajima EA, et al. Intersection of child abuse and children's exposure to domestic violence. Trauma Violence Abuse 2008; 9:84.
  20. Degue S, Dilillo D. Is animal cruelty a "red flag" for family violence? Investigating co-occurring violence toward children, partners, and pets. J Interpers Violence 2009; 24:1036.
  21. Egami Y, Ford DE, Greenfield SF, Crum RM. Psychiatric profile and sociodemographic characteristics of adults who report physically abusing or neglecting children. Am J Psychiatry 1996; 153:921.
  22. Deans KJ, Thackeray J, Askegard-Giesmann JR, et al. Mortality increases with recurrent episodes of nonaccidental trauma in children. J Trauma Acute Care Surg 2013; 75:161.
  23. Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA 1999; 281:621.
  24. Ellaway BA, Payne EH, Rolfe K, et al. Are abused babies protected from further abuse? Arch Dis Child 2004; 89:845.
  25. Connell CM, Bergeron N, Katz KH, et al. Re-referral to child protective services: the influence of child, family, and case characteristics on risk status. Child Abuse Negl 2007; 31:573.
  26. Thackeray JD. Frena tears and abusive head injury: a cautionary tale. Pediatr Emerg Care 2007; 23:735.
  27. Oral R, Yagmur F, Nashelsky M, et al. Fatal abusive head trauma cases: consequence of medical staff missing milder forms of physical abuse. Pediatr Emerg Care 2008; 24:816.
  28. Thorpe EL, Zuckerbraun NS, Wolford JE, Berger RP. Missed opportunities to diagnose child physical abuse. Pediatr Emerg Care 2014; 30:771.
  29. King WK, Kiesel EL, Simon HK. Child abuse fatalities: are we missing opportunities for intervention? Pediatr Emerg Care 2006; 22:211.
  30. Wood J. Occult fracture screening in young children at pediatric and non-pediatric hspitals. The Helfer Society Annual Meeting, April 7, 2014, Annapolis, MD.
  31. Wood JN, Feudtner C, Medina SP, et al. Variation in occult injury screening for children with suspected abuse in selected US children's hospitals. Pediatrics 2012; 130:853.
  32. Wood JN, Hall M, Schilling S, et al. Disparities in the evaluation and diagnosis of abuse among infants with traumatic brain injury. Pediatrics 2010; 126:408.
  33. Hettler J, Greenes DS. Can the initial history predict whether a child with a head injury has been abused? Pediatrics 2003; 111:602.
  34. Feldman KW, Bethel R, Shugerman RP, et al. The cause of infant and toddler subdural hemorrhage: a prospective study. Pediatrics 2001; 108:636.
  35. Helfer RE, Slovis TL, Black M. Injuries resulting when small children fall out of bed. Pediatrics 1977; 60:533.
  36. Nimityongskul P, Anderson LD. The likelihood of injuries when children fall out of bed. J Pediatr Orthop 1987; 7:184.
  37. Levene S, Bonfield G. Accidents on hospital wards. Arch Dis Child 1991; 66:1047.
  38. Lyons TJ, Oates RK. Falling out of bed: a relatively benign occurrence. Pediatrics 1993; 92:125.
  39. Ruddick C, Platt MW, Lazaro C. Head trauma outcomes of verifiable falls in newborn babies. Arch Dis Child Fetal Neonatal Ed 2010; 95:F144.
  40. Monson SA, Henry E, Lambert DK, et al. In-hospital falls of newborn infants: data from a multihospital health care system. Pediatrics 2008; 122:e277.
  41. Joffe M, Ludwig S. Stairway injuries in children. Pediatrics 1988; 82:457.
  42. Chiaviello CT, Christoph RA, Bond GR. Stairway-related injuries in children. Pediatrics 1994; 94:679.
  43. Docherty E, Hassan A, Burke D. Things that go bump ... bump ... bump: an analysis of injuries from falling down stairs in children based at Sheffield Children's Hospital. Emerg Med J 2010; 27:207.
  44. Zielinski AE, Rochette LM, Smith GA. Stair-related injuries to young children treated in US emergency departments, 1999-2008. Pediatrics 2012; 129:721.
  45. Belechri M, Petridou E, Trichopoulos D. Bunk versus conventional beds: a comparative assessment of fall injury risk. J Epidemiol Community Health 2002; 56:413.
  46. Mack KA, Gilchrist J, Ballesteros MF. Bunk bed-related injuries sustained by young children treated in emergency departments in the United States, 2001-2004, National Electronic Injury Surveillance System - All Injury Program. Inj Prev 2007; 13:137.
  47. D'Souza AL, Smith GA, McKenzie LB. Bunk bed-related injuries among children and adolescents treated in emergency departments in the United States, 1990-2005. Pediatrics 2008; 121:e1696.
  48. Powell EC, Jovtis E, Tanz RR. Incidence and description of high chair-related injuries to children. Ambul Pediatr 2002; 2:276.
  49. Schalamon J, Ainoedhofer H, Saxena AK, et al. Falls from highchairs. Eur J Pediatr 2006; 165:732.
  50. Smith GA, Bowman MJ, Luria JW, Shields BJ. Babywalker-related injuries continue despite warning labels and public education. Pediatrics 1997; 100:E1.
  51. Huntimer CM, Muret-Wagstaff S, Leland NL. Can falls on stairs result in small intestine perforations? Pediatrics 2000; 106:301.
  52. Chadwick DL, Bertocci G, Castillo E, et al. Annual risk of death resulting from short falls among young children: less than 1 in 1 million. Pediatrics 2008; 121:1213.
  53. Ehsani JP, Ibrahim JE, Bugeja L, Cordner S. The role of epidemiology in determining if a simple short fall can cause fatal head injury in an infant: a subject review and reflection. Am J Forensic Med Pathol 2010; 31:287.
  54. Allasio D, Fischer H. Immersion scald burns and the ability of young children to climb into a bathtub. Pediatrics 2005; 115:1419.
  55. Wood J, Rubin DM, Nance ML, Christian CW. Distinguishing inflicted versus accidental abdominal injuries in young children. J Trauma 2005; 59:1203.
  56. Farrell C, Rubin DM, Downes K, et al. Symptoms and time to medical care in children with accidental extremity fractures. Pediatrics 2012; 129:e128.
  57. Clark KD, Tepper D, Jenny C. Effect of a screening profile on the diagnosis of nonaccidental burns in children. Pediatr Emerg Care 1997; 13:259.
  58. Hight DW, Bakalar HR, Lloyd JR. Inflicted burns in children. Recognition and treatment. JAMA 1979; 242:517.
  59. Harper NS, Feldman KW, Sugar NF, et al. Additional injuries in young infants with concern for abuse and apparently isolated bruises. J Pediatr 2014; 165:383.
  60. Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers: those who don't cruise rarely bruise. Puget Sound Pediatric Research Network. Arch Pediatr Adolesc Med 1999; 153:399.
  61. Pierce MC, Magana JN, Kaczor K, et al. The Prevalence of Bruising Among Infants in Pediatric Emergency Departments. Ann Emerg Med 2016; 67:1.
  62. Kemp AM, Dunstan F, Nuttall D, et al. Patterns of bruising in preschool children--a longitudinal study. Arch Dis Child 2015; 100:426.
  63. Pierce MC, Kaczor K, Aldridge S, et al. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics 2010; 125:67.
  64. Dunstan FD, Guildea ZE, Kontos K, et al. A scoring system for bruise patterns: a tool for identifying abuse. Arch Dis Child 2002; 86:330.
  65. Randeberg LL, Winnem AM, Langlois NE, et al. Skin changes following minor trauma. Lasers Surg Med 2007; 39:403.
  66. Sirakova MA, Debelle G. Identifying human bite marks in children. Paediatr Child Health 2014; 24:550.
  67. Kemp A, Maguire SA, Sibert J, et al. Can we identify abusive bites on children? Arch Dis Child 2006; 91:951.
  68. Bariciak ED, Plint AC, Gaboury I, Bennett S. Dating of bruises in children: an assessment of physician accuracy. Pediatrics 2003; 112:804.
  69. Pilling ML, Vanezis P, Perrett D, Johnston A. Visual assessment of the timing of bruising by forensic experts. J Forensic Leg Med 2010; 17:143.
  70. Sheets LK, Leach ME, Koszewski IJ, et al. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics 2013; 131:701.
  71. Kemp AM, Maguire SA, Nuttall D, et al. Bruising in children who are assessed for suspected physical abuse. Arch Dis Child 2014; 99:108.
  72. Carpenter RF. The prevalence and distribution of bruising in babies. Arch Dis Child 1999; 80:363.
  73. Fischer H, Hammel PW, Dragovic LJ. Images in clinical medicine. Human bites versus dog bites. N Engl J Med 2003; 349:e11.
  74. Whittaker DK, Brickley MR, Evans L. A comparison of the ability of experts and non-experts to differentiate between adult and child human bite marks using receiver operating characteristic (ROC) analysis. Forensic Sci Int 1998; 92:11.
  75. Sweet D, Lorente M, Lorente JA, et al. An improved method to recover saliva from human skin: the double swab technique. J Forensic Sci 1997; 42:320.
  76. da Fonseca MA, Feigal RJ, ten Bensel RW. Dental aspects of 1248 cases of child maltreatment on file at a major county hospital. Pediatr Dent 1992; 14:152.
  77. Naidoo S. A profile of the oro-facial injuries in child physical abuse at a children's hospital. Child Abuse Negl 2000; 24:521.
  78. Kellogg N, American Academy of Pediatrics Committee on Child Abuse and Neglect. Oral and dental aspects of child abuse and neglect. Pediatrics 2005; 116:1565.
  79. Maguire S, Moynihan S, Mann M, et al. A systematic review of the features that indicate intentional scalds in children. Burns 2008; 34:1072.
  80. Hodgman EI, Pastorek RA, Saeman MR, et al. The Parkland Burn Center experience with 297 cases of child abuse from 1974 to 2010. Burns 2016; 42:1121.
  81. Kemp AM, Jones S, Lawson Z, Maguire SA. Patterns of burns and scalds in children. Arch Dis Child 2014; 99:316.
  82. Maguire S, Okolie C, Kemp AM. Burns as a consequence of child maltreatment. Paediatr Child Health 2014; 24:557.
  83. Faller-Marquardt M, Pollak S, Schmidt U. Cigarette burns in forensic medicine. Forensic Sci Int 2008; 176:200.
  84. Kemp AM, Maguire SA, Lumb RC, et al. Contact, cigarette and flame burns in physical abuse: a systematic review. Child Abuse Rev 2014; 23:35.
  85. Frechette A, Rimsza ME. Stun gun injury: a new presentation of the battered child syndrome. Pediatrics 1992; 89:898.
  86. Burdett-Smith P. Stun gun injury. J Accid Emerg Med 1997; 14:402.
  87. Fagen KE, Shalaby-Rana E, Jackson AM. Frequency of skeletal injuries in children with inflicted burns. Pediatr Radiol 2015; 45:396.
  88. Pawlik MC, Kemp A, Maguire S, et al. Children with burns referred for child abuse evaluation: Burn characteristics and co-existent injuries. Child Abuse Negl 2016; 55:52.
  89. Angel C, Shu T, French D, et al. Genital and perineal burns in children: 10 years of experience at a major burn center. J Pediatr Surg 2002; 37:99.
  90. MORITZ AR, HENRIQUES FC Jr. The reciprocal relationship of surface temperature and time in the production of hyperthermic cutaneous injury. Am J Pathol 1947; 23:897.
  91. Feldman KW. Help needed on hot water burns. Pediatrics 1983; 71:145.
  92. Maguire SA, Upadhyaya M, Evans A, et al. A systematic review of abusive visceral injuries in childhood--their range and recognition. Child Abuse Negl 2013; 37:430.
  93. Canty TG Sr, Canty TG Jr, Brown C. Injuries of the gastrointestinal tract from blunt trauma in children: a 12-year experience at a designated pediatric trauma center. J Trauma 1999; 46:234.
  94. Trokel M, Discala C, Terrin NC, Sege RD. Patient and injury characteristics in abusive abdominal injuries. Pediatr Emerg Care 2006; 22:700.
  95. Sowrey L, Lawson KA, Garcia-Filion P, et al. Duodenal injuries in the very young: child abuse? J Trauma Acute Care Surg 2013; 74:136.
  96. Gaines BA, Shultz BS, Morrison K, Ford HR. Duodenal injuries in children: beware of child abuse. J Pediatr Surg 2004; 39:600.
  97. Barnes PM, Norton CM, Dunstan FD, et al. Abdominal injury due to child abuse. Lancet 2005; 366:234.
  98. Holland AJ, Cass DT, Glasson MJ, Pitkin J. Small bowel injuries in children. J Paediatr Child Health 2000; 36:265.
  99. Lane WG, Rubin DM, Monteith R, Christian CW. Racial differences in the evaluation of pediatric fractures for physical abuse. JAMA 2002; 288:1603.
  100. Lane WG, Dubowitz H. What factors affect the identification and reporting of child abuse-related fractures? Clin Orthop Relat Res 2007; 461:219.
  101. Laskey AL, Stump TE, Perkins SM, et al. Influence of race and socioeconomic status on the diagnosis of child abuse: a randomized study. J Pediatr 2012; 160:1003.
  102. US Department of Health & Human Services, Administration for Children and Families, Youth and Families Children's Bureau. Child Maltreatment 2013. 2015.
  103. Pandya NK, Baldwin K, Wolfgruber H, et al. Child abuse and orthopaedic injury patterns: analysis at a level I pediatric trauma center. J Pediatr Orthop 2009; 29:618.
  104. 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.
  105. Maguire SA, Kemp AM, Lumb RC, Farewell DM. Estimating the probability of abusive head trauma: a pooled analysis. Pediatrics 2011; 128:e550.
  106. Trokel M, DiScala C, Terrin NC, Sege RD. Blunt abdominal injury in the young pediatric patient: child abuse and patient outcomes. Child Maltreat 2004; 9:111.
  107. Woodman J, Pitt M, Wentz R, et al. Performance of screening tests for child physical abuse in accident and emergency departments. Health Technol Assess 2008; 12:iii, xi.
  108. Lindberg DM, Shapiro RA, Laskey AL, et al. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics 2012; 130:193.
  109. Benger JR, Pearce V. Simple intervention to improve detection of child abuse in emergency departments. BMJ 2002; 324:780.
  110. McKinney A, Lane G, Hickey F. Detection of non-accidental injuries presenting at emergency departments. Emerg Med J 2004; 21:562.
  111. Sidebotham P, Biu T, Goldsworthy L. Child protection procedures in emergency departments. Emerg Med J 2007; 24:831.
  112. Rangel EL, Cook BS, Bennett BL, et al. Eliminating disparity in evaluation for abuse in infants with head injury: use of a screening guideline. J Pediatr Surg 2009; 44:1229.
  113. Louwers EC, Korfage IJ, Affourtit MJ, et al. Detection of child abuse in emergency departments: a multi-centre study. Arch Dis Child 2011; 96:422.
  114. Smeekens AE, Broekhuijsen-van Henten DM, Sittig JS, et al. Successful e-learning programme on the detection of child abuse in emergency departments: a randomised controlled trial. Arch Dis Child 2011; 96:330.
  115. Louwers EC, Korfage IJ, Affourtit MJ, et al. Effects of systematic screening and detection of child abuse in emergency departments. Pediatrics 2012; 130:457.
  116. Sittig JS, Post ED, Russel IM, et al. Evaluation of suspected child abuse at the ED; implementation of American Academy of Pediatrics guidelines in the Netherlands. Am J Emerg Med 2014; 32:64.
  117. Louwers EC, Korfage IJ, Affourtit MJ, et al. Accuracy of a screening instrument to identify potential child abuse in emergency departments. Child Abuse Negl 2014; 38:1275.
  118. Bailhache M, Leroy V, Pillet P, Salmi LR. Is early detection of abused children possible?: a systematic review of the diagnostic accuracy of the identification of abused children. BMC Pediatr 2013; 13:202.