Differential diagnosis of suspected child physical abuse
- Stephen C Boos, MD, FAAP
Stephen C Boos, MD, FAAP
- Associate Professor of Pediatrics
- Tufts University School of Medicine
- Section Editors
- Daniel M Lindberg, MD
Daniel M Lindberg, MD
- Section Editor — Pediatric Psychosocial Emergencies
- Associate Professor of Emergency Medicine and Pediatrics
- University of Colorado Kempe Center
- Jan E Drutz, MD
Jan E Drutz, MD
- Section Editor — General Pediatrics
- Professor of Pediatrics
- Baylor College of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
The differential diagnosis of the common clinical manifestations of child abuse is presented here.
The clinical manifestations of child abuse, the diagnostic evaluation for suspected child abuse, and the differential diagnosis of abusive head trauma are discussed separately. (See "Physical child abuse: Recognition" and "Physical child abuse: Diagnostic evaluation and management" and "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'Differential diagnosis'.)
When evaluating the child who is suspected of being physically abused, it is important to remember that findings that appear to be abusive may result from other causes.
The differential diagnosis of child abuse varies depending upon the clinical manifestations. Familiarity with the medical conditions or cultural practices that mimic child abuse can facilitate arrival at the correct diagnosis, initiation of appropriate therapy, and avoidance of the consequences of an unnecessary evaluation of and/or report of suspected child abuse. One helpful distinguishing feature is that many abused children present with multiple types of injuries (eg, bruising and fractures). Identifying multiple types of injuries decreases the likelihood that a single medical entity has produced all of the findings although certain conditions (eg, osteogenesis imperfecta [OI]) provide exception to this rule. It is most appropriately a consideration in children with fractures. Though data is weak, easy bruising is often cited in children with OI. Rare cases of subdural collections and retinal hemorrhage in children with OI have also been reported. (See "Differential diagnosis of the orthopedic manifestations of child abuse", section on 'Osteogenesis imperfecta'.)
The medical literature contains many assertions of medical conditions being confused for abuse that are incompletely documented or speculative. Sometimes these assertions are challenged, and other times not [1-3]. Ultimately, a clinician must consider the relative likelihoods of all potential conditions alongside the possibility that a child with a medical condition may, in addition, be abused . One study found that just under 5 percent of almost 3000 children evaluated for physical abuse had a cutaneous mimic (eg, Mongolian spot, impetigo, and bruising due to a bleeding disorder) . Six percent of children with cutaneous mimics still had "high concern" for child abuse when the full picture was considered. Another study found that 3 percent of these same children had non-cutaneous mimics, with or without a cutaneous finding; 7 percent of children with non-cutaneous mimics still had "high concern" for child abuse when the full picture was considered and another 21 percent had an "intermediate level of concern" .To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- De Leeuw M, Beuls E, Jorens P, et al. Delta-storage pool disease as a mimic of abusive head trauma in a 7-month-old baby: a case report. J Forensic Leg Med 2013; 20:520.
- Anderst J, Carpenter S. A single case report lacking details does not equal a mimic of abusive head trauma. J Forensic Leg Med 2013; 20:1149.
- Servaes S, Brown SD, Choudhary AK, et al. The etiology and significance of fractures in infants and young children: a critical multidisciplinary review. Pediatr Radiol 2016; 46:591.
- Nowak CB. Recognition and prevention of child abuse in the child with disability. Am J Med Genet C Semin Med Genet 2015; 169:293.
- Schwartz KA, Metz J, Feldman K, et al. Cutaneous Findings Mistaken for Physical Abuse: Present but Not Pervasive. Pediatr Dermatol 2014.
- Metz JB, Schwartz KA, Feldman KW, et al. Non-cutaneous conditions clinicians might mistake for abuse. Arch Dis Child 2014; 99:817.
- Naidoo S. A profile of the oro-facial injuries in child physical abuse at a children's hospital. Child Abuse Negl 2000; 24:521.
- Stewart GM, Rosenberg NM. Conditions mistaken for child abuse: Part II. Pediatr Emerg Care 1996; 12:217.
- Jackson J, Carpenter S, Anderst J. Challenges in the evaluation for possible abuse: presentations of congenital bleeding disorders in childhood. Child Abuse Negl 2012; 36:127.
- Carpenter SL, Abshire TC, Anderst JD, Section on Hematology/Oncology and Committee on Child Abuse and Neglect of the American Academy of Pediatrics. Evaluating for suspected child abuse: conditions that predispose to bleeding. Pediatrics 2013; 131:e1357.
- Minford AM, Richards EM. Excluding medical and haematological conditions as a cause of bruising in suspected non-accidental injury. Arch Dis Child Educ Pract Ed 2010; 95:2.
- Khair K, Liesner R. Bruising and bleeding in infants and children--a practical approach. Br J Haematol 2006; 133:221.
- Thomas AE. The bleeding child; is it NAI? Arch Dis Child 2004; 89:1163.
- Anderst JD, Carpenter SL, Abshire TC, Section on Hematology/Oncology and Committee on Child Abuse and Neglect of the American Academy of Pediatrics. Evaluation for bleeding disorders in suspected child abuse. Pediatrics 2013; 131:e1314.
- Gordon M, Prakash N, Padmakumar B. Factor XIII deficiency: a differential diagnosis to be considered in suspected nonaccidental injury presenting with intracranial hemorrhage. Clin Pediatr (Phila) 2008; 47:385.
- Daly KC, Siegel RM. Henoch-Schönlein purpura in a child at risk of abuse. Arch Pediatr Adolesc Med 1998; 152:96.
- Cyrulnik AA, Dawkins MC, Smalberger GJ, et al. Kaposiform hemangioendothelioma with Kasabach-Merritt syndrome mistaken for child abuse in a newborn. Cutis 2014; 93:E17.
- Greig AV, Harris DL. A study of perceptions of facial hemangiomas in professionals involved in child abuse surveillance. Pediatr Dermatol 2003; 20:1.
- Worthen M, Leonard TH, Blair TR, Gupta N. Experiences of Parents Caring for Infants with Rare Scalp Mass as Identified through a Disease-Specific Blog. J Am Board Fam Med 2015; 28:750.
- Bronicki LM, Stevenson RE, Spranger JW. Beyond osteogenesis imperfecta: Causes of fractures during infancy and childhood. Am J Med Genet C Semin Med Genet 2015; 169:314.
- Oestreich AE, Ahmad BS. The periphysis and its effect on the metaphysis. II. Application to rickets and other abnormalities. Skeletal Radiol 1993; 22:115.
- Castori M. Ehlers-Danlos syndrome(s) mimicking child abuse: Is there an impact on clinical practice? Am J Med Genet C Semin Med Genet 2015; 169:289.
- Bergeson PS, Weiss JC. Picture of the month. Phytophotodermatitis. Arch Pediatr Adolesc Med 2000; 154:201.
- Gruson LM, Chang MW. Berloque dermatitis mimicking child abuse. Arch Pediatr Adolesc Med 2002; 156:1091.
- Garty BZ. Garlic burns. Pediatrics 1993; 91:658.
- Parish RA, McIntire S, Heimbach DM. Garlic burns: a naturopathic remedy gone awry. Pediatr Emerg Care 1987; 3:258.
- Karmani S, Shedden R, De Sousa C. Orthopaedic manifestations of congenital insensitivity to pain. J R Soc Med 2001; 94:139.
- Ravanfar P, Dinulos JG. Cultural practices affecting the skin of children. Curr Opin Pediatr 2010; 22:423.
- Hansen KK. Folk remedies and child abuse: a review with emphasis on caida de mollera and its relationship to shaken baby syndrome. Child Abuse Negl 1998; 22:117.
- Ponder A, Lehman LB. 'Coining' and 'coning': an unusual complication of unconventional medicine. Neurology 1994; 44:774.
- Crutchfield CE 3rd, Bisig TJ. Images in clinical medicine. Coining. N Engl J Med 1995; 332:1552.
- Guarnaschelli J, Lee J, Pitts FW. "Fallen fontanelle" (caida de Mollera). A variant of the battered child syndrome. JAMA 1972; 222:1545.
- Frechette A, Rimsza ME. Stun gun injury: a new presentation of the battered child syndrome. Pediatrics 1992; 89:898.
- Caffey J. The whiplash shaken infant syndrome: manual shaking by the extremities with whiplash-induced intracranial and intraocular bleedings, linked with residual permanent brain damage and mental retardation. Pediatrics 1974; 54:396.
- Lindstrom CJ. The boiled fontanelle in Caida de Mollera. JAMA 1973; 225:1121.
- Schwengel D, Ludwig S. Rhabdomyolysis and myoglobinuria as manifestations of child abuse. Pediatr Emerg Care 1985; 1:194.
- Yercen N, Caglayan S, Yücel N, et al. Fatal hypernatremia in an infant due to salting of the skin. Am J Dis Child 1993; 147:716.
- Hlavaty L, Sung L. Resuscitation and Prevalence of External Facial, Neck, and Chest Injuries in Infants. Am J Forensic Med Pathol 2015; 36:301.
- Reyes JA, Somers GR, Taylor GP, Chiasson DA. Increased incidence of CPR-related rib fractures in infants--is it related to changes in CPR technique? Resuscitation 2011; 82:545.
- Maguire S, Mann M, John N, et al. Does cardiopulmonary resuscitation cause rib fractures in children? A systematic review. Child Abuse Negl 2006; 30:739.
- Franke I, Pingen A, Schiffmann H, et al. Cardiopulmonary resuscitation (CPR)-related posterior rib fractures in neonates and infants following recommended changes in CPR techniques. Child Abuse Negl 2014; 38:1267.
- DIFFERENTIAL DIAGNOSIS
- Bleeding disorders
- Salicylate exposure
- Mongolian spots
- Delayed sub-aponeurotic fluid mass
- Complementary and alternative therapies
- CONGENITAL INSENSITIVITY TO PAIN
- CULTURAL PRACTICES
- Caida de mollera
- INJURY DURING RESUSCITATION