Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Physical child abuse: Diagnostic evaluation and management

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


The diagnostic evaluation for physical abuse in children will be reviewed here. Recognition of physical abuse; the orthopedic aspects of child abuse; the differential diagnosis for suspected child abuse, including orthopedic injuries, abusive head trauma; and the evaluation of other types of child abuse (ie, sexual abuse, child neglect, and emotional abuse) are discussed separately:

(See "Physical child abuse: Recognition".)

(See "Orthopedic aspects of child abuse".)

(See "Differential diagnosis of suspected child physical abuse".)

(See "Differential diagnosis of the orthopedic manifestations of child abuse".)

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:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Aug 07, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Saade DN, Simon HK, Greenwald M. Missed opportunities for recognition in the ED. Acad Emerg Med 2002; 9:524.
  2. Rosen LA, Wissow LS. Effects of maltreatment on the child. In: Child Advocacy for the Clinician: An Approach to Child Abuse and Neglect, Williams and Wilkins, Baltimore 1990. p.12.
  3. Loder RT, Bookout C. Fracture patterns in battered children. J Orthop Trauma 1991; 5:428.
  4. DePanfilis D, Zuravin SJ. Predicting child maltreatment recurrences during treatment. Child Abuse Negl 1999; 23:729.
  5. Drake B, Jonson-Reid M, Way I, Chung S. Substantiation and recidivism. Child Maltreat 2003; 8:248.
  6. Connell CM, Vanderploeg JJ, Katz KH, et al. Maltreatment following reunification: predictors of subsequent Child Protective Services contact after children return home. Child Abuse Negl 2009; 33:218.
  7. • Fluke JD, Shusterman GR, Hollinshead D, Yuan YT, McDonald WR. Rereporting and recurrence of child maltreatment: Findings from NCANDS. ASPE Reports. 2005. http://aspe.hhs.gov/hsp/05/child-maltreat-rereporting/ (Accessed on June 07, 2013).
  8. Friedman SB, Morse CW. Child abuse: a five-year follow-up of early case finding in the emergency department. Pediatrics 1974; 54:404.
  9. Vandeven AM, Newton AW. Update on child physical abuse, sexual abuse, and prevention. Curr Opin Pediatr 2006; 18:201.
  10. Flaherty EG, Sege R. Barriers to physician identification and reporting of child abuse. Pediatr Ann 2005; 34:349.
  11. Dubow SR, Giardino AP, Christian CW, Johnson CF. Do pediatric chief residents recognize details of prepubertal female genital anatomy: a national survey. Child Abuse Negl 2005; 29:195.
  12. Trokel M, Waddimba A, Griffith J, Sege R. Variation in the diagnosis of child abuse in severely injured infants. Pediatrics 2006; 117:722.
  13. Levi BH, Brown G. Reasonable suspicion: a study of Pennsylvania pediatricians regarding child abuse. Pediatrics 2005; 116:e5.
  14. Pierce MC, Bertocci GE, Janosky JE, et al. Femur fractures resulting from stair falls among children: an injury plausibility model. Pediatrics 2005; 115:1712.
  15. Drummond R, Gall JA. Evaluation of forensic medical history taking from the child in cases of child physical and sexual abuse and neglect. J Forensic Leg Med 2017; 46:37.
  16. Ludwig S. Child abuse. In: Textbook of Pediatric Emergency Medicine, 5th ed, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.1761.
  17. Lamb ME, Orbach Y, Hershkowitz I, et al. A structured forensic interview protocol improves the quality and informativeness of investigative interviews with children: a review of research using the NICHD Investigative Interview Protocol. Child Abuse Negl 2007; 31:1201.
  18. Lindberg DM, Beaty B, Juarez-Colunga E, et al. Testing for Abuse in Children With Sentinel Injuries. Pediatrics 2015; 136:831.
  19. Lindberg D, Makoroff K, Harper N, et al. Utility of hepatic transaminases to recognize abuse in children. Pediatrics 2009; 124:509.
  20. Lane WG, Dubowitz H, Langenberg P. Screening for occult abdominal trauma in children with suspected physical abuse. Pediatrics 2009; 124:1595.
  21. Coant PN, Kornberg AE, Brody AS, Edwards-Holmes K. Markers for occult liver injury in cases of physical abuse in children. Pediatrics 1992; 89:274.
  22. Lindberg DM, Shapiro RA, Blood EA, et al. Utility of hepatic transaminases in children with concern for abuse. Pediatrics 2013; 131:268.
  23. Duffy SO, Squires J, Fromkin JB, Berger RP. Use of skeletal surveys to evaluate for physical abuse: analysis of 703 consecutive skeletal surveys. Pediatrics 2011; 127:e47.
  24. Rubin DM, Christian CW, Bilaniuk LT, et al. Occult head injury in high-risk abused children. Pediatrics 2003; 111:1382.
  25. Laskey AL, Holsti M, Runyan DK, Socolar RR. Occult head trauma in young suspected victims of physical abuse. J Pediatr 2004; 144:719.
  26. Karam O, La Scala G, Le Coultre C, Chardot C. Liver function tests in children with blunt abdominal traumas. Eur J Pediatr Surg 2007; 17:313.
  27. Christian CW, Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse. Pediatrics 2015; 135:e1337.
  28. 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.
  29. 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.
  30. Cameron CM, Lazoritz S, Calhoun AD. Blunt abdominal injury: simultaneously occurring liver and pancreatic injury in child abuse. Pediatr Emerg Care 1997; 13:334.
  31. Arieff AI, Kronlund BA. Fatal child abuse by forced water intoxication. Pediatrics 1999; 103:1292.
  32. Krugman SD, Zorc JJ, Walker AR. Hyponatremic seizures in infancy: association with retinal hemorrhages and physical child abuse? Pediatr Emerg Care 2000; 16:432.
  33. Moritz ML, Lauridson JR. Fatal Hyponatremic Encephalopathy as a Result of Child Abuse From Forced Exercise. Am J Forensic Med Pathol 2016; 37:7.
  34. Schilling S, Wood JN, Levine MA, et al. Vitamin D status in abused and nonabused children younger than 2 years old with fractures. Pediatrics 2011; 127:835.
  35. Paterson CR. Vitamin D deficiency and fractures in childhood. Pediatrics 2011; 127:973.
  36. Botash AS, Sills IN, Welch TR. Calciferol deficiency mimicking abusive fractures in infants: is there any evidence? J Pediatr 2012; 160:199.
  37. Mendelson KL. Critical review of 'temporary brittle bone disease'. Pediatr Radiol 2005; 35:1036.
  38. Sprigg A. Temporary brittle bone disease versus suspected non-accidental skeletal injury. Arch Dis Child 2011; 96:411.
  39. 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.
  40. Jenny C, Committee on Child Abuse and Neglect. Evaluating infants and young children with multiple fractures. Pediatrics 2006; 118:1299.
  41. 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.
  42. Schwengel D, Ludwig S. Rhabdomyolysis and myoglobinuria as manifestations of child abuse. Pediatr Emerg Care 1985; 1:194.
  43. Mukherji SK, Siegel MJ. Rhabdomyolysis and renal failure in child abuse. AJR Am J Roentgenol 1987; 148:1203.
  44. Ward MM. Factors predictive of acute renal failure in rhabdomyolysis. Arch Intern Med 1988; 148:1553.
  45. Grossman RA, Hamilton RW, Morse BM, et al. Nontraumatic rhabdomyolysis and acute renal failure. N Engl J Med 1974; 291:807.
  46. Yin S. Malicious use of pharmaceuticals in children. J Pediatr 2010; 157:832.
  47. Wiley CC, Wiley JF 2nd. Pediatric benzodiazepine ingestion resulting in hospitalization. J Toxicol Clin Toxicol 1998; 36:227.
  48. Pitetti RD, Whitman E, Zaylor A. Accidental and nonaccidental poisonings as a cause of apparent life-threatening events in infants. Pediatrics 2008; 122:e359.
  49. Hardoin RA, Henslee JA, Christenson CP, et al. Colic medication and apparent life-threatening events. Clin Pediatr (Phila) 1991; 30:281.
  50. Section on Radiology, American Academy of Pediatrics. Diagnostic imaging of child abuse. Pediatrics 2009; 123:1430.
  51. Ablin DS, Sane SM. Non-accidental injury: confusion with temporary brittle bone disease and mild osteogenesis imperfecta. Pediatr Radiol 1997; 27:111.
  52. Merten DF, Radkowski MA, Leonidas JC. The abused child: a radiological reappraisal. Radiology 1983; 146:377.
  53. Meyer JS, Gunderman R, Coley BD, et al. ACR Appropriateness Criteria(®) on suspected physical abuse-child. J Am Coll Radiol 2011; 8:87.
  54. Wood JN, Fakeye O, Feudtner C, et al. Development of guidelines for skeletal survey in young children with fractures. Pediatrics 2014; 134:45.
  55. Wood JN, Fakeye O, Mondestin V, et al. Development of hospital-based guidelines for skeletal survey in young children with bruises. Pediatrics 2015; 135:e312.
  56. Paine CW, Scribano PV, Localio R, Wood JN. Development of Guidelines for Skeletal Survey in Young Children With Intracranial Hemorrhage. Pediatrics 2016; 137.
  57. American College of Radiology. ACR Standards for Skeletal Surveys in Children. Resolution 22. American College of Radiology, Reston, VA,1997. p.23.
  58. American College of Radiology. ACR appropriateness criteria. Suspected physical abuse - child. http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/SuspectedPhysicalAbuseChild.pdf (Accessed on August 06, 2012).
  59. Offiah A, van Rijn RR, Perez-Rossello JM, Kleinman PK. Skeletal imaging of child abuse (non-accidental injury). Pediatr Radiol 2009; 39:461.
  60. British Society of Paediatric Radiology. Standard for skeletal surveys in suspected non-accidental injury (NAI) in children. Available at: www.bspr.org.uk/nai.htm. (Accessed on May 26, 2009).
  61. Lindberg DM, Berger RP, Reynolds MS, et al. Yield of skeletal survey by age in children referred to abuse specialists. J Pediatr 2014; 164:1268.
  62. Pekarsky AR, Botash AS. Skeletal surveys and head computed tomographies in the evaluation of child abuse: refining practice patterns. J Pediatr 2014; 164:1250.
  63. Datta S, Stoodley N, Jayawant S, et al. Neuroradiological aspects of subdural haemorrhages. Arch Dis Child 2005; 90:947.
  64. Mulroy MH, Loyd AM, Frush DP, et al. Evaluation of pediatric skull fracture imaging techniques. Forensic Sci Int 2012; 214:167.
  65. Culotta PA, Crowe JE, Tran QA, et al. Performance of computed tomography of the head to evaluate for skull fractures in infants with suspected non-accidental trauma. Pediatr Radiol 2017; 47:74.
  66. Sivit CJ, Taylor GA, Eichelberger MR. Visceral injury in battered children: a changing perspective. Radiology 1989; 173:659.
  67. Morzaria S, Walton JM, MacMillan A. Inflicted esophageal perforation. J Pediatr Surg 1998; 33:871.
  68. Geismar SL, Tilelli JA, Campbell JB, Chiaro JJ. Chylothorax as a manifestation of child abuse. Pediatr Emerg Care 1997; 13:386.
  69. Guleserian KJ, Gilchrist BF, Luks FI, et al. Child abuse as a cause of traumatic chylothorax. J Pediatr Surg 1996; 31:1696.
  70. Beckmann KR, Nozicka CA. Small bowel perforation: an unusual presentation for child abuse. J Am Osteopath Assoc 2000; 100:496.
  71. Raissaki M, Veyrac C, Blondiaux E, Hadjigeorgi C. Abdominal imaging in child abuse. Pediatr Radiol 2011; 41:4.
  72. Hilmes MA, Hernanz-Schulman M, Greeley CS, et al. CT identification of abdominal injuries in abused pre-school-age children. Pediatr Radiol 2011; 41:643.
  73. Baxter AL, Lindberg DM, Burke BL, et al. Hepatic enzyme decline after pediatric blunt trauma: a tool for timing child abuse? Child Abuse Negl 2008; 32:838.
  74. Thackeray JD, Scribano PV, Lindberg DM. Yield of retinal examination in suspected physical abuse with normal neuroimaging. Pediatrics 2010; 125:e1066.
  75. Li S, Mitchell E, Fromkin J, Berger RP. Retinal hemorrhages in low-risk children evaluated for physical abuse. Arch Pediatr Adolesc Med 2011; 165:913.
  76. Saperia J, Lakhanpaul M, Kemp A, et al. When to suspect child maltreatment: summary of NICE guidance. BMJ 2009; 339:b2689.
  77. Medical necessity for the hospitalization of the abused and neglected child. American Academy of Pediatrics. Committee on Hospital Care and Committee on Child Abuse and Neglect. Pediatrics 1998; 101:715.
  78. Hamilton-Giachritsis CE, Browne KD. A retrospective study of risk to siblings in abusing families. J Fam Psychol 2005; 19:619.
  79. Baldwin JA, Oliver JE. Epidemiology and family characteristics of severely-abused children. Br J Prev Soc Med 1975; 29:205.
  80. 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.
  81. Lang CA, Cox MJ, Flores G. Maltreatment in multiple-birth children. Child Abuse Negl 2013; 37:1109.