Physical child abuse: Recognition

INTRODUCTION — 

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: Evaluation and management".)

DEFINITION — 

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].

EPIDEMIOLOGY — 

In the United States, physical abuse accounts for approximately 11 percent of the over 540,000 annual cases of child maltreatment reported and validated by state child protection services [3]. In the United States and resource-rich European countries, the estimated prevalence of physical abuse at any time during childhood ranges from 5 to 16 percent, with as few as 5 percent of all episodes of physical abuse being reported to child protection agencies [4,5]. The impact of the 2019 to 2022 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic on rates of child abuse is unclear. Data from early in the pandemic is mixed, with papers showing increases, decreases, and no change in emergency department visits and hospitalizations for abuse [6-10]. Studies looking at official child maltreatment reports, which tend to be dominated by neglect reports, showed a decrease in recognized child maltreatment [11]. Changes in actual and recognized rates of abuse likely reflect a mix of protective and risk factors including the many stressors resulting from the pandemic, government assistance designed to counter those stresses, an increased number of adults in the home, the sequestering of children away from locations where abuse is commonly identified, and decrements in the functional capacity of child protection service agencies.

Among children younger than 15 years, the World Health Organization estimates that child abuse or neglect accounts for 13 percent of the 1.2 million annual deaths due to injury worldwide [4]. In the United States, up to 2500 children die of inflicted injuries annually with children under 1 year of age affected disproportionately [4]. The incidence of fatal child abuse may be underreported. As an example, in an observational study of death certificates reviewed by a multidisciplinary child fatality review team, of the children who died as a result of abuse or maltreatment, only half of the certificates included codes that were consistent with child abuse [12].

Since the mid-1970s there appears to be no significant change in the frequency of child maltreatment syndrome or assault, physical abuse deaths, and admissions for injuries related to child abuse in the United States, Canada, Sweden, Australia, New Zealand, and the United Kingdom despite increased child protection activities [13,14]. While recent government statistics indicate a decrease in the incidence of child abuse in the United States [15,16], an increase in both serious injury and death from child abuse has been documented, suggesting the possibility that decreases are due to changing definitions and administrative practices rather than improved recognition and prevention [17].

Risk factors — Certain factors place a child at higher risk for physical child abuse based upon observational studies [2]. While these factors clearly contribute to the occurrence of violent acts, and are crucial targets for prevention programs, they must not become the sole foundation for suspecting, evaluating, or diagnosing abuse:

●Child characteristics:

•Speech and language disorders, learning disabilities, conduct disorders, and non-conduct psychiatric disease [18,19] (see "Promoting safety in children with disabilities", section on 'Maltreatment or neglect')

•Failure to thrive

•Congenital anomalies, intellectual disability or other disabilities, or chronic or recurrent illnesses [20]

•Attention deficit disorder with hyperactivity children [21,22]

•Prematurity and low-birth weight, although the data are conflicting [23-27]

•Unplanned pregnancy

•Unwanted child

●Environment:

•Unrelated adolescent or adult male caregiver in the household [28]

•Domestic or intimate partner violence [29]

•Animal cruelty [30]

•Acute or chronic family stressors (eg, divorce or interpersonal conflict, illness, or job loss)

•Living in poverty

•Social isolation (distant or absent extended family)

●Caregiver features:

•Young or single parents

•Parents with lower levels of education

•Unrealistic expectations for child; poor knowledge of child development

•Negative perception of normal child behaviors [31]

•Caregiver was abused or neglected as a child, leading to abuse or neglect of their own children as a learned behavior

•Substance or alcohol use disorder

•Poorly controlled psychiatric illness (eg, psychosis, depression, impulse disorder) [32]

Consequences of missed abuse — In the United States, approximately 10 percent of abused children have been previously evaluated in a hospital setting with concerning presentations [33]. Abused children returned to an abusive environment without intervention are highly likely to be maltreated again and are at an increased risk for death [34-39]. Repeat maltreatment rates are estimated at about 33 percent. Several studies also indicate that clinicians may miss sentinel physical abuse injuries at prior medical care encounters [40-42]. For example, in a study of 232 children admitted for abusive head trauma, one in four children had one or more opportunities for less severe child maltreatment to be identified at earlier medical evaluations in a variety of settings [43]. Studies also show that clinicians demonstrate significant detection biases based on the patient's ethnicity or socioeconomic status [38,39,44-50]. Passing from a general state of awareness to concern for a particular patient often requires recognition of a "red flag" for abuse. Efforts to ensure that children who are being abused are identified as soon as possible has also led to a focus on universal screening of infants and young children as a possible remedy. (See 'Primary care settings' below and 'Acute care setting' below.)

APPROACH — 

To ensure timely recognition of physical child abuse in the emergency department, we advise the following approach:

●Immediate threats to the child must first be stabilized without concern for issues of child abuse.

●If a nonspecific condition; such as altered consciousness, vomiting, or pain does not have a clear medical explanation, trauma must be considered in the differential and a search for evidence of trauma incorporated into the assessment plan.

●When trauma is an active component of the differential diagnosis, a thorough history should probe for the occurrence and details of specific trauma events over a time period that accounts for the duration of symptoms and any reasonable symptom-free interval. If there are multiple caretakers, it is best that each caretaker be interviewed separately, so that their histories can be compared.

●When trauma is an active component of the differential diagnosis, a thorough physical examination should view and palpate all accessible surfaces of the body. Special attention should be given to the mouth, pinnae of the ears, the scalp, the buttocks and ano-genital region, and body folds such as the neck. Sentinel bruising or soft tissue injury (table 1) should prompt a diagnostic evaluation for child abuse. (See 'Oral or nasal injuries' below and 'Inflicted bruises' below.)

●When injury is identified by the initial assessment, the clinician should assess three issues:

•Does the injury possess a shape or pattern that indicates an abusive mechanism (loop-of-cord marks, slap marks, bites, immersion burns (figure 1 and figure 2))? (See 'Oral or nasal injuries' below and 'Intentional burns' below and 'Inflicted bruises' below.)

•Does the injury have an elevated statistical association with abuse such as subdural hematoma, rib fractures, femur fracture in non-walking children, pancreatic and proximal small bowel injury, immersion burn (table 2)? (See 'Fractures' below and 'Serious injury without explanation' below.)

•Does the given trauma history match the nature of the injury, the time course of the injury symptoms and healing, the history of other caretakers, and the child's developmental capacities (table 3)? (See 'Red flag history' below.)

●Assess the social history. This should include family stressors, drug use, the occurrence of domestic violence, and prior involvement with a children's protective services agency. Often a social work consult is the best way to achieve this goal. (See 'Additional factors' below.)

●If evaluation and social history lead to abuse concerns, initiate a full child abuse evaluation. (See "Physical child abuse: Diagnostic evaluation and management".)

●Have a low threshold for consulting with a multidisciplinary child abuse team that includes a child abuse specialist when considering physical child abuse as an etiology for specific findings. Some institutions without these resources have successfully developed relationships with referral centers and algorithms to prompt consultation [51,52].

●Report all suspicions for physical child abuse that persist after the initial assessment to the appropriate governmental agency. In many parts of the world, this reporting is mandatory. (See "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)

RED FLAG HISTORY — 

Certain specific historical features are associated with abuse and should raise suspicion. Consistent with the American Academy of Pediatrics guidelines for evaluation child physical abuse, we recommend careful evaluation for abuse for significantly injured children with any of the following (table 3) [2]:

●No history or denial of trauma despite severe injury [53,54]

●Implausible history for degree or type of injury

●Unexplained or excessive delay in seeking care

●Severe injury explained as self-inflicted or blamed on other young children or pets

●Caregiver histories that change with retelling or conflict with versions from other observers [53,55]

Although uncommon, some cases of physical abuse come to light based upon history from an observer or the victim. For this reason, it is best to interview a verbal child about a suspicious injury without caregivers present whenever possible.

Unexplained major trauma — Lack of an explanatory history in a patient with major trauma (eg, subdural hematoma or long bone fractures) is an important marker for abuse [53-55]. For example, among 163 children admitted for an acute traumatic intracranial injury, the absence of any explanatory history predicted abuse with 69 percent sensitivity and 97 percent specificity [53]. (See 'Approach' above.)

Significant injuries in children should be well explained by their history in most situations. Infants and young children should be closely supervised by adults. They also lack the independence and motor skills to get into dangerous circumstances without their caregiver's knowledge unless they are being neglected. Thus, with unintentional injuries in these patients, an adult should provide a credible history for any significant injuries.

Implausible mechanism of injury — Two major types of implausible mechanisms that may be provided by perpetrators of child abuse are:

●Inadequate mechanism to explain severity – Serious, head, eye, and internal injuries raise concern for abuse when an inadequate mechanism of injury (eg, short fall of the bed or fall down the stairs) is provided by the caregiver. (See "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'History' and "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children", section on 'Subdural hemorrhage' and "Child abuse: Anatomy and pathogenesis of retinal hemorrhages after abusive head trauma".)

Falls are among the most common causes of early childhood injury (see "Pediatric injury prevention: Epidemiology, history, and application", section on 'Epidemiology'). Many studies have examined special fall scenarios, including bunk beds, stairways, highchairs, or walkers [56-66]. As elevation and child ability increases, injury severity increases; serious injury can occur but is rare after short indoor falls (see "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children", section on 'Primary injury'). A literature review explored whether intestinal perforation could be explained by a fall downstairs and found that none of the 312 cases of intestinal perforation were due to falls [66] (see 'Visceral injuries' below). Similarly, fatalities from short indoor falls are extremely rare, occurring in perhaps 1 in 2,000,000 children per year [67,68].

As children become more capable and independent, they also become verbal, and may supply their own history. However, in the late toddler and early preschool ages, children may be active and independent enough to injure themselves unintentionally but lack sufficient communication skills to explain what happened. Minor injuries in these children are expected, and not always explained. Serious and internal injuries, however, still raise concern for abuse when an appropriate mechanism of injury is not provided by the caregiver.

●Developmentally improbable behavior by the child – A history that calls for developmentally improbable child behavior (eg, a scald burn in a 9-month-old attributed to the infant "turning on the hot water faucet") should also be seen as suspicious. Recognition of these false histories requires knowledge of normal developmental milestones and the range of normal motor skills by age.

Because inflicted burns must be differentiated from injuries caused by the child themselves, young children's ability to climb into a bathtub has been specifically evaluated. Children as young as 10 months old begin to climb into a tub, and, by 15 months of age, 50 percent of children can accomplish this [69]. By extension, a history of scaling any low barrier, such as a baby gate or a crib rail, must be considered at these ages.

The timing of typical developmental milestones is shown in the tables and reviewed separately (table 4 and table 5). (See "Developmental-behavioral surveillance and screening in primary care", section on 'Approach to surveillance'.)

Delay in seeking care — Delays that complicate care, prolong pain, or that occur in children with obvious, severe distress (eg, actively seizing, coma, or respiratory distress) are suspicious for abuse.

Delay in seeking care after an injury is more common in abuse cases when compared with unintentional injury [70-72]. However, there is a great deal of overlap for children who are injured without an obviously severe mechanism such as a motor vehicle collision. For example, one retrospective study of 121 children admitted to a single center for intraabdominal injury showed that 35 percent of children with low-velocity mechanisms of injury presented for care >12 hours after the injury compared with 54 percent of abused children [70]. In another study of 206 children younger than 6 years of age with accidental extremity fractures, 21 percent were seen more than eight hours after the injury [71]. Finally, among 105 children receiving care for burns in a pediatric emergency department, treatment delay beyond 24 hours was found in 19 percent of those children ultimately reported to child protection services compared with 6 percent of children who were not [73]. Thus, delay in seeking care by itself has a low specificity for abuse.

Injuries attributed to young children or pets — Siblings are known to injure each other, but serious injury inflicted by a sibling is a rare occurrence in our experience. Serious injury blamed on other young children may be a potential sign of abuse [73,74]. As an example, in one series of 105 children evaluated for burns in a pediatric emergency department, 38 percent of children reported to child protection had a history of the sibling causing the burn compared with 6 percent of children for whom a report was not filed [73].

Although not well-described in the literature, our experience suggests that pets are sometimes blamed for severe injuries (eg, "the dog knocked the child over").

RED FLAG PHYSICAL FINDINGS — 

Any concern for physical abuse should result in a thorough physical examination, with specific attention to the following regions (table 2):

●Scalp and fontanels

●Ears

●Oral cavity, including the buccal mucosa, labial and lingual frenula; the teeth; and the posterior pharyngeal wall

●Folds of the neck

●Buttocks

●Genitals

●Palms and soles

However, not all findings that appear abusive in nature actually result from abuse. The differential diagnosis of these findings and the diagnostic evaluation of suspected child abuse are discussed separately. (See "Differential diagnosis of suspected child physical abuse: Skin manifestations" and "Physical child abuse: Diagnostic evaluation and management".)

Inflicted bruises — Bruising is the most common form of both unintentional and abusive injury. The age of the child and the nature, shape, location, distribution, number, and size of bruises may each contribute to a concern for abuse as follows (table 1):

●Any bruising in infants younger than 6 months of age [75-78]

●More than one bruise in a pre-mobile infant and more than two bruises in a crawling child [79]

●Bruises located on the torso, buttocks, ear, neck, angle of the jaw, fleshy cheek or eyelid [78,80,81]

●Subconjunctival hemorrhages [78,82,83]

●Bruises with a pattern of the striking object (figure 1) (eg, slap, belt, or loop marks (picture 1); spoons; spatulas; or other objects) [84,85]

●Bruises with other previously reported, abuse-associated, pattern [86-88]

●Human bite marks [89,90]

The appearance of bruises should not be used to determine the timing of injury. Previously, the age of bruising relative to the timing of injury based upon history was sometimes used to raise suspicion for abuse. However, timing of bruises by physicians and forensic experts based upon color, tenderness, or swelling have poor interrater reliability and low accuracy, especially as bruises age [91,92]. Similarly, published tables that determine the age of a bruise using its color are inaccurate and misleading and should not be used.

Evidence supporting the increased likelihood of abuse based upon bruising characteristics is as follows:

●Patient age – Any bruising in babies who are not independently mobile is concerning for abuse, especially bruising to the ears, face, neck torso, and buttocks. An isolated bruise may be the only obvious indication of physical abuse. As an example, among children younger than 6 months of age referred for an abuse evaluation for apparently isolated bruising, 50 percent had an additional traumatic injury (fracture, brain injury, and/or abdominal injury) identified [75]. The clinical prediction rule TEN-4-FACESp (table 1) gains significant sensitivity by including all bruised children under age five months [78]. Among 200 infants younger than 12 months of age who were abused, 27 percent had a past "red flag" injury, compared with 8 percent of 100 children with intermediate likelihood of abuse and none of the 101 children with no concern for abuse [40]. Eighty percent of these red flag injuries were bruises.

Bruising is uncommon among healthy infants younger than 6 months of age who have not been abused, occurring in approximately 0.5 to 1 percent of patients seen during well care and emergency department visits [76,77]. This finding contrasts with observed rates of bruising from 18 to almost 50 percent of infants who are cruising or crawling [76,79]. The majority of walking children have bruises.

As infants get older, the frequency of bruising rises, even before they learn to pull to a stand and walk with support or "cruise." A study that followed infants for up to 12 weeks found that approximately 7 percent of pre-mobile children, from birth to 11 months old, had bruises at some point during that period [79]. During evaluation of infants without a concern for abuse who presented to a pediatric emergency department, about 6 percent of patients 6 months of age and older had bruises compared with approximately 1 percent of infants younger than 6 months of age.

●Location and number – The most concerning bruising locations are summarized by the mnemonic "TEN-4-FACESp," (table 1) which references [78,80]:

•Bruising to the torso, ear, and neck in children <4 years old

•Frenulum tear

•Any bruises in children ≤5 months old (many experts use <6 months old)

•Bruising of the angle of the jaw, fleshy cheek, eyelid, or sclera

•Any bruise with a pattern

In a multicenter validation study of over 2100 children with at least one bruise, the TEN-4-FACESp rule identified abuse with a sensitivity of 96 percent (95% CI 93-97 percent) and a specificity of 87 percent (95% CI 85-89 percent) with a positive predictive value of 64 percent (95% CI 60-68 percent, prevalence of abuse 19 percent) [78]. In addition, the presence of petechial bruising is more likely in abused children <6 years old compared with unintentionally injured children (likelihood ratio for abuse 8.1) [93].

The most common locations of unintentional bruises include the scalp, knee, shin, or thigh, though other areas, particularly the back, forearms, nose, or cheek, are sometimes injured in mobile children [76,79,84,94]. Pre-mobile children seldom have more than one bruise, and crawlers and cruisers seldom more than two, but walkers commonly had five or more bruises [79]. The majority of walking children have bruises which are typically multiple.

●Patterned injuries – Objects that deliver a highly concentrated force tear blood vessels in deep tissue. These tend to produce ecchymotic lesions that have blurred margins and a delayed appearance [85]. These bruises may be a positive image of the impactor, though central clearing is known to occur. Examples are bites, punches, grip marks (picture 2A-B), and most unintentional injuries.

Objects that have a high impact velocity, but diffuse their energy over a broad contact area shear dermal capillaries at their margins [85]. These tend to produce marginal petechiae that form an outline of the impacting object. These lesions often appear very shortly after trauma, initially have sharp margins, and may disappear quite rapidly. Examples include slap marks, belt marks (picture 3), loop-of-cord marks (picture 1), switches, spatulas, spoons, hangers, or other objects (figure 1). Sometimes these objects will also break the skin, forming superficial lacerations. A similar effect has been described with abusive squeezing of an extremity [87]. Patterns are unusual in unintentional injury and provide an objective basis for assessing the truthfulness of an explanatory history.

The presence of a bruise with identifiable shape had a likelihood ratio of 25.8 and occurred in fewer than 2 percent of non-abused children in one case-control study [84].

Most unintentional bruises are oval, anterior, and over bony prominences. Impacts by an object may leave a bruise that retains the shape of that object (figure 1). Other abuse-associated bruising patterns lack the imprint of the impacting object but have a stereotypical appearance that can be recognized, including palmar bruises due to tight squeezing of the child's clenched fist; linear, bilateral bruising to the buttocks that run parallel to the inter-gluteal cleft; and apical bruising of the pinna caused by a direct blow [81,86-88].

●Bite marks – Human bite marks consist of facing semi-lunar rows of box-shaped ecchymosis [89,90]. Dog bites, by contrast, have a long, narrow arch with prominent canines that commonly puncture the skin [95]. The pattern of tooth imprints can differentiate between adult and child assailants and possibly match a particular assailant. While there is no threshold that perfectly discriminates between a child or adult biter, a maxillary intercanine distance of >30 mm is generally considered to suggest an adult biter [89,90]. This determination must be represented cautiously, as research suggests that distinguishing between adult and child bites has limited accuracy, with an area under the receiver operator curve of 0.69 for the most experienced examiner [96]. Bite marks may also yield saliva and DNA, which can be collected using standard methods of evidence collection, as in cases of acute sexual assault [97]. Patterned injury, and particularly bite marks, should be photographed, with a size standard in the photo. The size standard should be at the same distance from the camera as the injury, and the size standard, injury, and camera back should all be in parallel planes.

Oral or nasal injuries — The following injuries raise concern for abuse [78,98-102]:

●Lip lacerations or bruising, especially in nonambulatory infants

●Lingual or labial frenulum tears, especially in nonambulatory infants – Frenulum tears may occur from accidental injury (as among ambulating toddlers) or from abusive mechanisms, such as force feeding or "bottle jamming" in young infants [38].

●Tongue lacerations, especially in nonambulatory infants

●Bruising or wounds of the buccal mucosa, gums, or palate, especially in nonambulatory infants

●Missing or fracture teeth with an absent or implausible history

●Maxillary or mandibular fractures with an absent or implausible history

●Bruising, lichenification, or scarring at the corners of the mouth from being gagged

●Epistaxis – While common at older ages, epistaxis is rare in children <2 years old [103,104]. Acute rhinitis, unintentional trauma and coagulopathy are the common causes of epistaxis in young children [103-106]. However, oronasal blood may indicate upper airway obstruction or external suffocation in cases of reported respiratory events [107,108]. In young infants, epistaxis associated with a respiratory event or without a readily apparent cause should prompt concern for child abuse [109,110].

Intentional burns — Abusive burns arise from scalds, contact with heated objects, flame, chemical exposure, microwave, other radiation, and electrical currents.

Physical findings of intentional burns include:

●Scalds in children younger than 5 years of age that do not fit the pattern of an unintentional spill [111,112]

●Scalds from hot tap water due to immersion, demonstrating a sharp upper line of demarcation ("high tide mark"), affecting both sides of the body symmetrically, or involving the lower extremities and/or perineum (picture 4 and picture 5 and picture 6) [111,112]

●Burns that have a sharply demarcated edge in the shape of the burning object (figure 2) (eg, clothing iron (picture 7), spatulas, spoons, grates, metal hair dryer grids, curling irons, or the metal tops of butane cigarette lighters) [113,114]

●Cigarette burns that appear as discreet circular burns 8 to 12 mm in diameter and are deep (eg, third degree burns) [115,116]

●Stun gun burns usually are multiple and appear as paired lesions approximately 0.5 cm in diameter and 5 cm apart [117,118]

●Deep partial-thickness and full-thickness burns [119]

●Burn extent >20 percent body surface area [119]

●Burns to the posterior trunk, buttocks, or genitals [120]

●The presence of additional injuries, other than the burn [119]

All of the above findings have greater significance as the child's age decreases. The peak age for abusive burning is in the third and fourth years of life and is frequently related to punishment for toilet-training mishaps.

Additional features of burns caused by abuse are as follows:

●No history of how a significant burn or burn scar occurred

●A history inconsistent with physical findings (eg, a brief [few seconds] exposure to bathtub water resulting in extensive second degree burns and independent determination of hot water temperature that gives a reading <49°C [120°F])

●The presence of other abusive injuries (eg inflicted bruises or fractures) [121]

●Scald burns, especially if bilateral and symmetric, involving the perineum, full thickness (third degree) (table 6), and >10 percent of the body surface area (figure 3) [112,122,123]

Other burn characteristics have been used to identify burns from their appearance.

●Scalds – Scalds from hot tap water due to immersion, demonstrating a sharp upper line of demarcation ("high tide mark"), affecting both sides of the body symmetrically, or involving the lower extremities and/or perineum are more likely to be inflicted (picture 4 and picture 5 and picture 6). Inflicted scalds are more likely to occur in children younger than 5 years of age [111]. Immersion of a child into a tub of hot water is a particularly recognizable abusive pattern [112]. These burns appear complex at first glance, but placing the child in the position they assumed while being burned will produce a planar superior delimitation of the burn, and fold unburned creases below this plane together so that they exclude the burning fluid. Sometimes the most dependent part of the body will be unburned, as it was pressed against the bottom of the tub during burning. Based upon two observational studies, scalds are the most common.

Unintentional hot fluid burns commonly occur due to spills. They usually involve the hand, forearm, shoulder, face, and upper chest when a child reaches up and pulls down a cup or pot of hot water or oil [113]. Scald injuries are more likely to be abusive when they are posterior, bilateral, and involve the buttocks, lower extremities, or both [111].

Evaluations of tap-water burns are best coordinated with an agency (eg, the regional fire department) that can go to the field, replicate the given history, and measure the temperature of any water at the tap, and within any involved vessel. This permits a given history to be tested. A relationship between exposure time, water temperature, and burn depth was developed for adults and applied to children [124,125]. The time needed to produce a partial thickness burn is exponentially and inversely related to temperature. While such burns require contact for several minutes if liquids are <49°C (120°F), burns can occur in seconds if fluids are >66°C (150°F). Circumstances that require a long immersion time, but in which the burn pattern indicates a static sustained contact, would require an unresponsive or immobilized child, also creating concern for abusive injury.

●Contact burns – Burns that have a sharply demarcated edge in the shape of the burning object are more common in abuse than accidental injury (figure 2) [114]. Examples include spatulas, spoons, grates, metal hair dryer grids, clothes irons, curling irons, and the metal tops of butane cigarette lighters. Among abused children, one-third of these burns were multiple, and two-thirds of multiple burns were on the face [114].

Children may be burned by heated objects when they move against the object, when the object falls on them, and when they grab the item. As a result, accidental burns usually lack a well-demarcated edge, and affect the palm of the hand or the front of the body [113]. Usually these burns only affect one site, but bilateral palm or sole burns have occurred when children walked onto or leaned against hot surfaces.

●Cigarette burns – Inflicted cigarette burns are usually discreet circular burns 8 to 12 mm in diameter. Sustained contact or displacement of the ash is necessary to produce a third-degree burn, identifying such burns as deliberately inflicted [115,116].

By contrast, with an inadvertent cigarette burn, the lit end of a cigarette, which can be several hundred degrees, is typically insulated with a cooler ash. Thus, when a child runs, walks, or falls against a lit cigarette, the resulting burn is typically irregular, isolated, and superficial.

The use of a checklist attached to all emergency department burn charts resulted in an increase in the identification of possible abuse from 3 to 12 percent of all burns [73,74]. Subsequently, a clinical prediction rule has been derived to predict abuse in burned children and consists of the following high-risk features [126]:

●Age <5 years

●Full-thickness burn

●Symmetric scalding on both sides of the body

●Atypical location of a scald burn such as back, buttocks, groin, or within the hairline

●Lack of adult supervision, especially in a child <5 years old

●Bathing scald

●History implausible because explanation is inconsistent with the child's developmental stage or does not fit the scald pattern

●Current or previous child protection involvement

Although it awaits validation in a large prospective cohort, preliminary results suggest that it shows promise for helping with the decision to proceed with a child protection evaluation in children with burns [127].

Fractures — Any fracture in an infant or young child is potentially concerning for child abuse. Fractures that suggest child abuse may come to light as an incidental finding during radiologic evaluation or as part of a skeletal survey when a concern for abuse based upon other clinical findings is present. The skeletal survey (table 7) is widely regarded as the best method for detecting fractures in children who have been abused.

Concern for physical abuse in children younger than 24 months of age is an absolute indication for obtaining a skeletal survey. Other indications for ordering a skeletal survey are discussed separately (table 8). (See "Physical child abuse: Diagnostic evaluation and management", section on 'Skeletal survey'.)

The following fractures are sufficiently concerning for abuse to warrant full evaluation in consultation with a child abuse expert or team (see "Orthopedic aspects of child abuse", section on 'Fracture patterns' and "Physical child abuse: Diagnostic evaluation and management"):

●Metaphyseal corner (or bucket handle) fractures (image 1 and image 2 and image 3 and figure 4)

●Rib fractures (image 4)

●Fractures of the sternum, scapula, or spinous processes

●Long bone fracture in a nonambulatory infant

●Multiple fractures in various stages of healing (image 5)

●Bilateral acute long bone fractures

●Vertebral body fractures and subluxations and no history of high-force trauma

●Digital fractures in children younger than 36 months of age or without a corresponding history

●Epiphyseal separations especially eg, transphyseal distal humeral fractures

●Skull fractures in children younger than 18 months of age with a concerning history (table 3) and associated intracranial hemorrhage, especially subdural hematoma (see "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children", section on 'Skull fractures')

Fractures with less specificity for abuse include:

●Isolated long bone fractures in ambulatory children

●Linear skull fractures

●Clavicle fractures

●Subperiosteal new bone formation

With every fracture, the possibility of inflicted injury must be considered, based upon the age of the child, overall injury pattern, stated mechanism of injury, and pertinent psychosocial factors. Orthopedic aspects of child abuse, including abusive fracture patterns and interpretation of findings is discussed separately. (See "Orthopedic aspects of child abuse".)

Serious injury without explanation — Internal injuries of the head, thorax, and abdomen are the most severe forms of child physical abuse. Even so, the spectrum of inflicted internal injuries includes entirely occult conditions that can be overlooked or silent.

Abusive head trauma — In children with intracranial injuries, no single physical finding definitively identifies abusive head trauma (AHT). However, features that are most predictive of child abuse include intracranial hemorrhage (especially a subdural hemorrhage) and any one of the following (see "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'Diagnosis'):

●Inadequate history (eg, no history of trauma, or a history that is inconsistent with the severity of the head injury)

●Apnea or seizures on presentation

●Associated fractures of the ribs, metaphyseal region, or long bones (see 'Fractures' above)

●Retinal hemorrhage(s) (see "Child abuse: Eye findings in children with abusive head trauma (AHT)")

●Any skull fracture other than an isolated, unilateral, nondiastatic, linear, parietal skull fracture

●Any bruising of the child's ears, neck, or torso (see 'Inflicted bruises' above)

The evaluation, epidemiology, and associated eye findings in children with AHT are discussed separately:

●(See "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children".)

●(See "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children".)

●(See "Child abuse: Eye findings in children with abusive head trauma (AHT)" and "Child abuse: Anatomy and pathogenesis of retinal hemorrhages after abusive head trauma".)

Visceral injuries — Diagnosis of a severe esophageal, pulmonary, cardiac, or abdominal injury in a child with a questionable or absent mechanism of injury is an important red flag for abuse, especially when it occurs in children younger than 4 years of age [128]. Victims of inflicted visceral injury often have other findings of abuse such as head injury, fractures, or cutaneous findings.

Inflicted abdominal trauma can be caused by direct blows or kicks to the abdomen, or by direct pressure (eg, standing or kneeling on the abdomen) which cause injury or rupture of the hollow organs (eg, duodenal hematoma, traumatic pancreatitis, or bladder rupture) or contusion or laceration of the solid organs (eg, liver, spleen, or kidneys) [128].

Serious abdominal injury after inflicted blunt trauma may be indicated by abdominal tenderness, abdominal distension, enlargement of the liver or spleen, or abdominal wall bruising. However, based upon a systemic review of five observational studies that compared a total of 68 abused children with 488 children injured unintentionally, nonspecific historical features such as vomiting or fussiness may be the only symptoms and few overt signs may be present on physical examination, including lack of cutaneous bruising [128]. Thus, evaluation for occult abdominal injury is an important part of any child abuse evaluation. (See "Physical child abuse: Diagnostic evaluation and management", section on 'Screening studies' and "Physical child abuse: Diagnostic evaluation and management", section on 'Abdominal injury'.)

Relative to children with unintentional abdominal injury, abused children more frequently have:

●Young age (<4 years) [70,128-133]

●High central abdominal injury, particularly perforation or hematoma of the duodenum or proximal jejunum or pancreatic disruption [70,131-133]

●Delayed presentation [70,128,131,132,134]

●Fatal injury [128]

Duodenal perforation or hematoma is especially rare in pediatric trauma patients; a systematic review of 88 studies found no duodenal injuries among 488 children with unintentional abdominal injuries requiring hospital admission [128].

Although a potential marker for abuse, delay in presentation has been described with unintentional abdominal injuries (eg, splenic laceration from a bicycle handlebar injury and jejunal perforation after falling onto a rock) [128].

The medical and/or surgical management of these injuries is discussed separately. (See "Thoracic trauma in children: Initial stabilization and evaluation" and "Pediatric blunt abdominal trauma: Initial evaluation and stabilization".)

Suspicious parent behaviors — The behavior of the parents and the interaction between family members should be observed carefully during the evaluation of the child. In addition to the red flag history features described above, the following behaviors are of concern (see "Physical child abuse: Diagnostic evaluation and management", section on 'Family interaction'):

●Arguing, roughness, or violence.

●Aloofness and lack of emotional interaction between parents or between parents and children.

●Inappropriate response to the severity of the injury (eg, lack of appropriate concern).

●A partial confession by the parent (eg, "I hit him, but not that hard") or a frank admission by parent that injury was inflicted. Such confessions occur occasionally and are an indication that the parent realizes that abuse is a problem and is seeking help.

ADDITIONAL FACTORS — 

Young age, a prior history of abuse in the household, and certain social factors (eg, domestic violence, substance use disorder or psychiatric illness in the caregiver, family stressors, or caregiver social isolation) can raise the level of concern for abuse in equivocal cases.

We recommend using factors other than race and socioeconomic status to determine the approach to testing or reporting of child abuse. Demographic factors that may guide efforts at prevention are discussed separately. (See 'Epidemiology' above.)

While several studies have shown associations between demographic factors such as race and socioeconomic status and abuse, these associations are not useful in the evaluation of an individual patient. Based upon observational studies, clinicians may perform more testing (eg, skeletal surveys) and make more reports to child protection services when evaluating minority children or children with low socioeconomic status when compared with the evaluation of White children or those with higher socioeconomic status [46-48,135-137].

When medical findings are suggestive of innocent injury, demographic and environmental factors may support intervening to aid the family and lessen risk. When medical findings are suggestive of abuse, even children from low-risk groups and privileged backgrounds must be protected. Only when medical indicators are equivocal should demographic and environmental factors prompt a consideration of protective action.

Young child age — In injured children, the likelihood that the injury is the result of abuse rises dramatically for younger children. Twenty-seven percent of maltreatment victims are less than three years old, and among fatally abused children, 47 and 81 percent were among children less than one year old or less than four years old, respectively [138]. Fifty percent of investigated infants younger than six months of age with apparently isolated bruising had unexplained internal injuries suggesting abuse [75]. In children younger than four years of age evaluated at a major children's hospital, the average age of abused traumatized children was 12 months, while that of non-abused children on the trauma registry was 22 months [139]. In virtually all studies of abusive head trauma or visceral injury, abused children are significantly younger than their non-abused counterparts [140-142]. While this trend holds in all forms of injury, the significance of the child's specific age varies with the injury under consideration. However, as noted in the American Academy of Pediatrics guidelines, younger age is an important factor when determining the need for an abuse evaluation and reporting to child protection services [2].

Prior abuse in the household — Prior known abuse of a child or sibling should increase the level of concern for abuse. For some patients, obtaining the history of prior abuse requires phone consultation with the primary care provider or the regional child protection services.

Being on a government child protection registry has a likelihood ratio for abuse of 12.4 for infants and just over 4 for older children presenting to an emergency department [143]. When physically abused infants known to children's protective service agencies are returned to their families or caregiver(s), 30 percent experience second abusive events including repeated physical abuse in 16 percent [36]. In 2013, about 12 percent of United States child abuse fatalities were receiving children's protective service agencies services at the time of their death [138]. Among siblings younger than two years of age or household contacts of abused, injured children, skeletal survey identified abusive fractures in 12 percent. This rose to 41 percent in siblings younger than 6 months of age and 56 percent among twins [144]. We recommend careful evaluation for abuse for all children who present with injuries after a prior diagnosis of abuse and for siblings of abused children. (See "Physical child abuse: Diagnostic evaluation and management".)

Social factors — Presence of the following factors on social history raises the level of concern for abuse when medical findings are equivocal and support additional investigation (see 'Epidemiology' above):

●Child characteristics:

•Failure to thrive

•Unwanted child

●Environment:

•Domestic or intimate partner violence

•Animal cruelty

•Acute or chronic family stressors (eg, divorce or interpersonal conflict, illness, or job loss)

•Social isolation (distant or absent extended family)

●Caregiver features:

•Unrealistic expectations for child; poor knowledge of child development [31]

•Negative perception of normal child behaviors

•Substance or alcohol use disorder

•Psychiatric illness (eg, depression, impulse disorder)

UNIVERSAL SCREENING

Acute care setting — Universal screening for child abuse involves screening for specific findings in every child under a certain age who comes for care. These findings may include clinician identification and documentation of red flags on history (table 3) and sentinel injuries suggesting abuse (table 2). To ensure timely identification of child abuse and to avoid the potential for escalating and recurrent injury if recognizable presentations of child abuse are missed, we suggest universal screening for physical abuse in all young children (<5 years old) who present to an emergency department (ED) for care [145]. When properly implemented, screening of children for abuse in the emergency department has been shown to be widely accepted by families and clinicians, to increase the proportion of patients referred to a children's protective services agency (CPS), and to have minimal effect on ED efficiency [146-151]. Screening also promotes compliance with regulations in many jurisdictions that require prompt identification of abused children receiving care in the ED and adherence to mandatory reporting obligations to Child Protective Services agencies. However, successful implementation of screening for child abuse in the emergency department depends upon several factors:

●Screening tool – The table provides examples of screening tools (table 9) [146,150-156]. These tools require screening by a nurse or emergency clinician during the course of patient care. Several tools have also been incorporated into the electronic health record (EHR) and may be enhanced by automated use of clinical information already entered into the electronic health record to trigger alerts for patients with possible child abuse and catch sentinel injuries that might be overlooked [146,157-162].

Universal emergency department screening instruments vary significantly by content, support in implementation, and studied outcome [163]. There is insufficient evidence to suggest a specific screening tool. Examples of tools include:

•ESCAPE tool (SPUTAVMO, P-CAST) – The ESCAPE tool, developed in the Netherlands under the acronym SPUTAVMO and adapted in Pennsylvania as P-CAST, is one of the first tools developed for child abuse screening in the ED setting [146-148]. In the Netherlands, universal screening with the ESCAPE tool increased the rate of detection of child abuse from a baseline of 0.1 percent to 0.5 percent of visits [148]. When used in three EDs, this tool had a sensitivity of 80 percent and specificity of 98 percent when compared against an expert panel determination of abuse [153]. Among screen-positive children, 40 percent were ultimately diagnosed with abuse compared with 0.9 percent of all children in the cohort. However, this tool calls for judgments that may introduce variation regarding the suspicion of abuse among clinicians. Thus, it could also increase opportunities for hidden bias to affect screening unless deployment is accompanied by comprehensive education that is augmented by quality monitoring.

P-CAST, an adaptation of the ESCAPE tool, was incorporated into the electronic medical record and studied in the EDs of a US hospital system [146]. The screen was completed in 67.6 percent of presenting children, of whom 1.9 percent were screened positive for possible abuse; half of positive screens resulted in a report to a CPS. Children who screened negative were highly unlikely to be referred to CPS (0.3 percent). P-CAST was also studied in combination with a CA-CDS system at a dedicated children's hospital [162]. The addition of the screening tool increased the number of children with identified concern by 60 percent. In this study, however, only 19 percent of children with positive screens were reported to CPS. Changes in institutional reporting rates, sensitivity and specificity were not reported in these two studies.

•Two-question abuse screen – The two-question abuse screen, emphasizes physical examination findings of sentinel injuries (table 2) [152]. Most of these components are objective and may reduce the risk of hidden bias in the evaluation and reporting of suspected child abuse compared with more subjective screening questions such as appropriateness of child-parent/primary caregiver interactions or behavior [164]. However, in one study, the two-question screen was not associated with increased referrals to CPS or prevention of subsequent abuse [165]. Screens based on the finding of sentinel injuries may be enhanced by other policies such as complete undressing and skin examination in all young children ("one and down, in a gown") which increase the ease and likelihood of clinicians examining all skin surfaces.

•Embedded electronic medical record (EMR) child abuse alert system – In a prospective study of an EMR-based child physical abuse alert system, thirty objective, age-specific triggers that were based upon the American Academy of Pediatrics child abuse guidelines were encoded into an electronic medical record and provided alerts based upon clinician entries into specific EMR fields [161]. When compared to a multidisciplinary child abuse team assessment of abuse, the triggered alerts had a sensitivity of 97 percent, specificity of 99 percent, and negative predictive value of 99.9 percent for possible, probable, or definite physical abuse in children <2 years old. The prevalence of abuse in this study was 0.3 percent.

In separate studies of this alert system that incorporated screening and natural language processing of free text into several different electronic health records and that was evaluated in a variety of ED settings, the system triggered alerts on approximately 2 to 4 percent of patients encounters, about half of which triggered due to a screening tool [157-159,161,162,166,167]. Identification of abuse suspicions and reports to CPS increased in some institutions but not others. The use of an associated child abuse order set substantially improved compliance with recommendations but varied substantially across institutions. Provider acceptance was variable, and close work with end users and responsiveness to local conditions in implementation was found to be very important. Some institutions have identified barriers to successful integration of embedded EMR child abuse alert systems [168]. Many users had difficulty mastering all the features of the system and some felt the system encroached upon their clinical autonomy or had disagreements with American Academy of Pediatrics recommendations for evaluation that were incorporated into standardized order sets.

Regardless of the screening tool that is used, the implementation of ED screening should be accompanied by longitudinal quality review of patient outcomes including the number of patients with positive screens referred to CPS, the number of such patients with confirmed child abuse, and whether the patient had subsequent abuse. In addition, the review should identify the number of patients with negative screens who subsequently are reported to CPS and diagnosed with child abuse. Thus, the ability to optimally monitor universal ED screening for abuse requires linkage with CPS case outcomes.

●Response to positive screen – In EDs with routine screening for abuse in young children, a positive screen first requires careful evaluation by an experienced emergency department clinician. If this evaluation confirms suspicion of child abuse, then the clinician should perform a diagnostic evaluation for abuse in consultation with a multidisciplinary child abuse team and ensure mandated reporting. In settings where child abuse expertise is not available or recommended diagnostic testing or imaging cannot be performed, the child should be transferred to the nearest center with a multidisciplinary child abuse team and pediatric resources to perform the diagnostic evaluation. (See "Physical child abuse: Diagnostic evaluation and management" and "Child abuse: Social and medicolegal issues", section on 'Mandatory reporting'.)

Of critical importance, the clinician should not perform a full diagnostic evaluation for physical child abuse and mandated reporting to a CPS agency solely on the basis of a positive screen for child abuse.

●Benefits – Many child abuse experts advocate for universal child abuse screening for children presenting to the ED; implementation has occurred in several ED settings [146-151]. This experience demonstrates that universal emergency department screening can increase the identification of concerning injuries and rates of detection of child abuse at initial presentation [148]. Furthermore, screening encourages compliance with guidelines for evaluation and reporting of suspected child abuse. However, successful deployment of universal screening in the ED requires a well-resourced development and evaluation team and high institutional commitment. In facilities with these resources, implementation must be preceded by careful work adapting to and preparing the end users’ workflow and followed by careful monitoring for both positive and negative impact to ED flow and both ED and child abuse resource utilization.

Whether, on balance, screening tools can be beneficial in practice will also depend on how a positive screen is managed; the tools are meant to prompt careful consideration of abuse, to support best practices for the evaluation and reporting of suspected child abuse, and to increase the numbers of children protected from recurrent abuse. Unsurprisingly, some efforts have achieved high usage and changed clinical decisions and system behavior [146-148], and some have not [156,165]. Where change has come, it has come in the form of increased concern, reporting and thus sensitivity [146-148]. Changes in specificity (proportion of positive screens that ultimately are identified as confirmed cases of abuse) with the increasing sensitivity have been poorly studied. Compliance with screening programs has been generally high, with positive screens impacting only a few percent of cases [146-148]. As such, burden on the ED, and on families, has been relatively low.

●Harms – The consequences of an unwarranted Child Protection Services and/or law enforcement report based upon false positive findings pose significant harm to the child, parents/primary caregivers, and other members of the family. As noted above, evidence suggests that in EDs that have implemented routine child abuse screening, positive screens for abuse frequently are not accompanied by CPS reporting or a finding of child abuse and may represent false positive findings [146,156,165,169]. Thus, positive screens or alerts for abuse require careful consideration by an experienced clinician prior to embarking on a diagnostic evaluation for child abuse and mandated reporting.

Screening also has the potential for a negative impact on overall ED patient flow and efficiency. This potential harm can be mitigated by selecting a tool that is not time-intensive and is augmented by information that is directly entered in the EHR during the course of routine clinical care as well as provision of sufficient resources for education, implementation, and monitoring of the screening process.

Primary care settings — Evidence is lacking to support universal screening for abuse in the primary care setting [170,171]. Until better formal methods are developed that have acceptable accuracy and can be easily implemented, we favor the broad distribution and use of current guidelines among all pediatric healthcare providers to enhance general awareness and to support timely recognition of child physical abuse during patient care. (See 'Society guideline links' below.)

ADDITIONAL RESOURCES — 

Additional data, evidence, and educational material related to child abuse can be found at the following links:

●Centers for Disease Control and Prevention

●Child Protection Evidence

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Child abuse and neglect" and "Society guideline links: Pediatric trauma".)

SUMMARY AND RECOMMENDATIONS

●Definition – 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. (See 'Definition' above.)

●Epidemiology – Physical child abuse accounts for thousands of injuries and deaths annually throughout the word. Recognition is essential because abused children who are returned to an abusive environment without intervention are highly likely to be maltreated again and are at an increased risk for death. (See 'Epidemiology' above and 'Risk factors' above.)

●Approach – We provide an approach to facilitate recognition of child abuse that emphasizes (see 'Approach' above):

•Actively maintaining child abuse in the differential diagnosis of trauma and puzzling medical presentations

•Careful evaluation for findings of abuse on history and physical examination (see 'Red flag history' above and 'Red flag physical findings' above)

•Utilization of multidisciplinary child abuse teams as consultants

•Prompt reporting of suspected child physical abuse to the appropriate governmental agency

Young age, a prior history of abuse in the household, and social factors (eg, domestic violence, caregiver substance use disorder or psychiatric illness, presence of family stressors, or family isolation) can also raise the level of concern for child physical abuse in equivocal cases. However, race or socioeconomic status should not be used to determine the need for further abuse evaluation. (See 'Additional factors' above.)

●Red flag findings – For children with red flag history or physical examination findings associated with physical child abuse (table 2 and table 3 and table 1), we recommend a complete evaluation for physical child abuse (table 10). Consultation with a multidisciplinary child abuse team that includes a child abuse specialist is optimal, where available, and may support transfer to a center with these resources. (See 'Red flag history' above and 'Red flag physical findings' above.)

The diagnostic evaluation of physical child abuse is discussed separately. (See "Physical child abuse: Diagnostic evaluation and management" and "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children".)

●Physical child abuse screening – For all young children (<5 years old) who present to an emergency department for care, we suggest routine screening for physical abuse with a validated screening tool (Grade 2C). When properly implemented and monitored, universal screening for abuse is associated with increased detection of child abuse and has the potential to prevent escalating and recurrent injury arising from missed presentations of child abuse. Successful implementation of screening requires multidisciplinary collaboration and high institutional commitment. (See 'Acute care setting' above.)

Evidence is lacking to support universal screening for physical child abuse in the primary care setting. (See 'Primary care settings' above.)