Medscape is available in 5 Language Editions – Choose your Edition here.


Child Abuse Follow-up

  • Author: Julia Magana, MD; Chief Editor: Kirsten A Bechtel, MD  more...
Updated: May 13, 2015

Further Outpatient Care

In addition to the medical follow-up needs (eg, orthopedic, surgical, neurological) of the abused child, these children often need follow up with a child abuse pediatrician, forensic interviewer, and mental health follow-up care. The recommended follow-up should be clearly documented. This is important since a child may be placed in another environment and a foster parent or CPS worker will be responsible for seeing that the child receives indicated medical follow-up care/consultation.


Further Inpatient Care

In some hospital settings, the child suspected of having been abused may be hospitalized if safety cannot otherwise be guaranteed. This course of action has several advantages. The severity of the injuries need not be the sole determining factor for hospitalization. Hospitalization may offer time to sort out difficult diagnostic (whether the injury is inflicted or accidental) and therapeutic (whether the child is safe at home) decisions.

When utilization policy does not permit admission for safety only, Child Protective Services (CPS) may place the child in a safe alternate shelter or foster home.



Depending on the complexity of pediatric subspecialty services needed, the clinician should consider transferring the child to a tertiary care children’s hospital with a multidisciplinary team that is experienced in the evaluation and management of child abuse.



Young victims who were seen with injuries that were documented but not referred to CPS or were referred and returned to the family can be reinjured, some with fatal outcomes.[1, 2, 3, 18, 19, 29] Appropriate suspicion, documentation, and referral are the best ways an emergency department (ED) provider can prevent child abuse.

Prevention programs, such as the Nurse-Family Partnership, EarlyStart, and Triple P programs; parenting classes; and home health services are available in many communities and target high-risk families. Local social workers can refer the family towards these supportive, preventative resources.



Physical injuries can leave permanent scars that disfigure the child and act as a constant reminder of trauma.

Child maltreatment exposure is potentially the single greatest risk factor in the development of mental illness.

Severe long-term complications may result from damage to organs or organ systems. This is especially true of traumatic brain injury that can lead to seizures, mental retardation, or cerebral palsy.



Without appropriate social service and mental health intervention, child abuse can be a recurrent and escalating problem.


Patient Education

Parents can be educated about appropriate discipline techniques, including discouraging the use of physical discipline, particularly in high-risk families.

Parents should be educated about the dangers of shaking infants, especially when the child presents with a chief complaint of fussiness.

For patient education resources, visit eMedicineHealth's Children's Health Center. Also, see eMedicineHealth's patient education articles Child Abuse, Bruises, and Black Eye.

Contributor Information and Disclosures

Julia Magana, MD Assistant Professor of Pediatric Emergency Medicine, Division of Emergency Medicine, University of California, Davis, School of Medicine

Julia Magana, MD is a member of the following medical societies: American Academy of Pediatrics, The Ray Helfer Society

Disclosure: Nothing to disclose.


Marilyn Kaufhold, MD, FAAP Clinical Instructor, Department of Pediatrics, University of California, San Diego, School of Medicine; Senior Medical Staff, Child Abuse Pediatrics, Rady Children's Chadwick Center for Children and Families

Marilyn Kaufhold, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, International Society for the Prevention of Child Abuse and Neglect, San Diego County Medical Society, The Ray Helfer Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.


Ann S Botash, MD Director, Child Abuse Referral and Evaluation Program, Professor and Vice Chair for Educational Affairs, Department of Pediatrics, State University of New York Upstate Medical University

Ann S Botash, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American Pediatric Society, Helfer Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Dylan M McKenney, MD Resident Physician, Department of Psychiatry, Maine Medical Center, Portland

Dylan M McKenney, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and Phi Beta Kappa

Disclosure: Nothing to disclose.

Lawrence R Ricci, MD Director of Spurwink Child Abuse Program, Assistant Professor, Department of Pediatrics, University of Vermont College of Medicine

Disclosure: Nothing to disclose.

  1. Ellaway BA, Payne EH, Rolfe K, Dunstan FD, Kemp AM, Butler I, et al. Are abused babies protected from further abuse?. Arch Dis Child. 2004 Sep. 89(9):845-6. [Medline]. [Full Text].

  2. Pierce MC, Kaczor K, Acker D, Carle M, Webb T, Brenzel AJ. Bruising missed as a prognostic indicator of future fatal and near-fatal physical child abuse. Pediatric Academic Societies’ Annual Meeting Honolulu, HI. 2008.

  3. Pierce MC, Smith S, Kaczor K. Bruising in infants: those with a bruise may be abused. Pediatr Emerg Care. 2009 Dec. 25(12):845-7. [Medline].

  4. United States. Congress. Senate. Committee on Health Education Labor and Pensions. Subcommittee on Children and Families. Protecting children, strengthening families : reauthorizing CAPTA : hearing before the Subcommittee on Children and Families of the Committee on Health, Education, Labor, and Pensions, United States Senate, One Hundred eleventh Congress. S. 3817 ed. Washington. 2010.

  5. Helfer RE. Why most physicians don't get involved in child abuse cases and what to do about it. Child Today. 1975 May-Jun. 4(3):28-32. [Medline].

  6. US Department of health and Human Services, Administration for Children and Families, Administration on Children Youth and Families Children’s Bureau. December 12, 2012. Undefined. 2011.

  7. Monuteaux MC, Lee L, Fleegler E. Children injured by violence in the United States: emergency department utilization, 2000-2008. Acad Emerg Med. 2012 May. 19(5):535-40. [Medline].

  8. Bellis MA, Hughes K, Jones A, Perkins C, McHale P. Childhood happiness and violence: a retrospective study of their impacts on adult well-being. BMJ Open. 2013. 3(9):e003427. [Medline].

  9. Dube SR, Felitti VJ, Dong M, Chapman DP, Giles WH, Anda RF. Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics. 2003 Mar. 111(3):564-72. [Medline].

  10. Dube SR, Miller JW, Brown DW, Giles WH, Felitti VJ, Dong M. Adverse childhood experiences and the association with ever using alcohol and initiating alcohol use during adolescence. J Adolesc Health. 2006 Apr. 38(4):444.e1-10. [Medline].

  11. Danese A, Tan M. Childhood maltreatment and obesity: systematic review and meta-analysis. Mol Psychiatry. 2013 May 21. [Medline].

  12. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998 May. 14(4):245-58. [Medline].

  13. Anda RF, Felitti VJ, Bremner JD, Walker JD, Whitfield C, Perry BD. The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci. 2006 Apr. 256(3):174-86. [Medline].

  14. Deans KJ, Thackeray J, Askegard-Giesmann JR, Earley E, Groner JI, Minneci PC. Mortality increases with recurrent episodes of nonaccidental trauma in children. J Trauma Acute Care Surg. 2013 Jul. 75(1):161-5. [Medline].

  15. 10 Leading Causes of Death by Age Group, United States-- 2010. Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC using WISQARS. 2010.

  16. Cole C. The memory of children. New York: Springer-Verlag; 1978.

  17. Pierce MC, Bertocci GE, Janosky JE, Aguel F, Deemer E, Moreland M. Femur fractures resulting from stair falls among children: an injury plausibility model. Pediatrics. 2005 Jun. 115(6):1712-22. [Medline].

  18. King WK, Kiesel EL, Simon HK. Child abuse fatalities: are we missing opportunities for intervention?. Pediatr Emerg Care. 2006 Apr. 22(4):211-4. [Medline].

  19. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. JAMA. 1999 Feb 17. 281(7):621-6. [Medline].

  20. Ricci L, Giantris A, Merriam P, Hodge S, Doyle T. Abusive head trauma in Maine infants: medical, child protective, and law enforcement analysis. Child Abuse Negl. 2003 Mar. 27(3):271-83. [Medline].

  21. Brown T. AAP updates guideline on child physical abuse. Medscape Medical News. WebMD Inc. Available at Accessed: May 13, 2015.

  22. Christian CW. The evaluation of suspected child physical abuse. Pediatrics. 2015 May. 135(5):e1337-54. [Medline].

  23. Carpenter RF. The prevalence and distribution of bruising in babies. Arch Dis Child. 1999 Apr. 80(4):363-6. [Medline].

  24. Labbe J, Caouette G. Recent skin injuries in normal children. Pediatrics. 2001 Aug. 108(2):271-6. [Medline].

  25. Mortimer PE, Freeman M. Are facial bruises in babies ever accidental?. Arch Dis Child. 1983 Jan. 58(1):75-6. [Medline].

  26. Pascoe JM, Hildebrandt HM, Tarrier A, Murphy M. Patterns of skin injury in nonaccidental and accidental injury. Pediatrics. 1979 Aug. 64(2):245-7. [Medline].

  27. Pierce MC, Kaczor K, Aldridge S, O'Flynn J, Lorenz DJ. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics. 2010 Jan. 125(1):67-74. [Medline].

  28. 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 Apr. 153(4):399-403. [Medline].

  29. Sheets LK, Leach ME, Koszewski IJ, Lessmeier AM, Nugent M, Simpson P. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics. 2013 Apr. 131(4):701-7. [Medline].

  30. Stephenson T, Bialas Y. Estimation of the age of bruising. Arch Dis Child. 1996 Jan. 74(1):53-5. [Medline].

  31. Langlois NE, Gresham GA. The ageing of bruises: a review and study of the colour changes with time. Forensic Sci Int. 1991 Sep. 50(2):227-38. [Medline].

  32. Kemp AM, Maguire SA, Nuttall D, Collins P, Dunstan F. Bruising in children who are assessed for suspected physical abuse. Arch Dis Child. 2013 Dec 4. [Medline].

  33. Degraw M, Hicks RA, Lindberg D,. Incidence of fractures among children with burns with concern regarding abuse. Pediatrics. 2010 Feb. 125(2):e295-9. [Medline].

  34. Maguire S, Moynihan S, Mann M, Potokar T, Kemp AM. A systematic review of the features that indicate intentional scalds in children. Burns. 2008 Dec. 34(8):1072-81. [Medline].

  35. Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K. Patterns of skeletal fractures in child abuse: systematic review. BMJ. 2008. 337:a1518. [Medline].

  36. Arkader A, Friedman JE, Warner WC Jr, Wells L. Complete distal femoral metaphyseal fractures: a harbinger of child abuse before walking age. J Pediatr Orthop. 2007 Oct-Nov. 27(7):751-3. [Medline].

  37. Kleinman PK, Perez-Rossello JM, Newton AW, Feldman HA, Kleinman PL. Prevalence of the classic metaphyseal lesion in infants at low versus high risk for abuse. AJR Am J Roentgenol. 2011 Oct. 197(4):1005-8. [Medline].

  38. Helfer RE, Slovis TL, Black M. Injuries resulting when small children fall out of bed. Pediatrics. 1977 Oct. 60(4):533-5. [Medline].

  39. Lyons TJ, Oates RK. Falling out of bed: a relatively benign occurrence. Pediatrics. 1993 Jul. 92(1):125-7. [Medline].

  40. Nimityongskul P, Anderson LD. The likelihood of injuries when children fall out of bed. J Pediatr Orthop. 1987 Mar-Apr. 7(2):184-6. [Medline].

  41. Reece RM, Sege R. Childhood head injuries: accidental or inflicted?. Arch Pediatr Adolesc Med. 2000 Jan. 154(1):11-5. [Medline].

  42. Rooks VJ, Eaton JP, Ruess L, Petermann GW, Keck-Wherley J, Pedersen RC. Prevalence and evolution of intracranial hemorrhage in asymptomatic term infants. AJNR Am J Neuroradiol. 2008 Jun. 29(6):1082-9. [Medline].

  43. Kellogg N. Oral and dental aspects of child abuse and neglect. Pediatrics. 2005 Dec. 116(6):1565-8. [Medline].

  44. Lane WG, Dubowitz H, Langenberg P. Screening for occult abdominal trauma in children with suspected physical abuse. Pediatrics. 2009 Dec. 124(6):1595-602. [Medline].

  45. Lindberg D, Makoroff K, Harper N, Laskey A, Bechtel K, Deye K. Utility of hepatic transaminases to recognize abuse in children. Pediatrics. 2009 Aug. 124(2):509-16. [Medline].

  46. Holmes JF, Sokolove PE, Brant WE, Palchak MJ, Vance CW, Owings JT. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med. 2002 May. 39(5):500-9. [Medline].

  47. Anderst JD, Carpenter SL, Abshire TC. Evaluation for bleeding disorders in suspected child abuse. Pediatrics. 2013 Apr. 131(4):e1314-22. [Medline].

  48. Archer JR, Wood DM, Dargan PI. How to use toxicology screening tests. Arch Dis Child Educ Pract Ed. 2012 Oct. 97(5):194-9. [Medline].

  49. Moller M, Gareri J, Koren G. A review of substance abuse monitoring in a social services context: a primer for child protection workers. Can J Clin Pharmacol. 2010 Winter. 17(1):e177-93. [Medline].

  50. Oral R, Bayman L, Assad A, Wibbenmeyer L, Buhrow J, Austin A. Illicit drug exposure in patients evaluated for alleged child abuse and neglect. Pediatr Emerg Care. 2011 Jun. 27(6):490-5. [Medline].

  51. Hoffman RJ, Nelson L. Rational use of toxicology testing in children. Curr Opin Pediatr. 2001 Apr. 13(2):183-8. [Medline].

  52. Lindberg DM, Shapiro RA, Blood EA, Steiner RD, Berger RP,. Utility of hepatic transaminases in children with concern for abuse. Pediatrics. 2013 Feb. 131(2):268-75. [Medline].

  53. Bennett BL, Mahabee-Gittens M, Chua MS, Hirsch R. Elevated cardiac troponin I level in cases of thoracic nonaccidental trauma. Pediatr Emerg Care. 2011 Oct. 27(10):941-4. [Medline].

  54. Day F, Clegg S, McPhillips M, Mok J. A retrospective case series of skeletal surveys in children with suspected non-accidental injury. J Clin Forensic Med. 2006 Feb. 13(2):55-9. [Medline].

  55. Meyer JS, Gunderman R, Coley BD, Bulas D, Garber M, Karmazyn B. ACR Appropriateness Criteria(®) on suspected physical abuse-child. J Am Coll Radiol. 2011 Feb. 8(2):87-94. [Medline].

  56. Prosser I, Maguire S, Harrison SK, Mann M, Sibert JR, Kemp AM. How old is this fracture? Radiologic dating of fractures in children: a systematic review. AJR Am J Roentgenol. 2005 Apr. 184(4):1282-6. [Medline].

  57. Lindberg DM, Shapiro RA, Laskey AL, Pallin DJ, Blood EA, Berger RP. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics. 2012 Aug. 130(2):193-201. [Medline].

A 4-year-old boy who was forcibly grabbed about the neck by his father. The 2 anterior chest bruises are consistent with thumbprints.
A 5-year-old girl who presented within 24 hours of being slapped on the leg. The markings are bruises and not erythema. The linear parallel lines are virtually diagnostic of a human handprint.
An 8-month-old infant who is brought into the emergency department by his mother with the history of having fallen from a changing table. Note the acute transverse midshaft humeral fracture. This fracture is most consistent with a snapping injury, not a fall onto a flat surface. The mother subsequently described grabbing the child's arm to lift him after the fall and hearing a snap.
A 2-month-old infant presented to the emergency department with the history from the father that the child had slipped in the tub the night before. Note the periosteal callus formation, indicating that the fracture is at least 1 week old and, thus, inconsistent with the history being offered.
A 15-month-old whose babysitter told the child's mother that she "lost it" and spanked too hard. This paddle injury is in a protected area rarely bruised accidentally and with gluteal cleft sparing. Note the areas of vertical bruising on either side of the gluteal cleft; this is characteristic of paddling.
A 4-year-old girl brought in by her father who picked her up from her mother's house and found these patterned, whip lashes on her buttocks and lower back. The patient reported her mom would get "really mad" at her.
A 5-year-old reported by his mother to have suddenly developed neck pain while playing at home. The mother denied any traumatic event and the child gave no history. This was reported to Child Protective Services as a likely inflicted injury. Inflicted ear bruises occur with pinching, pulling, twisting, cuffing, and punching.
A 5-year-old reported by his mother to have suddenly developed neck pain while playing at home. The mother denied any traumatic event and the child gave no history. This was reported to Child Protective Services as a likely inflicted injury. Inflicted ear bruises occur with pinching, pulling, twisting, cuffing, and punching.
A 3-month-old presented with the chief complaint of apparent life-threatening event but had extensive bruising, a spinal fracture, subdural hematoma, and multiple rib fractures in various stages of healing.
A 3-month-old presented with the chief complaint of apparent life-threatening event, but had extensive bruising, a spinal fracture, subdural hematoma, and multiple rib fractures in various stages of healing.
A 3-month-old presented with the chief complaint of apparent life-threatening event, but had extensive bruising, a spinal fracture, subdural hematoma, and multiple rib fractures in various stages of healing.
A 2-month-old brought to the emergency department with 2-day history of congestion, rhinorrhea, and cough. On the day of admission, the patient had poor feeding, lethargy, and episodes of apnea. A skeletal survey showed multiple rib fractures and there were extensive retinal hemorrhages in one eye. The parents denied a history of any trauma. The head CT scan showed multiple foci of subdural hematoma and subarachnoid hemorrhage predominantly over the bilateral convexities.
A 7-day-old boy who presented with unexplained bruises and multiple fractures, including these classic metaphyseal lesions seen at the distal femur. There was no history of birth trauma.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.