Diagnostic Considerations

The differential diagnosis depends on the type of injury, the age of the child, and the signs and symptoms. Most of the time, injury diagnosis is between accidental and inflicted trauma.

Bruise-related differential diagnoses are as follows:

Accidental bruises
Congenital dermal melanocytosis (Mongolian spots)
Hemangioma
Phytophotodermatitis
Immune thrombocytopenic purpura
Henoch-Schönlein purpura
Petechiae or subconjunctival hemorrhage from vomiting or coughing
Insect bites
Paint/ink on skin
Hemorrhagic disease of the newborn
Bleeding disorder (congenital or acquired)
Birth trauma
Hemophilia
Malignancy
Erythema multiforme
Folk healing practices (eg, coining, cupping)
Nevi

Skeletal fractures–related differential diagnoses are as follows:

Accidental fractures
Malignancy
Osteogenesis imperfecta
Rickets
Osteomyelitis
Bone fragility with chronic disease
Physiological subperiosteal new bone
Scurvy
Hypervitaminosis A
Congenital syphilis
Caffey disease
Birth trauma
Osteopenia of prematurity
Osteopenia

Burn-related differential diagnoses are as follows:

Accidental burns
Phytophotodermatitis
Impetigo
Folk healing practices (eg, coining, cupping)
Atopic dermatitis
Inflammatory conditions of the skin
Sunburn
Chemical burn
Contact dermatitis

Abusive head trauma (AHT)–related differential diagnoses are as follows:

Accidental head injury
Congenital or acquired coagulopathies (eg, hemophilia, vitamin K deficiencies, neonatal alloimmune thrombocytopenia)
Metabolic disease (eg, glutaric aciduria type 1)
Cerebral sinovenous thrombosis
Arteriovenous malformations
Unintentional asphyxia
Birth trauma
Bacterial meningitis
Leukemia
Solid brain tumors
Menkes disease

Workup

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.
U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child Maltreatment 2021. 2023. Available at https://www.acf.hhs.gov/cb/data-research/child-maltreatment.
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. [QxMD MEDLINE Link]. [Full Text].
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.
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. [QxMD MEDLINE Link].
Christian CW. The evaluation of suspected child physical abuse. Pediatrics. 2015 May. 135(5):e1337-54. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Farrell CA, Fleegler EW, Monuteaux MC, Wilson CR, Christian CW, Lee LK. Community Poverty and Child Abuse Fatalities in the United States. Pediatrics. 2017 May. 139 (5):[QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Danese A, Tan M. Childhood maltreatment and obesity: systematic review and meta-analysis. Mol Psychiatry. 2013 May 21. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Archambault É, Vigod SN, Brown HK, et al. Mental Illness Following Physical Assault Among Children. JAMA Netw Open. 2023 Aug 1. 6 (8):e2329172. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
National Vital Statistics System, National Center for Health Statistics, CDC. 10 Leading Causes of Death by Age Group, United States – 2015. Available at https://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2015-a.pdf. Accessed: June 27, 2018.
Nuño M, Ugiliweneza B, Bardini RL, Ozturk A, Stephenson JT, Magaña JN. Age-related mortality in abusive head trauma. J Trauma Acute Care Surg. 2019 Oct. 87 (4):827-35. [QxMD MEDLINE Link].
Nuño M, Ugiliweneza B, Zepeda V, et al. Long-term impact of abusive head trauma in young children. Child Abuse Negl. 2018 Nov. 85:39-46. [QxMD MEDLINE Link].
Cole C. The memory of children. New York: Springer-Verlag; 1978.
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. [QxMD MEDLINE Link].
Pierce MC, Kaczor K, Thompson R. Bringing back the social history. Pediatr Clin North Am. 2014 Oct. 61:889-905. [QxMD MEDLINE Link].
King WK, Kiesel EL, Simon HK. Child abuse fatalities: are we missing opportunities for intervention?. Pediatr Emerg Care. 2006 Apr. 22(4):211-4. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Choudhary AK, Servaes S, Slovis TL, Palusci VJ, Hedlund GL, Narang SK, et al. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol. May 23, 2018. [QxMD MEDLINE Link].
Carpenter RF. The prevalence and distribution of bruising in babies. Arch Dis Child. 1999 Apr. 80(4):363-6. [QxMD MEDLINE Link].
Labbe J, Caouette G. Recent skin injuries in normal children. Pediatrics. 2001 Aug. 108(2):271-6. [QxMD MEDLINE Link].
Mortimer PE, Freeman M. Are facial bruises in babies ever accidental?. Arch Dis Child. 1983 Jan. 58(1):75-6. [QxMD MEDLINE Link].
Pascoe JM, Hildebrandt HM, Tarrier A, Murphy M. Patterns of skin injury in nonaccidental and accidental injury. Pediatrics. 1979 Aug. 64(2):245-7. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Stephenson T, Bialas Y. Estimation of the age of bruising. Arch Dis Child. 1996 Jan. 74(1):53-5. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Pierce MC, Kaczor K, Lorenz DJ, et al. Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics. JAMA Netw Open. 2021 Apr 1. 4 (4):e215832. [QxMD MEDLINE Link]. [Full Text].
Degraw M, Hicks RA, Lindberg D,. Incidence of fractures among children with burns with concern regarding abuse. Pediatrics. 2010 Feb. 125(2):e295-9. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Flaherty EG, Perez-Rossello JM, Levine MA, Hennrikus WL; American Academy of Pediatrics Committee on Child Abuse and Neglect; Section on Radiology, American Academy of Pediatrics; Section on Endocrinology, American Academy of Pediatrics; Section on Orthop. Evaluating children with fractures for child physical abuse. Pediatrics. Jan 27, 2014. 133:e477-89. [QxMD MEDLINE Link].
Expert Panel on Pediatric Imaging:, Wootton-Gorges SL, Soares BP, Alazraki AL, Anupindi SA, Blount JP, et al. ACR Appropriateness Criteria® Suspected Physical Abuse-Child. J Am Coll Radiol. May 2017. 14:S338-S349. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Helfer RE, Slovis TL, Black M. Injuries resulting when small children fall out of bed. Pediatrics. 1977 Oct. 60(4):533-5. [QxMD MEDLINE Link].
Lyons TJ, Oates RK. Falling out of bed: a relatively benign occurrence. Pediatrics. 1993 Jul. 92(1):125-7. [QxMD MEDLINE Link].
Nimityongskul P, Anderson LD. The likelihood of injuries when children fall out of bed. J Pediatr Orthop. 1987 Mar-Apr. 7(2):184-6. [QxMD MEDLINE Link].
Reece RM, Sege R. Childhood head injuries: accidental or inflicted?. Arch Pediatr Adolesc Med. 2000 Jan. 154(1):11-5. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Kellogg N. Oral and dental aspects of child abuse and neglect. Pediatrics. 2005 Dec. 116(6):1565-8. [QxMD MEDLINE Link].
Lane WG, Dubowitz H, Langenberg P. Screening for occult abdominal trauma in children with suspected physical abuse. Pediatrics. 2009 Dec. 124(6):1595-602. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Anderst JD, Carpenter SL, Abshire TC. Evaluation for bleeding disorders in suspected child abuse. Pediatrics. 2013 Apr. 131(4):e1314-22. [QxMD MEDLINE Link].
Archer JR, Wood DM, Dargan PI. How to use toxicology screening tests. Arch Dis Child Educ Pract Ed. 2012 Oct. 97(5):194-9. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Hoffman RJ, Nelson L. Rational use of toxicology testing in children. Curr Opin Pediatr. 2001 Apr. 13(2):183-8. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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 Jan. 127:e47-52. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Magana JN, Kuppermann N. The PECARN TBI Rules Do Not Apply to Abusive Head Trauma. Acad Emerg Med. 2017 Mar. 24:382-384. [QxMD MEDLINE Link].
Choudhary AK, Bradford RK, Dias MS, Moore GJ, Boal DK. Spinal subdural hemorrhage in abusive head trauma: a retrospective study. Radiology. 2012. 262:216-23. [QxMD MEDLINE Link].
Kadom N, Khademian Z, Vezina G, Shalaby-Rana E, Rice A, Hinds T. Usefulness of MRI detection of cervical spine and brain injuries in the evaluation of abusive head trauma. Pediatr Radiol. 2014 Jul. 44:839-48. [QxMD MEDLINE Link].
Koumellis P, McConachie NS, Jaspan T. Spinal subdural haema- tomas in children with non-accidental head injury. Arch Dis Child. 2009. 94:216-9. [QxMD MEDLINE Link].
Wootton-Gorges SL, Stein-Wexler R, Walton JW, Rosas AJ, Coulter KP, Rogers KK. Comparison of computed tomography and chest radiography in the detection of rib fractures in abused infants. Child Abuse Negl. 2008. 32:659-63. [QxMD MEDLINE Link].
Sanchez TR, Lee JS, Coulter KP, Seibert JA, Stein-Wexler R. CT of the chest in suspected child abuse using submillisievert radiation dose. Pediatr Radiol. 2015. 45:1072-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
[Guideline] Christian CW, Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse. Pediatrics. 2015 May (Reaffirmed Nov 2021). 135 (5):e1337-54. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

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.

of 13

Author

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: Expert witness for: Yolo and Butte Counties, California.

Coauthor(s)

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.

Acknowledgements

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.

Child Abuse Differential Diagnoses

Diagnostic Considerations

References

Tables

Contributor Information and Disclosures

What would you like to print?