Guidelines
Guidelines Summary
American Academy of Pediatrics
Child physical abuse guidelines from the American Academy of Pediatrics (AAP) were updated in 2015 and reaffirmed in 2021. They include new information on the lasting effects of abuse and highlight risk factors for abuse and abusive injuries that are frequently overlooked. [1]
According to current guideline consensus, not all injuries require a comprehensive laboratory work-up. Instead, testing should be driven by the history and physical exam, as well as the prevalence and known natural history of the disease being considered.
Media Gallery
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Overlap of child maltreatment and domestic violence.
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Handprint on face. Image courtesy of Lawrence R. Ricci, MD.
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Handprint on leg. Image courtesy of Lawrence R. Ricci, MD.
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Patterned bruises inflicted with a belt. Image courtesy of Lawrence R. Ricci, MD.
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Bruises inflicted with switch. Image courtesy of Lawrence R. Ricci, MD.
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Bruises inflicted with switch. Image courtesy of Lawrence R. Ricci, MD.
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Switch. Image courtesy of Lawrence R. Ricci, MD.
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Bruises inflicted with wooden spoon. Image courtesy of Lawrence R. Ricci, MD.
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Bruises inflicted with belt. Image courtesy of Lawrence R. Ricci, MD.
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Buckle fracture of distal femur shaft. Image courtesy of Lawrence R. Ricci, MD.
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Duodenal hematoma. Image courtesy of Lawrence R. Ricci, MD.
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Burn from car seat. Image courtesy of Lawrence R. Ricci, MD.
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Car seat. Image courtesy of Lawrence R. Ricci, MD.
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Model for femoral neck fracture from being yanked from crib. Image courtesy of Lawrence R. Ricci, MD.
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Femoral neck fracture from being yanked from crib in previous image. Image courtesy of Lawrence R. Ricci, MD.
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Inflicted pinch mark shaft. Image courtesy of Lawrence R. Ricci, MD.
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Burn from being held down on hot cement. Image courtesy of Lawrence R. Ricci, MD.
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Old and new radius fracture. Image courtesy of Lawrence R. Ricci, MD.
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Child with slap mark. Image courtesy of Lawrence R. Ricci, MD.
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Radiograph of old radius and ulna fracture in child with slap mark. Image courtesy of Lawrence R. Ricci, MD.
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Radiograph of multiple rib fractures. Radiographs also revealed old radius and ulna fracture. The child presented with a slap mark. Image courtesy of Lawrence R. Ricci, MD.
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Sunburn. Image courtesy of Lawrence R. Ricci, MD.
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Burn inflicted with lighter. Image courtesy of Lawrence R. Ricci, MD.
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Subdural hemorrhage with midline shift. Image courtesy of Lawrence R. Ricci, MD.
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Fingernail scratch in child with acute subdural with shift. Image courtesy of Lawrence R. Ricci, MD.
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Ecological model for understanding violence.
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Adverse child experiences pyramid.
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National Pediatric Trauma Group registry findings.
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Acute distal femur buckle fracture; note absence of healing.
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Healing distal femur buckle fracture at 2-week follow-up; note sclerotic fracture line and periosteal new bone formation consistent with healing.
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Linear inflicted bruising extending from arm to back, inflicted by a belt. Same child shown again with back bruising.
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Overlying linear inflicted marks, which the child disclosed came from a belt. Same child is shown in image of arm and back.
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CT scan showing liver laceration. Child had severe abdominal bruising (see next image). Caregiver admitted to repeatedly punching the child in the abdomen.
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Abdominal bruising in a toddler who also had a liver laceration (also see previous CT scan).
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Example of ear bruising. Ear bruising is a rare accidental injury. This 10-month-old child was intubated for abusive head trauma (AHT) and spiral femur fracture and had this ear bruising in addition to other facial bruising.
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Dermal melanocytosis on a child with dark complexion
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Dermal melanocytosis on a child with light complexion. Dermal melanocytosis color hues may differ depending on the skin pigmentation of the child.
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Faint abdominal bruising. This toddler had elevated liver function test results, liver laceration found on abdominal CT scan, and an upper lip frenulum tear. Note that abdominal injury may be present with little or no bruising of the abdomen.
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Pattern bruising and extensive back bruising. The 4-year-old child was found dead in his home and had no reported history. Autopsy revealed duodenal hematoma and perforation as cause of death.
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Pattern contact burn on buttocks of diapered child. The burn likely came from the metal grate surrounding heater.
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Series of 3 photos of likely accidental hot water scald burn on the leg of an infant. Sparing of skin-to-skin contact areas indicates child was flexed at the knee and ankle at the time of injury, which was consistent with being seated in the kitchen sink. Burn injuries require detailed scene investigation. In this case, investigators confirmed the ease of turning on the faucet and the high temperature of the water from it.
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Example of strangulation/ligature marks on the neck of a toddler. Strangulation/ligature marks are often linear petechiae and may have fingernail scratches from the victim from struggling to free the airway.
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US Maltreatment Trends: 1990-2021. Courtesy of David Finkelhor, Crimes against Children Research Center, University of New Hampshire [Finkelhor D, Saito K, Jones L. Updated Trends in Child Maltreatment, 2021. Crimes Against Children Research Center, University of New Hampshire. Published March 2023. Online at: https://www.unh.edu/ccrc/sites/default/files/media/2023-03/updated-trends-2021_current-final.pdf.] (reprinted with permission).
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