Physical Child Abuse

Child physical abuse, a subset of child abuse, is defined in various ways. However, common to all definitions is the presence of an injury that the child sustains at the hands of a caregiver. These injuries are also commonly referred to as inflicted or non-accidental injuries. Some US states use broad definitions that encompass a wide range of injuries; other states use more narrow definitions that include specific signs and symptoms. Physical abuse can result in various injuries and injury patterns in children. This article focuses on several common examples of inflicted injury involving the skin (eg, burns, bruises), skeleton (eg, fractures), and central nervous system. 

Definitions of physical abuse

The federally funded National Incidence Study (NIS) is a congressionally mandated effort of the United States Department of Health and Human Services to provide updated estimates of the incidence of child abuse and neglect in the United States and measure changes in those estimates.[2]  NIS defines physical abuse as a form of maltreatment in which an injury is inflicted on the child by a caregiver via any of various nonaccidental means, including hitting with a hand, stick, strap, or other object; punching; kicking; shaking; throwing; burning; stabbing; or choking to the extent that demonstrable harm results.[3]

The advantage of a specific definition is that it objectively states what is and is not physical abuse; such a narrow scope, however, likely fails to identify all possible cases of physical abuse (eg, pulling the child's hair, biting the child's skin, forcing the child to hold uncomfortable positions for a prolonged period of time, etc.). Definitions may also attempt to characterize the severity of the injury; however, characterization is difficult because injuries vary greatly from, for example, no injury on exam, as physical abuse can at times leave no physical findings, to mild redness on the buttocks due to spanking that fades over several hours, to injuries so severe that the child dies. Newer definitions also aim to consider the sociocultural context in which the injury occurs, while recent medical definitions focus more on the effect of the injury on the child and less on the perceived intention of the caregiver. Importantly, inflicted trauma is consistent with the medical diagnosis of child physical abuse, and the determination of caregiver intent falls outside of the scope of medical practice. 

Finally, the effect of physical abuse may not be limited to the immediate injury findings. Long-term physical, emotional, behavioral, and cognitive issues are known to result from exposure to child physical abuse and other forms of child maltreatment.

Multifactorial nature of physical abuse

No single cause has been identified that explains the occurrence of all cases of child physical abuse, nor have we been able to accurately predict perpetrators of child physical abuse. The multifactorial nature of child physical abuse requires a more comprehensive amalgam of models and conceptual frameworks to account for its heterogeneity.

While attempts have been made to classify circumstances that may give rise to the occurrence of a child's injury via physically abusive actions, they fail to shed light on why those circumstances led to a child's injury in the first place.

Ecological model of human development and interaction

It is impossible and inadvisable to consider physical abuse of a child as an isolated incident with a single cause and a single effect. The ecological model of human development and interaction is generally regarded as an ideal conceptual framework from which to approach the complex interactions between the caregiver, child, family, social situation, and cultural values contributing to the physical abuse of a child.[4] Note the image below.

The ecological model sees a child functioning within a family (microsystem), the family functioning within a community (exosystem), the various communities linked together by a set of sociocultural values that influence them (macrosystem), and all of these systems operating over time (chronosystem). Each of these system components is interactional in nature, influencing and affecting one another. Similar events have different effects that depend on the period and circumstances in which the event occurs (eg, the child interacts and has an impact on the family, the family influences the child).

Environmental stress and caregiver frustration

Helfer[5]  builds on this ecological viewpoint and states that physical maltreatment arises when a caregiver and child interact around a particular event in a given environment with the end result being the injury to the child. Viewing maltreatment in this way allows consideration of the factors that the caregiver, child, and environment contribute to the child’s risk for injury. The caregiver is viewed as having a personal developmental history, personality style, psychological functioning, and coping strategies. Furthermore, the caregiver often has expectations of the child, as well as a particular level of ability to nurture the child's development and subsequently meet the child's developmental and caregiving needs.

The child, in turn, may have certain characteristics that make providing care more complex for a particular caregiver; nonetheless, caution must be used when considering the child's contribution to the abusive interactions. A "difficult" child does not justify abusive treatment by a caregiver. Specific factors that may place the child at higher risk for physical abuse have been found to include prematurity, poor bonding with caregiver, medical needs, various special needs (eg, attention deficit hyperactivity disorder), and a perception by the caregiver of the child being “different” (owing to physical, developmental, and/or behavioral/emotional factors) or "difficult" (owing to a child's temperament).

In infants, it is particularly important to recognize crying as a trigger for escalating caregiver frustration.[6] Subsequently, frustration has been described as manifesting in shaking of the crying infant. Research addressing shaking as an attempt to stop infant crying reveals that perpetrators described repeated shaking in more than 50% of cases, occurring daily for several weeks in approximately 20% of cases, prompted in all cases because prior shaking of the infant had reportedly led to a halt in the infant’s crying. Crying, however, has been increasingly recognized as a normal part of infant development. It has been found to increase steadily from approximately the second week of life, peaking at the second month, and eventually receding by the fourth or fifth month of life. This crying curve has been found to coincide with the incidence curve for abusive head trauma. Prevention strategies have subsequently aimed to normalize infant crying during this developmental period and equip caregivers with strategies to anticipate and preventively respond to increasing frustration that may ensue. 

Finally, the environment may contain stressors that may make caregiving suboptimal and may overextend the coping abilities of the caregiver. While exploring the role of environmental stress and caregiver frustration in the occurrence of child abuse, Straus and Kantor found a complex interaction between the amount of stress present in the family setting and the response of the caregivers.[7]  Importantly, not all stressed caregivers responded by inflicting harm on the children in the environment.

Straus and Kantor concluded that human beings have a capacity for acting violently both in and outside the family setting. Physical abuse can result if a specific situation arises having a relatively high degree of stress and a baseline amount of violence within it (eg, spanking the children, pushing or slapping a spouse). Thus, the risk of child physical abuse is related to the response of caregivers whose caregiving environment has a certain amount of overall risk for violent behavior. The caregivers' level of social connectedness to non-relatives seems to have a role to play in the children's risk for maltreatment. Children whose caregivers were socially isolated and under high degrees of stress were found to have higher rates of child physical abuse than those who were not as socially isolated. However, children whose caregivers had many family members living nearby did not achieve the same protective effect as did the non-familial social-connectedness group.

Intimate partner violence and child maltreatment

The relationship between domestic violence, or intimate partner violence (IPV), and child maltreatment is receiving increasing attention. Each year, millions of children witness episodes of family violence; 30%–60% of mothers of abused children are victims of IPV. Additionally, children whose mothers are victims of IPV are 6 times more likely to be emotionally abused, 4.8 times more likely to be physically abused, and 2.6 times more likely to be sexually abused compared to children living in families in which their mothers are not victims of IPV. The American Academy of Pediatrics (AAP) recommends that pediatricians assess for the presence of IPV in the child's family and notes that intervening on behalf of the victimized parent may be an effective child-abuse prevention strategy.[8]  Of note, a child’s exposure to IPV between their caregivers carries a significant risk of emotional and psychological harm, and is considered a form of psychological or emotional abuse. Note the image below. 

Corporal punishment and child maltreatment 

The relationship between the use of corporal punishment and the risk for physical abuse also remains an area of concern. Corporal punishment is defined as a method of discipline that employs physical force as a behavior modifier. Corporal punishment is nearly universal; 90% of US families report having used spanking as a means of discipline at some time. Corporal punishment has its roots in personal, cultural, religious, and societal views of children and how they are to be disciplined. Corporal punishment includes, but is not limited to, pinching, spanking, paddling, shoving, slapping, shaking, hair pulling, choking, excessive exercise, confinement in closed spaces, and denial of access to a toilet.

Discipline is a necessary component for child rearing, and appropriate discipline aims for limit setting, teaching right from wrong, assisting in decision making, and helping the child develop a sense of self-control. However, no reliable evidence in the medical literature supports the continued use of corporal punishment, and corporal punishment has not been found to effectively change undesired behaviors. As a result, the line separating corporal punishment and physical abuse is thin, as corporal punishment carries a significant risk of injury.

When physical force is used as a discipline technique, the concern arises that if the misconduct continues even after corporal punishment is applied, the caregiver may then become angry and frustrated and reapply the physical force. As the physical force is reapplied while the caregiver is becoming increasingly upset, the potential emerges for the caregiver to lose control and injure the child. Regardless of whether injuring the child was the intended outcome of the corporal punishment, the end result experienced by the child is that they have been hurt. Corporal punishment that results in physical injury is generally considered child physical abuse in the United States.

In addition to the risk of physical injury, corporal punishment has been found to be associated with negatively affecting the parent–child relationship, aggressive behaviors, and an increased risk of mental health disorders and problems with cognition.  

Caregivers who use corporal punishment are often angry, irritable, depressed, fatigued, and stressed. They typically apply the punishment at a time when they have "lost it," and caregivers frequently describe agitation while punishing their children, followed by remorse. To avoid the risk of harming the child and in order to model non-violent behavior for children, many healthcare professionals advocate child discipline via consistent, non-physical approaches. Approximately one half of US pediatricians report being generally opposed to the use of corporal punishment; about one third are completely opposed to its use. In 2018, the American Academy of Pediatrics (AAP) issued a policy statetement opposing corporal punishment and encouraging a pediatrician–parent partnership to develop non-physical disciplinary techniques based on an evidence-based understanding of normal childhood development.[9]  

Each type of injury sustained by a child has particular biomechanical elements and pathophysiology. It is important to note that child physical abuse can result in multiple types of injuries involving multiple body systems. 

This section will discuss mechanisms of injury and pathophysiology for skeletal injury (ie, fractures), cutaneous injuries such as bruises and burns, intrathoracic and intra-abdominal injury, and CNS injury, given their relatively increased frequency in child physical abuse. 

Skeletal fractures

Skeletal fractures are caused by the application of force to the bone. An essential step in the evaluation of skeletal injury in children is determining whether the injury evaluated is consistent with the history provided. This requires appropriate understanding of childhood development, specific characteristics of infant and child bone, and the mechanisms and forces needed to cause specific types of fractures.

The child's immature skeleton is characterized by more porous or trabecular bone than mature bone. Certain fracture types are only seen in developing, immature bone (eg, greenstick fractures, classic metaphyseal lesions, Salter-Harris fractures). The less-dense porous bone tolerates more deformity than adult bone and accounts for the bending and buckling injuries observed with greenstick and buckle fractures in children. The periosteum (the fibrous membrane that covers the bone) is thicker and more easily elevated off the bone in children. The child's joint capsule and ligaments are strong and relatively more resistant to stress than the bone and cartilage, accounting for less joint dislocations and ligamentous tears in childhood. Finally, bone healing is more rapid in children than in adults owing to more rapid bone turnover, which makes dating of childhood fractures more complicated (see Bone Healing and Dating of Injuries below).

While certain types of fractures (eg, posterior rib fractures, classic metaphyseal lesions) are more common and specific for inflicted injury and others are more common in accidental injury (eg, isolated simple skull fractures), there is no fracture that is pathognomonic for child physical abuse. All fractures must be carefully evaluated and correlated in the context of the child's medical history, developmental abilities, the history provided by the caregivers, and the constellation of physical findings. 

Fractures can be classified by location in the body (eg, skull vs long bone) and by location on the bone (eg, diaphyseal vs metaphyseal, posterior vs anterior rib). 

Specifically in long bones, fractures are described based on location and type, as follows: 

• Physeal fractures, or growth plate fractures, are inherent to children. They result from disruption of the cartilaginous physis, or growth plate, with or without involvement of the adjacent epiphysis or the metaphysis.

  The Salter-Harris classification is a commonly used approach to describe these fractures and their extension. Extension of physeal fractures depend on the external force applied; for example, longitudinal forces through the physis will result in a Salter-Harris Type I fracture, while a Salter-Harris Type V results from a crush or compression force to the growth plate. ​

• Metaphyseal fractures occur at the section of the bone adjacent to the physis, between the diaphysis and the epiphysis.  

  • The metaphysis is an area of rapid bone turnover in the growing infant and toddler. Metaphyseal fractures are specific to infants as they involve the immature physis.  

  • Planar microfractures through the immature part of the bone edge often appear like chips on radiographs and are known as classic metaphyseal lesions or CMLs (also referred to as corner fractures or bucket-handle fractures). CMLs are caused by shearing and tensile stress such as pulling, twisting, jerking, and rapid acceleration and deceleration forces to the extremity (such as during violent shaking).

• Diaphyseal fractures are breaks in the shaft of the long bones. 

  • Transverse fractures typically occur when a bending force is applied perpendicular to the long axis of the bone. 

  • Greenstick fractures are incomplete fractures with interruption of the cortex and periosteum typically resulting from bending forces. 

  • Spiral fractures occur when the force applied has a rotational component (ie, torque), with long oblique fractures resulting from a combination of bending and rotational forces. 

  • Buckle fractures (also known as torus fractures) are incomplete fractures resulting from buckling of the cortex due to the application of an axial load onto the long axis of the bone (ie, compression); buckle fractures occur commonly at the transition from diaphysis to metaphysis. Note the images below. 

 

The skull bones differ from long bones in that they develop within a membrane rather than from cartilage. Skull bone fractures typically result from blunt trauma to the head with a solid surface or object. Skull fractures often occur at or near the site of impact, however, owing to unique architectural features of the infant head, a single impact may result in bilateral, typically parietal, fractures or fractures remote from the site of impact. Skull fractures are common injuries in both accidental and inflicted injury. However, significant and clinically evident intracranial injury is more commonly found in cases of abuse (see CNS injury and Abusive Head Trauma below), while small, focal intracranial hemorrhage or injury without significant neurological symptoms is more common to accidental injuries. The advent of head CT 3D reconstruction has improved our recognition and characterization of skull fracture complexity. Determining the etiology of skull fractures requires a comprehensive contextualization of the history provided and assessment of additional clinical findings. The morphology of the skull fracture is typically insufficient to determine physical abuse. 

Ribs are common sites of fractures resulting from inflicted trauma (ie, physical abuse), particularly in infants. Posterior rib fractures, adjacent to the vertebral body, elicit particularly high concern for physical abuse. These fractures typically result when the rib levers over the adjacent transverse process of the vertebra during forceful anteroposterior chest compression (ie, squeezing). Contiguous rib fractures (fractures involving > 1 ipsilateral rib), bilateral rib fractures, and multiple rib fractures in different stages of healing should also elicit significant concern for child physical abuse. Direct blunt trauma to the ribs may also result in rib fractures. Careful understanding of the relationship between the location along the rib and the mechanism of injury is important when determining whether the history provided is consistent with the fracture identified. 

Bone healing and dating of injuries

Dating of bony injuries is a particularly important concept in the evaluation of child physical abuse because it may assist investigators in determining who had access to the child during the time period over which the injury is estimated to have occurred. The body of medical literature evaluating the precision of dating of fractures has evolved over the last decade. The classic teaching has been that fractured long bones, clavicles, and ribs heal in a predictable fashion, progressing through stages of subperiosteal new bone formation, soft and hard callus formation, and eventually, remodeling.  

This traditional description of bone healing includes general timelines for the estimated age of the injury based on the stage of healing seen at the time of injury identification. In young children, bone healing tends to occur more rapidly than in older children and adults. Newer studies of dating of fractures emphasize that the classic descriptions (eg, soft callus, hard callus) are based on histologic specimens rather than radiologic images, and significant inconsistencies exist among radiologic interpretations of healing phases.[10]  

Attempts have been made to characterize radiological features of fracture healing and generate more clinically relevant guidelines. Subperiosteal new bone formation is unlikely radiographically evident prior to 7 days after an injury, while callus formation typically becomes evident between 10 and 14 days, progressing over approximately 1–2 weeks. The remodeling phase is highly variable, however. In infants, long bone fractures have been found to appear radiologically remodeled by 3 months after the injury. However, beyond infancy, the timeframe is less predictable and is influenced greatly by multiple fractures, including the fracture type, location, and severity, as well as repetitive trauma to the fracture either due to repeated abusive events or handling of an injured infant prior to identification of the fracture.[11]

Metaphyseal fractures, specifically classic metaphyseal lesions (CMLs), differ from long bone fractures and are generally more difficult to date given the relative lack of disruption in the periosteum at the time of the fracture. This may frequently result in an absence of typical healing features such as callus formation. Similarly, skull fractures heal differently than do long bones because of their intramembranous nature and do not heal with significant callus formation either. While scalp swelling has been frequently associated to fracture acuity, it is neither a precise or universally consistent marker.[12] Recent research has suggested that skull fracture healing or fracture resolution in children ≤ 24 months old ranges broadly from weeks to months.[13]  

The evaluation of the healing process on radiographs permits a broad level of fracture dating and allows the healthcare professional to at least generally distinguish between acute and healing fractures in the same child. However, providers should exercise caution if attempting to more precisely date fracture age based on radiological findings alone. Close collaboration with an experienced pediatric radiologist is crucial when dating skeletal injuries in the evaluation of child physical abuse, and clarity regarding the limitations of fracture dating should be made clear to investigators.

Burns

Burns are injuries to the skin or other tissue primarily caused by heat (thermal burns), and arise from various heat sources such as hot liquids (scald burns), hot objects (contact burns), and flame (flame or flash burns). Other types of burns may result from chemicals, friction, radiation, and electricity. 

This section will focus on thermal burns considering they are the type of burn most commonly seen in child physical abuse. However, it is important to recognize that other relatively less common types of burns can also be seen as a result of child abuse. For example, inflicted chemical burns and microwave burns have been previously reported. 

Human skin is composed of 3 layers: the epidermis, dermis, and subcutaneous tissue. Burns are classified clinically depending on the depth of the injury and the involvement of the various skin layers. Superficial burns, which involve injury only to the uppermost tissue of the epidermis, present as red, painful areas without blisters. Complete healing without scarring is expected from superficial burns. Deeper burns that extend through the epidermis into the upper levels of the dermis are referred to as partial-thickness burns and present as painful blistering and weeping areas. Healing of partial-thickness burns varies, with different degrees of scarring depending on the involvement and extension of tissue damage. Finally, the deepest burns, full-thickness burns, extend past the epidermis and dermis into the subcutaneous tissue and fat. These burns essentially have destroyed the overlying skin, blood vessels, and associated nerves and present as white, insensate areas because of this destruction. A high degree of scarring and disfigurement typically results from full-thickness burns and significant medical and surgical management can be expected. While discrete classification is helpful, it is important to recognize that clinically, these burn classifications may overlap. 

Additionally, three concentric zones of affected tissues that help contextualize a burn injury’s pathophysiology have been described (see Thermal Burns). These zones involve both the superficial area of the burn as well as the underlying affected tissues. The zone of coagulation is the area in most direct contact with the heat source. In this zone, the skin undergoes immediate coagulation necrosis as its proteins denature, blood flow is limited, and cellular repair is no longer possible. The zone of stasis involves less heat energy exposure than that in the zone of coagulation. In the zone of stasis, while blood flow is decreased and these cells are injured, they retain potential for repair. Management goals must aim to restore adequate perfusion to prevent further expansion of the burn wound, avoiding further tissue injury and loss. The zone of hyperemia is the outermost zone of the burn and the zone with least direct injury. Therefore, these cells have the greatest potential for repair. This zone is characterized by increased perfusion secondary to vasodilation and the influx of inflammatory mediators.

All of these burn types and depths can be encountered in both inflicted and accidental burns in children. Evaluation of burns concerning for inflicted injury in children must include, as with any injury, a detailed history from the caregiver and child (if verbal), including a developmental history to determine the child’s capability of contributing to the injury (eg, "turned on the faucet," “climbed into the sink”). Physical examination should include assessment of the burned area. In scald burns, for example, understanding the time it takes for a certain burn to develop may be particularly helpful to determine the consistency of the history. However, while studies aimed at determining time to burn injury have been helpful, determining the time to injury or the age of the burn remains broadly imprecise. Critical assessment of the burned versus spared areas of skin can also be helpful in determining the position of the child at the time of the burn. Note the image below.

Careful gathering of information about what the child was wearing at the time, the time elapsed since the burn, symptom progression, and any topical treatments to the area is important when assessing the burn. Many childhood burns involve hot water in bathtubs or heated liquids in a kitchen setting. Scene investigations by child protective services or law enforcement can gather important information that may help in differentiating concerns between accidental and inflicted injury (eg, temperature of tap water, height of faucets from floor, ease of turning handles, food residue on clothing or at the scene, etc.).[14] Some states in the United States fund public health nursing programs that conduct home safety evaluations to ensure adequate heater temperatures and address home hazards when concerns do not particularly warrant child protective services or law enforcement involvement. 

Particular characteristics of the burn can help determine the consistency of the history provided. For example, histories involving spills typically result in flow pattern scald burns, while inflicted immersion burns may result in sharply demarcated burn edges, glove and stocking patterned burns, and doughnut-hole sparing over the buttocks. Similarly, both accidental and inflicted contact burns often reflect the object that caused the injury. Note the image below.

An understanding of the child’s developmental abilities, a detailed history, and clarification of the burn type and extent is important for a thorough assessment and can help address concerns for inflicted injury as well as guide management and prognosis. 

Bruising

Bruising occurs when a blunt mechanical force is applied to the skin to such a degree that capillaries (and potentially larger vessels) become disrupted resulting in the leakage of blood into the subcutaneous tissue. The amount and depth of extravasated blood as well as the size and location of the involved area accounts for the evolving appearance of the bruise. If force is applied via an object, the bruise may reflect the shape and geometry of the object. Similarly, patterned bruising may also reflect the mechanism of injury (ie, patterned bruising consistent with a grab, squeeze, spank, slap, or pinch).

In general, a bruise progresses through a series of colors that emanate from the breakdown of the extravasated blood into the components of hemoglobin. As the extravasated blood organizes itself and is resorbed, certain patterns of color change are expected; however, caution is advised because no clearly predictable chronology can be relied on with certainty. Attempting to date bruises by their color or appearance has been strongly discouraged, as data have consistently indicated that color is a poor predictor of bruise age.[15]

Intrathoracic and intra-abdominal trauma

Intrathoracic and intra-abdominal organ injuries often result from direct blunt trauma or transmitted acceleration-deceleration forces, and while less common, these injuries carry significant morbidity and mortality. 

Intra-abdominal injury is more common than intrathoracic injury, considering the protective feature of the rib cage, which is often involved in inflicted injury (ie, rib fractures). When present, cardiac and pulmonary contusions suggest blunt trauma to the chest. Disordered conduction such as commotio cordis can result from blunt trauma as well. The liver and the spleen are the most frequently involved intra-abdominal organs, although hollow viscus injury is an important cause of morbidity and mortality, often resulting from high-energy, focal impacts.

CNS trauma

CNS injury typically refers to injury of the brain and spinal cord, and is defined as either primary or secondary injury. Primary injury results from mechanical distortion of the underlying tissue at the moment of the trauma and is due to either a contact or inertial mechanism of injury. Contact injury results from skull deformation due to cranial impact, while inertial injury results from head rotational acceleration-deceleration forces either transmitted via the neck or subsequent to cranial impact. Children who sustain CNS trauma, particularly due to physical abuse, may present with a combination of contact and inertial primary injuries. Primary CNS injury subsequently initiates metabolic cascades that contribute to secondary CNS injury resulting from inflammation, ischemia, excitotoxicity, oxidative stress, and cell death. 

CNS primary injury often involves intracranial hemorrhage, including epidural hemorrhage, which is bleeding into the space between inner skull bone surface and the dura, frequently due to a direct injury to the middle meningeal artery; subdural hemorrhage, which is bleeding into the potential space between the inner surface of the dura and arachnoid membranes, typically caused by shearing of the bridging vessels that connect that brain surface to the dura; and subarachnoid hemorrhage, which is bleeding into the space between the inner surface of the arachnoid and the brain surface. Subpial hemorrhage involves hemorrhage between the pia matter and the cortical surface. It is increasingly recognized given advances in neuroimaging modalities but can be challenging to differentiate from subarachnoid hemorrhage.

Dating CNS injuries carries significant challenges. The appearance of blood, or attenuation, on CT is not a reliable indicator of injury timing. Brain MRI may be helpful in characterizing radiological features that suggest chronicity, such as membrane formation. However, caution should be exerted if attempting to draw a specific injury timeframe based on radiological findings. Close discussion with a pediatric radiologist - preferably a pediatric neuroradiologist - is strongly encouraged.[16] The clinical presentation is particularly important and can often assist in estimating timing. While epidural hemorrhages often are described as having a clinical “lucid-interval,” this is not typical of subdural hemorrhage, particularly considering the mechanisms of injury most often involved in inflicted trauma. Research suggests that patients who present markedly altered or symptomatic (ie, seizures, respiratory compromise) typically have suffered the injury shortly or immediately prior to neurological deterioration, and those with more subtle presentations are typically "not acting normal” after their injury.[17]

Other CNS injuries include parenchymal contusions (ie, direct injury to the brain tissue, typically due to blunt trauma) and intraparenchymal bleeding (ie, bleeding directly into brain matter or parenchyma). These primary injuries can be obscured or complicated by anoxic brain injury and brain edema, which are frequently seen in complex head injury, whether accidental or inflicted. CNS trauma is among the most serious forms of injury observed in the context of physical abuse.

Abusive head trauma (AHT)

Discussing CNS injury and physical abuse inevitably leads to a discussion of abusive head trauma (AHT),[18]  previously referred to by multiple other names including shaken baby syndrome (SBS) or shaking-impact syndrome. The mechanism of injury involves rotational acceleration-deceleration and shearing forces to the child’s developing brain tissue (ie, shaking) with or without associated head impact, and has been consistently supported by perpetrator statements.[19, 20] Such forces exceed those generated in normal handling and are different from the low-velocity translational forces (linear movement) that commonly occur in household falls. 

Retinal involvement is commonly associated with AHT, and often manifests as retinal hemorrhages with or without retinoschisis. Vitreoretinal traction and acceleration-deceleration forces, particularly in the setting of repetitive trauma, are believed to be the driving mechanisms of injury. Extensive, too-numerous-to-count retinal hemorrhages involving multiple layers of the retina and extending out to the ora serrata are not common to accidental injury, and are instead more frequently identified in cases of AHT. Retinoschisis (spliting of the retinal layers) and macular folds are also more commonly described in AHT in association with retinal hemorrhages. However, there is no pathognomonic retinal finding for AHT and eye findings should be considered within the constellation of historical and clinical findings. 

The original description of AHT (referred to as infant whiplash-syndrome at the time) described a clinical constellation of findings classically involving subdural hemorrhage, retinal hemorrhages (found in 65%–95% of cases), and skeletal fractures, such as classic metaphyseal lesions and posterior rib fractures (found in 30%–70% of cases), all of which are consistent with shearing forces during violent shaking. Although AHT is often associated with the findings listed above, no single injury or combination of findings is pathognomonic. Rather, the constellation of clinical findings in the context of the history provided warrants close evaluation to support the diagnosis. At times, however, the diagnosis may remain uncertain, with findings insufficient to completely support or exclude AHT. 

Since AHT was first described, a substantial amount of research has upheld the specificity of various clinical findings and shaking has been recognized as a dangerous and potentially lethal mechanism of injury. While courtrooms have challenged these conclusions given limitations in biomechanical, computational, and animal models, it is important to note that there is no significant controversy regarding the recognition of AHT within the medical field and the validity of AHT as a medical diagnosis has been supported by major national and international professional societies.[21]

Frequency

Child abuse and neglect is common, reportedly affecting at least 1 in every 7 children in the United States in 2019 and accounting for 1820 deaths in 2021.[22]  In order to understand the scope of child physical abuse, it is important to understand how the incidence of child maltreatment is determined. 

Data from child protective services (CPS) agencies reveal that, in 2021, approximately 3.9 million reports involving 7.1 million children were made. Of these, 54.2% were accepted as needing further investigation, and once evaluated, the investigations concluded that child abuse and neglect had affected approximately 600,000 children, with 16.0% of this total representing cases of substantiated physical abuse. In keeping with prior data, the most common form of substantiated abuse in 2021 was child neglect, which accounted for 76.0% of cases. Child sexual abuse followed, accounting for 10.1% of cases. Notably, multiple forms of child maltreatment, such as emotional and physical abuse, often co-exist.[22]   

One important source of epidemiological data is the National Child Abuse and Neglect Data Systems (NCANDS), a voluntary data collection system that gathers information from child protective service agencies in all 50 states, the District of Columbia, and the Commonwealth of Puerto Rico. These data allow examination of child maltreatment trends and are reported annually in reports to congress and in the Child Maltreatment report. Another important epidemiological data source is the National Incidence Study (NIS), last updated in 2010. The NIS views maltreated children who are investigated by CPS agencies as representing only the "tip of the iceberg." In the NIS methodology, children investigated by CPS are included along with maltreated children who are identified by "sentinels" or community professionals by using data gathered from a nationally representative sample of 122 counties. Sentinels in these counties report data about maltreated children identified by the following organizations: elementary and secondary public schools; public health departments; public housing authorities; short-stay general and children's hospitals; state, county, and municipal police/sheriff departments; licensed daycare centers; juvenile probation departments; voluntary social services and mental health agencies; shelters for runaway and homeless youth; and shelters for victims of domestic violence. CPS agencies in these counties provide data about all children in cases they accept for investigation during 1 of 2 reference periods (for example, September 4, 2005 through December 3, 2005, or February 4, 2006 through May 3, 2006). 

Estimating the extent of maltreatment is complex and challenging as the relatively strict criteria used by the NIS-4 generally requires that an act or omission result in demonstrable harm in order to be classified as abuse or neglect; this is denoted as the “Harm Standard” by the NIS.  In addition to the Harm Standard, the NIS-4 also reported on the Endangerment Standard, which encompasses those children who meet the Harm Standard as well as those who were not physically harmed by abuse or neglect but that had a CPS investigation that substantiated or indicated maltreatment. The Endangerment Standard is slightly more lenient than the Harm Standard in allowing a broader array of perpetrators, including adult caretakers other than parents in certain maltreatment categories as well as teenage caretakers as perpetrators of sexual abuse.  In this way, the Endangerment Standard provides a broader, more encompassing view of maltreatment in the United States.

Finkelhor et al analyzed trends in reporting and substantiation rates for child abuse and neglect from the early 1990s through 2021 and identified a declining trend in the number of substantiated cases of physical abuse. According to their most recent analysis,[23]  the incidence of substantiated physical abuse cases declined 64% from 1992 to 2021. Cases of child sexual abuse have also declined substantially, with a 63% decrease in the number of substantiated cases of sexual abuse. Child neglect, the most common form of child maltreatment, also showed a 20% decline in substantiated cases from 1992 to 2021. Note the image below.

While some declines in reports and substantiated cases have been attributed to the COVID-19 pandemic, presumably due to children having significantly limited surveillance outside of the home during this period, it is important to understand how these recent declines follow a long-term trend. Finkelhor et al have proposed a number of theories to explain this decreasing trend, including increased investment in law enforcement awareness of child maltreatment, improvements in child protection teams, and a more recent focus on addressing mental health conditions. Trends, however, are known to be dynamic, and trend surveillance is ongoing. 

Mortality/Morbidity

Mortality

An estimated 1820 children were known to have died as a result of maltreatment in 2021. Children aged < 3 years accounted for 66.2% of the child abuse and neglect fatalities, with infants younger than 1 year accounting for 45.6% of these cases. Child fatality rates were found to generally decrease with increasing age. When studying the types of maltreatment accounting for the fatalities, the breakdown is as follows:

• Child neglect - 77.7%

• Physical abuse - 42.8%

• Psychological abuse - 2.4%

• Child sexual abuse - 0.8%

Notably, many of the children who died as a result of maltreatment experienced multiple forms of abuse more frequently. The estimated death rate for child abuse and neglect in the United States is 2.46 per 100,000 children.[22]

Morbidity

Different forms of injury carry different risks. For example, CNS injury and abdominal injury in young children may be particularly serious. Those children that survive serious inflicted injuries, such as abusive head trauma, have variable outcomes that are challenging to prognosticate and may not be fully realized until years following their injuries as they begin to fail meeting expected developmental milestones, develop learning difficulties when starting school, or when behavioral issues become more apparent. Burns observed in child physical abuse cases can range from superficial and self-resolving to full-thickness and severe, requiring grafting and long-term therapy and rehabilitation. Finally, skeletal injuries may be isolated or multiple in nature and may be associated with other injuries. While fractures will generally heal, fractures not brought to prompt medical attention may carry risks of non-union, malalignment, poor healing, and deformity.

Morbidity related to child abuse is not limited to the physical implications of maltreatment.  A wealth of literature exists regarding the implications of exposure to adverse childhood experiences (ACEs), which include child physical or sexual abuse, exposure to family violence, neglect, and other adverse conditions.[24] The major finding of the Adverse Childhood Experiences (ACE) studies was a graded relationship between the number of adverse childhood experiences, tallied as an "ACE score," and the development of chronic medical and psychiatric illnessess as well as other comorbidities associated with death in adulthood. Note the image below. 

It is important to note, however, that although ACEs are important in understanding population risk factors and building prevention strategies, the ACE score has limited utility when applied at the individual level.[25, 26]  

Race

A specific racial breakdown for physical abuse was not provided in Child Maltreatment 2021; however, overall racial information for all cases of abuse is as follows: African American (21.5%), American Indian/Alaskan Native (1.5%), Asian (1.0%), Pacific Islander (0.2%), white (42.8%), multiple racial affiliations (6.1%), Hispanic (24.5%), with the remainder of children having unknown or unreported race or ethnicity.

NIS-4 compared 3 major race categories – White (non-Hispanic), Black (non-Hispanic), and Hispanic – and found that White and Black children differed significantly in their rates of experiencing overall Harm Standard abuse during the 2005–2006 NIS-4 study year. An estimated 10.4 cases per 1000 Black children were found to have suffered Harm Standard abuse during the NIS-4 study year, compared with 6 cases per 1000 white children and 6.7 cases per 1000 Hispanic children. The rate of substantiated reports of abuse of Black children is reportedly 1.7 times that of White children and 1.6 times that of Hispanic children. This over-representation of Black children and families has generated significant concern among policymakers and advocates as efforts and interventions to address maltreatment-related factors and social determinants of health disproportionally affecting children of color are urged. 

Sex

A specific sex-based breakdown is not provided in Child Maltreatment 2021; however, the overall incidence of child maltreatment was not markedly different in aggregate, with male children accounting for 47.5% and female children accounting for 52.2%, though males are more likely to be fatally injured.

NIS-4 found no significant difference between male and female children’s rates of experiencing serious harm under the Harm Standard. Since the 2006 NIS-3 data, the incidence rates for both sexes declined, but the males’ rate declined more than that of females with reported rates at 33% and 11%, respectively.

Age

A specific age-based breakdown was not provided for physical abuse in Child Maltreatment 2021; however, the overall unique count for substantiated cases by age was as follows: 1–3 years (18.7%), 4–7 years (22.2%), 8–11 years (19.0%), 12–15 years (18.8%), and 16–17 years (6.0%). Children younger than 1 year had the highest rate of victimization overall, accounting for 15.0% of all maltreated children.  The victimization rate of children this age is 25.1 per 1000 children.

The NIS-4 incidence of Harm Standard physical abuse is significantly lower for the youngest children (2.5 cases per 1000 children aged 0–2 years) compared with children aged 6–14 years (4.6 cases per 1000 or higher). The relatively low incidence rates for children younger than 2 years may actually reflect a detection problem; because children who are younger than school age are less observable to community professionals, their abuse may avoid detection unless particularly severe or prompting medical attention.

Childhood is a time of accidental injuries. Understanding the developmental level and abilities of the child is essential in determining if the history provided by the caregiver is a plausible explanation for the child's injury. It is also important to recognize that while developmental milestones provide a general expectation, each child being evaluated has their own developmental pace. Pediatricians and pediatric healthcare providers are generally able to understand the type of injuries associated to child’s developmental capabilities. Injuries that fall outside of the expected norm warrant close consideration in the context of the history provided, and if implausible given the child’s development, should raise concern for possible physical abuse. 

Once the full extent of the injury is determined based on physical examination and pertinent radiology and laboratory workup, the healthcare provider can further assess the plausibility of the explanation offered by the caregiver. At times, when abuse is considered, additional information from community partners, such as law enforcement and child protective services, can aid in clarifying historical details, which in turn can support or negate the provided information. Similarly, a child may, at times, present with a caregiver who was not present at the time the injury was sustained, resulting in incomplete information. When the injury is atypical for the child’s age and development, attempting to obtain a more complete history from the caregiver who was present is strongly encouraged, which may require support from community partners as well.  

Whenever a child is injured, a complete history regarding the circumstances surrounding the injury, as well the injury itself, is essential. As with any medical history, the provider should aim to obtain a history of present illness, past medical history, and review of systems. Basic questions to address the history of present illness include the following:

• When was the child last seen completely well (no symptoms, no caregiver concern whatsoever)?

• What was the date and time of the injury and when was it first noted, and how does it relate to the time of presentation?

• Where did the injury occur?

• Who witnessed the injury?

• What was happening prior to the injury?

• How did the child respond to the injury?

• What did the child do after the injury (ie, did the child resume normal activity)?

• What did the caregiver do after the injury?

• How long after the injury did the caregiver wait until seeking care for the child and how reasonable was that time?

• What prompted the caregiver to seek care?

• What symptoms was the child exhibiting, and what, if any, remedies did the caregiver attempt?

• Inquire about specific details related to the injury, such as distance and landing surface (if a fall) and temperature of water (if scald burn), among others.

In cases of maltreatment, the history is often inaccurate and misleading. The following historical elements should raise concerns for possible physical abuse:

• Details change, or additional scenarios are suggested, as additional trauma is identified or as the cause of the trauma is questioned

• Details are inconsistent among caregivers

• Caregivers provide implausible details not congruent with the trauma observed on examination

• Caregivers describe minor trauma, but the child displays major injury on examination

• No history of trauma is offered in a child whose development requires caregiver attention (ie, non-mobile infants)

• Injury described as self-inflicted is not possible given the age and developmental abilities of the child

• Caregivers demonstrate a significant and unreasonable delay in seeking treatment for the child

• Serious injury is attributed to a younger sibling or playmate

The past medical history should be explored for general health as well as previous trauma and hospitalizations. The source of healthcare and the developmental and social aspects of the child's life should also be explored. The following historical elements on review of systems should raise concerns for possible physical abuse:

• History of prior injuries attributed to benign causes, particularly in infants, such as intraoral bleeding, subconjunctival hemorrhages outside of the neonatal period, and bruising (see Physical below)

Physical examination of the child with an injury is crucial and the order of the complete examination is determined by the presenting condition of the child. Children with less severe injuries in stable condition can have the injured area examined last, since that area is most likely to be uncomfortable. Severely injured children in critical condition require life-saving measures first, following the standards of care for trauma life-support; other components of the examination follow from that point.

Because physical abuse often results from an ongoing pattern of unsafe care,[27]  performing a thorough head-to-toe examination is essential in order to identify other areas of either current or previous injury. 

Photodocumentation of cutaneous injuries, such as burns, bite marks, bruises, or other injuries, is very important and helpful in cases of child abuse. Quality photodocumentation includes 1) an orienting picture to the adjacent anatomical landmarks, 2) a close-up, focused photograph of the injury, and 3) a photograph of the injury with a measurement standard.

Photodocumentation, when used as an adjunct to standard medical written documentation, allows consulting physicians, child protective services (CPS) workers, law enforcement officials, attorneys, and others to view and better comprehend the injuries. It allows for discussion and peer review as well as for assessment of the finding’s evolution. Furthermore, quality photographs of injuries may be very helpful in legal proceedings. Photodocumentation should be performed in accordance with institutional policies and procedures and should be treated as protected health information under the Health Insurance Portability and Accountability Act (HIPAA).

This section will describe findings on physical examination, as well as radiological findings, that should elicit concern for child physical abuse. These include, but are not limited to, the following: 

• ​​Injury inconsistent with the history provided, especially if incongruent with a patient’s developmental capabilities

• Injuries at various stages of healing, such as multiple fractures 

• Presence of patterned cutaneous injuries, including immersion burns

• Multiple injuries or multiple types of injuries involving different body systems; for example, a constellation of findings involving subdural hemorrhage, retinal hemorrhages, and skeletal or cutaneous injuries

Sentinel injuries[28]  are important to recognize and every examination of an infant should include sentinel injury surveillance. Sentinel injuries are typically minor injuries in young non-mobile infants often identified incidentally and commonly dismissed given their perceived harmlessness. However, sentinel injuries have been found to commonly precede more serious, and even fatal, inflicted injuries. Sentinel injuries, when identified, should not be disregarded and, instead, should prompt further evaluation for occult injury and consideration of underlying physical abuse. Sentinel injuries include: 

• Any bruise in a non-ambulatory child, especially infants < 5 months old

• Oral injuries in infants such as frenula tears, lacerations or bruising to the palate or the pharynx, bruising to the lips, gums, or tongue

• Subconjunctival hemorrhages in otherwise healthy infants outside of the neonatal period. Birth-related subconjunctival hemorrhages typically resolve in 2–3 weeks. In healthy infants, subconjunctival hemorrhages do not typically result from infant crying or straining, and instead should raise concern for trauma (See DDx for more detail).

Bruising, particularly over bony prominences (ie, anterior shins, knees, elbows, forehead), is common in childhood once a child becomes mobile and ambulatory. A bruising clinical decision rule, TEN-4 FACESp, has been validated for helping to distinguish concerning bruising or mucocutaneous injuries in young children from typical childhood injuries.[29] Specifically, this clinical decision rule highlights that the following distribution of mucocutaneous injuries should elicit concern for physical abuse: 

• Any bruising in infants younger than 5 months, (see sentinel injuries above) 

• Bruising or mucocutanoues injury in children younger than 4 years old involving the following body areas (“TEN-4 FACES”): 

  • Torso

  • Ear(s)

  • Neck

  • Frenulum

  • Angle of the jaw

  • Cheeks (face, fleshy)

  • Eyelids 

  • Subconjunctiva (ie, subconjunctival hemorrhage)

• Bruising in a patterned ("-p") distribution, such as grab/squeeze marks, slap marks, spank marks, human bite marks, and marks consistent with implements (ie, loop marks, belt marks)

• Bruising to the genitals, buttocks, palms, and soles should also elicit significan concern, as well as bruising over body areas that do not overly bony prominences 

Skeletal injuries in children younger than 2 years may not be obvious and many fracture types can be accidental or inflicted. While there is no pathognomonic fracture for abuse, fractures and fracture features that should elicit concern for physical abuse include the following:​

• Any fracture in a nonambulatory infant without clear accidental and consistent mechanism

• Metaphyseal fractures (ie, classic metaphyseal lesions)

• Posterior rib fractures (see image below)

• Multiple fractures in different stages of healing

• Atypical fractures such as spinous process fractures and scapular fractures

Burn injuries that may suggest physical abuse include the following:

• Patterned contact burns in clear shape of hot object (eg, fork, clothing iron, curling iron, cigarette lighter) (see image below)

• Immersion burn pattern with sharp demarcation, stocking and glove distribution, and sparing of flexed protected areas or doughnut-hole sparing of the buttocks

• Splash/spill burn patterns not consistent with history or developmental abilities

• Cigarette burns

• Bilateral or mirror-image burns

• Localized burns to genitals, buttocks, and perineum (especially during a child's toilet-training phase)

• Burns in addition to other concerning injuries (ie, atypical bruising, fractures, etc.)

• Unreasonable excessive caregiver delay in seeking treatment

Other injuries that may prompt concern for child physical abuse include: 

• Intracranial hemorrhage, especially, subdural hemorrhage in the absence of a known underlying medical condition, particularly in infants. Diffuse or interhemispheric subdural hemorrhage in a young child or infant presenting with altered mental status should prompt additional evaluation for occult injury and consideration of inflicted injury. 

• Intra-abdominal solid organ or hollow viscus injuries, particularly in infants or young children, in the absence of a clear and consistent history of trauma.  

• Anogenital injuries are relatively uncommon, but important to recognize. Degloving penile injury, vaginal lacerations, anal lacerations, or colon perforations may require subspecialty evaluation and management (ie, pediatric urology, pediatric gynecology, and pediatric surgery).  Other, relatively minor injuries, such as bruising or superficial lacerations, may also be present and warrant close attention and documentation. Of note, vulvovaginal injury and vaginal penetrative trauma elicits concern for sexual abuse, which is beyond the scope of this article.

No one single cause has been identified to explain the occurrence of all cases of physical abuse. See Background for more detail.

The history and physical examination findings guide which laboratory and diagnostic imaging studies are necessary. Underlying medical conditions are often a consideration in the differential diagnosis of child physical abuse, and depending on the presenting finding(s), screening for potential physiological abnormalities is generally recommended (see DDx for more details).

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 workup. 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. 

The history and physical examination findings guide which laboratory and diagnostic imaging studies are necessary.

Bleeding concerns

If the patient presents with physical or radiological findings eliciting a differential diagnosis that includes a bleeding disorder, such as bruising or intracranial hemorrhage, a basic bleeding evaluation is a valuable screening tool and includes: 

• Complete blood count (ensure platelet count is included)
• Prothrombin time (PT)
• Activated partial thromboplastin time (aPTT)

Factor VIII, Factor IX, and von Willebrand assays are also recommended in initial screening for immobile children presenting with unexplained and concerning bruising. The prevalence of von Willebrand Disease, however, does not elicit significant concern when a patient presents with isolated intracranial hemorrhage, therefore von Willebrand assay is not recommended as initial screening in these cases.[37]

Consultation with pediatric hematology may be warranted to guide further laboratory workup and contextualize abnormal results.

Bone concerns

If a patient is found to have a skeletal injury (ie, fractures) eliciting a differential diagnosis that includes genetic bone disease or mineralization defect, the following screening levels are recommended:

• Serum calcium
• Serum magnesium
• Serum phosphorus
• Alkaline phosphatase levels, recognizing that levels may be elevated with fractures

Additionally, vitamin D 25-OH and intact PTH levels may also be appropriate.[38]

Interpretation of vitamin D levels in children is complex due to lack of robust evidence establishing normal values and thresholds below which bones would be clinically more susceptible to fracture. While vitamin D does have an important role in bone health and growth, the scientific evidence has failed to support correlation between low vitamin D levels and fractures in the absence of radiologically evident rachitic changes. 

Review of radiographs with a pediatric radiologist is ideal to evaluate bones for signs of poor growth, skeletal dysplasias, osteopenia, and abnormal healing. 

Abnormal lab results may warrant contextualization and clarification from a pediatric endocrinologist.

Similarly, genetics consultation may be warranted, particularly when considering genetic testing for conditions such as osteogenesis imperfecta. Genetic consultation is also paramount for the interpretation of genetic testing results and to guide subsequent testing, if warranted.[35]

Occult abdominal trauma screening

Screening for abdominal injury is currently recommended in young children who present with injuries concerning for physical abuse, even in the absence of clear external evidence of abdominal injury or symptoms such as tenderness, distention, or abdominal bruising.[39, 40] Note the image below. 

Screening recommendations for occult abdominal trauma include:

• aspartate aminotransferase (AST) 
• alanine aminotransferase (ALT) 

An AST or ALT value greater than 80 IU/L has been proposed as a cutoff to guide subsequent imaging (see Imaging for more details). 

Prior recommendations have also suggested screening with amylase and lipase levels for pancreatic injury, urine analysis for red blood cells to evaluate for urinary tract injury, and stool guaiac for intestinal injury. However, these markers are no longer supported for routine screening given insufficient evidence. Instead, obtaining these markers should be guided by clinical findings.  

Toxicology screening

Toxicology screening is indicated if the clinical situation suggests a possible ingestion as the cause of the findings on examination. For example, unexplained altered mental status, particularly in young, otherwise healthy children in the absence of intracranial injury, should elicit concern for occult intoxication. 

Often, a child presents from a household where drug use or production is suspected or confirmed. While there is no clear evidence-based recommendations, it is encouraged that treating physicians guide their evaluation by clinically relevant findings rather than by forensic purposes.

Urine and serum toxicology screening with corresponding confirmatory testing is the preferred method of testing.

While hair testing is often brought up as a forensically relevant method to assess drug exposure, it is not clinically useful and is not recommended in the acute setting.[41]

Consultation with medical toxicology may be warranted for interpretation of findings and to guide subsequent testing.

Other laboratory testing

Child physical abuse is a form of trauma and its evaluation should reflect as such. While the above recommendations stem from specific injury-guided research, the comprehensive evaluation of a child with suspected child physical abuse should reflect the child’s underlying injury. 

For example, blunt chest trauma may elicit concern for cardiac injury and may prompt troponin levels, while significant muscle injury may prompt creatine kinase levels. Testing, nonetheless, should be performed in accordance to standard of care and, whenever available, evidence-based guidelines. 

In addition to a comprehensive history and physical exam, radiological imaging is an important part of the evaluation of child physical abuse. Many injuries (such as fractures, brain trauma, and abdominal trauma) are not necessarily associated with external signs of trauma. Additionally, while many injuries may in fact be externally evident, clinically vague or silent injuries can often be identified with appropriate imaging and clinicians should maintain a high index of suspicion. This section will discuss indications of common imaging modalities involved in the evaluation of child physical abuse as per the American Academy of Pediatrics (AAP) and American College of Radiology (ACR) guidelines[42] (see Imaging in Child Abuse for additional details).

Skeletal survey

A skeletal survey is indicated in children ≤ 24 months old with concerns for child physical abuse; concerns may be prompted by injuries recognized on prior imaging such as another skeletal injury, brain injury, solid organ or hollow viscus injury, or by external signs of trauma (ie, mucocutaneous injury). A skeletal survey helps the physician assess for occult, clinically subtle, acute or healing fractures.[42]  It is important to differentiate between a skeletal survey and a babygram; a babygram is a non-targeted single radiograph of an infant's entire body and is not appropriate for occult injury screening purposes. 

When a skeletal injury concerning for physical abuse is identified or when the initial skeletal survey is negative, but significant concern for abusive injury persists, a follow-up skeletal survey is typically recommended 10–14 days after the initial skeletal survey is performed in children ≤ 24 months old; exclusion of the pelvis, spine, and skull films – if initially negative – can be considered to decrease radiation exposure.[43] A retrospective study of children assessed with skeletal surveys to evaluate for missed physical abuse and unsuspected fractures found that about 11% of the survey results were positive for a previously unsuspected fracture. The skeletal survey results directly influenced the diagnosis of abuse in 50% of the children with positive skeletal survey results.[44]

In children between 24 and 36 months old, the yield of the skeletal survey is believed to be lower than in those ≤ 24 months; however, the exact yield is unclear. A skeletal survey can be considered in this age group, particularly for children with significant injuries who are unable to localize pain. 

Children > 36 months are typically best imaged by way of focused radiographs of areas of concern rather than a complete skeletal survey. Areas of concern should be determined by the physical exam.

For close contacts of children ≤ 24 months with findings concerning for child physical abuse, the clinician should also consider they undergo a skeletal survey given a well-recognized increased risk of abuse in close contacts sharing an abusive care environment.[45]

Recommendations have supported the use of bone scintigraphy (ie, radionucleotide bone scan) as an adjunct to the skeletal survey, particularly when rib fractures or subtle long bone fractures are unclear on initial skeletal survey and concern for physical abuse is significant. However, concerns persist regarding this modality’s availability, the need for venipuncture and sedation, and challenges to the interpretation of other bony findings detected as the scan may remain active for up to a year. 

Neuroimaging

Because cranial and intracranial injury are common findings prompting concern for inflicted injury in young children and infants, neuroimaging modalities are important in the evaluation of child physical abuse. The modalities most commonly used are the non-contrast head CT and brain MRI. 

Non-contrast head CT is the imaging modality of choice in children presenting with signs and symptoms concerning for intracranial injury (ie, seizures, altered mental status, vomiting without associated diarrhea, apnea, etc.). If an intracranial injury is identified on head CT, brain MRI can be a valuable adjunct to further define the injury, identify features suggesting injury chronicity, and detect diffusion-weighted imaging abnormalities and evolving parenchymal injury. Additionally, the brain MRI may provide prognostic information that may help guide follow-up management.[42]  

Unenhanced brain MRI with diffusion-weighted imaging (DWI), gradient echo sequence, or susceptibility-weighted imaging (SWI) is sensitive for the detection of parenchymal injury, signs of torn or thrombosed bridging veins, and small amounts of extra-axial hemorrhage. 

The brain MRI, in cases concerning for abusive head trauma, is generally performed in stable patients 72–120 hours following a suspected acute injury (ie, patients with acute neurological alteration or deterioration) to best detect DWI abnormalities or cytotoxic edema. 

Evidence supports that spinal injuries, particularly ligamentous injury and spinal subdural hemorrhage, are relatively common findings in abusive head trauma. While cervical MRI is typically recommended in conjunction with brain MRI, the utility and feasibility of routine whole-spine MRI continues to be debated. 

Of note, studies have increasingly supported the use of fast MRI sequences as an accurate and feasible alternative to non-contrast head CT, though this is not yet readily available in all institutions and has not yet replaced the head CT as the initial imaging modality of choice.[46]

In infants < 6 months old presenting with injuries concerning for child physical abuse (ie,mucocutaneous injuries, skeletal injuries, etc.), consideration of non-contrast head CT to screen for occult intracranial injury is generally recommended.[47] In infants between 6 and 12 months, recommendations vary. In general, non-contrast head CT should be considered, particularly if the infant presents with neurological concerns (ie,irritability, vomiting without diarrhea, seizures, poor feeding, etc.) or cutaneous injuries on exam.[48]  

Evidence supporting close contact screening for occult intracranial injury is limited. However, the risk of concomitant abuse has been well established.[45]  There are increased calls for standardization of close contact screening with neuroimaging, especially when an index child presents with findings concerning for abusive head trauma and contacts are infants.[49]  

Abdominal and thoracic imaging

Abdominal CT with IV contrast is recommended when there are concerns for abdominal solid organ or hollow viscus injury. Signs that may prompt imaging include abdominal wall bruising, abdominal tenderness or pain, or abdominal distention.

Currently a liver transaminase value (ALT or AST) > 80 IU/L in children presenting with injuries concerning for child physical abuse has been proposed as a cutoff prompting consideration of abdominal CT with IV contrast in the absence of abdominal signs.[50]  Research to refine this cutoff value is ongoing. 

Chest CT is not routinely recommended for occult injury screening, unless clinically indicated. Chest CT may be helpful to clarify thoracic injury, including rib fractures. The risk of radiation versus the benefit of injury clarification must be weighed when chest CT is used for screening purposes or as an adjunct to the skeletal survey. 

Ophthalmologic exam (dilated fundus examination)

One particular procedure important to consider when concerns for abusive head trauma arise is a dilated fundus examination (DFE).[51]  

This diagnostic procedure uses mydriatic (dilating) eye drops to dilate the pupil and allow visualization of the fundus, including the retina, optic disc, macula, blood vessels, and other features with the use of an indirect ophthalmoscope. Fundus photography is often an adjunct to the DFE and should be encouraged whenever possible to allow for peer discussion and accurate documentation. 

Generally, recommendations for DFE in the evaluation of child physical abuse are driven by the identification of intracranial hemorrhage, particularly subdural hemorrhage, which have in turn elicited concern for abusive head trauma. The DFE is best to complete within the first 72 hours of presentation, but preferable within the first 24 hours, to best characterize retinal findings. While some retinal injuries may persist beyond 72 hours, the full extent of the presenting injuries may rapidly evolve and resolve.[52]  

The DFE should be performed by pediatric ophthalmology whenever possible (see Consultations). Concerns for acute neurological deterioration may require close monitoring of pupillary response, in turn delaying DFE. While less preferable, DFE after 72 hours may still be useful rather than deferring the examination altogether, although caution should be exerted when interpretating the findings. 

Close multidisciplinary coordination between involved subspecialties (ie, child abuse pediatrics, neurosurgery, critical care, and pediatric ophthalmology) is typically warranted (see Consultations for more detail).

Treatment for physical abuse is a complex endeavor involving an interdisciplinary team approach. The nature of the injury determines the form of medical therapy indicated. Similarly, psychosocial management is an important part of the approach to child physical abuse, and the details gathered during an investigation regarding the caregiving environment help determine the psychosocial support and interventions needed to keep the child safe.

General medical management

Injury due to child physical abuse can fall along a continuum of injury severity, requiring an equivalent level of medical care. For example, the most severely injured children, such as those with CNS injury, may require resuscitation and admission to intensive care with close management by critical care specialists. Tertiary hospital care is likely indicated for the more complex and severe injuries.

As with any trauma patient, a prompt response and stabilization with adequate assessment of airway, breathing, and circulation is paramount to improve outcomes and prognosis. A multitude of specialists may need to be involved in order to correctly evaluate and treat these seriously ill children (see Consultations for more detail). 

However, injury severity may not be the only factor driving medical intervention. For example, in young infants presenting with sentinel injuries, while the injury itself may be clinically minor, the concern it elicits and the risk to the infant if unaddressed is significant. Such injuries may result in admission for further medical workup, such as for occult injury, as well as pending safety planning by corresponding community partners. 

Psychosocial management 

Psychosocial management complements the medical management and typically requires a significant amount of coordination among various service providers, including the primary physician, consultants, and other healthcare providers. Involvement of a medical social worker is important to address caregiver concerns, determine child and family needs, and provide support during the child’s hospitalization. 

All 50 states, as well as the District of Columbia, the Commonwealth of Puerto Rico, and the US territories of American Samoa, Guam, the Northern Mariana Islands, and the Virgin Islands have statuses requiring mandated reporting of reasonable concerns for child maltreatment to child protective services or law enforcement agencies. Transferring a child’s care to another physician or hospital does not relieve the medical provider of their reporting responsibilities. In addition, thorough documentation in medical records and effective communication with investigators may improve outcomes of investigations and protect vulnerable children.[1]

The child protective services (CPS) agency in each community is responsible for performing investigations of cases in which physical abuse is a significant concern and often relies on the physicians to provide the details of the medical evaluation that have prompted or supported concerns. In addition, CPS assesses the caregivers' background, caregiving abilities and potential, environmental safety, risk for repeat abuse, and risk to other siblings. A variety of CPS service plan options are available, ranging from periodic contact with the child and family to removal of the child from the home, either temporarily or permanently, with termination of parental rights. Resources to aid in social needs are often provided as well. The CPS process for child maltreatment cases typically involves (1) screening of the report, (2) risk assessment and investigation of the accepted case (including caregiver interviews, medical information gathering, home evaluation, and possibility of contact with law enforcement), and finally, (3) determination of short and long-term safety plan for the child.

In many cases, law enforcement officials also become involved in the investigation. However, CPS and law enforcement are separate entities with different responsibilities and goals. It is important to remember that medical providers support the investigation but are not investigators themselves. Objective evaluation and interaction with caregivers is the cornerstone to effective management.  

Injuries resulting from child maltreatment may also require surgical intervention. As with medical care, surgical care is guided by the injuries sustained and may include numerous surgical specialties and subspecialties (see Consultations for more detail). 

As with medical and surgical care, the injuries identified guide specialty and subspecialty consultation.

• Child abuse pediatrics is a pediatric subspecialty certified by the American Board of Pediatrics.[53] Child abuse pediatricians (CAPs) specialize in understanding mechanisms of injury in cases that elicit concern for physical abuse, as well as in the evaluation and management when physical abuse and other forms of child maltreatment are considered. CAP expertise should be sought whenever possible in cases concerning for child abuse; their involvement can guide an evidence-based, comprehensive evaluation and either support concerns for physical abuse or identify an alternative explanation for the finding of concern.[54]

In addition to child abuse pediatrics, specific injuries and findings warrant consultation with specific pediatric specialties and subspecialties:

• Pediatric radiology – Routine involvement by a pediatric radiologist is ideal. Fractures commonly associated with inflicted injury are often subtle and can readily be missed without pediatric radiology expertise (ie, rib fractures, CMLs). Additionally, pediatric radiologists are instrumental when discussing dating of radiological findings and its limitations. Finally, pediatric radiologists are important in determining whether skeletal dysplasias or metabolic bone disease should be of particular concern when assessing skeletal injury. If a pediatric radiologist is not routinely available, attempts to consult one should be pursued when the specific scenarios described (ie, concern for underlying bone disease, dating fractures) are encountered in cases of physical abuse.

• Pediatric orthopedics – Pediatric orthopedic surgeons should be involved in the diagnosis and management of muscoloskeletal injury, particularly skeletal fractures, such as long bones, which typically require intervention. Pediatric orthopedic surgeons guide recommendations regarding casting and surgery, as well as follow-up to ensure appropriate healing.

• Pediatric neurosurgery– Some of the most severe injuries resulting from physical abuse involve the brain and intracranial contents. Intracranial hemorrhage, such as subdural hemorrhage, is common and warrants prompt evaluation by pediatric neurosurgery to guide further management recommendations, including potential surgical intervention.

• Pediatric ophthalmologists – Pediatric ophthalmologists are crucial to the comprehensive evaluation when abusive head trauma is considered. Serial follow-up with pediatric ophthalmology may be warranted for particularly extensive retinal injury, as well as vision follow-up. 

• Plastic surgery – Plastic surgeons may be needed to assist with the management of severe burns. Burns vary in severity and treatments range from cleansing the area to skin grafting; transfer to a burn unit may be indicated. 

• Physical medicine & rehabilitation (PM&R) – Children with particularly severe injuries, such as CNS injury and severe burns, will require close monitoring and a rehabilitation plan. Involving PM&R early in the child’s clinical course will help ensure a treatment plan is promptly established to help ensure the best prognosis. 

• Child psychiatry and/or behavioral-developmental pediatrics – The sequelae of child physical abuse is extensive and not only involves the child’s physical health but also their emotional health and their development. These subspecialists are helpful in assessing the child’s mental health needs, as well as to coordinate an overall psychosocial treatment plan. 

The following specialty and subspecialty consultations, while not always warranted, should be considered in the corresponding clinical scenarios:  

• Pediatric hematology – can assist with the interpretation of abnormal hematologic screening labs or with the evaluation, diagnosis, and management of bleeding disorders.

• Pediatric endocrinology– can assist with the interpretation of abnormal bone labs or when clinical details elicit heightened concern for metabolic bone disease.

• Genetics – should be consulted when concern for genetic disorders, such as osteogenesis imperfecta or other collagen disorders is heightened and when the interpretation of genetic testing results is warranted.[35]

Other subspecialty consultation, depending on the injury identified, may include the following:

• Pediatric neurology for seizure management and neurological deficits 

• Pediatric gynecology or pediatric urology for genital injury

• Pediatric otorhinolaryngology (ear, nose, and throat surgery) for injuries involving structures of the ears, nose, and throat such as trauma to the ear canal, injury to the nasal cartilage, or pharyngeal injury

• Pediatric maxillofacial surgery and pediatric dentistry for facial, oral, and dental trauma

• Pediatric dermatology for skin lesions that may require further evaluation and management 

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.