Last reviewed: July 2020
Last updated: April  2018



History and exam

Key diagnostic factors

  • presence of risk factors
  • age <3 years
  • altered mental status: irritability/lethargy/coma
  • clinical findings inconsistent with carer history
  • retinal/vitreal haemorrhages or retinoschisis

Other diagnostic factors

  • no known history of trauma
  • apnoea
  • seizure
  • vomiting
  • loss of muscle tone
  • brisk or asymmetrical reflexes
  • unexplained bruising
  • increasing head circumference
  • bulging fontanelle
  • long-bone fractures
  • mucosal injury or torn labial/lingual frena
  • anogenital signs and symptoms

Risk factors

  • age <1 year
  • peak of normal crying curve
  • male carer
  • unrelated adult household member
  • male sex
  • socio-economic stressors

Diagnostic investigations

1st investigations to order

  • cranial CT scan
  • FBC
  • liver function tests
  • toxicology screen
  • prothrombin time (PT)/aPTT/fibrinogen/von Willebrand’s testing
  • urinalysis
  • CSF analysis
More 1st investigations to order

Investigations to consider

  • cranial MRI
  • cranial ultrasound
  • skeletal survey
  • bone scintigraphy
  • blood culture
  • serum calcium
  • serum 1,25-dihydroxy vitamin D levels (calcidiol)
  • serum inorganic phosphorus
  • serum parathyroid hormone (PTH)
  • serum alkaline phosphatase
  • skin biopsy/fibroblast culture
  • post-mortem examination
More investigations to consider

Treatment algorithm


Consultant in PICU

Senior Research Fellow

Birmingham Children’s Hospital




BS receives grant funding from the UK NIHR Clinician Scientist Fellowship programme.

Dr Barney Scholefield would like to gratefully acknowledge Dr Joe Brierley, Dr Gavin Wooldridge, and Dr Alice Newton, previous contributors to this monograph. JB, GW, and AN declare that they have no competing interests.

Peer reviewersVIEW ALL

Attending Physician

Child Protection Team

Hasboro Children's Hospital

Assistant Professor of Pediatrics

Alpert Medical School

Brown University




AG declares that she has no competing interests.

Division Chief

Child Protection Program

UMass Memorial Medical Center




RM declares that she has no competing interests.

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