Last reviewed: 30 Oct 2021
Last updated: 14 Feb 2020



History and exam

Key diagnostic factors

  • presence of risk factors
  • inconsistent/changing history
  • unexplained/inconsistent injuries in isolation or in combination
  • bruising
  • subdural haemorrhages in an infant/young toddler
  • long-bone fractures in a pre-mobile child
  • multiple fractures of different ages and bilateral fractures
  • rib fractures in the absence of major trauma or pathological causes
  • immersion scalds
  • family known to social services
  • small bowel perforation in a child <3 years of age
  • torn frenum

Other diagnostic factors

  • poor parent-child bonding
  • faltering growth
  • dental neglect
  • petechiae with bruising
  • extensive, multilayered retinal haemorrhages extending to periphery
  • apnoea
  • cigarette burns
  • frequent accidental poisonings
  • contact burns
  • dental injuries
  • caustic burns

Risk factors

  • domestic violence
  • substance abuse/mental health disorder in parent/carer
  • excessive crying and/or frequent tantrums in infancy
  • lack of maturity/poor coping skills in parent/carer
  • parent/carer abused as a child
  • poor socio-economic status
  • demanding parenting role

Diagnostic investigations

1st investigations to order

  • FBC
  • clotting profile/coagulation studies
  • dilated funduscopy
  • photo-documentation of injuries
  • skeletal survey
  • CT brain
  • LFTs/amylase
  • serum calcium
  • serum phosphate
  • serum alkaline phosphatase
  • serum parathyroid hormone
  • serum 25-hydroxyvitamin D

Investigations to consider

  • radionuclide bone scan
  • MRI brain/spine
  • ultrasound abdomen
  • CT abdomen
  • platelet function studies and von Willebrand factor assays
  • x-ray mouth
  • forensic dental referral
  • forensic swabs for DNA
  • toxicology testing

Treatment algorithm



Amy Rindfleisch Gavril, MD, MSCI, FAAP


Medical Corps

United States Navy

Director, Education and Training

Armed Forces Center for Child Protection

Walter Reed National Military Medical Center




ARG declares that she has no competing interests. The view(s) expressed herein are those of the author and do not reflect the official policy or position of Walter Reed National Military Medical Center, the US Navy Bureau of Medicine, the US Navy Office of the Surgeon General, the Department of the Navy, Department of Defense, or the US Government.


Dr Amy R. Gavril would like to gratefully acknowledge Dr James L. Lukefahr, a previous contributor to this monograph, and the assistance of Dr Alison Kemp, Dr Sabine Maguire, and Kim Rolfe (Research Officer). JLL and KR each declare that they have no competing interests. AK and SM are the authors of a number of references cited in this monograph.

Peer reviewers

Naomi Sugar, MD

Clinical Professor

Department of Pediatrics

University of Washington School of Medicine




NS is an author of a number of references cited in this monograph.

Jonathan Thackeray, MD

Clinical Associate Professor

Department of Pediatrics

Center for Child and Family Advocacy

Columbus Children's Hospital




JT is an author of a reference cited in this monograph.

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