A world-wide phenomenon that can affect children of all ages; however, the highest incidence of abuse occurs to infants and toddlers.
Four principal categories are defined: physical abuse, emotional abuse (also commonly referred to as psychological maltreatment), sexual abuse, and neglect. Children may fall under 1 or a combination of the different categories.
An ongoing process that can take place in a family, institutional, or community setting, either by someone close to the child, such as a parent or primary caregiver or, more rarely, by a stranger.
Determining whether injuries have been caused accidentally or represent abuse is often challenging. Finding 1 or more suspicious injuries in a child should warrant a full evaluation to look for other injuries typical of abuse.
While legislation such as mandatory reporting varies among countries, the over-riding principle of "paramountcy" (i.e., that the welfare of the child is paramount) is universal.
Child abuse (including neglect) is any form of maltreatment of a child, either by inflicting harm or by failing to act to prevent harm. Children may be abused in a family, institutional, or community setting, by those close to them, such as a parent or caregiver or, more rarely, by a stranger. They may be abused by adults or by other children. There are 4 categories of child abuse: physical abuse, emotional abuse (also called psychological maltreatment), sexual abuse, and neglect. This monograph primarily addresses physical child abuse. For information on sexual child abuse, please see our detailed content on sexual abuse.
History and exam
Key diagnostic factors
- presence of risk factors
- inconsistent/changing history
- unexplained/inconsistent injuries in isolation or in combination
- 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
- cigarette burns
- frequent accidental poisonings
- contact burns
- dental injuries
- caustic burns
- 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
1st investigations to order
- clotting profile/coagulation studies
- dilated funduscopy
- photo-documentation of injuries
- skeletal survey
- CT brain
- 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
reasonable concern for, or high likelihood of, child abuse
Amy Rindfleisch Gavril, MD, MSCI, FAAP
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.
Naomi Sugar, MD
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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