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Child abuse

Last reviewed: 30 Oct 2023
Last updated: 25 Jul 2023



History and exam

Key diagnostic factors

  • inconsistent/changing history
  • unexplained/inconsistent injuries in isolation or in combination
  • bruising
  • subdural hemorrhages in an infant/young toddler
  • long bone fractures in a premobile child
  • multiple fractures of different ages and bilateral fractures
  • rib fractures in the absence of major trauma or pathologic causes
  • immersion scalds
  • family known to social services
  • small bowel perforation in a child <3 years of age
  • torn frenum
More key diagnostic factors

Other diagnostic factors

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

Risk factors

  • domestic violence
  • substance abuse/mental health disorder in parent/caregiver
  • excessive crying and/or frequent tantrums in infancy
  • lack of maturity/poor coping skills in parent/caregiver
  • parent/caregiver abused as a child
  • poor socioeconomic status
  • demanding parenting role
More risk factors

Diagnostic investigations

1st investigations to order

  • CBC
  • clotting profile/coagulation studies
  • dilated funduscopy
  • photo-documentation of injuries
  • skeletal survey
  • CT brain
  • LFTs/amylase/lipase
  • serum calcium
  • serum phosphate
  • serum alkaline phosphatase
  • serum parathyroid hormone
  • serum 25-hydroxyvitamin D
  • urinalysis
More 1st investigations to order

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
More investigations to consider

Treatment algorithm


reasonable concern for, or high likelihood of, child abuse



Marcella M. Donaruma-Kwoh, MD, FAAP

Associate Professor of Pediatrics

Baylor College of Medicine

Division of Public Health Pediatrics

Texas Children's Hospital




MMD declares that she has no competing interests.


Dr Marcella M. Donaruma-Kwoh would like to gratefully acknowledge Dr James L. Lukefahr and Dr Amy R. Gavril, previous contributors to this topic.


JLL and ARG declare no competing interests.

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 topic.

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 topic.

  • Differentials

    • Coagulopathy
    • Osteogenesis imperfecta (OI) and other bone fragility disorders
    • Glutaric aciduria
    More Differentials
  • Guidelines

    • Evaluation for bleeding disorders in suspected child abuse
    • Evaluation of suspected child physical abuse
    More Guidelines
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