Summary
Definition
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
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
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
Diagnostic investigations
1st investigations to order
- CBC
- 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
reasonable concern for, or high likelihood of, child abuse
Contributors
Authors
Amy Rindfleisch Gavril, MD, MSCI, FAAP
Commander
Medical Corps
United States Navy
Director, Education and Training
Armed Forces Center for Child Protection
Walter Reed National Military Medical Center
Bethesda
MD
Disclosures
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.
Acknowledgements
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
Seattle
WA
Disclosures
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
Columbus
OH
Disclosures
JT is an author of a reference cited in this monograph.
Differentials
- Coagulopathy
- Osteogenesis imperfecta (OI) and other bone fragility disorders
- Glutaric aciduria
More DifferentialsGuidelines
- Children exposed to maltreatment: assessment and the role of psychotropic medication
- ACR Appropriateness Criteria: head trauma: child
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