Child Abuse

Descriptive text is not available for this image BASICS

DESCRIPTION

  • Types of abuse: neglect (most common and highest mortality), physical abuse, emotional/psychological abuse, sexual abuse, and sexual exploitation
  • Neglect includes physical (e.g., failure to provide necessary food or shelter or lack of appropriate supervision), medical (e.g., failure to provide necessary medical or mental health treatment), educational (e.g., failure to educate a child or attend to special education needs), and emotional (e.g., inattention to a child’s emotional needs, failure to provide psychological care, or permitting the child to use alcohol or other drugs).
  • System(s) affected: gastrointestinal (GI), endocrine/metabolic, musculoskeletal, nervous, renal, reproductive, skin/exocrine, pulmonary, cardiac, immune, and psychiatric
  • Synonym(s): nonaccidental trauma; child maltreatment; inflicted injury

EPIDEMIOLOGY

Prevalence

Children’s Bureau report for federal fiscal year (FFY) 2022 (1):

  • Child Protective Services agencies received an estimated 4.3 million referrals alleging maltreatment, with a national screened-in referral rate of 29.0 referrals per 1,000 children.
  • Approximately 3 million children received either an investigation or alternative response. Of those investigated, 588,899 children (7.7 per 1,000) were found to be victims of abuse or neglect.
  • Neglect is the most common type of reported maltreatment at 74%, followed by physical abuse at 17% and sexual abuse at 10.6%.
  • The overall rate of child fatalities was 2.73 deaths per 100,000 children in the national population. The rate of child fatalities is slightly higher in boys compared to girls.
  • The majority of perpetrators are the parents of their victims (76.0%).

RISK FACTORS

  • American Indian or Alaska Native children had the highest rates of victimization.
  • Children from birth to 1 year had the highest rate of victimization 22.2 per 1,000 infants and highest rate of mortality.
  • Females have a slightly higher rate of victimization vs males.
  • Military families are at risk, especially with deployment.
  • Child risk factors: chronic illness, physical/congenital disability, developmental delay, preterm, unintended pregnancy
  • Caregiver risk factors : poverty, substance misuse, lower educational status, parental history of abuse, parental mental health issues, young and/or unmarried mother, poor support network, and domestic violence

GENERAL PREVENTION

  • Screen for risk factors at prenatal, postnatal, and pediatric visits.
  • Physicians can educate parents on a range of normal behaviors to expect in infants and children: for example anticipatory guidance on ways to handle crying infants; methods of discipline for toddlers

COMMONLY ASSOCIATED CONDITIONS

Failure to thrive, prematurity, developmental delays, poor school performance, poor social skills, low self-esteem, anxiety or depression

Descriptive text is not available for this image DIAGNOSIS

  • Relatively minor skin injuries, frenulum tears, or bruising in precruising infants may be the first indications of child physical abuse. These relatively minor, unexplained injuries have been termed “sentinel injuries.”
  • 27.5% had a sentinel injury (80% a bruise), 41.9% of those cases, HCW was aware of the injury (2)
  • Infants with injuries caused by child abuse often present with vague complaints.
  • Documentation
    • Critical elements include the following:
      • Brief statement of child’s disclosure or caregiver’s explanation, including any alternate explanations offered (Use direct quotations when possible.)
      • Time the incident occurred and date/time of disclosure
      • Whether witnesses were present
      • Developmental abilities of child
      • Objective medical findings
      • Other at-risk children in the household (siblings)
  • DO NOT use terms such as “rule out,” “R/O,” and “alleged.” Clearly state objective findings and medical provider’s opinion.
  • Obtain history from caregiver separately from the child.
  • Any description of abuse given by the child should be documented word for word using quotation marks in the child’s own language and attributed to the child whenever possible.
  • The child should not be rewarded after a disclosure (e.g., “Tell me what happened, and you can go back to your mom. . .”).
  • Documentation should include disposition of patient and record any report made to child welfare.

HISTORY

  • Use nonjudgmental, open-ended questions (ask: who, what, when, and where; NEVER why).
  • Document past medical history, developmental history, child’s temperament, and thorough social history including objective documentation of family interactions.
  • History of a sentinel injury should prompt consideration of abuse.
  • The following historical elements may suggest abusive injury:
    • History that is inconsistent with the injury or with the child’s developmental level
    • No explanation offered for the injury or injury blamed on sibling or another child
    • Important detail of explanation changes dramatically
    • Different witnesses provide different history.
    • There is delay in seeking treatment.
    • Denial of trauma in a child with injury
  • Nonspecific symptoms of abuse:
    • Behavior changes; self-destructive behavior; anxiety and/or depression
    • Sleep disturbances, night terrors; school problems

PHYSICAL EXAM

  • Examine child in a comfortable setting:
    • Explain what the exam will involve and why procedures are needed.
    • Allow child to choose who will be in the room.
    • Completely undress the child and have them wear a gown to perform a complete physical examination, including thorough skin exam.
  • Complete a general assessment for signs of physical abuse, neglect, and self-injurious behaviors:
    • Measurements, photographs, and careful objective descriptions are critical for accurate diagnosis.
  • A thorough physical exam includes:
    • Skin (completely undress, including diaper to visualize buttocks)
    • Head (including fontanels), eyes, ears, nose, and mouth (including frenulum)
    • Chest/abdomen
    • Anogenital area (visualization of external genital structures with labial separation and traction—no speculum)
    • Extremities
    • Review growth charts
  • Physical abuse findings
    • Skin markings (e.g., lacerations, burns, bruises, patterned injuries, bites)
    • Immersion injuries with clearly demarcated borders
    • Oral trauma (e.g., torn frenulum, loose teeth)
    • Ear bruising
    • Eye trauma (e.g., hyphema, subconjunctival hemorrhage)
    • Head/abdominal blunt trauma
    • Fractures
    • Patterns suggestive of abuse:
      • Bruises seen away from bony prominences (e.g., face, back, abdomen, arms, buttocks, ears, hands)
      • Multiple bruises in clusters or uniform shape
      • Patterned injuries (such as bite marks or the imprint of an object like a hand, belt, or cord) should be considered highly concerning for inflicted injury.
      • TEN-4-FACESp method to identify bruises suggestive of child abuse:
        • T: torso. E: ear; N: neck
        • 4: any bruise, anywhere on a child ≤4 months
        • F: frenulum; A: angle of jaw; C: cheeks; E: eyelids; S: subconjunctivae; p: patterned bruising
  • Sexual abuse findings
    • Unexplained penile, vaginal, hymenal, perianal, or anal injuries/bleeding/discharge
    • Pregnancy or sexually transmitted infections (STIs)
  • Neglect findings
    • Low-growth parameter trends, unclean, unkempt, rashes
    • Fearful or overly trusting
    • Abnormal development or growth parameters

DIFFERENTIAL DIAGNOSIS

  • Physical trauma mimics
    • Accidental injury; toxic ingestion
    • Bleeding disorders (e.g., von Willebrand disease, hemophilia)
    • Metabolic or congenital conditions
    • Conditions with skin manifestations (e.g., congenital dermal melanocytosis, Henoch-Schönlein purpura, meningococcemia, erythema multiforme, hypersensitivity, staphylococcal scalded skin syndrome, varicella, impetigo)
    • Cultural practices (e.g., cupping, coining)
  • Neglect mimics
    • Endocrinopathies (e.g., diabetes mellitus), constitutional growth delay
    • GI (clefts, malabsorption, irritable bowel), seizure disorder
  • Skeletal trauma mimics
    • Obstetrical trauma, nutritional (scurvy, rickets)
    • Infection (congenital syphilis, osteomyelitis)
    • Osteogenesis imperfecta

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

  • Directed by history and physical exam findings:
    • Urinalysis (abdominal/flank/back/genital trauma)
    • Complete blood count, coagulation studies
    • Electrolytes, creatinine, blood urea nitrogen, glucose
    • Liver and pancreatic function tests (abdominal trauma)
    • Guaiac stool (abdominal trauma)
  • In cases of suspected neglect:
    • Stool exam, calorie count, purified protein derivative and anergy panel, sweat test, lead and zinc levels
  • In cases of suspected sexual abuse:
    • STI testing:
      • Urine NAAT: gonorrhea, chlamydia, Trichomonas
      • Serum: HIV, hepatitis B and C serologies, syphilis
    • Urine/serum pregnancy test
  • In cases of suspected physical abuse:
    • Skeletal survey: 22 radiographs surveying each bone of the body, examining for evidence of acute or healing fractures
      • Recommended for:
        • Infants aged <6 months with bruising, regardless of pattern
        • Children <2 years with bruising concerning for abuse or domestic violence (see TEN-4-FACESp in Physical Exam section)
        • All children <2 years with fractures and poorly explained injuries
        • All children <2 years who live with an abused child should be evaluated
        • May also consider for any age child in which the patient has impaired mobility or communication skills
    • Noncontrast Head CT:
      • Consider brain magnetic resonance imaging (MRI) of head/neck/spine for further evaluation of more subtle findings, brain parenchyma, intracerebral edema, or hemorrhage.
      • All abused children with skull fracture found on skeletal survey
      • All infants <6 months (perhaps <1 year) when any physical abuse is suspected
      • All infants in whom nonaccidental head injury is suspected.
    • CT scan of abdomen with IV contrast:
      • Children with clinical concern for abdominal injury (abdominal bruising, peritonitis, or a positive abdominal ultrasound) or history of blunt abdominal trauma and abdominal tenderness
    • Dilated fundoscopic exam: Presence of retinal hemorrhages is highly concerning for abusive head trauma.
      • For any child with intracranial hemorrhage; within 24 to 72 hours of initial presentation
  • High risk imaging findings:
    • Fractures in nonambulatory patients (Children who are not walking or cruising rarely have bruising or fractures from “short falls.”)
    • Corner or bucket-handle fractures
    • Posterior rib fractures in infants
    • Injury to liver/spleen/pancreas in blunt abdominal trauma

Follow-Up Tests & Special Considerations

In cases of sexual abuse where there is concern for exposure to body fluids, forensic evidence kit collection may be indicated up to 120 hours post assault.

Descriptive text is not available for this image TREATMENT

MEDICATION

First Line

  • Consider antibiotics postexposure prophylaxis in postpubertal children as indicated for STIs. Of note, do not prophylactically treat prepubertal children with antibiotics for STIs.
  • If exposure to body fluids is of concern, consider HIV postexposure prophylaxis.
    ALERT

    Emergency contraception reduces rate of pregnancy after sexual assault:
  • Levonorgestrel (Plan B): single dose of 1.5 mg or two 0.75-mg doses taken together or 12 hours apart; effective up to 72 hours OR
  • Ulipristal (Ella): 30-mg single dose as soon as possible; effective up to 120 hours

ISSUES FOR REFERRAL

When responding to possible abuse, consider:

  • The child’s safety
    • Is the child at imminent risk for additional harm if sent back to the environment where the possible perpetrator has access to the child?
    • Are there other children in the home/environment who may also be at risk?
  • Work with child welfare to ensure family is complying with a plan of safe care that may include the following:
    • Mental health referrals for the victim and other family members, including siblings
    • Any follow-up with medical subspecialties, as needed
    • Continue to support the caregivers through the process when possible

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Admission if moderate/severe injuries, psychological trauma, inability to coordinate safe discharge plan

Descriptive text is not available for this image ONGOING CARE

PATIENT EDUCATION

PROGNOSIS

Without intervention, child abuse is often a chronic and escalating phenomenon.

COMPLICATIONS

Sexual, physical, and emotional abuse in childhood are risk factors for poorer adult mental and physical health. This includes maltreatment, depression, substance misuse, suicide attempts, and risky sexual behaviors.

Authors

Sasha S. Svendsen, MD
Martha Rose Fredette, MD

REFERENCES

  1. U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child Maltreatment 2022. https://www.acf.hhs.gov/cb/report/child-maltreatment-2022. Accessed September 20, 2024.
  2. Sheets LK, Leach ME, Koszewski IJ, et al. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics. 2013;131(4):710–717.  [PMID:23478861]

Descriptive text is not available for this image CODES

ICD10

  • T74.12XA Child physical abuse, confirmed, initial encounter
  • T74.32XA Child psychological abuse, confirmed, initial encounter
  • T74.22XA Child sexual abuse, confirmed, initial encounter
  • T74.92XA Unspecified child maltreatment, confirmed, initial encounter
  • T74.02XA Child neglect or abandonment, confirmed, initial encounter

SNOMED

  • 371779005 Physical child abuse
  • 371775004 Emotional abuse of child
  • 700229002 Victim of child sexual abuse (finding)
  • 473453008 child victim of psychological or emotional abuse (finding)
  • 419686005 victim of infant/child neglect (finding)
  • 397940009 victim of child abuse (finding)

CLINICAL PEARLS

  • Mandated reporting is required for suspected child abuse and neglect; the medical provider does not have to prove abuse before reporting.
  • When a bruise is present, it should be considered as a potential sentinel injury for physical abuse if no plausible explanation is given.
  • Neglect is the most common and lethal form of abuse.

Last Updated: 2026

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