Serious injury without a history of significant trauma
Insufficiently explained delay in seeking care for a child with a clear injury
History that is inconsistent between caregivers and/or with the child’s developmental abilities
Exposure to other family violence (intimate partner violence, child abuse, elder abuse, animal abuse)
Serious injury attributed to a young child or pet
Concern for abuse identified by routine screening or clinical decision tool

Accidental injuries usually occur over bony prominences and on anterior body surfaces
Any bruise in an infant up to 4 months and 30 days old, even if minor in appearance (sentinel injury)³
A bruise in a child <4 years old of: Torso, Ears, Neck, Frenulum, Angle of the jaw, Cheeks (soft part), Eyelids or Subconjunctivae or Patterned (TEN-4 FACESp)³
Burns whose pattern suggests an implement or immersion

Any fracture in a non-ambulatory child
Humeral or femoral fracture in a child <18 months old⁴
Rib fracture in a child <3 years old⁴
Classic metaphyseal fracture of the long bones in the arms or legs of an infant
Fractures in different stages of healing
Fracture of spine, hands/feet, pelvis, scapula, sternum, without history of significant trauma

High risk symptoms: apnea, altered mental status, seizure without a fever
High risk signs: scalp swelling/deformity, bruise in young infants (<6 months old)
Intracranial injury without history of trauma or medical explanation
Abusive head trauma can be present even without typical symptoms of head injury
Subdural hemorrhage is the most common intracranial finding in abuse

Abdominal, thoracic, and spinal injuries also occur with abuse; they are concerning for abuse when there is no clear mechanism of injury