Suspected Physical Child Abuse

Children under 3 years of age are at highest risk for serious injuries from abuse. Being alert to findings that suggest abuse will improve early recognition and prevent recurrent, escalating abuse. The extent of the workup performed in the emergency department (ED) will vary based on geography, acuity of injury, and services available. Early consultation with a Pediatric Referral Centre or child protection team is recommended.¹

HISTORY²

• 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

BRUISES/BURNS/FACIAL INJURIES (Most Common Findings in Abuse)

• 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

FRACTURES (See TREKK Fracture Recommendations)

• 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

HEAD INJURIES⁵ (See TREKK Severe Head Injury Recommendations)

• 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

OTHER INJURIES

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

INITIAL EVALUATION/MANAGEMENT

• Stabilize, evaluate, and treat all injuries according to trauma protocols (See TREKK Multisystem Trauma Recommendations)
• Obtain a good history by asking open-ended questions
• Is a history of trauma provided?
  • Yes – ask about the mechanism, timing, preceding circumstances, and who was present; note the onset/timing of child’s signs and symptoms after the incident
  • No – ask about when the child was last well and when signs and symptoms were first noted
• Perform a complete physical exam including a head-to-toe skin assessment, paying close attention to TEN-4-FACESp areas (see above) and genitalia
• Plot height, weight, and head circumference (<2 years old) on a growth chart

REPORTING OF SUSPECTED ABUSE TO A CHILD PROTECTION SERVICES AGENCY

• Medical professionals in the US and Canada are mandated by law to report cases of suspected abuse to a child protection services agency
• The duty to report is based on having reasonable concern that a child has been or is at risk of being abused; a definitive diagnosis of abuse is not required
• The report should include: the age of the child; why or how the child presented; what injuries the child sustained; why you are concerned about abuse; your level of concern for abuse
• A standardized approach to child abuse, including clinical decision support, evidence-based tools/guidelines and peer review should be used to mitigate bias⁶

COMMUNICATION WITH FAMILY/CAREGIVERS

• Communicate objective findings or concerns of abuse with caregivers in a non-judgmental, empathic manner
• Use statements that reassure the family that the focus is on doing what is right for their child and that a uniform approach is taken to all children with concerning injuries
• It is not the role of medical professionals to determine the perpetrator of abuse

WORKUP FOR SUSPECTED ABUSE^7,8,9

DISPOSTION

• Children may be discharged home if: they are medically stable; there is a plan for safe disposition made in conjunction
  with child protection services agency and, if indicated, Pediatric Referral Centre; if needed, plan for arranging follow-up
  testing/hand off to Pediatric Referral Centre and/or primary care provider
• Reporting to child protection services should be completed prior to disposition unless the child is unstable
• If unable to complete the above requirements, admit or transfer to a Pediatric Referral Centre

Thank you to the following content experts who led the development of this resource.

Marc Auerbach, MD, MSCi EIIC Knowledge Management Domain Co-Lead, Associate professor of Pediatrics and Emergency Medicine, Yale Director of Pediatric Simulation at the Yale Center for Medical Simulation

Carmen Coombs, MD, MPH Department of Pediatrics, Division of Child Advocacy, Division of Pediatric Emergency Medicine, UPMC Children’s Hospital of Pittsburgh

Dan Lindberg, MD Attending physician, Department of Emergency Medicine and Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, University of Colorado School of Medicine

Julia Magaña, MD Associate Professor of Emergency Medicine-Pediatrics Emergency Medicine, UC Davis, Child Protection Team

Amy E Ornstein, MDCM, MSc, FRCPC, FAAP Medical Director, START (Suspected Trauma and Abuse Response Team), Head, Division of General Pediatrics, Professor of Pediatrics, Dalhousie University

Supriya Sharma, MD Fellow, Department of Emergency Medicine Fellow, Child Abuse Pediatrics, Harbor-UCLA Medical Center

Gunjan Tiyyagura MD, MHS Associate Professor of Pediatrics and Emergency Medicine, Section of Pediatric Emergency Medicine, Yale University School of Medicine

Thank you to the TREKK Editorial Committee and those in the EIIC KEAP Program who provided editorial support and expertise in the development of this resource. Thank you to the following people who coordinated and oversaw the development process:

Robin Goodman, MSN, RN, CPEN EIIC Knowledge Management Domain, Project Manager

Mona Jabbour, MD, MEd, FRCPC TREKK Co-Director, Interim Chair/Chief, Department of Pediatrics Associate Professor, Pediatrics and Emergency Medicine, University of Ottawa Children’s Hospital of Eastern Ontario

Mary Anne Nurmi, MSc TREKK Knowledge Broker

Sarah Reid, MD Pediatric Emergency Physician, CHEO, Ottawa Associate Professor, Departments of Pediatrics and Emergency Medicine, University of Ottawa

Marc Vazquez, MHA/MBA, PMP EIIC Knowledge Broker

1. The American College of Surgeons. (2019). Best practice guidelines for trauma center recognition of child abuse, elder abuse, and Intimate partner violence. Accessed April 24, 2023.
2. Escobar MA Jr, Flynn-OʼBrien KT, Auerbach M, et al. The association of nonaccidental trauma with historical factors, examination findings, and diagnostic testing during the initial trauma evaluation. J Trauma Acute Care Surg. 2017;82(6):1147-1157.
3. Pierce MC, Kaczor K, Lorenz DJ, et al. Validation of a decision rule to predict abuse in young children based on bruising characteristics. JAMA Netw Open. 2021;4(4):e215832.
4. Mitchell IC, Norat BJ, Auerbach M, et al. Identifying maltreatment in infants and young children presenting with fractures: Does age matter?. Acad Emerg Med. 2021;28(1):5-18.
5. Ornstein, AE. An approach to child maltreatment documentation and participation in the court system. Pediatric Child Health. 2013;18(8):e44-47.
6. Riney, L. C., Frey, T. M., Fain, E. T., Duma, E. M., Bennett, B. L., & Murtagh Kurowski, E. (2018). Standardizing the evaluation of nonaccidental trauma in a large pediatric emergency department. Pediatrics, 141(1).
7. Bloemen EM, Rosen T, Cline Schirra JA, et al. Photographing Injuries in the Acute Care Setting: Development and Evaluation of a Standardized Protocol for Research, Forensics, and Clinical Practice. Acad Emerg Medicine. 2016;23(5):653-9.
8. Narang, S. K., Fingarson, A., Lukefahr, J., Sirotnak, A. P., Flaherty, E. G., Gavril, C. A., Hoffert Gilmartin, A. B., Haney, S. B., Idzerda, S. M., Laskey, A., Legano, L. A., Messner, S. A., Mohr, B., Moles, R. L., Nienow, S., & Palusci, V. J. (2020). Abusive head trauma in infants and children. Pediatrics, 145(4).
9. The American College of Surgeons – TQIP. (2018). Best practices guidelines in imaging.
10. Berger RP, Fromkin J, Herman B, Pierce MC, Saladino RA, Flom L, Tyler-Kabara EC, McGinn T, Richichi R, Kochanek PM. Validation of the Pittsburgh Infant Brain Injury Score for abusive head trauma. Pediatrics. 2016 Jul;138(1):e20153756.

For a complete list of the evidence that informed the creation of the Suspected Child Abuse Bottom Line Recommendations see the Evidence Repository here.

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of community acquired pneumonia in children in the emergency department. The TREKK Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. THIS DOCUMENT IS SUBJECT TO FULL DISCLAIMER HERE: trekk.ca/terms-of-use