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Child Physical Abuse And Neglect

Child Physical Abuse And Neglect

Article Author:
Casey Brown
Article Author:
Musa Yilanli
Article Editor:
Angela Rabbitt
11/20/2020 1:27:40 PM
For CME on this topic:
Child Physical Abuse And Neglect CME
PubMed Link:
Child Physical Abuse And Neglect


Approximately one in four children experience child abuse or neglect in their lifetime. Of maltreated children, 18% are abused physically, 78% are neglected, and 9% are abused sexually. The fatality rate for child maltreatment is 2.2/1000 children annually, making homicide the second leading cause of death in children younger than age one. Exposure to violence during childhood can have lifelong health consequences, including poor physical, emotional, and mental health. Prevention, diagnosis, and treatment of physical child abuse is key to preventing these adverse health outcomes; however, child physical abuse is under-detected and under-reported by medical providers.[1][2][3][4][5]


Risk Factors: Young age, prematurity, special needs, twins, colic/crying, behavior problems, and toilet training/accidents increase the risk for child physical abuse. Perpetrator risk factors include poverty, parental alcohol or drug abuse, and domestic violence in the home (30% to 60% co-occurrence); 91% of the time the perpetrator is a parent.[6][7][8][9]

Sentinel Injuries: Sentinel injuries are seemingly minor injuries, such as bruises and intraoral injuries, in non-mobile infants that often precede more serious abuse. When providers appropriately diagnose and respond to sentinel injuries, escalation of the abuse can be prevented. These injuries occur in 25% of abused infants. They are known to providers 42% of the time but rarely reported.

Bruises: Suspicious bruising includes bruises that are:

  • Present in non-cruising infants
  • Patterned (such as a looped cord or bite)
  • In protected areas (ears, genitals, buttocks).

Bruises cannot be dated accurately. The absence of bruising does not rule out abuse as children without bruising can have significant internal injuries (head trauma, fractures, abdominal trauma).

Head Trauma: Abusive head trauma (AHT) is the leading cause of death from physical abuse in children younger than age two. Crying is the usual trigger for AHT. Some children present with shock/coma, but others present with non-specific symptoms such as irritability, sleepiness, fever, vomiting, respiratory distress or apnea. A third of AHT cases have a history of a sentinel injury, 85% have retinal hemorrhages, and 30% to 70% have other injuries like rib fractures, bruising, among others).

Fractures: In children younger than age one, 25% of fractures are abusive. Concerning fractures include those that are:

  • Found in a non-mobile infant
  • Multiple and unexplained
  • Of varying ages
  • Bucket handle/corner fractures/CMLs
  • Rib fractures younger than 1.5 years (7 in 10 are abusive)
  • Femur fractures younger than 1.5 years (1 in 3 are abusive)
  • Skull fractures younger than 1.5 years (1 in 3 are abusive).

Burns: Scalding and immersion burns are the most common forms of inflicted burns. Burns that are symmetric, uniform in depth, spare skin creases and lack splash burns suggest forced immersion. Patterned contact burns with distinct margins and lack of a grazing pattern should raise concern for abuse. Mimics like chemical burns (Senna), toxic epidermal necrolysis, and staphylococcus scalded skin should be considered.


Maltreatment of children varies by country and definition. Despite these limitations, studies have found a quarter of all adults report enduring physical abuse as children. One in five females and one in 13 males report experiencing childhood sexual abuse. Emotional abuse and neglect are common. Females are especially vulnerable to sexual violence, exploitation, and abuse.[10][11][12][13]

In the United States, the Child Protective Services estimated that nine out of 1000 children in are victims of child maltreatment. Most were victims of neglect. Physical abuse, sexual abuse, and other types of maltreatment are less common, making up 18%, 9%, and 11% of cases, respectively.

History and Physical

The purpose of a medical evaluation in suspected physical abuse is to obtain a detailed injury history, identify occult injuries, and screen for medical conditions that may mimic or predispose the child to injury.

History: Document how the injury occurred, the last time the child was normal/injury free, the child’s developmental level, and risk factors for abuse. A history that should raise concerns about abuse include:

  • The absence of a history
  • Unexplained delay in seeking care
  • A history that is not consistent with the injuries or the child’s developmental abilities.

A thorough skin examination is vital as injuries may be located in hidden or protected areas. Note the general appearance, behavior of the child, and growth parameters which may indicate signs of neglect. Inspect the scalp for trauma, the mouth, and dentition for caries and oral/frenulum injuries, perform an abdominal exam, the range of motion of the extremities evaluating for fracture/limited motion, and a neurologic exam to assess tone and mental status.


Laboratory screening for abdominal injury (assessment of liver and pancreas function and urinalysis) are recommended in children under age five because the physical exam has a low sensitivity for detection of abusive intrabdominal injuries in young children. An abdominal CT should be completed if screening labs are elevated. A skeletal survey and repeat survey in 3 weeks is indicated in children younger than two years to identify occult fractures and assess bone health. Occult fractures are found on an initial skeletal survey 11% of the time, in infants with bruising 50% of the time, on a follow-up skeletal survey 46% of the time, and in siblings of abused children 12% of the time. The neurologic exam lacks sensitivity for AHT. Thus, a head CT in potentially abused infants younger than six months is recommended. If concerning intracranial injuries are noted, retinal examination by a pediatric ophthalmologist and MRI/MRV of the brain and spine are recommended. Occult drug exposure has increasingly been noted in victims of physical abuse, and some centers recommend comprehensive urine drug testing for children younger than age 5. It is important to remember that the lack of additional injuries on occult injury surveillance does not lessen the abuse concern for the initial injury.

Evaluation for medical mimics of abuse: Children with bruises or bleeding should be evaluated for bleeding disorders, including an assessment of the locations of bruises (children with bleeding disorders have excessive bruising in locations that are commonly bruised accidentally), and laboratory evaluation of coagulation, platelet function, and von Willebrand disease. Evaluation of fractures includes assessing for a family history of bone disease, radiographic and laboratory evaluation of bone health including disorders of bone metabolism and mineralization. In children with intracranial hemorrhage, consider metabolic diseases and other medical conditions such as glutaric aciduria, meningitis, and vitamin K deficiency in neonates. 

Treatment / Management

In all cases, suspicion for physical abuse mandates a report to child protective services and/or law enforcement. The provider does not need to be certain that abuse has occurred, rather they should report when they are suspicious that abuse has occurred or will occur. Consultation with specialists or a child maltreatment team can be helpful in guiding the evaluation and response.

Differential Diagnosis

  • Bleeding disorders (e.g. Hemophilia)
  • Eczema
  • Ehlers-Danlos syndrome
  • Folk healing practices
  • Hemangiomas
  • Idiopathic Thrombocytopenic Purpura (ITP)
  • Malignancy
  • Mongolian spots
  • Osteogenesis imperfect type 1
  • Phytophotodermatitis

Enhancing Healthcare Team Outcomes

All healthcare workers including nurse practitioners have a legal and moral duty to report child abuse. In all cases, suspicion for physical abuse mandates a report to child protective services and/or law enforcement. The provider does not need to be certain that abuse has occurred, rather they should report when they are suspicious that abuse has occurred or will occur. Consultation with specialists or a child maltreatment team can be helpful in guiding the evaluation and response.


[1] Komori K,Komori M,Eitoku M,Joelle Muchanga SM,Ninomiya H,Kobayashi T,Suganuma N, Verbal abuse during pregnancy increases frequency of newborn hearing screening referral: The Japan Environment and Children's Study. Child abuse     [PubMed PMID: 30807899]
[2] Jawadi AH,Benmeakel M,Alkathiri M,Almuneef MA,Philip W,Almuntaser M, Characteristics of Nonaccidental Fractures in Abused Children in Riyadh, Saudi Arabia. Saudi journal of medicine     [PubMed PMID: 30787851]
[3] McAnee G,Shevlin M,Murphy J,Houston J, Where are all the males? Gender-specific typologies of childhood adversity based on a large community sample. Child abuse     [PubMed PMID: 30780010]
[4] Fredman SJ,Le Y,Marshall AD,Garcia Hernandez W,Feinberg ME,Ammerman RT, Parents' PTSD symptoms and child abuse potential during the perinatal period: Direct associations and mediation via relationship conflict. Child abuse     [PubMed PMID: 30753996]
[5] Tener D,Silberstein M, Therapeutic interventions with child survivors of sibling sexual abuse: The professionals' perspective. Child abuse     [PubMed PMID: 30685626]
[6] Woolf SM,Leventhal JM,Gaither JR,Hardikar P,Langhan ML,Bechtel K,Auerbach MA,Tiyyagura G, Oral injuries in children less than 24 months of age in a pediatric emergency department. Child abuse     [PubMed PMID: 30639971]
[7] Tenkorang EY, Explaining the links between child marriage and intimate partner violence: Evidence from Ghana. Child abuse     [PubMed PMID: 30622050]
[8] Catone G,Signoriello S,Pisano S,Siciliano M,Russo K,Marotta R,Carotenuto M,Broome MR,Gritti A,Senese VP,Pascotto A, Epidemiological pattern of bullying using a multi-assessment approach: Results from the Bullying and Youth Mental Health Naples Study (BYMHNS). Child abuse     [PubMed PMID: 30612071]
[9] Schwartz JA,Wright EM,Valgardson BA, Adverse childhood experiences and deleterious outcomes in adulthood: A consideration of the simultaneous role of genetic and environmental influences in two independent samples from the United States. Child abuse     [PubMed PMID: 30605796]
[10] Palermo T,Pereira A,Neijhoft N,Bello G,Buluma R,Diem P,Aznar Daban R,Fatoumata Kaloga I,Islam A,Kheam T,Lund-Henriksen B,Maksud N,Maternowska MC,Potts A,Rottanak C,Samnang C,Shawa M,Yoshikawa M,Peterman A, Risk factors for childhood violence and polyvictimization: A cross-country analysis from three regions. Child abuse     [PubMed PMID: 30554126]
[11] Fleckman JM,Taylor CA,Theall KP,Andrinopoulos K, The association between perceived injunctive norms toward corporal punishment, parenting support, and risk for child physical abuse. Child abuse     [PubMed PMID: 30544032]
[12] Rafferty J,Mattson G,Earls MF,Yogman MW, Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice. Pediatrics. 2019 Jan;     [PubMed PMID: 30559118]
[13] Dillard R,Maguire-Jack K,Showalter K,Wolf KG,Letson MM, Abuse disclosures of youth with problem sexualized behaviors and trauma symptomology. Child abuse     [PubMed PMID: 30537621]