Child Abuse / Non-Accidental Trauma

Key considerations: Abusive head trauma (shaken baby), Internal organ injury, Occult fractures

Cannot miss

history: Detailed mechanism from EACH caregiver separately, developmental history; exam: Full skin survey (document all injuries with photos), fundoscopic exam, neurologic exam; labs: CBC, CMP, coags, lipase, UA (hematuria = abdominal trauma); LFTs: AST/ALT >80 suggest liver injury; imaging: Skeletal survey (all children <2yr with suspected abuse); CT head without contrast (all <6 months or any with neuro symptoms); CT abdomen if LFTs elevated or abdominal exam concerning; bedside: Photodocumentation of injuries

immediate: Treat acute injuries; Ensure child safety — do NOT discharge to unsafe environment; general: Mandatory reporting to child protective services (CPS); Social work involvement; Siblings should also be evaluated; Forensic interview if verbal age

admit: Any injury requiring treatment, pending CPS investigation, unsafe home; discharge: Only with CPS approval and documented safe placement; consults: Child abuse pediatrics team, social work, CPS, law enforcement

Any bruise in a non-cruising infant is abuse until proven otherwise — TEN-4 rule (Torso, Ear, Neck in <4yr; any bruise in <4mo)
Physicians are mandated reporters — you need reasonable suspicion, not proof
Classic metaphyseal lesions (corner/bucket-handle fractures) are highly specific for abuse