← Diagnosis and Management Guides
Non-Accidental Trauma (Child Abuse)
Key considerations: Abusive head trauma (shaken baby), Occult fractures, Abdominal organ injury from abuse
Cannot miss
- Abusive head trauma (shaken baby)
- Occult fractures
- Abdominal organ injury from abuse
- Retinal hemorrhages
- Burns in suspicious pattern
- Sexual abuse
Likely diagnoses
- Accidental injury consistent with developmental stage
Red flags
- Injury inconsistent with developmental stage
- Delay in seeking care
- Changing or inconsistent history
- Multiple injuries in different stages of healing
- Bruising in non-mobile infant (TEN-4 rule)
- Patterned injuries (belt marks, cigarette burns, bite marks)
- Subdural hematomas in infant without major trauma history
Workup
- history: Detailed mechanism — does it match the injury?; Timeline of events; All caregivers present at time of injury; Previous ED visits, injuries, CPS involvement; Developmental milestones (rolling, crawling, walking); Social history: stressors, substance use, domestic violence; exam: Full skin survey — document ALL bruises, marks, scars; Frenulum injuries (forced feeding); Ear bruising (highly specific for abuse); Genital and anal exam if sexual abuse suspected; Neurological exam including fontanelle; Ophthalmologic exam for retinal hemorrhages; labs: Skeletal survey (mandatory <2 years if abuse suspected); CBC, CMP, lipase, amylase, LFTs (occult abdominal injury); Coagulation studies (rule out bleeding disorder); Urinalysis for hematuria; imaging: CT head non-contrast (if <2 years or any neurological concern); Skeletal survey: AP of every long bone, hands, feet, skull, spine, ribs; Repeat skeletal survey in 2 weeks for healing fractures; CT abdomen/pelvis with IV contrast if abdominal injury suspected; bedside: Document injuries with body diagrams and photographs; Measure and describe each injury precisely
Management
- immediate: Stabilize any acute injuries; Ensure child safety — do NOT discharge to suspected abuser; Mandatory reporting to CPS — this is legally required; general: Multidisciplinary approach: social work, CPS, law enforcement; Careful documentation is critical — use exact quotes from caregivers; Avoid accusatory language with family during initial assessment; specific: diagnosis: Abusive head trauma; steps: CT head immediately; Ophthalmologic exam for retinal hemorrhages; Skeletal survey; Neurosurgery consult if subdural/epidural; Admit to PICU; diagnosis: Occult fractures; steps: Full skeletal survey; Classic metaphyseal lesions (corner fractures) are HIGHLY specific for abuse; Posterior rib fractures in infants are highly specific for abuse; Coagulation studies to rule out bleeding disorder
Disposition
- admit: Any confirmed or highly suspected NAT — admit for safety and workup completion; Abusive head trauma; Significant injury requiring treatment; Unsafe discharge environment; discharge: NEVER discharge to suspected abuser; Only after CPS involvement, safety plan, and safe caregiver identified; consults: Child abuse specialist / child protection team; Ophthalmology for retinal hemorrhage evaluation; Social work — mandatory; CPS — mandatory reporting
Clinical pearls
- TEN-4 rule: bruising on Torso, Ears, Neck in child <4 years OR ANY bruise in infant <4 months = high specificity for abuse
- Bruises in non-cruising infants: "those who don't cruise rarely bruise" — any bruise in pre-mobile infant needs evaluation
- Classic metaphyseal lesions (corner/bucket-handle fractures) are PATHOGNOMONIC for abuse
- You are a MANDATORY REPORTER — report reasonable suspicion, not certainty. You do not need to prove abuse.
Source and review
- AAP Policy on Child Abuse 2015, Pediatric Emergency Medicine (Fleisher & Ludwig), PECARN TBI prediction rules. Last reviewed: 2024-11-01