Non-accidental trauma (NAT) is a leading cause of injury-related morbidity and mortality in young children, with ~25% of abused children having prior sentinel injuries that were missed. [1] Approximately 69% of confirmed cases involve children under 1 year of age. [2] Early recognition is lifesaving — among children with abusive head trauma, one-third had prior opportunities for diagnosis that were missed. [1]
1. History
- Obtain history from the child (if verbal) and each caregiver separately, using open-ended, nonaccusatory questions [3]
- Key HPI elements: exact timing and mechanism of injury, symptom onset and progression, who was present, child's baseline behavior, and any behavioral changes [3]
- Red flag history features: [2][4-5]
- No history of trauma provided, or vague/absent explanation for significant injury
- History that is inconsistent, changing, or developmentally implausible for the child's motor abilities
- Mechanism described is incompatible with the type/severity of injury
- Delay in seeking care (most common history finding in one series — 58%) [2]
- Multiple caregivers providing conflicting accounts
- In abusive head trauma, 85–95% of cases present with either no history of trauma or a history inconsistent with findings [5]
2. Alarm Features
- Any bruise in a non-ambulatory infant — "If you don't cruise, you don't bruise" [6]
- Bruising in the TEN-4-FACESp regions: Torso, Ears, Neck in children <4 years; Frenulum, Angle of jaw, Cheeks, Eyelids, Subconjunctivae, or Patterned bruising (96% sensitivity, 87% specificity for abuse) [5]
- Torn frenulum in an infant [6-7]
- Subconjunctival hemorrhage [1]
- Patterned injuries (loop marks, belt marks, handprints) [1]
- Injuries in multiple stages of healing [1][8]
- Injuries to multiple organ systems [8]
- Seizures in an infant with head injury (associated with abusive head trauma) [1]
- Apnea, vomiting, or altered mental status in an infant without clear etiology [7]
- Failure to thrive or increasing head circumference [6]
3. Medications
- No medications cause NAT, but consider whether the child is on anticoagulants or has a bleeding disorder that could explain bruising — this must be ruled out in the workup [5]
- Avoid attributing bruising to medications without thorough evaluation
- Treatment medications: pain management with weight-based acetaminophen or ibuprofen; specific injury-directed treatment (e.g., antiepileptics for seizures from abusive head trauma, surgical intervention for intracranial hemorrhage)
4. Diet
- Assess for signs of nutritional neglect: failure to thrive, vitamin D deficiency, rickets
- Rickets and metabolic bone disease can mimic fractures from abuse — nutritional history is essential to the differential [6][9]
- Vitamin D and calcium deficiency should be evaluated with labs when fractures are present [4]
5. Review of Systems
- Neurologic: seizures, vomiting, irritability, lethargy, apnea, altered consciousness
- MSK: limping, refusal to use an extremity, swelling, pain with movement
- Skin: bruises, burns, bite marks in any location
- GI: abdominal pain, vomiting, bloody stools (occult abdominal trauma)
- GU: hematuria, genital pain or bleeding
- Behavioral: regression, sleep disturbance, excessive fearfulness, withdrawal
- Growth: weight loss, poor weight gain, developmental delay
6. Collateral History and Family History
- Interview caregivers separately; note discrepancies [3]
- Obtain history from EMS, daycare providers, teachers, and other witnesses
- Family history: osteogenesis imperfecta, bleeding disorders (hemophilia, von Willebrand disease), Ehlers-Danlos syndrome, metabolic bone disease [3][6]
- Social context: domestic violence in the home, substance abuse, parental mental health issues, prior CPS involvement, social isolation [10]
- Assess siblings — they are also at risk and may need evaluation including skeletal survey [5]
7. Risk Factors
- Child factors: age <1 year (highest risk), prematurity, disability, chronic illness, colic, twins [10]
- Caregiver factors: young or single parent, substance abuse, mental health disorders, history of being abused, domestic violence, prior CPS involvement [10]
- Environmental factors: poverty, social isolation, unstable housing, frequent moves [10]
- Children with disabilities and special health care needs are at increased risk of abuse [4]
The following figure illustrates a systematic approach to assessing risk factors across parent/carer, child, and environmental domains:
8. Differential Diagnosis
9. Past Medical History
- Prior ED visits or hospitalizations for injury — sentinel injuries are present in ~25% of abused children before a severe event [1]
- Prior fractures, especially if unexplained
- Birth history: prematurity, NICU stay (risk for osteopenia), difficult delivery
- Chronic conditions: cerebral palsy, developmental delay, metabolic disorders
- Prior CPS reports or investigations
- Immunization and well-child visit compliance (missed visits may indicate neglect)
10. Physical Exam
Perform a complete head-to-toe examination with the child fully undressed in a gown. [1]
- Skin: Inspect all surfaces including scalp, behind ears, neck, axillae, trunk, buttocks, genitalia, inner thighs, soles of feet. Document size, shape, color, location, and pattern of all bruises, burns, bite marks, and scars [1]
- Head: Palpate fontanelles and sutures; measure occipitofrontal circumference in infants <1 year; assess for scalp swelling or boggy hematoma [6]
- Eyes: Funduscopic exam for retinal hemorrhages (strongly associated with abusive head trauma) [1][7]
- Oral cavity: Inspect for torn frenulum (labial and lingual), palatal petechiae, mucosal tears, dental injuries [5]
- Abdomen: Palpate for tenderness, guarding, distension (occult abdominal trauma) [7]
- Extremities: Palpate all long bones for tenderness, swelling, crepitus; assess range of motion; note pseudoparalysis [6]
- Neurologic: GCS, pupillary response, tone, reflexes, fontanelle tension
- Growth parameters: Plot weight, length, and head circumference — assess for failure to thrive [6]
The following figure from Pierce et al. demonstrates the discriminatory value of bruise location, showing that bruising to the buttocks, cheeks, ears, neck, and torso is strongly associated with abuse compared to accidental injury:
11. Lab Studies
Per AAP recommendations: [3-4][7]
- Metabolic bone disease workup: serum calcium, phosphorus, alkaline phosphatase, PTH, 25-hydroxyvitamin D
- Coagulation studies: PT, PTT, INR (rule out bleeding disorders)
- CBC with differential: anemia, thrombocytopenia
- Hepatic transaminases (AST/ALT): screen for occult abdominal trauma — elevated in liver injury (obtain if AST >80 or ALT >80, consider abdominal CT) [7]
- Lipase/amylase: pancreatic injury screening
- Urinalysis: hematuria suggesting renal/bladder injury
- Urine drug screen: if ingestion or exposure suspected
- Fecal occult blood: GI injury screening
12. Imaging
First-line: [4][12]
- Skeletal survey (21+ views per ACR/SPR protocol): recommended for all children <2 years with suspected abuse. Identifies occult fractures in ~10–26% of cases. Never use a "babygram" [4][13]
- Follow-up skeletal survey at 2 weeks: identifies additional healing fractures in 8–38% of cases; recommended for all children with high suspicion and negative or positive initial survey [4-5]
- Non-contrast head CT: first-line for all children <6 months with suspected abuse, and any child with neurologic symptoms or concern for head trauma [4][12]
Additional imaging: [3][12]
- Brain MRI: to further characterize intracranial injury, detect diffuse axonal injury, or evaluate hypoxic-ischemic injury
- Contrast-enhanced abdominal/pelvic CT: if elevated liver enzymes, lipase, or clinical concern for visceral injury
- Skeletal survey may be considered in select children aged 2–5 years, particularly with craniocerebral trauma, abdominal injuries, or high-specificity fractures [1]
High-specificity fractures for abuse: [6][9]
- Classic metaphyseal lesions (corner/bucket-handle fractures)
- Posterior rib fractures in infants
- Scapular, sternal, and spinous process fractures
13. Special Tests
- TEN-4-FACESp clinical decision rule: bruising to Torso, Ears, Neck in children <4 years; Frenulum, Angle of jaw, Cheeks, Eyelids, Subconjunctivae, Patterned bruising — 96% sensitivity, 87% specificity [5]
- PECARN rules do NOT apply in suspected NAT — standard clinical decision rules for head CT and abdominal injury were not validated in this population [14]
- Funduscopic examination (dilated, by ophthalmology): for retinal hemorrhages in children <2 years with suspected abusive head trauma [1][3]
- Pediatric HITS screening tool: 5-item validated questionnaire to identify abuse exposure [3]
- Red Flag Scorecard: ≥2 history findings + 1 physical/imaging finding — 79% sensitivity [2]
14. ECG
- ECG is not routinely indicated unless there is concern for cardiac contusion (direct chest trauma) or arrhythmia
- Consider if there are anterior chest wall bruises or rib fractures with hemodynamic instability
- Myocardial contusion may present with ST changes, arrhythmias, or elevated troponin
15. Assessment
- No single finding is pathognomonic for abuse — diagnosis requires integration of history, exam, imaging, and labs [1]
- The constellation of inconsistent history + injuries in non-exploratory locations + developmental implausibility is the strongest indicator [2][5]
- Severity ranges from minor sentinel injuries (bruises, frenulum tears) to life-threatening abusive head trauma and abdominal injuries
- Approximately 25% of all fractures in children <1 year are attributable to abuse [6]
- Abusive head trauma is the leading cause of death from physical abuse [5]
- Bias in reporting exists — children from historically marginalized groups are disproportionately reported and investigated; structured screening tools help reduce this disparity [4][14]
16. Treatment Plan
Initial stabilization
- ABCs per ATLS/PALS guidelines; treat life-threatening injuries first [8]
- Hemodynamic stabilization, airway management as needed
- Seizure management (benzodiazepines, then levetiracetam or phenobarbital for abusive head trauma)
Injury-specific treatment
- Neurosurgical consultation for intracranial hemorrhage requiring intervention
- Orthopedic management of fractures
- Surgical consultation for abdominal injuries
- Pain management with weight-based dosing
Mandatory actions
- Report to Child Protective Services (CPS) — mandated in all US states when there is reasonable suspicion; incontrovertible proof is NOT required [4][7]
- Consult child abuse pediatrician (or telemedicine if unavailable) [14-15]
- Social work consultation
- Document all findings meticulously with photographs, body diagrams, and detailed descriptions
- Evaluate siblings and household contacts — they are also at risk [5][16]
17. Disposition
Admit if: [6]
- Any intracranial injury or suspected abusive head trauma (consider PICU)
- GCS <15 even with normal head CT
- Significant injuries requiring monitoring or surgical intervention
- Inability to ensure child safety at discharge
- Ongoing workup needed (skeletal survey, labs, ophthalmology consult)
Observation/hold
- If CPS investigation is pending and safe discharge cannot be confirmed
- If awaiting child abuse pediatrician evaluation
Discharge considerations
- A face-to-face care team "huddle" (ED physician, RN, social worker) must occur before any ED discharge when NAT suspicion has been raised [6]
- Safe disposition plan confirmed with CPS
- Never discharge to the suspected abuser
Consultation triggers
- Child abuse pediatrician, ophthalmology, neurosurgery, orthopedics, pediatric surgery as indicated
- Transfer to a pediatric center with child abuse expertise if resources are unavailable locally — transfer does not relieve reporting responsibility [8]
18. Follow Up / Return Precautions
- Follow-up skeletal survey at 2 weeks — critical for detecting healing fractures not visible on initial imaging [4-5]
- Outpatient child abuse team follow-up [6]
- CPS follow-up and safety planning
- Return precautions for caregivers (if child is discharged to a safe environment):
- Seizures, vomiting, excessive sleepiness, irritability, poor feeding, apnea
- New swelling, bruising, or refusal to move an extremity
- Any behavioral changes
- Expected recovery depends on injury severity; abusive head trauma carries significant risk of long-term neurodevelopmental disability
- Preventive programs (e.g., Nurse-Family Partnership, Triple-P Positive Parenting Program) should be offered when risk factors are identified [3]
References
1. Has This Child Experienced Physical Abuse?. — Shah SN, Fong HF, Haney SB, et al. The Journal of the American Medical Association. 2025.
2. Development of the Red Flag Scorecard Screening Tool for Identification of Child Physical Abuse in the Emergency Department. — Naik-Mathuria B, Johnson BL, Todd HF, et al. Journal of Pediatric Surgery. 2023.
3. Child Abuse: Approach and Management. — Suniega EA, Krenek L, Stewart G. American Family Physician. 2022.
4. Evaluating Young Children With Fractures for Child Abuse: Clinical Report. — Haney S, Scherl S, DiMeglio L, et al. Pediatrics. 2025.
5. Abusive Head Trauma in Infants and Children: Technical Report. — Narang SK, Haney S, Duhaime AC, et al. Pediatrics. 2025.
6. Best Practices Guidelines for Trauma Center Recognition of Child Abuse, Elder Abuse, and Intimate Partner Violence. — Christine S. Cocanour MD FACS FCCM, Randall S. Burd MD PhD FACS, James W Davis MD FACS, et al American College of Surgeons (2019). 2019.
7. Physical Abuse of Children. — Berkowitz CD. The New England Journal of Medicine. 2017.
8. Best Practices Guidelines In Imaging. — Gail T. Tominaga MD FACS, Mark Bernstein MD, Michael R. Aquino MD MHSc, et al American College of Surgeons (2018). 2018.
9. Physical Abuse and Neglect of Children. — Dubowitz H, Bennett S. Lancet. 2007.
10. Safeguarding. — Dannika Buckley, Lottie Mount Clinical Guide to Paediatrics. 2022.
11. Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics. — Pierce MC, Kaczor K, Lorenz DJ, et al. JAMA Network Open. 2021.
12. ACR Appropriateness Criteria® Suspected Physical Abuse-Child: Update 2025. — Expert Panel on Pediatric Imaging, Mirsky DM, Bardo DME, et al. Journal of the American College of Radiology : JACR. 2026.
13. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. — Marin JR, Lyons TW, Claudius I, et al. Pediatrics. 2024.
14. Systems-Based Care of the Injured Child: Technical Report. — Flynn-O'Brien KT, Srinivasan V, Fallat ME. Pediatrics. 2025.
15. Optimal Resources for Children's Surgical Care 2021. — Douglas Barnhart, Patrick Cartwright, Craig Derkay, et al American College of Surgeons. 2022.
16. International Consensus Statement on the Radiological Screening of Contact Children in the Context of Suspected Child Physical Abuse. — Mankad K, Sidpra J, Mirsky DM, et al. JAMA Pediatrics. 2023.