Anticipatory Guidance

Child Abuse


More than 3.6 million child maltreatment cases were investigated in 2005.  Of these cases approximately 900,000 cases were determined to be substantiated.  Exact definitions of what constitutes child maltreatment vary from state to state.  The Child Abuse Protection and Treatment Act (CAPTA) defines child abuse as any recent act or failure to act resultig in death, serious physical or emotional harm, sexual abuse, or iminent risk of harm; involving a child;and caused by a parent or caretaker who is responsible for the child's welfare. In general, child maltreatment consists of neglect, physical abuse, sexual abuse, and emotional abuse; physical abuse is second only to neglect in the number of child maltreatment cases. 


  1. In US, over 1 million cases of abuse/neglect are substantiated by Child Protective Services annually
  2. Estimated prevalence of physcial abuse at anytime during childhood is 5-35% in the US
  3. The World Health Organization estimate that childhood abuse or neglect accounts for 13% of deaths worldwide
  4. In 1993, it was estimate that 3% of children are neglected.

 Risk Factors

  • Age- the incidence of maltreatment is inversely proportional to victim age; children aged birth to 3 years have the highest rates of maltreatment
  • Low infant birth weight
  • Congenital drug addiction
  • Having 2 or more siblings
  • Children with learning/language disabilities or conduct disorders
  • Maternal depression
  • Parental drug/alcohol abuse or psychiatric illness
  • Having an unwed or young mother
  • Presence of unrelated adults at home
  • History of domestic violence between guardians
  • Low Socioeconomic status or low educataional level.
  • Significant life stressors


  • Screen for risk factors
  • Provide anticipatory guidance on normal behavior of children
  • Suggest appropriate disciplinary methods
  • Suggest methods to reduce parental stress
  • Provide resources for parental training programs

Differential Diagnosis

  • Bleeding disorders
  • Salicylate ingestion
  • Vasculitis
  • Cupping, coining, spooning
  • Underlying oseogenesis imperfecta

Signs of Maltreatment

  • Explanation of injury inconsistent with the age or development of the child
  • Explanation of injury inconsistent with severity or pattern of injury
  • No explanation of child's injury
  • Frequent changes regarding the mechanism of injury
  • Explanations regarding the mechanism of injury vary among witnesses


When child maltreatment is suspected, all care givers (parents, babysitters, etc.) should be interviewed separately and the child should be interviewed in the absence of parents if possible. 

Thorough documentation is essential; whenever possible try to document the direct quotes of witnesses.  Avoid commenting on the feasibility of the mechanism of injury proposed by care givers when initially interviewing them. Avoid putting words into the mouths of care givers.  Do not worry about getting every detail of the story.  Remember your first responsibility is to the health and safety of your patient.  Leave formal interrogation to the police, CPS, and Department of Child and Family Services workers.

  • Document the child's behavior and activity before, during, and after the injury
  • Document proposed mechanism of injury
  • Document the time between injury and presentation to physician
  • Document if there were any witness
  • Document if any other siblings or children remain at risk; this must be reported to CPS immediately

Physical Exam

For suspected child maltreatment cases have a high level of suspicion for severe head injuries or possible internal bleeding.  You must do a complete skin exam looking for any soft tissue bruises, lacerations, or scares.  Perform a complete neurological exam with glascow coma scale.

  • Document the general appearance of the child
  • Document and plot the height, weight, and head circumference
  • Document the size, location, and approximate age of any bruises or lacerations
  • Document any obvious fractures.
  • Use a body diagram or photographs to document findings


The following list contains suggestions for further workup/ evaluation of suspected victims of child maltreatment.  When determining which tests are necessary, one must consider the individual circumstances of a particular case.  

  • Lab Test
  • CBC
  • BMP
  • LFT
  • Pancreatic Enzymes
  • Prealbumin
  • Retinal Exam
  • Radiological Imaging
  • Skeletal Survey
  • Head CT
  • Abd CT


  • Secure the immediate safety of the child
  • Secure the immediate safety of any children that remain in the care of the suspected abuser
  • Treat any injuries the child has sustained
  • Report suspicions to the CPS and the police
  • Work with CPS to establish a safety plan that includes into who's care the child should be discharged
  • Work with CPS to establish close medical and psychological follow up for the victim and family

Learn More:

Childhelp- Prevention and Treatment of Child Abuse

Illinois Department of Child and Family Services

References and Additional Information

  1. Kellogg, et al. Evaluation of Suspected Child Physical Abuse Pediatrics Vol 119 No 6
  2. Gaudiosi, et al. Child Maltreatment 2005 US Department of Health and Human Services
  3. Jenny, et al. Evaluating Infants and Children with Multiple Fractures Pediatrics Vol 118 No 3
  4. Gilbert et al.  Burden and Consequences of Child Maltreatment in High_income Countries.  Lancet 2009 Jan 3 373; 68-81
  5. Jain AM  Emergency Department Evaluattion of Child Abise.  Emerg Med Clin NA 1999 August.