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  • Identifying child abuse is challenging because the histories provided are typically inaccurate, nonspecific physical examination findings predominate, and physicians fail to include child abuse in their differential diagnosis.
  • A careful, complete medical evaluation and detailed documentation are important components in cases of suspected child abuse.
  • A key aspect in making a diagnosis of physical abuse is identifying the incompatibility of the history of trauma with the injuries identified.
  • Skeletal injuries, such as metaphyseal corner fractures and posterior rib fractures, have a high specificity for inflicted injury and child abuse.
  • Abusive head trauma encompasses a spectrum of abnormalities including subdural hematomas, skull fracture, and retinal hemorrhages.
  • Neglect is the most common type of maltreatment reported. Neglect encompasses medical, supervisional, educational, physical, and nutritional forms.
  • Physicians should consider child abuse in the differential diagnosis of all children presenting with injuries.


Child maltreatment is a serious cause of morbidity and mortality affecting young children in the United States and around the world. Child physical abuse is physical harm to a child at the hands of a caregiver that may encompass a single incident or repeated incidents.1 Examples of physical abuse include abusive head trauma (the “shaken baby syndrome”), immersion burns, skeletal injuries, and inflicted, patterned bruises. According to recent data in Child Maltreatment 2006, there were 3.3 million referrals to child welfare agencies in the United States in 2006. Investigation into these referrals revealed abuse in 30% cases, involving nearly 1 million children. It is estimated that in 2006, there were more than 1500 deaths in the United States related to abuse and neglect.2 Abuse is ranked as the third leading cause of homicide in children older than 1 year of age. The youngest children are most at risk for being abused. It is important to note that more than one-third of child abuse fatalities were involved with child welfare agencies prior to the child's death. This fact highlights the critical nature of a complete medical evaluation, thorough documentation, and communication with the child welfare system investigators. Children commonly present initially to an emergency department with injuries or medical problems caused by abuse and neglect. Thus, it is imperative that emergency health care professionals have knowledge of the function and mechanics of the child welfare system within their community, and have protocols for the evaluation and treatment of children suspected of being abused or neglected.


The spectrum of child abuse and neglect is broad and includes physical abuse (16%), sexual abuse (9%), emotional abuse (6.6%), and neglect (60%). There are many manifestations of neglect including medical, supervisional, physical, nutritional, and emotional forms. The broad spectrum of child abuse and neglect can range from clearly inflicted injuries pathognomonic for abuse to suspicious scenarios and injuries that warrant further investigation by the local child protection agency. The diagnosis of child abuse depends on information obtained from the medical history, physical examination, and injuries identified by ancillary studies. It is critical that a detailed ...

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