What is the appropriate initial management for a child suspected of being a victim of child abuse?

Initial Management of Suspected Child Abuse

When child abuse is suspected, immediately ensure the child's safety by admitting them to the hospital to separate them from potential perpetrators, as 95% of abuse occurs within the family, then proceed with systematic documentation, imaging, and mandatory reporting to child protective services. 1

Immediate Safety and Stabilization

• Remove the child from the suspected abusive environment immediately by hospital admission, which serves as the first critical step in victim protection 1
• Assess for life-threatening injuries requiring emergent intervention, particularly neurological compromise or hemodynamic instability 2
• Stabilize any acute medical conditions before proceeding with comprehensive abuse evaluation 3

Systematic Clinical Assessment

History Taking

• Obtain a complete medical history from the child (if developmentally appropriate) and caregivers separately, documenting exact quotes 3
• Pay particular attention to inconsistencies between the injury pattern and the provided history, as discrepancies are a hallmark of abusive trauma 2
• Document the child's developmental capabilities to assess whether injuries could have occurred as described 2
• Record all previous injuries, emergency department visits, and any prior child protective services involvement 2

Physical Examination

• Perform a thorough head-to-toe examination, documenting all injuries with photographs and detailed descriptions for medico-legal purposes 3
• Look for specific high-risk injury patterns: multiple fractures in different stages of healing, dorsal rib fractures, complex skull fractures, physeal fractures, patterned bruises, immersion burns, and any fractures in children under 12 months 1
• Examine for abdominal findings including bruising, distension, tenderness, hypoactive bowel sounds, which may indicate occult intra-abdominal injury 2, 4

Age-Specific Imaging Protocols

Children ≤24 Months Old (Variant 1)

This is the highest-risk age group requiring the most comprehensive evaluation 2

• X-ray skeletal survey is mandatory (rating 9/9) as the universal screening examination, as fractures occur in over half of abused children and rib fractures may be the only finding in 30% 2
• Perform repeat limited skeletal survey after 2 weeks to detect healing fractures that were initially occult and provide fracture dating information 2
• Head CT without contrast (rating 5/9) or MRI head without contrast (rating 6/9) should be performed even in neurologically asymptomatic infants, as clinically occult abusive head trauma is common in young infants 2
• Tc-99m bone scan (rating 4/9) serves as a complementary study to detect occult fractures not visible on plain radiographs 2

Children >24 Months Old (Variant 2)

• X-ray of specific areas of concern (rating 9/9) based on clinical findings 2
• Consider full skeletal survey (rating 5/9) in children unable to verbalize pain locations 2
• Head CT without contrast (rating 6/9) or MRI head without contrast (rating 5/9) based on clinical suspicion 2

Children with Neurological Signs or High-Risk Features (Variant 3)

This represents the emergent scenario requiring immediate comprehensive imaging 2

• Both skeletal survey AND head CT without contrast are mandatory (both rating 9/9) 2
• Use CT in the emergent setting for rapid assessment; MRI head without contrast (rating 8/9) should follow in the non-emergent setting as it detects additional findings in 25% of cases 2
• MRI cervical spine without contrast (rating 8/9) should be strongly considered at the time of brain MRI, as unsuspected spinal injuries occur in >36% of cases, particularly ligamentous injuries at the craniocervical junction 2
• MRI complete spine (rating 5/9) is reserved for cases where distinguishing abusive from accidental trauma is unclear 2

Suspected Thoracoabdominal Injuries (Variant 4)

Abdominal injuries from abuse carry a 6-fold increased mortality risk compared to accidental trauma 2

• Contrast-enhanced CT of abdomen and pelvis is the gold standard for hemodynamically stable children with suspected intra-abdominal injury 2, 4
• Obtain liver transaminases and pancreatic enzymes, as elevations may indicate occult trauma even without obvious clinical findings 2, 4
• Skeletal survey remains mandatory in children ≤24 months with thoracoabdominal injury due to high polytrauma rates 2, 4
• Up to 10% of abused children have intra-abdominal injury, with nearly half requiring surgical intervention 2
• Bowel and pancreatic injuries occur disproportionately more in abuse versus accidental trauma 2

Laboratory and Ancillary Testing

• Obtain liver transaminases (AST, ALT) and pancreatic enzymes (lipase, amylase) in all cases with abdominal concerns, as abnormalities may be the only indicator of occult trauma 2, 4
• Consider coagulation studies and metabolic workup to differentiate abuse from conditions mimicking abuse (e.g., osteogenesis imperfecta, bleeding disorders) 2
• Ophthalmologic examination for retinal hemorrhages is critical in suspected abusive head trauma 1

Mandatory Reporting and Documentation

• Report all cases of suspected child abuse to child protective services immediately—this is a legal requirement with penalties for failure to report 3, 5
• Complete detailed medico-legal documentation including injury diagrams, photographs, and exact quotes from history 3
• Reporting to law enforcement is strongly advised in addition to child protective services 5
• Documentation should include assessment of 16 specific factors when evaluating supervisory neglect, including the child's age, maturity, duration left alone, environmental dangers, and past allegations 2

Critical Pitfalls to Avoid

• Never assume abdominal symptoms indicate only abdominal pathology—in children with head trauma and GI symptoms, perform head CT first as vomiting may indicate increased intracranial pressure 6
• Do not rely on ultrasound alone for abdominal trauma evaluation, as it is significantly less sensitive than CT for detecting solid organ injuries and hemoperitoneum 2, 4
• Avoid dismissing injuries in pre-ambulatory infants as accidental—any fracture in a child under 12 months is highly suspicious for abuse 1
• Do not underestimate "mild" presentations, as delayed presentation is common in abusive abdominal trauma and outcomes are worse than accidental trauma 2
• Remember that even careful caregivers may experience brief lapses leading to injury—distinguish this from patterns of decisions placing children at ongoing significant risk 2

Multidisciplinary Team Mobilization

• Activate the hospital's child abuse management team immediately upon suspicion 3
• Coordinate with social services, child protective services, law enforcement, and specialized abuse pediatricians 3, 7
• Arrange appropriate follow-up care including psychological evaluation and therapy, as the long-term psychological impact varies widely but can be severe 5
• Ensure the child's safety is maintained throughout the evaluation and after discharge through coordination with protective services 3