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## Complete Summary

#### GUIDELINE TITLE

Evaluation of suspected child physical abuse.

#### BIBLIOGRAPHIC SOURCE(S)

Kellogg ND, American Academy of Pediatrics Committee on Child Abuse and
Neglect. Evaluation of suspected child physical abuse. Pediatrics 2007
Jun;119(6):1232-41. \[70 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17545397)

#### GUIDELINE STATUS

This is the current release of the guideline.

All clinical reports and policy statements from the American Academy of
Pediatrics automatically expire 5 years after publication unless
reaffirmed, revised, or retired at or before that time.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Child physical abuse

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Prevention\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Pediatrics

#### INTENDED USERS

Advanced Practice Nurses\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To provide guidance in the clinical approach to the evaluation of
suspected physical abuse in children

#### TARGET POPULATION

Children who are suspected victims of abuse

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis/Evaluation**

1.  Medical and family history

2.  Physical exam

3.  Skeletal survey

4.  Tests for hematologic disorders (complete blood cell count,
    platelets, prothrombin time, partial thromboplastin time,
    international normalized ratio, bleeding time)

5.  Liver enzymes (aspartate aminotransferase and alanine
    aminotransferase)

6.  Pancreatic enzyme tests (amylase and lipase)

7.  Urinalysis

8.  Magnetic resonance imaging (head/neck)

9.  Computed tomography (head, abdomen)

10. Cardiac enzymes (troponin and creatine kinase with muscle and brain
    subunits)

11. Radionuclide bone scan

12. Skin biopsy for fibroblast culture and/or venous blood for DNA
    analysis (for suspected Osteogenesis imperfecta)

13. Complete neurological assessment

14. Bone-mineralization disorder tests (blood calcium, alkaline
    phosphatase, phosphorus, vitamin D, and parathyroid hormone)

15. Retinal examination by an ophthalmologist

16. Documentation of all bruising and skin injuries

**Management/Treatment**

1.  Referral to investigative agencies

2.  Referral to appropriate medical providers

3.  Legal issues (physician testimony)

#### MAJOR OUTCOMES CONSIDERED

Incidence of physical child abuse

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**[Role of the Pediatrician]{.underline}**

Although consideration of nonabusive causes of injuries may merit
additional evaluation and testing, the physician is mandated by law to
report suspicions of abuse and should not delay reporting pending
confirmatory testing or information. In all states, the law also
provides some type of immunity for good-faith reporting. Once a
suspected victim is identified and further assessment and management is
required, using a pediatric child abuse consultant, if available, early
in this process may obviate the need for invasive or expensive testing
and can help direct the pediatrician toward appropriate evaluation. The
detection and diagnosis of child physical abuse depends on the
clinician\'s ability to recognize suspicious injuries, conduct a careful
and complete physical examination with judicious use of auxiliary tests,
and consider whether the caregivers\' explanation is supported by the
characteristics of the injury or injuries and the child\'s developmental
capabilities. The physician should also ensure that the child\'s
immediate medical and safety needs are met. Child abuse injuries,
particularly traumatic brain injuries, may result in significant
long-term disabilities including learning deficits,
attention-deficit/hyperactivity disorder, behavioral problems, seizures,
spasticity, blindness, paralysis, and mental retardation. Continuity of
care for such children is essential, especially if they are transferred
to other caregivers or foster homes.

Many hospitals and communities have developed child abuse--assessment
teams of pediatricians and other professionals who specialize in the
assessment of suspected victims of child abuse. Such teams usually have
access to additional information from law enforcement and child
protective services, such as scene investigation, that may facilitate
more thorough injury assessment and diagnosis. Involving such teams
early in the process can ensure accurate and comprehensive assessments
and information sharing among the medical and nonmedical disciplines
involved and can provide for intermediate and long-term management of
the child and family. Pediatricians with expertise in evaluating
suspected abuse should provide training and assistance to emergency
physicians and other first responders to enhance detection and
appropriate referral of these patients.

Many regions do not have specialized child abuse teams but do have
physicians with expertise in child abuse. Pediatricians should know
which hospitals in their region have the most available expertise in the
emergency evaluation of suspected child abuse. In turn, pediatricians
with expertise in child abuse often act as consultants for emergency
departments and child protective services. Close collaboration is
necessary, particularly for establishing how the child should be
transported between facilities, who should notify child protective
services, who should notify the caregiver(s) of suspected abuse and
when, and whether law enforcement should be notified. For those who do
not require emergent transportation by ambulance, child protective
services may facilitate transportation of a suspected child victim from
one facility to another, assist in notifying the caregivers and law
enforcement of suspected abuse, and provide an emergent safety plan on
hospital discharge or clinic dismissal.

**Clinical Presentation and Settings**

Infants and children are reported as suspected victims of physical abuse
when 1 or more of the following occurs:

-   An individual (including a professional) sees and reports a
    suspicious injury

-   An individual witnesses an abusive event

-   A caregiver observes symptoms and brings the child in for medical
    care but is unaware that the child has sustained an injury

-   An individual asks a child if he or she has been hurt in an abusive
    way

-   The abuser thinks the inflicted injury is severe enough to require
    medical attention

-   The child victim discloses abuse

The clinical approach to an infant or child with possible abusive
injuries is not significantly different from standard pediatric care. As
with all patients, a severely injured child must be stabilized before
further evaluation is undertaken. This initial evaluation may encompass
a trauma response team and pediatric specialists in surgery, emergency
medicine, and critical care. Careful documentation may not be possible
initially and must always be secondary to resuscitation and
stabilization of the patient. Once the child is stabilized, a careful
and well-documented history, as always, is the most critical element of
the medical evaluation. Using quotes whenever possible, the pediatrician
should document descriptions of the mechanisms of injury or injuries,
onset and progression of symptoms, and the child\'s developmental
capabilities. The physical examination should include detailed
documentation, either by body diagrams and/or photographs, of any
concerning cutaneous findings and should include a thorough search for
other signs that may suggest a nontraumatic cause. If the child is
verbal, it may be helpful to gather parental and patient histories
separately. If abuse is a concern after this preliminary evaluation,
consultation with a child abuse pediatrician, pediatric specialist, or
pediatrician experienced in this area, if available, may be helpful in
determining the best way to proceed with assessment.

**Medical History**

The interview of parents or caregivers of infants or children who
present with serious injuries may be conducted in an outpatient or
inpatient setting. If the child presents to a clinic with a serious
injury that requires further medical care in a specialty (e.g.,
orthopedics) or hospital setting, the clinician may opt to gather the
minimum information to establish a need for reporting to child
protective services. Any statements made by the caregiver regarding the
injury should be documented accurately and completely. Once the
clinician has assessed all the injuries, including approximate ages of
injuries (when possible), a careful, complete, and detailed history
should be obtained from the caregivers.

Explanations that are concerning for intentional trauma include:

1.  No explanation or vague explanation for a significant injury

2.  An important detail of the explanation changes dramatically

3.  An explanation that is inconsistent with the pattern, age, or
    severity of the injury or injuries

4.  An explanation that is inconsistent with the child\'s physical
    and/or developmental capabilities; and

5.  Different witnesses provide markedly different explanations for the
    injury or injuries

Information regarding the child\'s behavior before, during, and after
the injury occurred, including feeding times and levels of
responsiveness, should be gathered. Victims of significant trauma
usually have observable changes in behavior. Access to caregivers and
caregiver activities before, during, and after the injury occurred are
also important to document. Other information that may be useful in the
medical assessment of suspected physical abuse includes:

1.  Past medical history (trauma, hospitalizations, congenital
    conditions, chronic illnesses)

2.  Family history (especially of bleeding, bone disorders, and
    metabolic or genetic disorders)

3.  Pregnancy history (wanted/unwanted, planned/unplanned, prenatal
    care, postnatal complications, postpartum depression, delivery in
    nonhospital settings)

4.  Familial patterns of discipline

5.  Child temperament (easy to care for or fussy child)

6.  History of past abuse to child, siblings, or parents

7.  Developmental history of child (language, gross motor, fine motor,
    psychosocial milestones)

8.  Substance abuse by any caregivers or people living in the home

9.  Social and financial stressors and resources; and

10. Violent interactions among other family members

**Physical Examination**

Physicians must also consider that unusual events, including accidents,
do happen to children and may produce injuries that are not
characteristically seen from accidental causes. An injury pattern is
rarely pathognomonic for abuse or accident without careful consideration
of the explanation provided. In addition, both inflicted and accidental
injuries may be seen simultaneously in a child.

*General Assessment*

The child\'s alertness and demeanor may reflect neurologic status and
degree of discomfort and pain. A thorough and complete neurologic
examination must be performed. Spontaneous and symmetrical movement of
all extremities should be noted, as well as any of the child\'s
responses that indicate pain when extremities are examined and moved.
Because abusive caregivers are rarely informative regarding the injuries
that have been inflicted, special care should be taken during the
examination of the child\'s extremities and neck, which may be fractured
and require immobilization until diagnostic radiographs can be
performed. Evidence of spinal cord injury, such as abnormal reflexes,
muscle tone, or responsiveness to tactile stimuli, should be carefully
pursued.

When the child is stable, height, weight, and fronto-occipital
circumference should be carefully measured and then plotted on a growth
chart. Previous measurements obtained from past medical visits should
also be obtained to gauge whether growth velocity has been appropriate.
Plotting parameters is essential, because clinicians may miss
significant growth failure in infants and children if the clinician
relies only on their clinical impressions.

Evidence of neglect may be seen during the general examination of the
infant or child; extensive dental caries, severe diaper dermatitis, or
neglected wound care may be noted in addition to injuries that raise
suspicion of abuse. Bald areas on the scalp may sometimes be seen with
severe nutritional deficits or with traumatic alopecia. These findings
should be differentiated from nonabusive or benign causes such as tinea
capitis, alopecia areata, and occipital bald spots caused by supine
positioning of young infants.

If the child can be interviewed, his or her demeanor should be noted
during questioning. Some children display strong nonverbal cues of
anxiety and reluctance when answering questions regarding potential
abuse, because they are protective of their abuser or they fear
retribution for \"telling.\" Others may appear openly fearful of their
abuser. Such responses may be important to consider when a safety plan
for the child is made.

*Skin Injuries*

Location, size, and shape of any bruises, lacerations, burns, bites, or
other skin injuries should be documented in a medical chart as well as
with high-quality 35-mm or digital photographs. Inspection for injuries
should be thorough and involve all aspects of the neck and head; mouth;
extremities, including feet and hands; genitals; anus; buttocks; torso;
and back. Obscure sites for inflicted injuries include the ears,
especially the posterior aspects, the neck and angle of the jaw, scalp,
and the frenula of the lip and tongue. In contrast to accidental
injuries, inflicted injuries tend to occur on surfaces away from bony
prominences, such as the neck, head, buttocks, trunk, hands, and upper
arms. Hematomas of the scalp may be detected through palpation or may be
visualized on radiographs. Some deeper bruises may not be readily
visible for several hours; areas that are painful to palpate may require
further examination in 1 to 2 days, when bruises may become apparent.
Measurement of skin injuries may assist in determining the mechanism of
injury and/or object used to inflict the injury.

Bite marks can yield important forensic information; referral to
professionals that can gather such information and maintain a chain of
custody is advisable. Bite marks, recent or healed, should be carefully
measured and photodocumented when possible; an intercanine distance of
more than 2 cm suggests a human adult-sized bite. In some facilities,
forensic odontologists are available and may use special examination and
photographic techniques to analyze bite marks. Fresh bites should be
swabbed with sterile, premoistened cotton-tipped applicators for
forensic analysis of potential genetic markers found in saliva.

Burn injuries may be chemical, thermal (including exposure to scalding
liquids or hot objects), or electrical. The child\'s clothing worn
during the burn should be collected and may provide information
regarding the cause of the burn. Burns inflicted with hot objects can be
difficult to differentiate from accidental mechanisms, because both
burns may be patterned. The history, number of burns, and continuity of
the burn pattern over curved body surfaces may indicate a greater
probability of inflicted trauma. Accidental scalds most commonly involve
hot liquids pulled or splashed onto the child\'s upper extremities,
torso, and or neck and head. Inflicted scalds or forced-immersion burns
may be well demarcated in pattern, with few or no splash marks. When
evaluating an apparent burn injury, other noninflicted causes to
consider include chemical burns of the buttocks with senna-containing
laxatives, bullous impetigo, and accidents.

*Cranial Injuries*

Infants with intracranial injuries frequently have no or nonspecific
symptoms, so the absence of neurologic symptoms should not exclude the
need for imaging. Careful consideration of symptoms, signs, history, and
judicious use of other ancillary tests should guide the clinician in
determining the need for imaging.

Abuse should be suspected when there is a history of minor head trauma
such as a short fall in children with multiple, complex, diastatic, or
occipital skull fractures. Whenever an infant or child presents with a
skull fracture, care should be taken to ensure that there are no other
injuries.

A fundoscopic examination for retinal hemorrhages should be considered
for any infant or young child who is a suspected victim of physical
abuse. Under optimal conditions, an ophthalmologist with pediatric
experience should conduct an examination of dilated pupils by using
indirect ophthalmoscopy. The ophthalmologist should provide
documentation of the retinal hemorrhages by photography or detailed
annotated drawings. Location, depth, and extent of retinal hemorrhages
may distinguish between abusive and nonabusive causes of head trauma.

*Thoracoabdominal Injuries*

Auscultation, performed before palpation, may reveal decreased or no
bowel sounds if the child has sustained intraabdominal injury. If the
intestines, liver, or spleen have been ruptured, guarding or abdominal
muscle rigidity may be noted on palpation. Abdominal bruising is often
not seen, even with severe blows to the abdomen. Liver and pancreatic
enzyme tests are helpful in screening children for abdominal trauma,
especially when the child presents with acute symptoms or shortly after
the incident has occurred. A urinalysis may also lead to the discovery
of unexpected trauma to the urinary tract and kidneys. Radiographic
studies, including computed tomography, are helpful in determining the
types and severity of intraabdominal trauma and are warranted in most
cases when the physical examination is unreliable because of patient
age, presence of other injuries that may obfuscate the abdominal
examination, or the presence of head injury.

*Skeletal Injuries*

Careful palpation of the legs, arms, feet, hands, ribs, and head may
reveal acute or healing (callus formation) fractures. If a fracture is
suspected, surfaces should be carefully examined for \"grab marks\" that
may indicate restraint or areas that were pulled or twisted to create
the fracture; however, absence of such bruising does not exclude abusive
mechanisms of injury. Soft tissue swelling, with or without bruising,
may indicate more recent trauma. Many fractures, including rib and
metaphyseal fractures, may not be clinically detectable, so a negative
clinical examination should not preclude the need for a skeletal
radiologic survey when inflicted trauma is suspected, particularly in
children younger than 2 years.

Long-bone fractures that should be evaluated carefully for nonaccidental
causes include metaphyseal fractures and spiral/oblique fractures,
especially in nonambulatory infants; both types of fractures have been
associated with accidental mechanisms of injury as well.

A complete neurologic assessment, including reflexes, cranial nerves,
sensorium, gross motor, and fine motor abilities, should be conducted.
Abnormalities may reflect current or past injuries to the central
nervous system. Abused children may also have developmental disabilities
because of deprivation in the home environment or other causes.

**Diagnostic Testing and Consultations**

When abuse is suspected as the cause of an injury, the clinician may
conduct tests to screen for other injuries or underlying medical causes
for the injury. The extent of diagnostic testing depends on several
factors including the severity of the injury, the type of injury, the
age of the child, and examination findings. In general, the more severe
the injury and younger the child, the more extensive is the need for
diagnostic testing for other injuries. The Table below is a summary of
tests, some of which may be used during a medical assessment for
suspected abuse.

When one child is identified as a suspected victim of abuse, siblings
and other child contacts of the suspected abuser should also be assessed
for injuries. The extent of the assessment depends on the child\'s age,
symptoms, and signs; infants and toddlers may require more extensive
testing, because symptoms and signs may be less useful in determining
the presence of occult inflicted injuries.

**Table. Diagnostic Tests That May Be Used in the Medical Assessment of
Suspected Physical Abuse and Differential Diagnoses**

+------------+---------------------------+----------------------------+
| **Type of  | **Diagnostic Tests**      | **Comments**               |
| Injury or  |                           |                            |
| C          |                           |                            |
| ondition** |                           |                            |
+============+===========================+============================+
| Fractures  | Skeletal survey: humeri,  | 1.  Recommended for all    |
|            | forearms, femurs, lower   |     children with          |
|            | legs, hands, feet, skull, |     fractures and children |
|            | cervical spine, thorax    |     with any suspicious    |
|            | (including oblique views) |     injuries under age 2   |
|            | and lumbar spine, pelvis  |                            |
|            |                           | 2.  Repeat skeletal survey |
|            |                           |     in 2 weeks for         |
|            |                           |     high-risk cases        |
|            |                           |                            |
|            |                           | 3.  Single whole-body      |
|            |                           |     films are unacceptable |
+------------+---------------------------+----------------------------+
| Bruises    | Tests for hematologic     | 1.  Recommended when       |
|            | disorders: CBC count,     |     bleeding disorder is a |
|            | platelets, prothrombin    |     concern because of     |
|            | time, partial             |     clinical presentation  |
|            | thromboplastin time, INR, |     or family history      |
|            | bleeding time; additional |                            |
|            | testing (e.g., factor     | 2.  A DIC screen should be |
|            | levels) may be indicated  |     performed for patients |
|            | after initial screening   |     with intracranial      |
|            | tests                     |     injury, because        |
|            |                           |     intraparenchymal       |
|            |                           |     damage can alter       |
|            |                           |     coagulation            |
|            |                           |                            |
|            |                           | 3.  PFa-100: platelet      |
|            |                           |     function activity is   |
|            |                           |     preferable to bleeding |
|            |                           |     time for establishing  |
|            |                           |     platelet function but  |
|            |                           |     is not widely          |
|            |                           |     available              |
+------------+---------------------------+----------------------------+
| Liver      | Liver enzyme tests:       | 1.  May be helpful in      |
| Injury     | aspartate                 |     diagnosing occult      |
|            | aminotransferase and      |     hepatic injury         |
|            | alanine aminotransferase  |                            |
+------------+---------------------------+----------------------------+
| Pancreatic | Pancreatic enzymes:       |                            |
| injury,    | amylase and lipase        |                            |
| pseudocyst |                           |                            |
+------------+---------------------------+----------------------------+
| Urinary    | Urinalysis                |                            |
| sy         |                           |                            |
| stem/renal |                           |                            |
| injury     |                           |                            |
+------------+---------------------------+----------------------------+
| In         | MRI: head/neck            | 1.  Diffusion-weighted     |
| tracranial |                           |     scan may surpass CT in |
| and        |                           |     characterizing extent  |
| ex         |                           |     of intercerebral edema |
| tracranial |                           |                            |
| injury     |                           | 2.  May provide better     |
|            |                           |     dating of intracranial |
|            |                           |     injuries than CT       |
|            |                           |                            |
|            |                           | 3.  More sensitive than CT |
|            |                           |     for subtle             |
|            |                           |     intracranial injuries  |
|            |                           |     in patients with       |
|            |                           |     normal CT results and  |
|            |                           |     abnormal neurologic    |
|            |                           |     exams                  |
|            |                           |                            |
|            |                           | 4.  More sensitive than    |
|            |                           |     plain radiographs and  |
|            |                           |     CT for detecting       |
|            |                           |     cervical spine         |
|            |                           |     fractures/injury       |
+------------+---------------------------+----------------------------+
| In         | CT scan: head^a^          | 1.  When used in           |
| tracranial |                           |     conjunction with       |
| and        |                           |     radiographs, may       |
| ex         |                           |     enhance detection of   |
| tracranial |                           |     skull fractures        |
| injury     |                           |                            |
+------------+---------------------------+----------------------------+
| In         | Urine: organic acids      | 1.  Screen for glutaric    |
| tracranial |                           |     aciduria type 1        |
| injury     |                           |                            |
+------------+---------------------------+----------------------------+
| Intra      | CT scan: abdomen          | 1.  IV contrast should be  |
| -abdominal |                           |     used and is preferable |
| injuries   |                           |     to PO                  |
+------------+---------------------------+----------------------------+
| Cardiac    | Cardiac enzymes: troponin |                            |
| injury     | and creatine kinase with  |                            |
|            | muscle and brain subunits |                            |
|            | (CK-MB)                   |                            |
+------------+---------------------------+----------------------------+
| Skeletal   | Radionuclide bone scan    | 1.  Better for acute rib   |
|            |                           |     fractures and subtle,  |
|            |                           |     nondisplaced long-bone |
|            |                           |     fractures              |
+------------+---------------------------+----------------------------+
| Os         | Skin biopsy for           |                            |
| teogenesis | fibroblast culture and/or |                            |
| imperfecta | venous blood for DNA      |                            |
|            | analysis                  |                            |
+------------+---------------------------+----------------------------+
| Bone-mine  | Calcium, alkaline         |                            |
| ralization | phosphatase, phosphorus,  |                            |
| disorders: | vitamin D, and            |                            |
| rickets    | parathyroid hormone       |                            |
+------------+---------------------------+----------------------------+

Tests should be ordered judiciously and in consultation with the
appropriate genetics, hematology, radiology, and child abuse
specialists. Careful consideration of the patient\'s history, age, and
clinical findings should guide selection of the appropriate tests. CBC
indicates complete blood cell; INR, international normalized ratio; DIC,
disseminated intravascular coagulation; CT, computed tomography; IV,
intravenous; PO, oral; CK-MB, creatine kinase MB band.

^a^CT scanning may provide clinically relevant information more
expeditiously than MRI in some facilities.

**Documentation and Diagnostic Considerations**

Complete documentation of visible injuries on body diagrams and with
photographs is strongly urged and facilitates peer review as well as
court testimony, when required. Diagnostic impressions should address
whether the explanation adequately correlates with the severity, age,
pattern, and distribution of the injury or injuries and the likelihood
of nonaccidental causes for the injury. If a child has sustained a
serious injury because he or she was left unsupervised in a dangerous
environment, the physician should report suspected neglect or
inappropriate adult supervision, including injuries sustained while
under the care of an intoxicated adult, to child protective services.
When the child is evaluated or tested for other nonabusive causes,
documentation should reflect the results of this assessment as well. In
general, concern for abuse is greatest for infants younger than 12
months regardless of the severity of the injury.

**[Treatment]{.underline}**

Once medical assessment and stabilization are achieved and a referral
has been made to investigative agencies, the physician should ensure
that the child receives the necessary follow-up services. The child\'s
primary care physician should be notified, and child protective services
should ensure that the family complies with the plan of care. These
services should not only include referral to appropriate medical
providers but also address the psychological effects of abuse or neglect
on the young child, the siblings, and the nonoffending caregiver.
Because adult-partner violence commonly co-occurs with child abuse,
several family members may require medical and mental health assistance.
Medical passports, which are abbreviated medical chart forms usually
kept by foster parents and presented at each medical visit, are
recommended to optimize treatment regimens in children who are shifted
among agencies and individuals during the course of the child abuse
investigation.

**[Legal Issues]{.underline}**

All 50 states have statutes that mandate reporting of suspected child
abuse and neglect; the physician is not required to prove abuse before
reporting. Familiarity with state laws will ensure that physicians
report to the appropriate agency within the required time frame; some
states have provided the option of making such a report through the
Internet. Information on specific state laws are provided by the
Children\'s Bureau (Administration for Children and Families, US
Department of Health and Human Services; see
[http://www.childwelfare.gov/systemwide/laws_policies/](http://www.childwelfare.gov/systemwide/laws_policies)).
Many states have laws that permit physicians to evaluate children who
are suspected victims of abuse, to conduct tests, and to take
photographs without parental consent.

The physician may be required to write a sworn statement of his or her
findings and to testify in civil or criminal trial proceedings.
Physicians are expected to testify to the facts on the basis of their
knowledge and experience in pediatrics and, when appropriate, in child
abuse. As such, they may be asked to render opinions regarding the
normal developmental capabilities of children at certain ages as well as
the mechanisms of injury, severity of the injury, and prognosis.
Pediatricians should not testify to anything that is beyond their level
of knowledge or expertise.

**Conclusions**

Child physical abuse is a common problem of childhood. The physician
must be able to recognize suspicious injuries, conduct a comprehensive
and careful examination with appropriate auxiliary tests, critically
assess the explanation provided for the injury or injuries, and
establish the probability that the explanation does or does not
correlate with the pattern, severity, and/or age of the injury or
injuries. The physician is responsible for reporting suspected abuse,
documenting his or her opinions clearly, and providing the necessary
information and expertise to investigative and legal personnel and
parents, when appropriate. In addition, pediatricians are uniquely
qualified to work with parents and caregivers to prevent abuse by
providing anticipatory guidance on normal child behavior and its
management. Finally, physicians must advocate that children in foster
care who have medical or mental health problems receive the appropriate
services and medications and continuity of care through a medical home,
and that a medical passport is maintained for these children.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting each recommendation is not specifically
stated.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Accurate and timely diagnosis of children who are suspected victims of
abuse can ensure appropriate evaluation, investigation, and outcomes for
these children and their families

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

The guidance in this report does not indicate an exclusive course of
treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Kellogg ND, American Academy of Pediatrics Committee on Child Abuse and
Neglect. Evaluation of suspected child physical abuse. Pediatrics 2007
Jun;119(6):1232-41. \[70 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17545397)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2007 Jun

#### GUIDELINE DEVELOPER(S)

American Academy of Pediatrics - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American Academy of Pediatrics

#### GUIDELINE COMMITTEE

Committee on Child Abuse and Neglect

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee on Child Abuse and Neglect, 2006-2007*: Carole Jenny, MD,
MBA, *Chairperson*; Cindy W. Christina, MD; Roberta A. Hibbard, MD;
Nancy D. Kellogg, MD; Betty S. Spivack, MD; John Stirling, Jr, MD

*Liaisons*: David L. Corwin, MD, American Academy of Child and
Adolescent Psychiatry; James A. Mercy, PhD, Centers for Disease Control
and Prevention

*Staff*: Tammy Hurley

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

All clinical reports and policy statements from the American Academy of
Pediatrics automatically expire 5 years after publication unless
reaffirmed, revised, or retired at or before that time.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American Academy of Pediatrics
(AAP) Policy Web
site](http://aappolicy.aappublications.org/cgi/content/full/pediatrics;119/6/1232).

Print copies: Available from American Academy of Pediatrics, 141
Northwest Point Blvd., P.O. Box 927, Elk Grove Village, IL 60009-0927.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI Institute on September 4, 2007.
The information was verified by the guideline developer on September 18,
2007.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions. Please contact the
Permissions Editor, American Academy of Pediatrics (AAP), 141 Northwest
Point Blvd, Elk Grove Village, IL 60007.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008