Physical Child Abuse

Information has been excerpted from VisualDx clinical decision support system as a public health service. Additional information, including symptoms, diagnostic pearls, differential diagnosis, best tests, and management pearls, is available in VisualDx.


Physical child abuse means injury to the child either by acts of commission (abuse, ie, inflicted injury as opposed to an accidental injury) or omission (neglect). Physical abuse can occur in children of any age but has a mean age of 6 years. Over 75% of fatalities occur in children younger than 3 years of age, with neonates and infants (children younger than 12 months) at the highest risk for serious injury or death.

Abuse can occur by hitting, whipping, biting, kicking, choking, shaking, burning, or any physical means.
Population risk factors that have been identified to increase the potential for abuse may include young parents, children with special health care needs or developmental disorders, substance use or mental health issues in the home, and poverty.*

*Note: Risk factors are population risk factors and should never be relied on to decide who to further evaluate, who to report, when to worry about abuse, etc. Doing so may result in misdiagnosis and delay to diagnosis. The facts of the specific case are far more important than profiling who is at risk.

Related topics: bruise of child abusepediatric abusive head traumachild sexual abuse

Look For

Injuries inconsistent with history or developmental age of the child, scars, hyperpigmentation, and bruises.

Check for oral mucosal trauma, such as torn frenula (both upper and lower labial frenula and lingular frenula), in infants and young children.

Check for subconjunctival hemorrhages in nonmobile infants outside of the neonatal period.

Consider bruises that are inconsistent with the developmental age of the child or that are on multiple body surfaces, or, most importantly, fit the TEN-4 FACESp criteria (for children younger than 4 years of age who have bruising present at the time of the examination):

  • TEN-FACES – Body region bruised (torso, ear, neck [TEN]; frenulum, angle of jaw, cheeks [fleshy], eyelids, and subconjunctivae [FACES])
  • 4 – Bruising anywhere on an infant 4.99 months and younger
  • p – Patterned bruising

There is often a delay in seeking medical care, and there may be temporal or factual inconsistencies in the patient’s history, for example, injuries described may be incompatible with presentation.

Bruises: Look for geometric patterns such as from belt buckles, loops from electric cords, the imprint of the hand, ropes, or linear marks from sticks or rods. Bruises or physical marks can occur anywhere, though the buttocks, arms, head, and neck are the most common locations.


  • Cigarette burns are characteristically small and round and may present with scars or new lesions; however, caution is advised in making this diagnosis unless the burn is fresh and/or disclosure criteria are met, as there are many mimics of cigarette burns.
  • Immersion injuries are typically symmetric and have sharp lines or drops from splashes.

Head injuries: The child may appear lethargic or irritable, or have vomiting without diarrhea or fever, macrocephaly, or frank neurologic signs such as seizures.

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