Child abuse

• Accidental injuries: Typically on bony prominences; history often consistent with injury.
• Non-accidental injuries: Injuries at different stages of healing, defensive injuries, or injuries in areas less prone to accidental trauma (e.g., buttocks, inner thighs).
• Hematologic disorders: Conditions like hemophilia or ITP causing easy bruising, but typically with a medical history suggesting bleeding tendency.
• Osteogenesis Imperfecta: Recurrent fractures with minimal trauma, often with a history of blue sclera, hearing loss, or dental issues.

• Failure to thrive: Often due to neglect; lack of weight gain despite appropriate intake suggests other medical causes like malabsorption.
• Developmental delay: Could result from neglect, especially in a stimulating environment; consider other causes like cerebral palsy or autism.
• Poor hygiene: May indicate neglect but also consider socioeconomic factors or skin conditions.

• Urinary tract infections (UTIs): Common in young children; consider sexual abuse if recurrent or with other signs of trauma.
• Genital injuries: Unexplained or unusual injuries may raise suspicion of sexual abuse.
• Sexualized behavior: Consider in context; children may exhibit inappropriate sexual knowledge or behaviors beyond their developmental level.
• STIs: In children, raise suspicion of abuse; however, consider vertical transmission or non-sexual contact (e.g., contaminated objects).

• Behavioral disorders: Consider ADHD, conduct disorder, or anxiety, but assess for possible underlying emotional abuse.
• Attachment disorders: Can result from early emotional abuse; distinguish from ASD or other developmental disorders.
• Low self-esteem: Chronic exposure to emotional abuse may manifest as low self-worth or social withdrawal.
• School refusal: May indicate underlying anxiety, bullying, or emotional abuse at home.

Enquire about the specific incident or symptoms that led to the presentation. Assess the consistency of the history provided by the child and caregiver. Consider whether the injury is consistent with the history, and if the timing of the injury corresponds to the history provided.

Explore the child’s previous medical history for any recurrent unexplained injuries or frequent visits to the emergency department. Review family history for any evidence of domestic violence or substance abuse. In the social history, assess for factors like parental separation, unemployment, or housing instability which might increase the risk of abuse.

Document any developmental delays or regression which may be a sign of emotional abuse or neglect. Assess for any behavior changes, such as withdrawal, aggression, or sexualized behavior, that could indicate abuse. Consider school performance and relationships with peers as indicators of overall well-being.

• Skeletal survey: Indicated if physical abuse is suspected, especially in non-verbal children or those under 2 years of age.
• CT/MRI of the head: Consider if there are signs of head injury or neurological symptoms.
• Bone scans: May be used to detect occult fractures not seen on initial X-rays.

• Full blood count and coagulation profile: To rule out bleeding disorders that may mimic signs of abuse.
• Toxicology screen: Consider if there is suspicion of poisoning or drug ingestion.
• Sexually transmitted infection (STI) screening: Indicated if sexual abuse is suspected, even in the absence of symptoms.