ABP Child Abuse Pediatrics cheat sheet

TEN-4 rule: bruising to the torso, ears, or neck in a child aged 4 years or younger, or any bruise in an infant younger than 4 months, is suspicious for inflicted injury.

Sentinel injury: a minor injury such as a bruise in a pre-mobile infant or an infant younger than 6 months can precede severe abuse and warrants a full evaluation.

Abusive head trauma has no single diagnostic feature; subdural hemorrhage, retinal hemorrhage, and encephalopathy may co-occur, but their absence does not exclude abuse.

Retinal hemorrhage evaluation uses dilated indirect ophthalmoscopy by an ophthalmologist; extensive, multilayered hemorrhages in a young infant without major accidental trauma raise concern for abusive head trauma.

Skeletal survey is indicated for suspected abuse in children younger than 2 years; repeat the survey about 2 weeks later to detect healing fractures.

Classic metaphyseal lesions and posterior rib fractures are highly specific for abuse in infants and require significant force.

Occult abdominal trauma screening includes ALT, AST, lipase, and urinalysis; abnormal results or symptoms warrant imaging such as CT.

Check CBC, PT, PTT, INR, and fibrinogen before attributing unexplained bruising or bleeding to abuse, especially with atypical patterns.

Most sexually abused children have normal anogenital examinations; delayed disclosure, recantation, and absence of physical findings do not exclude abuse.

Anogenital examination uses supine frog-leg and prone knee-chest positions with labial traction; avoid unnecessary repeat examinations.

A complete hymenal transection or cleft through the hymen to its base is a concerning finding for penetrating trauma, while hymenal tags and variants are not diagnostic.

Acute sexual assault evidence collection follows local protocol; DNA evidence may be collected up to 72 hours or longer, with STI prophylaxis and emergency contraception offered as indicated.

STI testing in sexual abuse uses NAAT for chlamydia and gonorrhea at exposed sites, syphilis serology, HIV testing, and hepatitis B testing, with follow-up testing as recommended.

In a prepubertal child, vaginal chlamydia or gonorrhea beyond the neonatal period is diagnostic of sexual contact and must be reported.

Forensic interviews are non-leading, developmentally appropriate, conducted by trained professionals at child advocacy centers, and ideally recorded to reduce repeated questioning.

Child sexual exploitation includes child sexual abuse material, trafficking, grooming, and online solicitation; all require reporting to authorities.

Neglect is the most common form of maltreatment and includes physical, supervisory, medical, educational, and emotional subtypes.

Growth faltering is weight or length below expected for age or crossing percentiles downward; plot weight, length, and head circumference and calculate z-scores.

Medical neglect is failure to seek or follow through with necessary care; distinguish willful neglect from barriers such as cost, transportation, and health literacy.

Supervisory neglect considers the child's developmental age, duration of unsupervised time, hazards, and adequacy of the caregiver.

Physical neglect signs include poor hygiene, inadequate clothing, malnutrition, untreated dental disease, and unsafe shelter.

Risk factors for neglect include poverty, parental substance use, mental illness, domestic violence, and social isolation, but poverty alone does not establish neglect.

Neglect evaluation includes home visiting, growth chart review, immunization and dental status, school attendance, and family assessment.

Hospital admission may be used for observed feeding, weight monitoring, and multidisciplinary assessment when outpatient evaluation is inconclusive or safety is uncertain.

Psychological maltreatment categories include spurning, terrorizing, isolating, exploiting or corrupting, denying emotional responsiveness, and neglecting mental health, medical, or educational needs.

Factitious disorder imposed on another is caregiver falsification or induction of illness in a child, formerly called Munchausen syndrome by proxy, and it constitutes abuse.

FDIA red flags include symptoms present only with the caregiver, inconsistent laboratory results, multiple providers, unusual infections, and unexplained bleeding.

FDIA evaluation includes reviewing all records, separating the child from the caregiver, and using covert video only with legal guidance.

FDIA management includes reporting to child protective services, protecting the child, multidisciplinary assessment, and psychiatric evaluation of the caregiver.

Psychological maltreatment often coexists with physical abuse or neglect and is assessed through parent-child interaction and caregiver behavior.

Psychological maltreatment harms attachment, brain development, self-regulation, and mental health and may require trauma-focused therapy.

Mandated reporting threshold is reasonable suspicion of abuse or neglect, not proof; good-faith reports are legally protected and reporting does not end the medical evaluation.

Documentation includes verbatim quotes, body diagrams, photographs with scale, and precise descriptions of injuries and behaviors.

Chain of custody documents each transfer of forensic evidence, specimens, or photographs using sealed containers, labels, and signatures to preserve admissibility.

Multidisciplinary teams include medical providers, child protective services, law enforcement, mental health clinicians, and victim advocates.

Child advocacy centers coordinate forensic interviews, medical examinations, mental health care, and family advocacy in one setting.

Legal proceedings may involve civil child protective, criminal, and family court; testimony distinguishes factual findings from expert opinions.

Prevention programs include home visitation, abusive head trauma prevention such as the Period of PURPLE Crying, safe sleep education, and parenting support.

Advocacy includes policy change, funding for prevention, community education, and addressing vicarious trauma among professionals.