Differential diagnosis of suspected child physical abuse

INTRODUCTION — The differential diagnosis of conditions that may be mistaken for child abuse is presented here.

The clinical manifestations of child abuse, the diagnostic evaluation for suspected child abuse, and the differential diagnosis of abusive head trauma are discussed separately. (See "Physical child abuse: Recognition" and "Physical child abuse: Diagnostic evaluation and management" and "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'Differential diagnosis'.)

APPROACH — When evaluating the child who is suspected of being physically abused, it is important to remember that findings that appear to be abusive may result from other causes.

The differential diagnosis of child abuse varies depending upon the clinical manifestations. Familiarity with the medical conditions or cultural practices that mimic child abuse can facilitate arrival at the correct diagnosis, initiation of appropriate therapy, and avoidance of the consequences of an unnecessary evaluation for and/or report of suspected child abuse.

One helpful distinguishing feature is that many abused children present with multiple types of injuries (eg, bruising and fractures). Identifying multiple types of injuries decreases the likelihood that a single medical entity has produced all of the findings, although certain conditions (eg, osteogenesis imperfecta, Menkes disease, or congenital insensitivity to pain) provide exceptions to this rule. (See 'Conditions with multisystem manifestations' below.)

On the other hand, studies of children evaluated for child abuse suggest a low frequency of cutaneous or noncutaneous mimics in these patients [1,2]. For example, of almost 3000 children evaluated for physical abuse, approximately 5 percent had a cutaneous mimic (eg, dermal melanosis, impetigo, and bruising due to a bleeding disorder) [1]. Six percent of children with cutaneous mimics still had "high concern" for child abuse when the full picture was considered. Another study found that 3 percent of these same children had noncutaneous mimics (eg, osteomalacia, osteoporosis, or vitamin D deficiency), with or without a cutaneous finding; 7 percent of children with noncutaneous mimics still had "high concern" for child abuse when the full picture was considered and another 21 percent had an "intermediate level of concern" [2]. Thus, the presence of a condition that mimics child abuse does not exclude the possibility that abuse has occurred. The full clinical picture including all historical features and physical findings must be assessed when abuse is suspected.

The medical literature contains many assertions of medical conditions being confused for abuse that are incompletely documented or speculative. Sometimes these assertions are challenged, and other times not [3-6]. Ultimately, a clinician must consider the relative likelihoods of all potential conditions alongside the possibility that a child with a medical condition may, in addition, be abused [7].

The recognition and diagnostic evaluation for physical child abuse are discussed in greater detail separately. (See "Physical child abuse: Recognition" and "Physical child abuse: Diagnostic evaluation and management".)

BRUISES — Bruises are the most common type of injury in abused children [8]. However, nonabusive traumatic bruising is also common once infants are cruising or walking. (See "Physical child abuse: Recognition", section on 'Inflicted bruises'.)

In addition to abusive and nonabusive traumatic bruising, the differential diagnosis of bruising includes a number of medical disorders, including:

●Bleeding disorders

●Vitamin K deficiency

●Salicylate ingestion

●Immunoglobulin A vasculitis (Henoch-Schönlein purpura) and other vasculitides

●Dermal melanosis (formerly Mongolian spots)

●Hemangiomas

●Delayed subaponeurotic fluid mass

Nonabusive traumatic bruising in healthy children — Bruising is the most common form of both unintentional and abusive injury. The age of the child and the nature, shape, location, distribution, number, and size of bruises can be used to raise or lower the suspicion for abuse. Bruising is uncommon among healthy infants younger than six months of age who have not been abused. This finding contrasts with observed rates of bruising of up to 50 percent of infants who are cruising or crawling. The majority of walking children have bruises.

The most common locations of unintentional bruises include the scalp, knee, shin, or thigh, though other areas, particularly the back, forearms, nose, or cheek, are sometimes injured in mobile infants and children. Premobile infants seldom have more than one bruise, and crawlers and cruisers seldom more than two, but walkers commonly had five or more bruises. The majority of walking children have bruises, which are typically multiple. During validation of the TEN-4-FACES-P clinical prediction rule, common areas of bruising in children under four years old included the lower leg (64 percent), knee (34 percent), forehead (27 percent), upper leg (12 percent), lower arm (8 percent), orbital rim, and zygoma (8 percent each) [9]. In a cross-sectional study of children 0 to 13 years, bruise locations associated with eight common accidental injury mechanisms consisted of the shin, knee, forehead, and elbow [10].

By contrast, the following bruising characteristics should raise suspicion for child abuse (see "Physical child abuse: Recognition", section on 'Inflicted bruises'):

●Any bruising in infants younger than six months of age

●More than one bruise in a premobile infant and more than two bruises in a crawling child

●Bruises located on the torso, ear, neck, or buttocks

●Bruises with a pattern of the striking object (figure 1) (eg, slap, belt, or loop marks (picture 1); spoons; spatulas; or other objects)

●Human bite marks

Bleeding disorders — An evaluation of the child's coagulation may be warranted either to detect the coagulopathy that often results from traumatic brain injury, or to test for coagulopathy that could result in bruising, retinal hemorrhage or intracranial bleeding [11-13]. The American Academy of Pediatrics (AAP) has published guidance regarding the evaluation for bleeding disorders when child abuse is suspected [14]. The report encourages careful review of the child's past medical history, family medical history, and physical examination. Providers should remember that, epidemiologically, abusive bruising is much more common than inherited or acquired coagulopathy. When child abuse is suspected based upon bruising, the evaluation for child abuse and reporting to child protection should not be delayed awaiting the results of specialized coagulation testing or consultation with a pediatric hematologist.

Initial testing depends upon whether the child is being evaluated for abusive bruising or intracranial hemorrhage (algorithm 1). Coagulation studies may be unnecessary when abuse is witnessed, injuries are clearly patterned so as to indicate abuse, or when there is medical evidence of abuse that does not include bleeding.

For children who do not receive vitamin K at birth (often home births, alternative medicine, or in less developed health care environments), bleeding from vitamin K deficiency most commonly occurs in the first three months of life with bleeding from mucosal surfaces, prior incisions such as circumcisions, cutaneous bruising, and deeper muscle bruising [15,16]. Rarely, vitamin K deficiency occurs in children with malabsorption of fat soluble vitamins (eg, cystic fibrosis or liver disease). (See "Overview of vitamin K", section on 'Predisposing conditions'.)

When abnormalities are identified, consultation with a hematologist who has pediatric expertise is encouraged before ordering more advanced testing. (See "Physical child abuse: Diagnostic evaluation and management", section on 'Evaluation for bleeding disorders' and "Approach to the child with bleeding symptoms".)

Bleeding disorders mistaken for child abuse include factor VIII and IX deficiencies, von Willebrand disease, immune thrombocytopenia (ITP), platelet function abnormalities, and thrombocytopenia caused by leukemia or other myelodysplasias [15,17,18]. Multiple chromosomal and nonchromosomal congenital syndromes are associated with thrombocytopenia [19]. Fewer than 3 percent of premobile infants (ie, young infants who are not yet rolling over) with bleeding disorders have a bruise and fewer than 10 percent of infants who are rolling over and who have bleeding disorders have a bruise [20]. The most common location for these bruises are the knees, shins, forehead, and nose.

Once children walk, bruises are more numerous, and a wider distribution is seen. Bruising of the ears, neck, genitals and hands are unusual at all ages, and bruising of the buttocks and anterior trunk are rare in premobile infants. About 15 percent of children with hemophilias present in a way that may be confused with abuse. Only half of these children have a family history of a named bleeding disorder. While excess nonpatterned bruising, or "fingertip" bruising may be seen, a more developed patterned bruise has not been described in these children. A minority of these children present with more serious bleeding, such as intracranial hemorrhage. Some secondary bleeding disorders including disseminated intravascular coagulation, and liver failure may result from trauma or create bleeding that mimics trauma.

Salicylate exposure — Salicylate exposure (typically acute ingestion but also possible with chronic ingestion or cutaneous exposure) can cause bruising because of decreased platelet adhesion and increase in capillary permeability [17]. Children with acute salicylate ingestion usually have other clinical signs such as vomiting, hyperventilation, and metabolic acidosis. The diagnosis is confirmed with a measurement of plasma salicylate concentration. (See "Salicylate (aspirin) poisoning: Clinical manifestations and evaluation".)

Vasculitis — Children who have immunoglobulin A vasculitis (IgAV; Henoch-Schönlein purpura [HSP]), acute hemorrhagic edema of childhood (AHEC), acute hemorrhagic edema of infancy (AHEI), and other vasculitides have purpuric lesions caused by breakdown of the capillary walls (picture 2). These lesions may appear diffusely on the body in areas not typically associated with bruising from normal activities (eg, shins) and can be mistaken for child abuse [21,22]. The diagnosis of vasculitis is often suggested by the initial appearance (eg, palpable purpura), accompanying features, such as abdominal pain, joint pain, and/or hematuria in patients with IgAV (HSP), and when new bruises continue to develop under clinical supervision. (See "IgA vasculitis (Henoch-Schönlein purpura): Clinical manifestations and diagnosis" and "Vasculitis in children: Evaluation overview".)

Dermal melanosis (formerly Mongolian spots) — Dermal melanosis, previously referred to as Mongolian spots, are common bluish-green areas of skin discoloration often seen in African American, Hispanic, or Asian infants. While typically described as disappearing by one year, many persist, sometimes into adulthood. They are seen most commonly on the buttocks and lower back, but may extend over the entire back and on extremities (picture 3). At first glance, they may be confused easily with fresh bruising, but dermal melanoses fade over months to years rather than days. The characteristic coloring and location of dermal melanoses and the absence of swelling or tenderness also help to differentiate them from bruising [17]. Nevi and hemangiomas occasionally may create similar confusion, and are distinguished in a similar manner. Preliminary evidence suggests that transcutaneous bilirubin testing may be helpful to differentiate bruising from dermal melanosis without requiring extended follow-up [23]. (See "Skin lesions in the newborn and infant", section on 'Dermal melanocytosis'.)

Hemangiomas — Hemangiomas are congenital malformations of vascular tissue forming a benign tumor (picture 4 and picture 5). They are most commonly recognized under the surface of the skin, where their appearance depends on their depth. Hemangiomas have occasionally been mistaken for bruises and reported as child abuse [24,25]. Additionally, hemangiomas may rarely cause coagulopathy through consumption of platelets and circulating clotting factors in the Kasabach-Merritt syndrome. (See "Infantile hemangiomas: Epidemiology, pathogenesis, clinical features, and complications" and "Infantile hemangiomas: Evaluation and diagnosis".)

Delayed subaponeurotic fluid mass — Subaponeurotic fluid mass is rare condition presenting as fluid filled masses on the scalp of infants up to 18 weeks of age. Medical providers may be unfamiliar with the condition, and as a result, 13 percent of parents or caregivers described questioning about possible child abuse [26]. Subaponeurotic fluid collections should be distinguished from subgaleal hemorrhage. A dropping hematocrit or bruising on the forehead, eyelids, behind the ears or at the nape of the neck indicates sub-galeal hemorrhage. Both management and implications for trauma are different with this entity.

FRACTURES — Findings on plain radiographs that may mimic inflicted fractures include (see "Differential diagnosis of the orthopedic manifestations of child abuse"):

●Fracture present:

•Nonabusive trauma

•Osteogenesis imperfecta

•Pathologic fracture due to osteopenia caused by limited mobility in children with cerebral palsy or other neuromuscular disease

•Congenital insensitivity to pain

•Pathologic fractures from metabolic bone disease, including rickets, vitamin C and copper deficiency, cholestatic liver disease, or neoplasm

These patients are at heightened risk for fractures and clinical scenarios that may mimic abuse. For example, in a retrospective review of 94 children with 216 long bone fractures in the setting of known skeletal fragility including genetic connective tissue disorder, metabolic bone disease, neurologic disorder, and other chronic disease, nearly half of patients sustained only one fracture, 21 percent sustained two, 13 percent sustained three, and 18 percent sustained four or more. Multiple fractures were more common in infants than older children. More than half of the children (57 percent) were nonambulatory at the time of fracture. A substantial minority of children were asymptomatic at diagnosis (29 percent), and fractures were incidentally found on imaging for other concerns over one-fourth of the time. In nearly half of cases (45 percent), there was no trauma history to account for the injury. The frequencies at which individual bones were injured were: femur (33 percent), tibia (22 percent), humerus (13 percent), radius (12 percent), fibula (12 percent), and ulna (7 percent) [27]. The radiographic evaluation and features of abusive fractures are discussed separately. (See "Orthopedic aspects of child abuse", section on 'Radiographic evaluation' and "Orthopedic aspects of child abuse", section on 'Fracture patterns'.)

●Fracture absent:

•Normal bone variants [28]

•Periosteal reaction from drugs, infection, or infantile cortical hyperostosis (Caffey disease)

BURNS — The differential diagnosis of burns in possible victims of child abuse includes abusive and nonabusive burns, phytophotodermatitis, various complementary and alternative therapies, and impetigo. The differences between intentional and unintentional burns are discussed in detail separately. (See "Physical child abuse: Recognition", section on 'Intentional burns'.)

Phytophotodermatitis — Phytophotodermatitis is a burn-like skin lesion that occurs when sunlight interacts with photosensitizing compounds (eg, bergamot, psoralen) found in certain fruits, vegetables, or fragrance products; limes are most common, but lemons, figs, parsnips, and celery also have been implicated (table 1) [17,29,30]. The burn-like lesions are characterized by erythema and bullae, often in unusual patterns corresponding to the contact (streaks from dripping juice, handprints from adults handling the sensitizing material and then handling the child) or around the hands and mouth after the child handles or ingests the agent (picture 6). The eruption typically appears hours to days after exposure, which can make the lesion more difficult to relate to the contact [17,29].

Complementary and alternative therapies — Garlic application to the skin of infants as a naturopathic remedy has been reported to cause bullae and partial-thickness burns [31,32]. Additional culture-specific complementary and alternative therapies that may cause irritant hyper- or hypo-pigmentation, blisters, or burns to the skin are discussed below. (See 'Cultural practices' below.)

Chemical and irritant burns — Exposure to a wide range of chemicals may create destructive lesions of the skin that can be mistaken for thermal or inflicted injury [33]. Most such burns come from common household cleaning products. Bleach has been singled out because it is readily available and initial exposure may be nonpainful [34]. Cases of perianal burning from exposure to diarrhea following ingestion of senna alkaloid-based laxatives have also been reported [35,36]. These burns occur in diapered children and can closely mimic the pattern of inflicted immersion burns but typically do not extend beyond the diaper area. A history of exposure to senna-based laxatives is usually elicited.

Impetigo — Impetigo is a skin infection, usually caused by staphylococci or streptococci, that can look similar to a cigarette burn (picture 7). Impetigo involves only the superficial layers of the skin; the lesions are flat, crusted, and heal cleanly. In contrast, inflicted cigarette burns penetrate more deeply (usually full-thickness), have heaped-up margins, and heal with scarring [17]. (See "Impetigo".)

CONDITIONS WITH MULTISYSTEM MANIFESTATIONS — Multisystem manifestations suggestive of trauma (eg, fractures, subdural hematomas, and retinal hemorrhages) without an explanatory history increases the chance of child abuse. Conditions that may be confused with multisystem trauma are rare but include osteogenesis imperfecta (OI), Menkes disease, Ehlers-Danlos syndrome, and congenital insensitivity to pain.

Osteogenesis imperfecta — Children with OI have manifested other findings that may raise concern for child abuse. Easy bruising is often mentioned in reviews of OI, and OI patients have altered coagulation and skin biomechanics [37]. Subdural and retinal hemorrhages have also been reported in children with OI [38]. Though the picture is not typical of classic acute abusive head trauma, these children may be confused with milder presentations of abusive head trauma. The skeletal manifestations of OI are discussed in greater detail separately. (See "Differential diagnosis of the orthopedic manifestations of child abuse", section on 'Osteogenesis imperfecta' and "Osteogenesis imperfecta: An overview".)

Menkes disease — Menkes disease is a rare X-linked recessive disorder of copper transport that typically presents with coarse brittle hair due to "pili torti" and neurologic deterioration in the first few months of life. Children with Menkes disease have presented with subdural collections, acute neurologic deterioration, retinal hemorrhage, metaphyseal end plate changes resembling the classic metaphyseal fracture, and other fractures, causing confusion with abusive head trauma. Excess wormian bones may be a clue to the syndrome, and identification of pili torti under the microscope is virtually diagnostic. Laboratory diagnosis is made by identifying decreased serum copper and ceruloplasmin and confirmed by identifying mutations of the ATP7A gene. (See "Differential diagnosis of the orthopedic manifestations of child abuse", section on 'Copper deficiency'.)

Ehlers-Danlos syndrome — Ehlers-Danlos syndrome (EDS) is a common family of connective tissue and collagen disorders with highly variable presentation. Common forms of EDS produce easily bruised and injured skin, with a velvety texture, hyper-distensibility (picture 8), and unusual papyraceous scaring (picture 9). Some forms of EDS create increased joint mobility that predisposes to orthopedic problems in older mobile children (picture 10). Rarer forms of EDS cause fragility of large blood vessels and internal organs, and may present with internal injuries following relatively mild trauma. Such a situation might be expected to cause concern for child abuse. Claims that EDS causes confusion with abusive fractures has been asserted in the courtroom [39].

Other than an overlap form of EDS with OI, which demonstrates mutations in the Col 1A1 and Col 1A2 genes, EDS is not known to lead to fracture in infancy and should not be used as an alternative etiology during evaluation for possible child abuse [39]. In one longitudinal study of orthopedic records of patients with EDS, the prevalence of fractures did not appear to be elevated relative to normal children [40]. As noted above, these children are older, but the rate is not significantly elevated above the incidence of fracture in the healthy population. In another retrospective case-control study that evaluated 21 individuals with genetically or criterion-based diagnosis of EDS beginning in infancy and compared with 63 matched controls, EDS patients had significantly more fractures during childhood (odds ratio 3.4 [95% CI 1.2 to 9.7]) [41]. However, no EDS patient had a fracture during the first year of life, and a minority of them sustained more than a single fracture. (See "Clinical manifestations and diagnosis of Ehlers-Danlos syndromes", section on 'Clinical manifestations and diagnosis'.)

Laboratory evaluation for EDS in children depends upon findings. Hypermobile type EDS is the most common variant but lacks a laboratory marker and has significant overlap with normal childhood flexibility. Elevated bleeding scores are reported in 56 percent of hypermobile EDS children and easy bruising in 36 percent [42]. Because diagnosis is by Beighton scoring, which cannot be reliably performed in young children, bruising in infants with hypermobile EDS has not been explored. More serious internal bleeding, including intracranial bleeding, and rupture of viscera is known to occur in vascular type EDS, also known as type IV, and associated with mutations in the COL 3A1 gene. These rarely occur in other EDS subtypes [43]. (See "Clinical manifestations and diagnosis of Ehlers-Danlos syndromes", section on 'Genetics and pathogenesis' and "Clinical manifestations and diagnosis of Ehlers-Danlos syndromes", section on 'Hypermobile EDS'.)

Congenital insensitivity to pain — Hereditary sensory autonomic neuropathies are a rare group of disorders of the peripheral nerves in which the victim is unable to sense pain and often temperature, whereas all other sensation (light touch, deep touch, proprioception) remains intact. (See "Hereditary sensory and autonomic neuropathies".)

These disorders may be inherited in an autosomal dominant or recessive fashion, or may be sporadic. Because of the lack of pain and/or temperature sensation, injuries and secondary infections are common occurrences. Injuries include bruises, burns, lacerations, fractures, and bite wounds (often self-inflicted because of the lack of pain, resulting in mutilation or amputation of the lips or fingertips). The wounds typically are undetected by caretakers because of the lack of complaint from the child. If the wounds remain open, they may become infected, leading to bacteremia, osteomyelitis, and other sequelae. (See "Hereditary sensory and autonomic neuropathies".)

Plain radiographs may demonstrate multiple fractures of varying ages, and residual deformities from undetected and unset fractures are common occurrences. Even fractures that are diagnosed and immobilized may heal poorly because of continued weight-bearing on the affected limb [44]. The fracture patterns may be similar to those seen in intentional injury. In contrast to the radiographic findings in the severe forms of OI, the bones are of normal density. (See "Orthopedic aspects of child abuse", section on 'Fracture patterns'.)

The diagnosis of congenital insensitivity to pain can be made by taking a careful history and performing a thorough neurologic evaluation that includes pain and temperature testing. Sensory nerve conduction velocity is slowed or absent, and nerve biopsy may reveal a decrease in myelination or fewer unmyelinated fibers than normal. One type (type 4, congenital insensitivity to pain and anhidrosis) involves recurrent unexplained episodes of hyperpyrexia in infancy caused by the absence of sweating. Anhidrosis may be secondary to the lack of innervation of the eccrine sweat glands. (See "Hereditary sensory and autonomic neuropathies".)

CULTURAL PRACTICES — Many cultures use various means to mark the skin in order to treat various illnesses and conditions. They include cupping, coining, spooning, moxibustion, caida de mollera, and salting [45-48]. While some cultural practices, such as female genital cutting, are generally considered to be abusive in developed countries, the practices described below have not been reported to cause harm to the child and in fact, demonstrate efforts to improve the child’s health. They should not be considered as a form of abuse. Because cultural practices may be administered instead of bringing children to effective medical care, they may at times be a part of medical neglect.

Cupping — In cupping, the air in an open-mouthed vessel is heated by various means, and then, the vessel is applied to the skin. The suction force created by the cooling and contracting of the heated air is thought to "draw out" the ailment. The heated air and the rim of the cup burn the skin. This technique is used in Middle Eastern, Southeast Asian, Latin American, and Eastern European cultures [17,49]. Cupping presents as multiple, grouped circular ecchymoses, usually on the back. Central ecchymosis or petechiae result from the suction effect of the heated air as it cools and contracts (picture 11).

Coining — Coining is used in Southeast Asian cultures to treat fever, headache, and chills [50,51]. In Vietnamese, this process is referred to as "cao gio" or "scratch the wind" since it is thought to release illness-causing "bad winds" from the body [49,52]. Oiled skin is rubbed firmly with the edge of a coin, producing multiple, symmetric linear red marks, usually on the back (picture 12). Serious complications, including severe burns that required skin grafting when the oil on the skin caught fire, have been reported, but this is generally a benign procedure that should not be considered maltreatment [52].

Spooning — Spooning ("quat sha") is similar to coining and is used in China to rid the body of the evil spirits that are thought to cause illness. In this procedure, wet skin is rubbed with a porcelain spoon, producing multiple linear, and symmetric ecchymoses [17,49].

Moxibustion — Moxibustion is the therapeutic burning of pieces of moxa herb (mugwort or Artemisia vulgaris) or yarn on the skin. It is used in Southeast Asia, where it is considered a form of acupuncture. The lesions of moxibustion appear as a pattern of small discrete circular burns and may be confused with cigarette burns (picture 13) [17,49,53].

Caida de mollera — "Caida de mollera" refers to a sunken anterior fontanel, associated with a "bolita" or bump on the hard palate that is believed in some Mexican-American subcultures to cause illness. Attempts to correct this condition may include any combinations of the following:

●Poultices of herbs, raw egg, and/or soap shavings over the fontanel [49,52]

●Shaving of the head over the fontanel [52]

●Oral suction over the fontanel by a curandero or folk healer [17,49,54]

●Pressure on the hard palate [49,55]

●Immersion of the top of the head in water [52,56]

●Slapping of the soles of the feet or shaking the infant vertically while holding him or her upside down

The last maneuver has been proposed to cause the physical findings characteristic of shaken baby syndrome [17,49,54,55]. However, a detailed analysis of the cultural practice demonstrates that this may not be the case [49]. The "shaking" reported by the observers is not violent, the motion is not rotational, and there have been no reports of intracranial or retinal hemorrhages associated with the practice since the first case was reported in 1972 [52], despite its ongoing use in Mexican and Mexican-American communities [49]. (See "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children" and "Child abuse: Eye findings in children with abusive head trauma (AHT)".)

Salting — Salting (application of salt to the skin, or packing in salt) is an old Turkish custom that is thought to improve the health of a newborn's skin. A case of epidermolysis, severe hypernatremia, and death in a 30-day-old infant who had been intermittently salted since birth has been reported [57].

INJURY DURING RESUSCITATION — Trauma and thus child abuse, should be considered in any child requiring unexpected resuscitation or resuscitation for a previously unknown condition. Resuscitation itself, however, is a well-recognized cause of traumatic injury. As an example, in one observational study of 226 infants younger than one year of age who were resuscitated and died, external injuries on the face, neck, and chest were seen in 12 percent of patients (21 with abrasions and 6 with contusions) [58]. However, fingernail abrasions, petechiae, or fingertip contusions were rare, regardless of whether resuscitation occurred or not. Contusions were more common in homicide (child abuse) victims. Another study of 51 newborns, infants, and toddlers found at least one injury in 27.5 percent [59]. Most injuries are cutaneous, though superficial contusion of internal organs is sometimes seen.

Posterior rib fractures from resuscitation can occur but are infrequently identified on conventional radiography, occurring in up to 3 percent of young infants when the thumb-encircling technique is used [60] and in <0.5 percent of older infants and children [61-63]. When resuscitation is a premortem event, computed tomography (CT) and autopsy find rib fractures more commonly than plain radiographs. For example, in one case series, 9 of 15 infants who had chest encircling cardiopulmonary resuscitation (CPR) had rib fractures found on autopsy or CT despite no rib fractures seen on skeletal survey [64]. CT identified 41 anterior fractures, and autopsy identified an additional five anterior fractures.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Child abuse and neglect".)

SUMMARY

●Approach – The differential diagnosis of suspected child abuse varies depending upon the clinical manifestations. Familiarity with the medical conditions or cultural practices that mimic child abuse can facilitate (see 'Approach' above):

•Arrival at the correct diagnosis

•Initiation of appropriate therapy

•Avoidance of the consequences of an unnecessary evaluation and/or report of suspected child abuse

The presence of multiple types of injuries (eg, bruising and fractures) suggests abuse because conditions that mimic abuse typically only cause one type of finding.

The presence of a condition that mimics child abuse does not exclude the possibility that abuse has occurred. The full clinical picture including all historical features and physical findings must be assessed when abuse is suspected.

●Bruises – Nonabusive traumatic bruising, undiagnosed bleeding disorders, salicylate ingestion, vasculitis, and dermal melanoses (formerly Mongolian spots) comprise the most common medical disorders mistaken for inflicted bruising in children. (See 'Bruises' above.)

●Fractures – The differential diagnosis of inflicted fractures includes (see "Differential diagnosis of the orthopedic manifestations of child abuse"):

•Nonabusive trauma

•Normal variants

•Osteogenesis imperfecta

•Periosteal reaction from drugs or infection

•Cerebral palsy

•Congenital insensitivity to pain

•Pathologic fractures from metabolic bone disease, including rickets, vitamin C and copper deficiency, cholestatic liver disease, or neoplasm

●Burns – Lesions that appear like burns may arise from phytophotodermatitis, impetigo, bleach exposure, diarrhea caused by senna laxatives, or various complementary and alternative medicine therapies. (See 'Burns' above.)

●Conditions with multisystem manifestations – Multisystem manifestations suggestive of trauma (eg, fractures, subdural hematomas, and retinal hemorrhages) without an explanatory history increases the chance of child abuse. Conditions that may be confused with multisystem trauma are rare but include osteogenesis imperfecta, Menkes disease, Ehlers-Danlos syndrome, and congenital insensitivity to pain. (See 'Conditions with multisystem manifestations' above.)

●Cultural practices – Many cultures use various means to mark the skin in order to treat various illnesses and conditions. They include cupping, coining, spooning, moxibustion, various treatments for caida de mollera, and salting. These practices produce skin lesions that are characteristic and may be confused with inflicted injury. They can, at times, be associated with medical neglect of acute illnesses. (See 'Cultural practices' above.)

●Injury during resuscitation – Although resuscitation is associated with traumatic injury in children, child abuse should be considered in any child requiring unexpected resuscitation or resuscitation for a previously unknown condition. (See 'Injury during resuscitation' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Erin Endom, MD, who contributed to earlier versions of this topic review.