About This Page
This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Four categories of child maltreatment: physical abuse, emotional abuse, sexual abuse, and neglect (most common)
- Suspicious patterns: bruising in non-mobile infants, bruises in unusual sites (ears, neck, buttocks), patterned injuries, injuries inconsistent with developmental stage or history
- Fractures concerning for NAI: metaphyseal (corner/bucket handle), posterior rib, scapular, sternal — especially in non-mobile children
- If NAI suspected: document injuries clearly (body maps), do NOT discharge — refer to senior paediatrician and children's social care
- Investigations: skeletal survey (all children <2 years with suspected physical abuse), head CT if <1 year, ophthalmoscopy (retinal haemorrhages), coagulation screen
- ALL healthcare professionals have a statutory duty to safeguard children — you do NOT need certainty to refer, only concern
Overview
Child maltreatment is any form of physical, emotional, or sexual abuse, or neglect, that causes actual or potential harm to a child. It is a major public health problem. Neglect (persistent failure to meet a child's basic needs) is the most common form of maltreatment. Physical abuse includes hitting, shaking, burning, suffocation, and fabricated/induced illness (formerly Munchausen by proxy). Healthcare professionals play a critical role in recognising abuse, as they may be the first to see unexplained injuries or patterns of concern. The key principle is that safeguarding is everyone's responsibility.
Epidemiology
Approximately 1 in 5 children experience some form of maltreatment. In England, around 50,000 children are subject to a child protection plan at any time. Neglect accounts for approximately 50% of registrations, emotional abuse 35%, physical abuse 8%, and sexual abuse 4%. Risk factors include parental substance misuse, domestic violence, parental mental illness, social isolation, poverty, and childhood disability. Infants under 1 year are at the highest risk of fatal child abuse.
Clinical Features
Symptoms
Injuries inconsistent with the history provided or the child's developmental stage
Changing or inconsistent history from caregivers
Delay in seeking medical attention
Multiple presentations to different healthcare settings
Child appears withdrawn, fearful of parent, or overly compliant
Disclosure by the child
Signs
Bruising in non-mobile infants (babies who are not yet cruising) — "those who don't cruise rarely bruise"
Bruises in unusual locations: ears, neck, buttocks, back, face (TEN-4 rule: Torso, Ear, Neck in child <4 years)
Patterned injuries: belt marks, bite marks, cigarette burns, ligature marks
Multiple injuries at different stages of healing
Signs of neglect: poor hygiene, severe nappy rash, dental caries, failure to thrive, unmet medical needs
Retinal haemorrhages (abusive head trauma / shaken baby syndrome)
Investigations
First-line
Detailed documentationBody maps, photographs (with consent), detailed history — document in child's own words if disclosure made. Record who said what
Skeletal surveyMANDATORY in all children <2 years with suspected physical abuse. Full skeletal X-ray series — repeat at 11–14 days for healing fractures
Coagulation screen and FBCTo exclude bleeding disorders (e.g. haemophilia, ITP, von Willebrand disease) before attributing bruising to abuse
Second-line
Head CTIn all children <1 year with suspected abuse — look for subdural haemorrhage (particularly bilateral, different ages)
OphthalmoscopyBy ophthalmologist — retinal haemorrhages (especially multilayered, extensive) suggest abusive head trauma
Urine toxicologyIf poisoning or drug administration suspected
Specialist
MRI brainMore sensitive than CT for parenchymal injury — arrange after initial CT if concern
Forensic medical examinationIf sexual abuse suspected — by trained specialist, in a suitable setting (SARC if available)
1
Immediate actions
- If immediate risk to life: ensure child safety — admit to hospital
- Do NOT discharge if NAI suspected — senior paediatrician must assess
- Document all injuries with body maps and photographs
- Take a careful history from caregivers SEPARATELY
- Perform appropriate investigations
2
Referral
- Refer to children's social care (MASH/CART) — you need CONCERN, not certainty
- Inform parents of the referral unless this would place the child at further risk
- If child is in immediate danger and social care cannot be reached: contact police
- Complete a written referral within 48 hours of telephone referral
3
Multi-agency working
- Strategy discussion within 24–48 hours involving social care, police, health
- Section 47 investigation if significant harm suspected
- Child protection conference within 15 working days
- Child Protection Plan if threshold met — regular core group meetings and review conferences
4
Documentation and information sharing
- Record concerns clearly and contemporaneously in medical notes
- Share information with relevant agencies — safeguarding overrides normal confidentiality rules (Children Act 2004)
- Complete local safeguarding proforma/referral form
- If in doubt: discuss with named doctor/nurse for safeguarding or local safeguarding team
Complications
- Ongoing abuse: If not identified and acted upon
- Abusive head trauma: Leading cause of death from child abuse — subdural haemorrhage, retinal haemorrhages, encephalopathy
- Long-term psychological harm: PTSD, anxiety, depression, attachment difficulties, personality disorders
- Repeat presentations: Children may present multiple times before abuse is recognised
- Death: Approximately 50–60 children die from abuse or neglect in England each year
UKMLA Exam Tips
- 1"Those who don't cruise rarely bruise" — any bruising in a non-mobile infant must be investigated
- 2Metaphyseal fractures (corner/bucket handle) are highly specific for NAI
- 3Posterior rib fractures in infants — highly suggestive of squeezing (abuse)
- 4Retinal haemorrhages (especially bilateral, multilayered) + subdural haemorrhage + encephalopathy = abusive head trauma triad
- 5You need CONCERN to refer, NOT certainty. Safeguarding overrides confidentiality
- 6Neglect is the most common form of child maltreatment — not physical abuse
- 7Document carefully, use body maps, record the child's own words verbatim in quotation marks
practicetest your knowledge on child safeguardingApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — paediatrics and beyond.
open q-bank