About This Page
This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- Clinicians are mandated reporters: reasonable suspicion is enough to report; proof is not required
- Red flags include inconsistent history, delay in care, injuries inconsistent with developmental stage, patterned injuries, and multiple injuries at different stages
- Bruising in a non-mobile infant is concerning; TEN-4-FACESp bruising patterns are high-yield
- Skeletal survey is indicated in young children when physical abuse is suspected, especially under age 2
- Abusive head trauma may present with vomiting, seizures, apnea, altered mental status, retinal hemorrhages, and subdural hemorrhage
Overview
Child abuse and neglect must be considered whenever the injury pattern, history, developmental ability, or caregiver behavior does not fit. The physician’s role is to treat injuries, document objectively, evaluate for occult trauma, protect the child, and report suspected maltreatment to child protective services. Step 2 CK commonly tests mandatory reporting and the principle that suspicion, not certainty, triggers reporting.
Epidemiology
Child maltreatment affects children across all socioeconomic groups. Young children, children with disabilities, and children with high caregiving needs are at increased risk. Physical abuse is a major cause of serious injury and death in infants and toddlers, and neglect is the most common reported maltreatment category.
Clinical Features
Symptoms
Caregiver history is vague, changing, implausible, or inconsistent with injury severity
Delay in seeking care for significant injury
Vomiting, seizure, apnea, lethargy, or altered mental status in abusive head trauma
Poor hygiene, hunger, missed medical care, or inadequate supervision suggesting neglect
Disclosure by child or concerning behavior/sexualized behavior
Signs
Bruising in non-mobile infant or bruising on torso, ears, neck, frenulum, angle of jaw, cheeks, eyelids, or patterned areas
Burns with sharp lines, immersion pattern, stocking-glove distribution, or cigarette marks
Fractures: ribs, metaphyseal lesions, scapula, sternum, spinous process; multiple fractures of different ages
Retinal hemorrhages, subdural hemorrhage, or unexplained neurologic signs
Failure to thrive, poor hygiene, untreated dental disease, or medical neglect
Investigations
First-line
Stabilization and full physical examABCs first, pain control, complete skin exam with measurements, neurologic assessment, and genital exam when indicated by trained clinicians
Objective documentationRecord caregiver statements verbatim, developmental abilities, injury size/location/pattern, photographs per policy, and body diagrams
Skeletal surveyRecommended in children <2 years with suspected physical abuse; consider in older children depending presentation
Head imagingCT head acutely if neurologic symptoms; MRI for detailed brain injury assessment
Second-line
Labs for occult injuryCBC, CMP, lipase/amylase, urinalysis; coagulation studies if bruising/bleeding differential is relevant
Ophthalmologic examEvaluate retinal hemorrhages in suspected abusive head trauma
Repeat skeletal surveyOften performed about 2 weeks later to detect healing fractures not initially visible
Specialist
Child protection team/social workCoordinate safety assessment, reporting, forensic documentation, and follow-up
Neurosurgery/ophthalmology/orthopedicsAs indicated by head injury, retinal findings, or fractures
Management
AAP clinical guidance on evaluation of suspected child physical abuse and bruising in infants1
Immediate duties
- Treat urgent medical problems first
- Report suspected abuse to child protective services according to state law; do not wait for certainty
- Ensure the child is discharged only to a safe environment
2
Medical evaluation
- Look for occult injuries: fractures, intracranial injury, abdominal trauma, burns, and oral injuries
- Consider mimics such as bleeding disorders, osteogenesis imperfecta, accidental injury, cultural practices, or dermatologic lesions, but do not let this delay reporting when suspicion is reasonable
- Evaluate siblings or household contacts when abuse is suspected
3
Neglect
- Assess nutrition, supervision, medical care, hygiene, education, housing, and caregiver capacity
- Address immediate needs with social work, food/housing resources, and safety planning
- Medical neglect requires balancing caregiver understanding, access barriers, and risk of serious harm
Complications
- Death or recurrent injury: Failure to identify abuse can return a child to danger
- Neurodevelopmental disability: Abusive head trauma can cause seizures, cerebral palsy, blindness, and cognitive impairment
- Psychological trauma: Abuse and neglect increase risk of PTSD, depression, substance use, and chronic disease
- Occult injury: Rib fractures, abdominal injury, and intracranial bleeding may be missed without targeted evaluation
USMLE Step 2 CK Exam Tips
- 1Mandated reporting requires suspicion, not proof
- 2Bruising in a non-mobile infant is abuse until proven otherwise
- 3Posterior rib fractures and classic metaphyseal lesions are highly specific for abuse
- 4Inconsistent history or injury inconsistent with developmental stage is a major red flag
- 5Do not confront caregivers or send the child home before safety assessment
- 6Abusive head trauma: subdural hemorrhage + retinal hemorrhages + neurologic symptoms
- 7Skeletal survey is key in suspected abuse under age 2
practicetest your knowledge on child abuse & neglectApply what you've learnt with USMLE Step 2 CK-style questions from the iatroX Q-Bank — pediatrics and beyond.
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