Nonaccidental Injury in Pediatric Patients: Detection, Evaluation, and Treatment | EB Medicine

Nonaccidental Injury in Pediatric Patients: Detection, Evaluation, and Treatment

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Table of Contents
About This Issue

We know that approximately one-third of the children who died from nonaccidental injuries had been previously evaluated for injuries that healthcare providers did not recognize as abuse. This issue outlines evidence-based strategies to help emergency clinicians recognize signs of abuse while dealing sensitively with caregivers. In this issue, you will learn to:

Recognize sentinel injuries

Identify injury patterns that are specific for abuse

Describe the range of findings present in abusive head trauma

Take a patient history that will reveal key indicators of abuse

Order diagnostic studies that reveal abuse, while minimizing radiation

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Epidemiology
  6. Etiology
  7. Differential Diagnosis
    1. Bruises and Burns
    2. Fractures
    3. Intracranial Hemorrhage
    4. Retinal Hemorrhage
  8. Prehospital Care
  9. Emergency Department Evaluation
    1. History
    2. Physical Examination
      1. Sentinel Injuries
        • Bruises
        • Oral Injuries
      2. Burns
      3. Abusive Head Trauma
        • Clinical Prediction Rules for Abusive Head Trauma
        • Hpoxic-Ischemic Injury
        • Retinal Hemorrhages
        • Consultation With an Ophthalmologist
      4. Abusive Thoracoabdominal Injury
      5. Fractures
  10. Diagnosis and Management
    1. Cutaneous Injury
    2. Abusive Head Trauma
    3. Thoracoabdominal Injury
      1. Laboratory Testing
      2. Imaging
    4. Skeletal Injury
  11. Special Circumstances
    1. Children With Special Needs
    2. Cultural, Complementary, and Alternative Medical Considerations
    3. Intimate Partner Violence
  12. Controversies and Cutting Edge
    1. Subdural Hematoma and Retinal Hemorrhage in Relation to Hypoxic-Ischemic Events
    2. Retinal Hemorrhage and Seizures
    3. Fractures and Rickets
    4. Documentation
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls in the Management of Cases of Suspected Nonaccidental Injury
  16. Cost-Effective Strategies
  17. Clinical Pathway For Evaluation of Nonaccidental Injuries in Children
  18. Tables and Figures
    1. Table 1. Differential Diagnosis of Nonaccidental Injuries
    2. Table 2. Standard Views in a Radiographic Skeletal Survey to Evaluate for Occult Skeletal Trauma
    3. Figure 1. Sentinel Injuries
    4. Figure 2. Example of an Ear Bruise Included in the TEN-4 Decision Rule
    5. Figure 3. Distinct Clustered-Patterned Abusive Bruising
    6. Figure 4. Abusive Versus Accidental Scald Burns
    7. Figure 5. Cigarette Burn on a School-aged Child
    8. Figure 6. Multiple Preretinal and Intraretinal Hemorrhages Extending to the Periphery
    9. Figure 7. Intracranial Hemorrhages on Computed Tomography
    10. Figure 8. Cranial Computed Tomography With 3-Dimensional Reconstruction
    11. Figure 9. Rib Fractures on Chest Radiography
  19. References


Emergency clinicians are likely to encounter physical abuse in children, and they must be prepared to recognize its many manifestations and take swift action. Pediatric nonaccidental injury causes considerable morbidity and mortality that can often be prevented by early recognition. Nonaccidental injuries present with a wide array of symptoms that may appear to be medically inconsequential (such as bruising in a premobile infant), but are actually sentinel injuries indicative of child abuse. This issue provides guidance regarding factors that contribute to abuse in children, key findings on history and physical examination that should trigger an evaluation for physical abuse, and laboratory and radiologic tests to perform when child abuse is suspected.

Case Presentations

A mother brings her 3-month-old boy to the ED for vomiting and irritability. She says that the boy's father told her the baby wouldn’t stop crying and had vomited several times. The mother states the baby had been fine when she left for work that morning. The patient’s medical history is significant for colic and an episode of blood from his mouth 1 month ago. On physical examination, the baby is irritable, his anterior fontanelle is full, and his pupils react bilaterally. The patient continues to vomit several times in the ED and remains irritable and afebrile. You are worried that the vomiting and irritability are signs of abusive head trauma and you consider how to approach brain imaging in this patient. You then wonder whether you should order laboratory tests and assess for other occult injuries with a skeletal survey. Would an ophthalmological examination be indicated in this patient? Finally, you consider how and when to approach the family about a child protective services referral.

A 2-month-old boy was transported to the ED by EMS. A neighbor had called 911 because of concerns of domestic violence between the parents. The mother denies domestic violence and says that the baby seems to be having some difficulty breathing. On physical examination, the patient is fussy but consolable. He is afebrile, but is breathing rapidly, with a respiratory rate of 70 breaths/min. There are bruises on his anterior and posterior torso and crepitus of his chest wall. When asked how the patient may have sustained the bruises, the mother states the baby may have “rolled” and hit the edge of the crib. You are concerned about physical abuse as a cause of your patient’s presentation. You wonder if domestic violence between caregivers is a risk factor for physical abuse in children. Should the developmentally implausible history provided by the mother make you more worried about abuse? You start to consider which laboratory, imaging tests, and consultations you should pursue to evaluate both for possible physical abuse and to exclude other diagnoses, such as a bleeding disorder.

A 3-year-old boy was sent to the ED from daycare after he refused to sit down due to pain in his buttock region. When his daycare teacher removed his pull-up diaper, she noted he had symmetric blistering in a circular region around his buttocks, with some central clearing. When asked how this happened, the boy said the bath water was too hot the day before. His father added that maybe a sibling pushed him into the water. Given the symmetry and donut-shaped appearance of this burn, you wonder if you should consider an intentional submersion burn in a young child of toilet-training age as a cause of this patient’s presentation? As you think about the differential diagnosis, you start considering which consultants could further assist you with this diagnosis. Finally, you start thinking about whether you should involve child protective services.


In 2015, about 683,000 infants and children in the United States were determined by Child Protective Services (CPS) to have been maltreated and, of these, 17.2% were physically abused.1 Based on self-reports by victims, the incidence of maltreatment, including episodes not reported to CPS, is likely much higher.1-5 Most maltreatment-related fatalities occur in children aged < 3 years.1 The majority of children with injuries concerning for abuse are seen in emergency departments (EDs).6-9 Notably, approximately 30% of children who died from abuse were previously evaluated by healthcare providers, often in the ED setting, for injuries that were not recognized to be the result of abuse.10-13

Even when there is uncertainty, the diagnosis of nonaccidental injury must be considered and evaluation initiated, as improvements in early detection and reporting of maltreatment could reduce morbidity and mortality. However, the presentations of nonaccidental injuries are variable and sometimes medically inconsequential and may thus be missed. This issue of Pediatric Emergency Medicine Practice provides a comprehensive, evidence-based review of the historical and physical examination findings that are concerning for abuse, injury patterns that are highly specific for abuse, and the use of screening tests and other available resources for diagnostic evaluation and management of cases when abuse is suspected.

Critical Appraisal of the Literature

A literature search was performed using the PubMed and Ovid MEDLINE® databases as well as the Cochrane Database of Systematic Reviews from their start until 2016. The following keywords were searched: child abusechild maltreatmentnonaccidental trauma, and inflicted injury in various combinations with the key words epidemiologydiagnosisevaluationmanagementprognosisemergency departmentabusive head traumaburnsbruisingintraoral injurysentinel injuryabdominal injurythoracic injuryeye injuryfracturesskeletal injuriessiblings, and domestic violence. References in the bibliographies of relevant review articles were also examined. Together, over 200 articles and websites were reviewed.

Literature on nonaccidental injuries consists largely of descriptive case series, retrospective case-controlled studies, and cohort studies. Additional limitations include a lack of prospective and epidemiological data, comparative studies that identify features between intentional and unintentional injuries, and data on abusive findings in children with disabilities.

The definition of the term child abuse varies across studies, and authors define abuse across a spectrum that falls within the categories of confirmed abuse, suspected abuse, indeterminate cases, and excluded abuse. Even within each category, definitions vary. Variability also exists in the inclusion criteria by injury severity, as many studies include only injuries that require hospital admission, intensive care unit admission, trauma registry inclusion, or injuries that cause death. Some studies include patients only when there is a consultation to a child abuse specialist. Thus, though researchers have performed systematic reviews on many topics associated with physical abuse (oral injuries, bruising, burns, abusive head trauma [AHT], fractures, retinal findings, and visceral findings), they struggle to draw conclusions on true associations between various factors and physical abuse.

Risk Management Pitfalls in the Management of Cases of Suspected Nonaccidental Injury

1. “I thought bruising on the lower extremities could be a normal finding in a 3-month-old infant.”

Bruising is the most common detectable injury in maltreatment; it is missed as a sentinel injury in about one-third of fatal or near-fatal abusive injuries. Though bruising to anterior lower legs in mobile children can commonly occur from accidental injuries, bruising is uncommon in children who are premobile (in general, children aged < 6 months).

2. “I thought I had to wait until I was certain that some form of abuse had occurred before I reported to CPS.”

All medical providers are considered mandated reporters and should report any concern for the possibility of abuse to CPS as soon as suspicion arises. A local child protection specialty physician can also be contacted to discuss concerns. Reporting to CPS facilitates the investigation and the mobilization of resources to help the child, and does not automatically trigger removal of the child from the home.

3. “I did not consider AHT on my differential because the infant had a seizure and vomiting and had no external signs of injury.”

Recognizing AHT can be difficult, as it can present with subtle signs and symptoms. However, shaking without impact may result in no external signs of injury. AHT is important to consider in the differential diagnosis, especially when the history does not point to a clear cause or does not explain the presentation.

4. “This infant has mild vitamin D deficiency; therefore, this must be the cause of his fractures.”

Insufficiency/deficiency of vitamin D levels in the blood does not constitute rickets. Fractures in patients with rickets resemble structural insufficiency fractures and are present in the face of florid rachitic changes in the bones. Fractures associated with rickets are also consistent with the injury mechanism. They tend to be seen in mobile infants aged > 6 months. They are not associated with classic metaphyseal fractures, posterior medial rib fractures, vertebral fractures, or skull fractures.

5. “A 2-month-old child could have bleeding from his mouth from hitting himself with a toy.”

Always consider the developmental stage of the child and whether the injury makes sense with that developmental stage. Premobile infants presenting with inadequately explained oral injuries must be evaluated for abuse.

6. “I got the chest x-ray to look for aspiration pneumonia. I was not looking for rib fractures.”

Always assess radiographic studies in a systematic manner. For example, look at image quality, soft tissue and bones, the airway and mediastinum, lungs, heart, diaphragm, etc. Rib fractures are not typically visible until there is callus formation, which occurs approximately 7 to 10 days postinjury. Among children with abusive fractures, approximately 20% were missed initially, including a large fraction that were present but missed on initial imaging studies.18

7. “This family is so nice and the parents are very wealthy, they couldn’t have abused their baby.”

Abuse can happen to children of all social and ethnic demographics. Abuse cases are more often missed on first presentation to the ED due to provider biases and the misconception that abuse only happens in certain populations.

8. “The bruising pattern on this boy makes me concerned for child abuse. I will make him an appointment with his pediatrician and she can decide if there needs to be a referral to CPS.”

Emergency clinicians are considered mandatory reporters of abuse. It is inappropriate to wait for a follow-up appointment with a pediatrician to make a CPS referral. It might not be safe for this child to go home with the family and wait for the appointment. The patient could be lost to follow-up and may be further harmed.

9. “This child probably has multiple fractures because she was born prematurely.”

Children with chronic medical problems are a uniquely at-risk population and have higher rates of abuse than the general pediatric population. Children with chronic illness or disability often place higher emotional, physical, financial, and social demands on their caregivers. Caregivers with limited support and poor coping skills may feel overwhelmed by the responsibility of caring for a child with special needs.

10. “The patient has loop-shaped bruises on his torso, but his platelets and coagulation studies are normal. I will arrange for follow-up with a hematologist.”

Coagulopathies may cause petechiae and ecchymoses, but bruises that are patterned, multiple, or occurring in clusters may occur from physical abuse.

Tables and Figures

Table 1. Differential Diagnosis of Nonaccidental Injuries


Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

  1. Child Maltreatment 2015. U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children Youth and Families Children’s Bureau; 2015. Accessed June 15, 2017. (Government report)
  2. Afifi TO, Mather A, Boman J, et al. Childhood adversity and personality disorders: results from a nationally representative population-based study. J Psychiatr Res. 2011;45(6):814-822. (Retrospective cohort; 34,653 patients)
  3. MacMillan HL, Jamieson E, Walsh CA. Reported contact with child protection services among those reporting child physical and sexual abuse: results from a community survey. Child Abuse Negl. 2003;27(12):1397-1408. (Community-based survey; 9953 responses)
  4. Hussey JM, Chang JJ, Kotch JB. Child maltreatment in the United States: prevalence, risk factors, and adolescent health consequences. Pediatrics. 2006;118(3):933-942. (National longitudinal survey; 15,197 responses)
  5. Fergusson DM, Horwood LJ, Woodward LJ. The stability of child abuse reports: a longitudinal study of the reporting behaviour of young adults. Psychol Med. 2000;30(3):529-544. (Longitudinal survey; 1265 patients)
  6. * King AJ, Farst KJ, Jaeger MW, et al. Maltreatment-related emergency department visits among children 0 to 3 years old in the United States. Child Maltreat. 2015;20(3):151-161. (Retrospective cohort; 10,095 abused children)
  7. Palazzi S, de Girolamo G, Liverani T. Observational study of suspected maltreatment in Italian paediatric emergency departments. Arch Dis Child. 2005;90(4):406-410. (Retrospective cohort; 10,175 children assessed for abuse)
  8. Bleeker G, Vet NJ, Haumann TJ, et al. [Increase in the number of reported cases of child abuse following adoption of a structured approach in the VU Medical Centre, Amsterdam, in the period 2001-2004]. Ned Tijdschr Geneeskd. 2005;149(29):1620-1624. (Retrospective cohort; 220 cases)
  9. Keshavarz R, Kawashima R, Low C. Child abuse and neglect presentations to a pediatric emergency department. J Emerg Med. 2002;23(4):341-345. (Retrospective cohort; 105 cases)
  10. King WK, Kiesel EL, Simon HK. Child abuse fatalities: are we missing opportunities for intervention? Pediatr Emerg Care. 2006;22(4):211-214. (Retrospective cohort; 44 cases)
  11. * Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA. 1999;281(7):621-626. (Retrospective cohort; 173 cases)
  12. Carty H, Pierce A. Non-accidental injury: a retrospective analysis of a large cohort. Eur Radiol. 2002;12(12):2919-2925. (Retrospective cohort; 467 cases)
  13. Thorpe EL, Zuckerbraun NS, Wolford JE, et al. Missed opportunities to diagnose child physical abuse. Pediatr Emerg Care. 2014;30(11):771-776. (Retrospective cohort; 77 cases)
  14. The Child Abuse Prevention and Treatment Act (CAPTA) 2010. U.S. Department of Health & Human Services, Administration for Children and Families; 2011. Accessed June 15, 2017. (Documentation of federal law)
  15. Sedlak AJ, Mettenburg J, Basena M, et al. Fourth national incidence study of child abuse and neglect (NIS–4): report to Congress. U.S. Department of Health & Human Services, Administration for Children and Families; 2010. Accessed June 15, 2017. (Government report)
  16. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Natl Health Stat Report. 2010(26):1-31. (National survey on United States ED visits in 2007; 117 million ED visits)
  17. Gausche-Hill M, Schmitz C, Lewis RJ. Pediatric preparedness of US emergency departments: a 2003 survey. Pediatrics. 2007;120(6):1229-1237. (Survey; 1489 cases)
  18. * Ravichandiran N, Schuh S, Bejuk M, et al. Delayed identification of pediatric abuse-related fractures. Pediatrics. 2010;125(1):60-66. (Retrospective cohort; 258 cases)
  19. Trokel M, Waddimba A, Griffith J, et al. Variation in the diagnosis of child abuse in severely injured infants. Pediatrics. 2006;117(3):722-728. (Retrospective cohort; 2253 cases)
  20. Ziegler DS, Sammut J, Piper AC. Assessment and follow-up of suspected child abuse in preschool children with fractures seen in a general hospital emergency department. J Paediatr Child Health. 2005;41(5-6):251-255. (Retrospective cohort; 98 cases)
  21. * Schmitt BD. Seven deadly sins of childhood: advising parents about difficult developmental phases. Child Abuse Negl. 1987;11(3):421-432. (Review article)
  22. Brewster AL, Nelson JP, Hymel KP, et al. Victim, perpetrator, family, and incident characteristics of 32 infant maltreatment deaths in the United States Air Force. Child Abuse Negl. 1998;22(2):91-101. (Retrospective cohort; 32 patients)
  23. Krugman RD. Fatal child abuse: analysis of 24 cases. Pediatrician. 1983;12(1):68-72. (Retrospective cohort; 24 cases)
  24. * Barr RG, Trent RB, Cross J. Age-related incidence curve of hospitalized shaken baby syndrome cases: convergent evidence for crying as a trigger to shaking. Child Abuse Negl. 2006;30(1):7-16. (Retrospective case review; 273 patients)
  25. Reijneveld SA, van der Wal MF, Brugman E, et al. Infant crying and abuse. Lancet. 2004;364(9442):1340-1342. (Prospective cohort; 3259 patients)
  26. Flaherty EG, Stirling J Jr. Clinical report--the pediatrician’s role in child maltreatment prevention. Pediatrics. 2010;126(4):833-841. (Review article)
  27. Sullivan PM, Knutson JF. The association between child maltreatment and disabilities in a hospital-based epidemiological study. Child Abuse Negl. 1998;22(4):271-288. (Retrospective cohort; 3881 patients)
  28. Sidebotham P, Heron J. Child maltreatment in the “children of the nineties”: a cohort study of risk factors. Child Abuse Negl. 2006;30(5):497-522. (Prospective cohort; 14,256 patients)
  29. Oates RK, Davis AA, Ryan MG. Predictive factors for child abuse. Aust Paediatr J. 1980;16(4):239-243. (Retrospective cohort; 56 patients)
  30. Kelleher K, Chaffin M, Hollenberg J, et al. Alcohol and drug disorders among physically abusive and neglectful parents in a community-based sample. Am J Public Health. 1994;84(10):1586-1590. (Nested case-control study; 11,662 patients)
  31. Cadzow SP, Armstrong KL, Fraser JA. Stressed parents with infants: reassessing physical abuse risk factors. Child Abuse Negl. 1999;23(9):845-853. (Randomized controlled trial; 151 patients)
  32. Paulson JF, Dauber S, Leiferman JA. Individual and combined effects of postpartum depression in mothers and fathers on parenting behavior. Pediatrics. 2006;118(2):659-668. (National longitudinal survey; 5089 families)
  33. * Brown J, Cohen P, Johnson JG, et al. A longitudinal analysis of risk factors for child maltreatment: findings of a 17-year prospective study of officially recorded and self-reported child abuse and neglect. Child Abuse Negl. 1998;22(11):1065-1078. (Prospective cohort; 644 families)
  34. Burrell B, Thompson B, Sexton D. Predicting child abuse potential across family types. Child Abuse Negl. 1994;18(12):1039-1049. (Case control study; 113 patients)
  35. Stiffman MN, Schnitzer PG, Adam P, et al. Household composition and risk of fatal child maltreatment. Pediatrics. 2002;109(4):615-621. (Population-based case-control study; 471 patients)
  36. Knapp JF, Dowd MD. Family violence: implications for the pediatrician. Pediatr Rev. 1998;19(9):316-321. (Review article)
  37. Wood JN, Hall M, Schilling S, et al. Disparities in the evaluation and diagnosis of abuse among infants with traumatic brain injury. Pediatrics. 2010;126(3):408-414. (Retrospective cohort; 3063 patients)
  38. Schwartz KA, Metz J, Feldman K, et al. Cutaneous findings mistaken for physical abuse: present but not pervasive. Pediatr Dermatol. 2014;31(2):146-155. (Prospective cohort; 137 patients)
  39. Christian CW, States LJ. Medical mimics of child abuse. AJR Am J Roentgenol. 2017;208(5):982-990. (Review article)
  40. Bays J. Conditions mistaken for child physical abuse. In: Reece R, Ludwig S, eds. 2nd ed. Child Abuse and Neglect: Medical Diagnosis and Management. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:177-206. (Book review)
  41. Leventhal JM, Griffin D, Duncan KO, et al. Laxative-induced dermatitis of the buttocks incorrectly suspected to be abusive burns. Pediatrics. 2001;107(1):178-179. (Retrospective case reports; 4 patients)
  42. Stewart GM, Rosenberg NM. Conditions mistaken for child abuse: part II. Pediatr Emerg Care. 1996;12(3):217-221. (Review article)
  43. Bronicki LM, Stevenson RE, Spranger JW. Beyond osteogenesis imperfecta: causes of fractures during infancy and childhood. Am J Med Genet C Semin Med Genet. 2015;169(4):314-327. (Review article)
  44. Topor LS, Borus JS, Aspinwall S, et al. Fractures among inpatients in a pediatric hospital. Hosp Pediatr. 2016;6(3):143-150. (Retrospective cohort; 56 patients)
  45. Pepin MG, Byers PH. What every clinical geneticist should know about testing for osteogenesis imperfecta in suspected child abuse cases. Am J Med Genet C Semin Med Genet. 2015;169(4):307-313. (Review article)
  46. Chapman T, Sugar N, Done S, et al. Fractures in infants and toddlers with rickets. Pediatr Radiol. 2010;40(7):1184-1189. (Retrospective cohort; 45 children)
  47. Shore RM, Chesney RW. Rickets: part I. Pediatr Radiol. 2013;43(2):140-151. (Review article)
  48. Shore RM, Chesney RW. Rickets: part II. Pediatr Radiol. 2013;43(2):152-172. (Review article)
  49. Perez-Rossello JM, McDonald AG, Rosenberg AE, et al. Absence of rickets in infants with fatal abusive head trauma and classic metaphyseal lesions. Radiology. 2015;275(3):810-821. (Retrospective cohort; 46 patients)
  50. Al-Habdan I. Birth-related fractures of long bones. Indian J Pediatr. 2003;70(12):959-960. (Retrospective cohort; 21 fractures)
  51. Walters MM, Forbes PW, Buonomo C, et al. Healing patterns of clavicular birth injuries as a guide to fracture dating in cases of possible infant abuse. Pediatr Radiol. 2014;44(10):1224-1229. (Retrospective cohort; 131 radiographs)
  52. McKeag H, Christian CW, Rubin D, et al. Subdural hemorrhage in pediatric patients with enlargement of the subarachnoid spaces. J Neurosurg Pediatr. 2013;11(4):438-444. (Retrospective cohort; 177 patients)
  53. Vester ME, Bilo RA, Karst WA, et al. Subdural hematomas: glutaric aciduria type 1 or abusive head trauma? A systematic review. Forensic Sci Med Pathol. 2015;11(3):405-415. (Review article)
  54. Levin AV. Retinal hemorrhages: advances in understanding. Pediatr Clin North Am. 2009;56(2):333-344. (Review article)
  55. Pham H, Enzenauer RW, Elder JE, et al. Retinal hemorrhage after cardiopulmonary resuscitation with chest compressions. Am J Forensic Med Pathol. 2013;34(2):122-124. (Prospective cohort; 22 patients)
  56. Franke I, Pingen A, Schiffmann H, et al. Cardiopulmonary resuscitation (CPR)-related posterior rib fractures in neonates and infants following recommended changes in CPR techniques. Child Abuse Negl. 2014;38(7):1267-1274. (Retrospective cohort; 80 patients)
  57. Mandated reporters of child abuse and neglect: summary of state laws. U.S. Department of Health & Human Services, Administration for Children and Families; 2008. Accessed June 15, 2017. (State survey)
  58. Leventhal JM, Asnes AG, Pavlovic L, et al. Diagnosing abusive head trauma: the challenges faced by clinicians. Pediatr Radiol. 2014;44 Suppl 4:S537-S542. (Review article)
  59. Asnes AG, Leventhal JM. Managing child abuse: general principles. Pediatr Rev. 2010;31(2):47-55. (Review article)
  60. 60. Rubin DM, Christian CW, Bilaniuk LT, et al. Occult head injury in high-risk abused children. Pediatrics. 2003;111(6 Pt 1):1382-1386. (Retrospective cohort; 65 patients)
  61. Laskey AL, Holsti M, Runyan DK, et al. Occult head trauma in young suspected victims of physical abuse. J Pediatr. 2004;144(6):719-722. (Retrospective cohort; 51 patients)
  62. Emerson MV, Jakobs E, Green WR. Ocular autopsy and histopathologic features of child abuse. Ophthalmology. 2007;114(7):1384-1394. (Retrospective case series; 118 patients)
  63. Levin AV, Christian CW. The eye examination in the evaluation of child abuse. Pediatrics. 2010;126(2):376-380. (Review article)
  64. * Lindberg D, Makoroff K, Harper N, et al. Utility of hepatic transaminases to recognize abuse in children. Pediatrics. 2009;124(2):509-516. (Prospective observational cohort; 1272 patients)
  65. Lindberg DM, Berger RP, Lane WG. PECARN abdominal injury rule should exclude potentially abused children. Ann Emerg Med. 2013;62(3):276-277. (Letter to the editor)
  66. Baxter AL, Lindberg DM, Burke BL, et al. Hepatic enzyme decline after pediatric blunt trauma: a tool for timing child abuse? Child Abuse Negl. 2008;32(9):838-845. (Retrospective cohort; 176 patients)
  67. Christian CW. The evaluation of suspected child physical abuse. Pediatrics. 2015;135(5):e1337-e1354. (Review article)
  68. * Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers: those who don’t cruise rarely bruise. Puget Sound Pediatric Research Network. Arch Pediatr Adolesc Med. 1999;153(4):399-403. (Prospective cohort study; 973 patients)
  69. Carpenter RF. The prevalence and distribution of bruising in babies. Arch Dis Child. 1999;80(4):363-366. (Prospective cohort study; 177 patients)
  70. Pierce MC, Magana JN, Kaczor K, et al. The prevalence of bruising among infants in pediatric emergency departments. Ann Emerg Med. 2016;67(1):1-8. (Prospective observational cohort; 2488 patients)
  71. Labbe J, Caouette G. Recent skin injuries in normal children. Pediatrics. 2001;108(2):271-276. (Prospective cohort study; 1467 subjects)
  72. * Sheets LK, Leach ME, Koszewski IJ, et al. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics. 2013;131(4):701-707. (Retrospective case control study; 300 patients)
  73. Petska HW, Sheets LK, Knox BL. Facial bruising as a precursor to abusive head trauma. Clin Pediatr (Phila). 2013;52(1):86-88. (Review article)
  74. Pierce MC, Smith S, Kaczor K. Bruising in infants: those with a bruise may be abused. Pediatr Emerg Care. 2009;25(12):845-847. (Case series; 3 cases)
  75. Thackeray JD. Frena tears and abusive head injury: a cautionary tale. Pediatr Emerg Care. 2007;23(10):735-737. (Case series; 3 cases)
  76. Naidoo S. A profile of the oro-facial injuries in child physical abuse at a children’s hospital. Child Abuse Negl. 2000;24(4):521-534. (Retrospective case review; 300 cases)
  77. Harper NS, Feldman KW, Sugar NF, et al. Additional injuries in young infants with concern for abuse and apparently isolated bruises. J Pediatr. 2014;165(2):383-388.e1. (Prospective observational cohort; 2890 patients)
  78. Maguire S, Mann MK, Sibert J, et al. Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review. Arch Dis Child. 2005;90(2):182-186. (Systematic review; 23 studies; 7 nonabusive, 14 abusive, 2 both)
  79. * Pierce MC, Kaczor K, Aldridge S, et al. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics. 2010;125(1):67-74. (Prospective case control study; 95 subjects)
  80. Kemp AM, Maguire SA, Nuttall D, et al. Bruising in children who are assessed for suspected physical abuse. Arch Dis Child. 2014;99(2):108-113. (Cross sectional study; 519 patients)
  81. Maguire S, Mann MK, Sibert J, et al. Can you age bruises accurately in children? A systematic review. Arch Dis Child. 2005;90(2):187-189. (Systematic review; 167 studies reviewed, 3 included)
  82. Jessee SA. Detecting and reporting child maltreatment--dentists’ obligations. Gen Dent. 1994;42(3):218-221. (Review article)
  83. McNeese MC. When to suspect child abuse. Am Fam Physician. 1982;25(6):190-197. (Review article)
  84. Macintyre DR, Jones GM, Pinckney RC. The role of the dental practitioner in the management of non-accidental injury to children. Br Dent J. 1986;161(3):108-110. (Review article)
  85. Maguire S, Hunter B, Hunter L, et al. Diagnosing abuse: a systematic review of torn frenum and other intra-oral injuries. Arch Dis Child. 2007;92(12):1113-1117. (Systematic review; 9 studies, 27 children)
  86. Lopez MR, Abd-Allah S, Deming DD, et al. Oral, jaw, and neck injury in infants and children: from abusive trauma or intubation? Pediatr Emerg Care. 2014;30(5):305-310. (Prospective observational study; 105 patients)
  87. Kidd AJ, Beattie TF, Campbell-Hewson G. Frenal injury in children is not pathognomic of non-accidental injury. Emerg Med J. 2010;27(1):52. (Retrospective cohort; 21 patients)
  88. Chester DL, Jose RM, Aldlyami E, et al. Non-accidental burns in children--are we neglecting neglect? Burns. 2006;32(2):222-228. (Retrospective cohort; 436 patients)
  89. Hayek SN, Wibbenmeyer LA, Kealey LD, et al. The efficacy of hair and urine toxicology screening on the detection of child abuse by burning. J Burn Care Res. 2009;30(4):587-592. (Retrospective cohort analysis; 263 patients)
  90. Shah A, Suresh S, Thomas R, et al. Epidemiology and profile of pediatric burns in a large referral center. Clin Pediatr (Phila). 2011;50(5):391-395. (Prospective cohort; 236 patients)
  91. Wibbenmeyer L, Liao J, Heard J, et al. Factors related to child maltreatment in children presenting with burn injuries. J Burn Care Res. 2014;35(5):374-381. (Prospective cohort; 68 patients)
  92. Purdue GF, Hunt JL, Prescott PR. Child abuse by burning--an index of suspicion. J Trauma. 1988;28(2):221-224. (Prospective cohort; 71 patients)
  93. Thombs BD. Patient and injury characteristics, mortality risk, and length of stay related to child abuse by burning: evidence from a national sample of 15,802 pediatric admissions. Ann Surg. 2008;247(3):519-523. (Retrospective cohort; 15,802 patients)
  94. Maguire S, Moynihan S, Mann M, et al. A systematic review of the features that indicate intentional scalds in children. Burns. 2008;34(8):1072-1081. (Systematic review; 258 studies reviewed, 26 included)
  95. Pawlik MC, Kemp A, Maguire S, et al. Children with burns referred for child abuse evaluation: Burn characteristics and co-existent injuries. Child Abuse Negl. 2016;55:52-61. (Retrospective cohort; 215 patients)
  96. Peck MD, Priolo-Kapel D. Child abuse by burning: a review of the literature and an algorithm for medical investigations. J Trauma. 2002;53(5):1013-1022. (Review article)
  97. Seifert D, Krohn J, Larson M, et al. Violence against children: further evidence suggesting a relationship between burns, scalds, and the additional injuries. Int J Legal Med. 2010;124(1):49-54. (Retrospective cohort; 20 patients)
  98. Degraw M, Hicks RA, Lindberg D. Incidence of fractures among children with burns with concern regarding abuse. Pediatrics. 2010;125(2):e295-e299. (Retrospective cohort; 1676 patients)
  99. Fagen KE, Shalaby-Rana E, Jackson AM. Frequency of skeletal injuries in children with inflicted burns. Pediatr Radiol. 2015;45(3):396-401. (Retrospective cohort; 142 patients)
  100. Christian CW, Block R. Abusive head trauma in infants and children. Pediatrics. 2009;123(5):1409-1411. (Review article)
  101. Hinds T, Shalaby-Rana E, Jackson AM, et al. Aspects of abuse: abusive head trauma. Curr Probl Pediatr Adolesc Health Care. 2015;45(3):71-79. (Review article)
  102. Narang S, Clarke J. Abusive head trauma: past, present, and future. J Child Neurol. 2014;29(12):1747-1756. (Review article)
  103. Chiesa A, Duhaime AC. Abusive head trauma. Pediatr Clin North Am. 2009;56(2):317-331. (Review article)
  104. Niederkrotenthaler T, Xu L, Parks SE, et al. Descriptive factors of abusive head trauma in young children--United States, 2000-2009. Child Abuse Negl. 2013;37(7):446-455. (Retrospective cohort; 32,942 patients)
  105. Acker SN, Roach JP, Partrick DA, et al. Beyond morbidity and mortality: the social and legal outcomes of non-accidental trauma. J Pediatr Surg. 2015;50(4):604-607. (Retrospective cohort; 254 patients)
  106. Xiang J, Shi J, Wheeler KK, et al. Paediatric patients with abusive head trauma treated in US emergency departments, 2006-2009. Brain Inj. 2013;27(13-14):1555-1561. (Retrospective cohort; 10,773 patients)
  107. Nuno M, Pelissier L, Varshneya K, et al. Outcomes and factors associated with infant abusive head trauma in the US. J Neurosurg Pediatr. 2015:1-8. (Retrospective cohort; 5195 patients)
  108. Starling SP, Holden JR, Jenny C. Abusive head trauma: the relationship of perpetrators to their victims. Pediatrics. 1995;95(2):259-262. (Retrospective cohort; 151 cases)
  109. Adamsbaum C, Grabar S, Mejean N, et al. Abusive head trauma: judicial admissions highlight violent and repetitive shaking. Pediatrics. 2010;126(3):546-555. (Retrospective observational cohort; 112 cases)
  110. Adamsbaum C, Morel B, Ducot B, et al. Dating the abusive head trauma episode and perpetrator statements: key points for imaging. Pediatr Radiol. 2014;44 Suppl 4:S578-S588. (Review article)
  111. De Leeuw M, Beuls EA, Jorens PG, et al. History of an abusive head trauma including a lucid interval and a retinal hemorrhage is most likely false. Am J Forensic Med Pathol. 2013;34(3):271-276. (Retrospective case control study; 47 cases)
  112. Starling SP, Patel S, Burke BL, et al. Analysis of perpetrator admissions to inflicted traumatic brain injury in children. Arch Pediatr Adolesc Med. 2004;158(5):454-458. (Retrospective cohort; 171 patients)
  113. Kemp A, Cowley L, Maguire S. Spinal injuries in abusive head trauma: patterns and recommendations. Pediatr Radiol. 2014;44 Suppl 4:S604-S612. (Review article)
  114. Sieswerda-Hoogendoorn T, Boos S, Spivack B, et al. Educational paper: Abusive head trauma part I. Clinical aspects. Eur J Pediatr. 2012;171(3):415-423. (Review article)
  115. Hettler J, Greenes DS. Can the initial history predict whether a child with a head injury has been abused? Pediatrics. 2003;111(3):602-607. (Retrospective case-control study; 163 cases)
  116. Thompson A, Bertocci G, Pierce MC. Assessment of injury potential in pediatric bed fall experiments using an anthropomorphic test device. Accid Anal Prev. 2013;50:16-24. (Biomechanical study)
  117. Joffe M, Ludwig S. Stairway injuries in children. Pediatrics. 1988;82(3 Pt 2):457-461. (Prospective cohort; 363 patients)
  118. Helfer RE, Slovis TL, Black M. Injuries resulting when small children fall out of bed. Pediatrics. 1977;60(4):533-535. (Retrospective survey cohort; 161 patients)
  119. Case ME. Accidental traumatic head injury in infants and young children. Brain Pathol. 2008;18(4):583-589. (Review article)
  120. Reece RM, Sege R. Childhood head injuries: accidental or inflicted? Arch Pediatr Adolesc Med. 2000;154(1):11-15. (Retrospective cohort; 287 patients)
  121. Bechtel K, Stoessel K, Leventhal JM, et al. Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma. Pediatrics. 2004;114(1):165-168. (Prospective cohort; 87 patients)
  122. Piteau SJ, Ward MG, Barrowman NJ, et al. Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review. Pediatrics. 2012;130(2):315-323. (Systematic review; 24 studies)
  123. Pitetti RD, Maffei F, Chang K, et al. Prevalence of retinal hemorrhages and child abuse in children who present with an apparent life-threatening event. Pediatrics. 2002;110(3):557-562. (Prospective cohort; 128 patients)
  124. Guenther E, Powers A, Srivastava R, et al. Abusive head trauma in children presenting with an apparent life-threatening event. J Pediatr. 2010;157(5):821-825. (Retrospective cohort; 627 patients)
  125. Hymel KP, Armijo-Garcia V, Foster R, et al. Validation of a clinical prediction rule for pediatric abusive head trauma. Pediatrics. 2014;134(6):e1537-e1544. (Prospective observational cross-sectional study; 291 patients)
  126. Cowley LE, Morris CB, Maguire SA, et al. Validation of a prediction tool for abusive head trauma. Pediatrics. 2015;136(2):290-298. (Prospective cohort; 198 patients)
  127. Berger RP, Fromkin J, Herman B, et al. Validation of the Pittsburgh Infant Brain Injury Score for abusive head trauma. Pediatrics. 2016;138(1). (Prospective case-control validation study; 1040 patients)
  128. Kadom N, Khademian Z, Vezina G, et al. Usefulness of MRI detection of cervical spine and brain injuries in the evaluation of abusive head trauma. Pediatr Radiol. 2014;44(7):839-848. (Retrospective cohort; 74 patients)
  129. Matschke J, Buttner A, Bergmann M, et al. Encephalopathy and death in infants with abusive head trauma is due to hypoxic-ischemic injury following local brain trauma to vital brainstem centers. Int J Legal Med. 2015;129(1):105-114. (Prospective cohort; 50 cases)
  130. Choudhary AK, Ishak R, Zacharia TT, et al. Imaging of spinal injury in abusive head trauma: a retrospective study. Pediatr Radiol. 2014;44(9):1130-1140. (Retrospective cohort; 183 patients)
  131. Binenbaum G, Mirza-George N, Christian CW, et al. Odds of abuse associated with retinal hemorrhages in children suspected of child abuse. J AAPOS. 2009;13(3):268-272. (Retrospective cross-sectional study; 110 patients)
  132. Burkhart ZN, Thurber CJ, Chuang AZ, et al. Risk factors associated with retinal hemorrhage in suspected abusive head trauma. J AAPOS. 2015;19(2):119-123. (Retrospective cohort; 168 patients)
  133. Binenbaum G, Forbes BJ. The eye in child abuse: key points on retinal hemorrhages and abusive head trauma. Pediatr Radiol. 2014;44 Suppl 4:S571-S577. (Review article)
  134. Maguire SA, Watts PO, Shaw AD, et al. Retinal haemorrhages and related findings in abusive and non-abusive head trauma: a systematic review. Eye (Lond). 2013;27(1):28-36. (Systematic review; 62 studies)
  135. Binenbaum G, Chen W, Huang J, et al. The natural history of retinal hemorrhage in pediatric head trauma. J AAPOS. 2016;20(2):131-135. (Retrospective cohort; 52 patients)
  136. Maguire S, Upadhyaya M, Evans A, et al. A systematic review of abusive visceral injuries in childhood-range and recognition. Child Abuse Negl. 2013;37:430-445. (Review article)
  137. Roaten J, Patrick B, Nydam D, et al. Nonaccidental trauma is a major cause of morbidity and mortality among patients at a regional level 1 pediatric trauma center. J Pediatr Surg. 2006;41. (Retrospective cohort; 6186 patients)
  138.  Ledbetter D, Hatch E, Feldman K, et al. Diagnostic and surgical implications of child abuse. Arch Surg. 1988;123:1101-1105. (Review article)
  139. Schnitzer PG, Ewigman BG. Child deaths resulting from inflicted injuries: household risk factors and perpetrator characteristics. Pediatrics. 2005;116(5):e687-e693. (Retrospective case-control study; 447 patients)
  140. Cooper A, Floyd T, Barlow B, et al. Major blunt abdominal trauma due to child abuse. J Trauma. 1988;28(10):1483-1487. (Retrospective cohort; 10,000 cases)
  141. Wood J, Rubin DM, Nance ML, et al. Distinguishing inflicted versus accidental abdominal injuries in young children. J Trauma. 2005;59(5):1203-1208. (Retrospective cohort; 121 patients)
  142. Trokel M, Discala C, Terrin NC, et al. Patient and injury characteristics in abusive abdominal injuries. Pediatr Emerg Care. 2006;22(10):700-704. (Retrospective cohort; 664 patients)
  143. Trokel M, DiScala C, Terrin NC, et al. Blunt abdominal injury in the young pediatric patient: child abuse and patient outcomes. Child Maltreat. 2004;9(1):111-117. (Retrospective cohort; 927 patients)
  144. Sivit CJ, Taylor GA, Eichelberger MR. Visceral injury in battered children: a changing perspective. Radiology. 1989;173(3):659-661. (Prospective cohort; 69 patients)
  145. Barnes PM, Norton CM, Dunstan FD, et al. Abdominal injury due to child abuse. Lancet. 2005;366(9481):234-235. (Retrospective cohort; 184 patients)
  146. Huntimer CM, Muret-Wagstaff S, Leland NL. Can falls on stairs result in small intestine perforations? Pediatrics. 2000;106(2 Pt 1):301-305. (Meta-analysis; 677 cases)
  147. Gunther WM, Symes SA, Berryman HE. Characteristics of child abuse by anteroposterior manual compression versus cardiopulmonary resuscitation: case reports. Am J Forensic Med Pathol. 2000;21(1):5-10. (Case series; 3 cases)
  148. McEniery J, Hanson R, Grigor W, et al. Lung injury resulting from a nonaccidental crush injury to the chest. Pediatr Emerg Care. 1991;7(3):166-168. (Case report)
  149. Bliss D, Silen M. Pediatric thoracic trauma. Crit Care Med. 2002;30(11 Suppl):S409-S415. (Review article)
  150. Guleserian KJ, Gilchrist BF, Luks FI, et al. Child abuse as a cause of traumatic chylothorax. J Pediatr Surg. 1996;31(12):1696-1697. (Case report)
  151. Geismar SL, Tilelli JA, Campbell JB, et al. Chylothorax as a manifestation of child abuse. Pediatr Emerg Care. 1997;13(6):386-389. (Case report)
  152. Sagar M, Shukla S, Bradley-Dodds K. Nonaccidental trauma presenting with respiratory distress and pleural effusion. Pediatr Emerg Care. 2012;28(1):61-63. (Case report)
  153. Cumberland GD, Riddick L, McConnell CF. Intimal tears of the right atrium of the heart due to blunt force injuries to the abdomen. Its mechanism and implications. Am J Forensic Med Pathol. 1991;12(2):102-104. (Case series; 6 cases)
  154. Cohle SD, Hawley DA, Berg KK, et al. Homicidal cardiac lacerations in children. J Forensic Sci. 1995;40(2):212-218. (Case series)
  155. Karpas A, Yen K, Sell LL, et al. Severe blunt cardiac injury in an infant: a case of child abuse. J Trauma. 2002;52(4):759-764. (Case report)
  156. Denton JS, Kalelkar MB. Homicidal commotio cordis in two children. J Forensic Sci. 2000;45(3):734-735. (Case series; 2 cases)
  157. Lauridson JR, Cromblin KL. Prolonged abusive chest compressions in an infant: an occult form of child abuse: review of hemodynamics. Am J Forensic Med Pathol. 2015;36(4):274-275. (Case report)
  158. Carter KW, Moulton SL. Pediatric abdominal injury patterns caused by “falls”: a comparison between nonaccidental and accidental trauma. J Pediatr Surg. 2016;51(2):326-328. (Retrospective case-control study; 180 patients)
  159. Nimkin K, Kleinman PK. Visceral Trauma and Miscellaneous Abuse and Neglect. 3rd ed. Cambridge United Kingdom: Cambridge University Press; 2015. (Review/chapter)
  160. Gaines BA, Shultz BS, Morrison K, et al. Duodenal injuries in children: beware of child abuse. J Pediatr Surg. 2004;39(4):600-602. (Retrospective cohort; 32 patients)
  161. Kondolot M, Yagmur F, Yikilmaz A, et al. A life-threatening presentation of child physical abuse: jejunal perforation. Pediatr Emerg Care. 2011;27(11):1075-1077. (Case report)
  162. Maguire SA, Upadhyaya M, Evans A, et al. A systematic review of abusive visceral injuries in childhood--their range and recognition. Child Abuse Negl. 2013;37(7):430-445. (Systematic review; 88 studies)
  163. deRoux SJ, Prendergast NC. Lacerations of the hepatoduodenal ligament, pancreas and duodenum in a child due to blunt impact. J Forensic Sci. 1998;43(1):222-224. (Case report)
  164. Gurland B, Dolgin SE, Shlasko E, et al. Pneumatosis intestinalis and portal vein gas after blunt abdominal trauma. J Pediatr Surg. 1998;33(8):1309-1311. (Case report)
  165. Ziegler DW, Long JA, Philippart AI, et al. Pancreatitis in childhood. Experience with 49 patients. Ann Surg. 1988;207(3):257-261. (Retrospective cohort; 49 cases)
  166. Waseem M, Perales O. Pancreatic injury: accidental or nonaccidental. Pediatr Emerg Care. 2008;24(10):679-681. (Case report)
  167. Tolia V, Patel AS, Amundson GM. Pancreatic fracture secondary to child abuse: the role of computed tomography in its diagnosis. Clin Pediatr (Phila). 1990;29(11):667-668. (Review article)
  168. Dodds WJ, Taylor AJ, Erickson SJ, et al. Traumatic fracture of the pancreas: CT characteristics. J Comput Assist Tomogr. 1990;14(3):375-378. (Case series; 5 cases)
  169. Lindberg DM, Shapiro RA, Blood EA, et al. Utility of hepatic transaminases in children with concern for abuse. Pediatrics. 2013;131(2):268-275. (Retrospective cohort; 1538 patients)
  170. Lane WG, Lotwin I, Dubowitz H, et al. Outcomes for children hospitalized with abusive versus noninflicted abdominal trauma. Pediatrics. 2011;127(6):e1400-e1405. (Retrospective case control; 4434 patients)
  171. Kleinman PK, Marks SC Jr., Richmond JM, et al. Inflicted skeletal injury: a postmortem radiologic-histopathologic study in 31 infants. AJR Am J Roentgenol. 1995;165(3):647-650. (Prospective cohort; 31 patients)
  172. Worlock P, Stower M, Barbor P. Patterns of fractures in accidental and non-accidental injury in children: a comparative study. Br Med J (Clin Res Ed). 1986;293(6539):100-102. (Retrospective case-control; 861 patients)
  173. Kleinman P. Bony thoracic trauma. In: Kleinman P, ed. Diagnostic Imaging of Child Abuse. 3rd ed. Cambridge United Kingdom: Cambridge University Press; 2015:110-148. (Textbook chapter)
  174. Kleinman P. Skeletal trauma: general considerations. In: Kleinman P, ed. Diagnostic Imaging of Child Abuse. 3rd ed. Cambridge United Kingdom: Cambridge University Press; 2015:34-47. (Textbook chapter)
  175. Kogutt MS, Swischuk LE, Fagan CJ. Patterns of injury and significance of uncommon fractures in the battered child syndrome. Am J Roentgenol Radium Ther Nucl Med. 1974;121(1):143-149. (Review article)
  176. Feldman KW, Brewer DK. Child abuse, cardiopulmonary resuscitation, and rib fractures. Pediatrics. 1984;73(3):339-342. (Retrospective cohort; 113 patients)
  177. Kleinman PK, Schlesinger AE. Mechanical factors associated with posterior rib fractures: laboratory and case studies. Pediatr Radiol. 1997;27(1):87-91. (Prospective cohort; 12 cases)
  178. Maguire S, Mann M, John N, et al. Does cardiopulmonary resuscitation cause rib fractures in children? A systematic review. Child Abuse Negl. 2006;30(7):739-751. (Systematic review; 427 studies, 923 children)
  179. Ward MG, Ornstein A, Niec A, et al. The medical assessment of bruising in suspected child maltreatment cases: A clinical perspective. Paediatr Child Health. 2013;18(8):433-442. (Review article)
  180. Anderst JD, Carpenter SL, Abshire TC. Evaluation for bleeding disorders in suspected child abuse. Pediatrics. 2013;131(4):e1314-e1322. (Review article)
  181. Collins PW, Hamilton M, Dunstan FD, et al. Patterns of bruising in preschool children with inherited bleeding disorders: a longitudinal study. Arch Dis Child. 2016;0:1-8. (Prospective longitudinal observational study; 105 children with bleeding disorders)
  182. Herman BE, Makoroff KL, Corneli HM. Abusive head trauma. Pediatr Emerg Care. 2011;27(1):65-69. (Review article)
  183. Orman G, Wagner MW, Seeburg D, et al. Pediatric skull fracture diagnosis: should 3D CT reconstructions be added as routine imaging? J Neurosurg Pediatr. 2015;16(4):426-431. (Retrospective cohort; 250 patients)
  184. Vazquez E, Delgado I, Sanchez-Montanez A, et al. Imaging abusive head trauma: why use both computed tomography and magnetic resonance imaging? Pediatr Radiol. 2014;44 Suppl 4:S589-S603. (Review article)
  185. Flom L, Fromkin J, Panigrahy A, et al. Development of a screening MRI for infants at risk for abusive head trauma. Pediatr Radiol. 2016;46(4):519-526. (Prospective cohort; 87 patients)
  186. Buttram SD, Garcia-Filion P, Miller J, et al. Computed tomography vs magnetic resonance imaging for identifying acute lesions in pediatric traumatic brain injury. Hosp Pediatr. 2015;5(2):79-84. (Retrospective cohort; 105 patients)
  187. Leeper CM, Nasr I, McKenna C, et al. Elevated admission international normalized ratio strongly predicts mortality in victims of abusive head trauma. J Trauma Acute Care Surg. 2016;80(5):711-716. (Retrospective cohort; 101 patients)
  188. Greiner MV, Lawrence AP, Horn P, et al. Early clinical indicators of developmental outcome in abusive head trauma. Childs Nerv Syst. 2012;28(6):889-896. (Retrospective cohort; 71 patients)
  189. Chevignard MP, Lind K. Long-term outcome of abusive head trauma. Pediatr Radiol. 2014;44 Suppl 4:S548-S558. (Review)
  190. Frasier LD. Abusive head trauma in infants and young children: a unique contributor to developmental disabilities. Pediatr Clin North Am. 2008;55(6):1269-1285. (Review)
  191. Coant PN, Kornberg AE, Brody AS, et al. Markers for occult liver injury in cases of physical abuse in children. Pediatrics. 1992;89(2):274-278. (Prospective cohort; 49 patients)
  192. Lane WG, Dubowitz H, Langenberg P. Screening for occult abdominal trauma in children with suspected physical abuse. Pediatrics. 2009;124(6):1595-1602. (Retrospective cohort; 244 patients)
  193. American Academy of Pediatrics Section on Radiology. Diagnostic imaging of child abuse. Pediatrics. 2009;123(5):1430-1435. (Guidelines for diagnostic imaging in cases of suspected maltreatment)
  194. Sanchez TR, Grasparil AD, Chaudhari R, et al. Characteristics of rib fractures in child abuse-the role of low-dose chest computed tomography. Pediatr Emerg Care. 2016 Jan 12. [Epub ahead of print] (Retrospective cohort; 16 cases)
  195. Rezende Neto JB, Diniz HO, Filho CS, et al. Blunt traumatic rupture of the heart in a child: case report and review of the literature. J Trauma. 2001;50(4):746-749. (Case report)
  196. Frick EJ Jr, Pasquale MD, Cipolle MD. Small-bowel and mesentery injuries in blunt trauma. J Trauma. 1999;46(5):920-926. (Retrospective cohort; 5303 patients)
  197. Killeen KL, Shanmuganathan K, Poletti PA, et al. Helical computed tomography of bowel and mesenteric injuries. J Trauma. 2001;51(1):26-36. (Retrospective cohort; 150 cases)
  198. Bixby SD, Callahan MJ, Taylor GA. Imaging in pediatric blunt abdominal trauma. Semin Roentgenol. 2008;43(1):72-82. (Review article)
  199. Shankar KR, Lloyd DA, Kitteringham L, et al. Oral contrast with computed tomography in the evaluation of blunt abdominal trauma in children. Br J Surg. 1999;86(8):1073-1077. (Retrospective cohort; 60 patients)
  200. Menaker J, Blumberg S, Wisner DH, et al. Use of the focused assessment with sonography for trauma (FAST) examination and its impact on abdominal computed tomography use in hemodynamically stable children with blunt torso trauma. J Trauma Acute Care Surg. 2014;77(3):427-432. (Prospective cohort; 887 cases)
  201. Menichini G, Sessa B, Trinci M, et al. Accuracy of contrast-enhanced ultrasound (CEUS) in the identification and characterization of traumatic solid organ lesions in children: a retrospective comparison with baseline US and CE-MDCT. Radiol Med. 2015;120(11):989-1001. (Retrospective cohort; 73 patients)
  202. Wood JN, Fakeye O, Feudtner C, et al. Development of guidelines for skeletal survey in young children with fractures. Pediatrics. 2014;134(1):45-53. (Rand UCLA method for consensus)
  203. Duffy SO, Squires J, Fromkin JB, et al. Use of skeletal surveys to evaluate for physical abuse: analysis of 703 consecutive skeletal surveys. Pediatrics. 2011;127(1):e47-e52. (Retrospective cohort; 703 patients)
  204. American Academy of Pediatrics: Section on Radiology. Diagnostic imaging of child abuse. Pediatrics. 2009;123(5):1430-1435. (Review article)
  205. Harper NS, Eddleman S, Lindberg DM. The utility of follow-up skeletal surveys in child abuse. Pediatrics. 2013;131(3):e672-e678. (Prospective observational study; 2890 patients)
  206. Harper NS, Lewis T, Eddleman S, et al. Follow-up skeletal survey use by child abuse pediatricians. Child Abuse Negl. 2016;51:336-342. (Prospective observational cohort; 2049 patients)
  207. Berger RP, Panigrahy A, Gottschalk S, et al. Effective radiation dose in a skeletal survey performed for suspected child abuse. J Pediatr. 2016;171:310-312. (Actuarial analysis)
  208. Lindberg DM, Shapiro RA, Laskey AL, et al. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics. 2012;130(2):193-201. (Observational cross-sectional study; 134 patients)
  209. Van Horne BS, Moffitt KB, Canfield MA, et al. Maltreatment of children under age 2 with specific birth defects: a population-based study. Pediatrics. 2015;136(6):e1504-e1512. (Population-based study)
  210. Newacheck PW, Strickland B, Shonkoff JP, et al. An epidemiologic profile of children with special health care needs. Pediatrics. 1998;102(1 Pt 1):117-123. (Epidemiologic profile)
  211. Lilly E, Kundu RV. Dermatoses secondary to Asian cultural practices. Int J Dermatol. 2012;51(4):372-379. (Review article)
  212. Look KM, Look RM. Skin scraping, cupping, and moxibustion that may mimic physical abuse. J Forensic Sci. 1997;42(1):103-105. (Review article)
  213. Christian CW, Scribano P, Seidl T, et al. Pediatric injury resulting from family violence. Pediatrics. 1997;99(2):E8. (Retrospective cohort; 139 patients)
  214. Peedicayil A, Sadowski LS, Jeyaseelan L, et al. Spousal physical violence against women during pregnancy. BJOG. 2004;111(7):682-687. (Population-based, multicenter, cross-sectional household survey; 9938 patients)
  215. Dube SR, Anda RF, Felitti VJ, et al. Exposure to abuse, neglect, and household dysfunction among adults who witnessed intimate partner violence as children: implications for health and social services. Violence Vict. 2002;17(1):3-17. (Retrospective cohort; 17,337 patients)
  216. Hornor G. Domestic violence and children. J Pediatr Health Care. 2005;19(4):206-212. (Literature review on the role of primary care providers and intimate partner violence)
  217. Wood JN, Fakeye O, Mondestin V, et al. Development of hospital-based guidelines for skeletal survey in young children with bruises. Pediatrics. 2015;135(2):e312-e320. (Expert consensus guideline development)
  218. Thackeray JD, Hibbard R, Dowd MD. Intimate partner violence: the role of the pediatrician. Pediatrics. 2010;125(5):1094-1100. (Clinical report)
  219. Wood SL, Sommers MS. Consequences of intimate partner violence on child witnesses: a systematic review of the literature. J Child Adolesc Psychiatr Nurs. 2011;24(4):223-236. (Review article)
  220. Anda RF, Croft JB, Felitti VJ, et al. Adverse childhood experiences and smoking during adolescence and adulthood. JAMA. 1999;282(17):1652-1658. (Retrospective cohort; 9215 patients)
  221. Hillis SD, Anda RF, Felitti VJ, et al. Adverse childhood experiences and sexually transmitted diseases in men and women: a retrospective study. Pediatrics. 2000;106(1):E11. (Retrospective cohort; 5450 patients)
  222. Hillis SD, Anda RF, Felitti VJ, et al. Adverse childhood experiences and sexual risk behaviors in women: a retrospective cohort study. Fam Plann Perspect. 2001;33(5):206-211. (Prospective cohort; 5060 patients)
  223. Lang AJ, Stein MB, Kennedy CM, et al. Adult psychopathology and intimate partner violence among survivors of childhood maltreatment. J Interpers Violence. 2004;19(10):1102-1118. (Case-control; 72 patients)
  224. Sousa C, Herrenkohl TI, Moylan CA, et al. Longitudinal study on the effects of child abuse and children’s exposure to domestic violence, parent-child attachments, and antisocial behavior in adolescence. J Interpers Violence. 2011;26(1):111-136. (Retrospective cohort; 457 patients)
  225. Moylan CA, Herrenkohl TI, Sousa C, et al. The effects of child abuse and exposure to domestic violence on adolescent internalizing and externalizing behavior problems. J Fam Violence. 2010;25(1):53-63. (Longitudinal survey; 457 patients)
  226. Peek-Asa C, Maxwell L, Stromquist A, et al. Does parental physical violence reduce children’s standardized test score performance? Ann Epidemiol. 2007;17(11):847-853. (Prospective cohort; 306 patients)
  227. Lemmey D, McFarlane J, Willson P, et al. Intimate partner violence. Mothers’ perspectives of effects on their children. MCN Am J Matern Child Nurs. 2001;26(2):98-103. (Prospective cohort; 72 cases)
  228. Rivara FP, Anderson ML, Fishman P, et al. Intimate partner violence and health care costs and utilization for children living in the home. Pediatrics. 2007;120(6):1270-1277. (Longitudinal cohort study; 1391 cases)
  229. Geddes JF, Hackshaw AK, Vowles GH, et al. Neuropathology of inflicted head injury in children. I. Patterns of brain damage. Brain. 2001;124(Pt 7):1290-1298. (Prospective cohort; 53 patients)
  230. Geddes JF, Vowles GH, Hackshaw AK, et al. Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants. Brain. 2001;124(Pt 7):1299-1306. (Autopsy case-control study; 51 cases)
  231. Geddes JF, Tasker RC, Hackshaw AK, et al. Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in ‘shaken baby syndrome’? Neuropathol Appl Neurobiol. 2003;29(1):14-22. (Cohort study; 50 patients)
  232. Rafaat KT, Spear RM, Kuelbs C, et al. Cranial computed tomographic findings in a large group of children with drowning: diagnostic, prognostic, and forensic implications. Pediatr Crit Care Med. 2008;9(6):567-572. (Retrospective cohort; 156 patients)
  233. Hurley M, Dineen R, Padfield CJ, et al. Is there a causal relationship between the hypoxia-ischaemia associated with cardiorespiratory arrest and subdural haematomas? An observational study. Br J Radiol. 2010;83(993):736-743. (Retrospective observational cohort; 50 patients)
  234. Byard RW, Blumbergs P, Rutty G, et al. Lack of evidence for a causal relationship between hypoxic-ischemic encephalopathy and subdural hemorrhage in fetal life, infancy, and early childhood. Pediatr Dev Pathol. 2007;10(5):348-350. (Retrospective cohort; 48 patients)
  235. Odom A, Christ E, Kerr N, et al. Prevalence of retinal hemorrhages in pediatric patients after in-hospital cardiopulmonary resuscitation: a prospective study. Pediatrics. 1997;99(6):E3. (Prospective cohort study; 43 patients)
  236. Sandramouli S, Robinson R, Tsaloumas M, et al. Retinal haemorrhages and convulsions. Arch Dis Child. 1997;76(5):449-451. (Prospective cohort study; 32 chldren)
  237. Tyagi AK, Willshaw HE, Ainsworth JR. Unilateral retinal haemorrhages in non-accidental injury. Lancet. 1997;349(9060):1224. (Prospective cohort study; 32 children)
  238. Mei-Zahav M, Uziel Y, Raz J, et al. Convulsions and retinal haemorrhage: should we look further? Arch Dis Child. 2002;86(5):334-335. (Prospective study; 153 children)
  239. Curcoy AI, Trenchs V, Morales M, et al. Do retinal haemorrhages occur in infants with convulsions? Arch Dis Child. 2009;94(11):873-875. (Prospective cohort study; 389 children with seizures)
  240. Keller KA, Barnes PD. Rickets vs. abuse: a national and international epidemic. Pediatr Radiol. 2008;38(11):1210-1216. (Case series and commentary; 4 patients)
  241. Slovis TL, Chapman S. Evaluating the data concerning vitamin D insufficiency/deficiency and child abuse. Pediatr Radiol. 2008;38(11):1221-1224. (Editorial)
  242. Schilling S, Wood JN, Levine MA, et al. Vitamin D status in abused and nonabused children younger than 2 years old with fractures. Pediatrics. 2011;127(5):835-841. (Retrospective cohort; 118 patients)
  243. Irazuzta JE, McJunkin JE, Danadian K, et al. Outcome and cost of child abuse. Child Abuse Negl. 1997;21(8):751-757. (Retrospective cohort; 937 cases)
  244. Wright MS, Litaker D. Childhood victims of violence. Hospital utilization by children with intentional injuries. Arch Pediatr Adolesc Med. 1996;150(4):415-420. (Retrospective cohort; 1495 patients)
  245. DiScala C, Sege R, Li G, et al. Child abuse and unintentional injuries: a 10-year retrospective. Arch Pediatr Adolesc Med. 2000;154(1):16-22. (Retrospective case-control study; 18,828 patients)
  246. Rivara FP, Kamitsuka MD, Quan L. Injuries to children younger than 1 year of age. Pediatrics. 1988;81(1):93-97. (Retrospective cohort; 156 patients)
  247. Campbell KA, Berger RP, Ettaro L, et al. Cost-effectiveness of head computed tomography in infants with possible inflicted traumatic brain injury. Pediatrics. 2007;120(2):295-304. (Computer modeling cost analyses)
  248. Greiner MV, Greiner HM, Care MM, et al. Adding insult to injury: nonconvulsive seizures in abusive head trauma. J Child Neurol. 2015;30(13):1778-1784. (Retrospective cohort; 199 patients)
  249. Poole MK, Seal DW, Taylor CA. A systematic review of universal campaigns targeting child physical abuse prevention. Health Educ Res. 2014;29(3):388-432. (Review article)
  250. Prinz RJ, Sanders MR, Shapiro CJ, et al. Population-based prevention of child maltreatment: the U.S. Triple P system population trial. Prev Sci. 2009;10(1):1-12. (Randomized controlled trial; 18 counties)
  251. Prinz RJ, Sanders MR, Shapiro CJ, et al. Addendum to “Population-based prevention of child maltreatment: the U.S. Triple P system population trial.” Prev Sci. 2016;17(3):410-416. (Randomized controlled trial; 18 counties)
Publication Information

Gunjan Tiyyagura, MD; Meghan Beucher, MD; Kirsten Bechtel, MD

Publication Date

July 2, 2017

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