August 2021 – Identifying Maltreatment in Infants and  Young Children Presenting with Fractures: Does Age Matter?


CPG Citation:  Mitchell IC, Norat BJ, Auerbach M, et al.  Identifying Maltreatment in Infants and  Young Children Presenting with Fractures: Does Age Matter?   Acad Emerg Med  2021  Jan;28(1):5-18.  

Downloadable at:  doi: 10.1111/acem.14122 

Scope of Guideline:   This guideline is intended for practitioners/facilities who evaluate  injured children for potential child abuse. 

Summary download – click

Key Words:    Child abuse, fractures, risk stratification. 

Key Recommendations:  Each recommendation is accompanied by the “strength” of  recommendation and the level of evidence (LoE) supporting that recommendation 

Recommendations Strength, LoE
FOR Clinical Action 
In children presenting to a health care facility with a rib fracture, who  were not in an independently verified incident, we strongly recommend  routine child abuse evaluations for patients younger than 3 years of age. 

In children presenting to a health care facility with a humeral fracture, who were not in an independently verified incident,  we strongly recommend routine child abuse evaluations for patients  younger than 18 months of age. 

In children presenting to a health care facility with a femoral fracture aged less than 18 months, who were not in an independently verified incident, we strongly recommend routine evaluation to identify child abuse.

Strong,; Moderate

LoE Strong; Moderate

LoE Strong; Moderate LoE

Benefits of Recommendations: 

These recommendations can raise the likelihood of finding infant/young child victims of child  abuse, and intervening in order to address acute injuries during index ED visit, and worse  future outcomes (ie. critical injury, death). 

In this review, the presence of rib fractures in children <3yo was associated with a 96%  incidence in child abuse determination.   

For children <18mo with a humeral fracture, the abuse incidence was 48%.   

Finally, in children with femoral fractures, the incidence of abuse was 34% (<12mo) and  25% (<18mo). 

There are likely racial, gender and other socioeconomic biases that may influence differential  screening of injured children for actual abuse.  For example, more complete abuse evaluations  is more likely to occur in African-American or lower SES populations, whereas they are more  likely to be overlooked in Caucasian and higher SES encounters.  The implementation of  routine complete abuse evaluations in children with these fractures could obviate some of  these.

These guidelines were developed as a collaborative initiative between the Pediatric Trauma  Society (PTS), Eastern Association for the Surgery of Trauma (EAST), and RE Helfer Society  (Child Abuse Pediatrics).  These recommendations complement the 2015 AAP Child Abuse and  Neglect position statement (PDF available for download at

Harms/Adverse Effects of Recommendations: 

Routine screening of injured for child abuse will potentially lead to increased stress in  parents/caregivers, and may lead to excessive use of imaging resources and radiation  exposures.  Parents/caregivers could be reassured that progression to routine complete abuse  screening is in the child’s (and presumably parents/caregivers) best interests.   

Reporting of suspected/detected child abuse will also create stress/upset for parents/ caregivers, but the physical safety/wellbeing of the child is generally paramount, and legally  required of ED staff. 

There was insufficient evidence to inform recommendations for other fractures (forearm,  hand, lower leg, foot). 

Barriers to UptakeThere may be some resource issues around routine complete child abuse  screening in smaller community ED’s that lack pediatrics consultation support.  There also be  reluctance to complete Xray skeletal surveys on infants/young children, but this cannot be in  impediment to being thorough in evaluating/protecting children at risk.  Finally, ED clinicians  need to have a clear appreciation of injuries that are suggestive of child abuse, especially those  inconsistent with developmental milestones. 

There is no reported participation of parents/child caregivers in this guideline project which,  given the significant sensitivity of the clinical topic, would have been critical to ensure patient  priorities, values/preferences and equity considerations (GRADE Evidence-to-Decision  framework). 

Facilitators of UptakeEmergency departments of any size should have policies/protocols in  place to address the evaluation & management of potential child abuse victims, either in hospital or to local pediatric EDs with appropriate child protection services. 

Concerns re: imaging radiation of complete skeletal surveys may be partially obviated with the  growing role of ED point-of-care ultrasound (POCUS), which has shown diagnostic  characteristics for detecting various skeletal fractures (long bone, distal radius, infant skull).   There are no know official recommendations (yet) regarding replacing complete Xray skeletal  surveys with ED POCUS. 

Disclaimer (if any stated):  No conflicts of interest disclosed by authors (reported) Funding reported:  None reported 

Grading System Used:  GRADE system

Institute of Medicine 2011 Trustworthiness Standards

Rating Domain Rating (Good/Fair/Poor)
Establishing transparency Good
Managing conflict of interest in CPG development  groupGood
Group composition (range of stakeholders  involved)Good
Critical evaluation of supporting evidence Good
Framing recommendations based on supporting  evidenceGood
Clear articulation of recommendations Fair
External review by relevant stakeholders/  organizationsPoor
Updating schedule Poor
Implementation issues Fair