. 2015 Jul;136(1):35–43. doi: 10.1542/peds.2014-4192

TABLE 2.

Required and Highly Recommended Elements in the Medical Evaluation for Suspected Child Abuse

Domain	Consensus	Injury type
Domain	Consensus	Intracranial hemorrhage	Long bone fracture	Skull fracture
History of presenting illness	Required	Child age, source of history, injury history, symptom timeline, caregiver present at time of injury or illness	Child age, source of history, injury history, symptom timeline, caregiver present at time of injury or illness, caregiver response to symptoms, outside hospital or prehospital medical care	Child age, source of history, injury history, symptom timeline, caregiver present at time of injury or illness, caregiver response to symptoms, outside hospital or prehospital medical care
	Highly recommended	Caregiver response to symptoms, outside hospital or prehospital medical care, discrepancies in history	Discrepancies in history	Discrepancies in history
Past medical history	Required	Past injuries, surgeries, easy bleeding, seizures, skin concerns, special health care needs	Past injuries and fractures	Past injuries and fractures
	Highly recommended	Past Fractures, vomiting, growth pattern, known primary care provider, hospitalizations, medications	Dental concerns, hearing loss, skin concerns, growth pattern, hospitalizations, medications, special health care needs	Skin concerns, growth pattern, hospitalizations, special health care needs
Pre- and perinatal history (infants <6 mo of age unless otherwise specified)	Required	Estimated gestational age, birth complications, perinatal care (eg, vitamin K)	Estimated gestational age, birth complications	Birth complications
	Highly recommended	Prenatal care, prenatal injury, prenatal drug exposure, estimated gestational age,^a birth weight, birth discharge timing, perinatal care (eg, vitamin K),^a perinatal illness, neonatal state screen	Prenatal care, prenatal nutrition, estimated gestational age,^a birth weight, perinatal illness	Prenatal care, prenatal injury, estimated gestational age, birth weight
Developmental history	Required	Developmental stage	Developmental stage	Developmental stage
	Highly recommended	Parental concerns for development	Parental concerns for development	Parental concerns for development
Dietary history	Required	N/A	Diet (eg, breast vs formula fed; vitamins given; picky eater)^b	N/A
	Highly recommended	N/A	Diet (eg, breast vs formula fed; vitamins given; picky eater)^a^,^c^,^d	N/A
Family history	Required	Easy bleeding or known bleeding disorder	Bone fragility, osteogenesis imperfecta	Bone fragility
	Highly recommended	Metabolic disorder, seizures, early childhood deaths, mental illness	Metabolic disorders, collagen disorders	Osteogenesis imperfecta, metabolic disorders, collagen disorders
Social history	Required	Description of child care settings	N/A	Description of child care settings, previous abuse/neglect of this child
	Highly recommended	Previous abuse/neglect of this child, intimate partner violence, caregiver history of abuse/neglect, past CPS involvement for household	Description of child care settings, previous abuse/neglect of this child, parenting difficulties, intimate partner violence, caregiver history of child abuse/neglect, past CPS involvement for household, past legal involvement of caregiver	Intimate partner violence, caregiver history of abuse/neglect, past CPS involvement for household
Laboratory	Required	Complete blood count, coagulation screening (PT/PTT), liver enzymes (ALT/AST)	N/A	N/A
	Highly recommended	Basic metabolic panel, pancreatic enzymes (amylase/lipase)	Alkaline phosphatase, calcium/phosphorous	N/A
Radiology	Required	Head CT,^a^,^b^,^c skeletal survey^a^,^b^,^c	Head CT,^b skeletal survey^a^,^b^,^c	Head CT,^a skeletal survey^a
	Highly recommended	Head CT,^d brain MRI	Focused extremity	N/A
Consultations	Required	Pediatric ophthalmology^a^,^b	N/A	N/A
	Highly recommended	Pediatric ophthalmology^c^,^d	N/A	N/A

Expert consensus for evaluation of suspected physical abuse in children aged 0 to 60 mo unless indicated by footnotes. N/A, no elements were identified by expert consensus. ALT/AST, alanine transaminase/aspartate aminotransferase; CT, computed tomography; MRI, magnetic resonance imaging; PT/PTT, prothrombin time/partial thromboplastin time.

^{^a}

In children aged 6–11 mo.

^{^b}

In children aged <6 mo.

^{^c}

In children aged 12–23 mo.

^{^d}

In children aged 24–60 mo.