24.1 Child Maltreatment, Pediatric Human Trafficking & Trauma-Informed Acute Care
Key Takeaways
Bruising flagged by TEN-4-FACESp and unexplained oral injury in a nonmobile infant warrant assessment in developmental and clinical context.
Use separate imaging pathways for the index child and household contacts. Tailor bleeding and abdominal studies to the presentation, and arrange follow-up skeletal imaging when concern persists.
Offer a trained forensic evaluation under the applicable consent and evidence protocol. Start indicated HIV nPEP promptly within 72 hours and use age- and exposure-specific STI and pregnancy care.
Report at the applicable legal threshold while evaluating the child. Use private, trauma-informed inquiry and a coordinated safety response for suspected exploitation.
Child Maltreatment, Pediatric Human Trafficking and Trauma-Informed Acute Care
Quick Answer: Stabilize the child, assess immediate safety, and examine injuries in the context of development and the reported mechanism. Use TEN-4-FACESp to flag bruising that needs evaluation. Select occult-injury studies by age and presentation, and report when the applicable legal threshold is met while the workup continues. After sexual assault, separate the forensic evidence window from the 72-hour HIV prophylaxis window. Provide private, trauma-informed care when exploitation is possible.
Recognize sentinel injuries and abusive head trauma
Ask separately, when feasible, how and when the injury occurred, who was present, and what the child can actually do. Examine skin, mouth, scalp, eyes and the neurologic and musculoskeletal systems as indicated. Bruising or an oral injury with no plausible explanation in a nonmobile infant can be a sentinel injury. A torn frenulum raises concern in that context and can also occur accidentally. Compare the history and developmental ability with the entire pattern of findings.
TEN-4-FACESp applies to children younger than 4 years who have bruising. A positive result includes bruising of the torso, ear or neck, any bruise in an infant younger than 5 months (4.99 months or younger in the validation study), bruising involving the frenulum, angle of the jaw, fleshy cheeks, eyelids or subconjunctivae, or patterned bruising. A positive screen prompts further assessment. Evaluate a suspicious oral tear or immersion burn on its own merits. Bruising-rule validation · Sentinel injury study · AAP oral injury report
Abusive head trauma may result from inflicted impact, shaking or both. Presentations include vomiting, poor feeding, irritability, apnea, seizures or altered consciousness. Stabilize airway, ventilation and circulation and treat neurologic emergencies while arranging evaluation. Interpret findings together with the history, age, examination, other injuries and differential.
| Finding | Clinical interpretation |
|---|---|
| Subdural hemorrhage or brain injury | Multiple or interhemispheric subdural collections and associated hypoxic-ischemic injury can raise concern. Consider plausible accidental mechanisms, birth-related findings in the young infant, and medical causes. Mixed density alone cannot establish separate events or date an injury. |
| Retinal hemorrhage | Extensive bilateral, multilayered hemorrhages extending to the retinal periphery increase concern. Birth, severe accidental trauma and medical conditions are among the alternatives. Obtain an experienced dilated ophthalmologic examination promptly when head trauma findings warrant it. |
| Rib and metaphyseal fractures | Unexplained rib fractures, including posterior fractures, and classic metaphyseal lesions (corner or bucket-handle appearance) warrant careful assessment. Review resuscitation, birth history and bone fragility when relevant. A long-bone fracture in a nonambulatory child needs an explanation that fits development. |
| Skull fracture | Assess the reported impact, fracture pattern and associated brain or extracranial findings. A linear fracture can occur after an accidental fall. Complexity alone cannot establish the cause. |
AAP abusive head trauma report · AAP fracture evaluation report
Select occult-injury studies by age and presentation
- Index child. For suspected physical abuse with no apparent neurologic, skeletal or visceral injury in a child 24 months or younger, the ACR 2025 update rates a dedicated skeletal survey and noncontrast head CT as usually appropriate. The AAP fracture report describes a dedicated survey of 21 images, with additional or substitute views when indicated. A single whole-body film lacks the necessary detail. For a suspicious fracture, the AAP indicates head imaging before 6 months of age and says to consider it before 1 year. For children older than 24 months, use targeted radiographs and consider a survey through age 5 when suspicion is high or localization is difficult. For acute neurologic or head trauma findings, obtain noncontrast head CT urgently. MRI helps define brain injury or investigate persistent concern despite a negative CT. Discuss concurrent spine MRI when indicated. Arrange a follow-up skeletal survey at about two weeks after positive or equivocal initial films, or after negative films when strong concern persists. The ACR specifies 10–14 days for its negative-initial-studies scenario.
- Household contacts. Coordinate a separate safety assessment and examination for siblings and other exposed children. ACR recommends a survey for asymptomatic household contacts 24 months or younger. The 2023 international consensus discussed by the AAP also recommends brain imaging, preferably MRI, for contacts younger than 12 months. Review the contact's age, exam and circumstances with child abuse pediatrics and radiology.
- Abdominal injury. Abdominal pain, tenderness, distension, bruising or other evidence of visceral injury warrants trauma evaluation. In a stable child with suspected intra-abdominal injury, use CT with IV contrast when indicated. For occult injury, AST/ALT can guide selective imaging. A study in children evaluated for abuse supported considering CT for either value above 80 IU/L. A newer CAPNET cohort of children younger than 5 years without abdominal signs or symptoms found low yield and questioned universal screening in that subgroup. Weigh the entire presentation, enzyme magnitude and trend, and local child abuse and trauma protocols. Pancreatic enzymes and urinalysis can help when the injury pattern warrants them.
- Bleeding and bone disorders. In a nonmobile child with unexplained bruising, evaluate bleeding disorders alongside abuse. When testing is indicated for suspicious bruising, the AAP panel includes CBC with platelets, PT, aPTT, von Willebrand factor antigen and activity, and factors VIII and IX. For concerning intracranial hemorrhage, begin with CBC/platelets, PT and aPTT when testing is indicated. Add VIII and IX with a trauma history or possible trauma and fibrinogen and D-dimer with neurologic compromise. Consult hematology for tailored testing when indicated. Check bone health in unexplained fractures as appropriate, including calcium, phosphate and alkaline phosphatase, with vitamin D, PTH or testing for conditions such as osteogenesis imperfecta guided by the findings. Review baseline skin findings such as congenital dermal melanocytosis. A bleeding or bone disorder can coexist with inflicted injury.
ACR imaging variants · AAP fracture evaluation report · AAP bleeding evaluation · Transaminase study · CAPNET occult abdominal injury cohort · Contact-child imaging consensus
Respond to sexual abuse or assault
Address injury, pain and immediate safety. Offer a trained pediatric or adolescent medical-forensic examiner, explain each step, seek permission or consent under applicable law and seek developmentally appropriate assent. Document who supplied each account, quote relevant statements, describe findings objectively, and follow evidence handling and chain-of-custody procedures. Ask open questions needed for care and safety and coordinate detailed forensic interviewing with trained staff. A normal examination is common and does not exclude abuse.
| Decision | Clinical approach |
|---|---|
| Forensic collection | Use the jurisdiction's window and consult the forensic team promptly. The DOJ pediatric protocol recommends a minimum 72-hour collection window and allows case-specific collection beyond it. Adolescent protocols also vary. Offer examination and support even when collection is no longer indicated. |
| HIV nonoccupational postexposure prophylaxis (nPEP) | Offer for substantial-risk assault within 72 hours when the source has HIV without known sustained suppression or when source status is unknown and the exposure merits treatment. Give the first dose as soon as possible, ideally within 24 hours, without waiting for laboratory results. Use a 28-day regimen chosen for age, weight, renal function and interactions. A preferred option for eligible children aged at least 2 years and weighing at least 14 kg is bictegravir/emtricitabine/tenofovir alafenamide. Consult pediatric HIV expertise as needed. Obtain baseline HIV, renal, liver and hepatitis B testing, and pregnancy and other exposure tests as indicated. Arrange a check within 24 hours and HIV testing at 4–6 and 12 weeks per CDC guidance. |
| Prepubertal STI care | Individualize testing by symptoms, exposure sites, ability to describe the event, and risk. Use appropriate assays and confirm positive results as CDC recommends. Routine presumptive antibiotic treatment is generally deferred. Arrange repeat evaluation when early testing may miss infection. |
| Adolescent STI and pregnancy care | CDC's usual regimen for female adolescent survivors is ceftriaxone, doxycycline and metronidazole. For male adolescent survivors, the usual regimen is ceftriaxone and doxycycline. Review exposure sites, pregnancy, allergy and alternatives. Offer emergency contraception if pregnancy is possible. Pills can be used through day 5, with ulipristal more effective than levonorgestrel on days 3–5. Review hepatitis B vaccination and HBIG by vaccination and source status. Offer eligible HPV vaccination and arrange follow-up. |
DOJ pediatric forensic protocol · DOJ adolescent forensic protocol · CDC 2025 nPEP guideline · CDC STI care in children · CDC STI care in adolescents · CDC emergency contraception
Report concerns and arrange a safe disposition
CAPTA conditions federal grants on state procedures for reporting known or suspected maltreatment. State law establishes the clinician's duty, reporting threshold, timelines, recipients and emergency custody authority. Report promptly when the threshold is met, often reasonable suspicion, while the evaluation continues. An internal consult cannot substitute for a legally required report. Assess who can safely take the child home. For immediate danger or attempted removal to an unsafe setting, activate the hospital's emergency safeguarding process with child protection, security, legal counsel or law enforcement as appropriate. Confirm who has authority to restrict departure under applicable law. Explain confidentiality limits and coordinate safe documentation and communication. CAPTA state grant provisions · HIPAA reporting and disclosures · AAP adolescent confidentiality
Medical child abuse. Fabricated or induced illness can expose a child to harmful treatment. Recurrent unexplained episodes, discordance between caregiver reports and independent observations, or unexplained infections or toxic exposures can prompt review. Establish a timeline from original records and continue looking for medical explanations. Involve child abuse pediatrics and the treating teams to coordinate medically necessary care, reporting and safety. Any protective separation or specialized observation requires the appropriate multidisciplinary and legal process. Assess barriers and offer support when unmet medical or basic needs raise concerns about neglect. AAP caregiver-fabricated illness report · AAP maltreatment prevention report
Identify and respond to trafficking and exploitation
Under U.S. federal law, inducing a person younger than 18 to engage in a commercial sex act meets the severe sex trafficking definition without proof of force, fraud or coercion. The federal severe labor trafficking definition involves force, fraud or coercion for involuntary servitude or related exploitation. A companion who controls speech or identification, unsafe working or living conditions, injuries or repeated sexual health visits can prompt further inquiry. Identity, immigration status, tattoos or foster placement cannot establish trafficking.
Use PEARR to guide the response: provide privacy, educate, ask, respect and respond. Arrange private conversation safely and explain confidentiality and its limits first. Offer a qualified interpreter as needed. Use open-ended questions about safety, living and work conditions, freedom to leave, threats and control. A validated short sex-trafficking screen can help assess at-risk adolescents in settings like those studied. It flags risk and does not assess labor trafficking. Use developmentally appropriate clinical inquiry for labor exploitation. Offer care and a warm handoff to advocacy, social work or child protection even without disclosure. Coordinate immediate safety and any required report without confronting the companion. SAMHSA's principles include safety, transparency, peer support, collaboration, choice, and attention to cultural, historical and gender context. Federal trafficking definitions · AAP trafficking report · Screening study · PEARR tool · SAMHSA trauma-informed guidance
A nonmobile 3-month-old is brought to the ED after brief irritability. A caregiver reports that the infant rolled off a low sofa. The infant is alert and feeding and has an unexplained ear bruise and a torn upper labial frenulum. There is no abdominal tenderness or bruising. Which plan best addresses the findings?
Consult child abuse pediatrics, obtain a skeletal survey and noncontrast head CT, assess for bleeding and other occult injury, and report promptly under applicable law.
Order coagulation studies alone and discharge if results are normal and the infant continues to feed.
Wait for outpatient ophthalmology and bone density testing before contacting child protection.
Use a single whole-body radiograph and defer head imaging unless vomiting or seizures develop.
A postpubertal 15-year-old presents 18 hours after vaginal sexual assault with a substantial-risk HIV exposure. The source’s HIV and hepatitis B status are unknown. Her hepatitis B series is documented as incomplete. The examination shows minor abrasions. Pregnancy is possible and she fears parental disclosure. Which plan is most appropriate?
Wait for source testing and baseline serologies before starting HIV prophylaxis, and postpone pregnancy prevention.
Explain privacy limits and offer consent-based forensic care, start indicated HIV prophylaxis now, and offer STI prevention, hepatitis B vaccination and emergency contraception. Follow applicable reporting law.
Use the minor abrasions to determine that transmission was unlikely and guarantee that nobody will be notified.
Collect forensic evidence before discussing consent and withhold prophylaxis until the forensic report is available.
A 16-year-old presents with pelvic pain and recurrent trichomoniasis. An accompanying adult controls her phone and ID, answers every question and refuses to leave. The adolescent becomes quiet when he interrupts. What is the most appropriate approach while addressing her medical needs?
Question the adolescent about exploitation in front of the adult to see whether their accounts agree.
Use the companion as interpreter and discharge after prescribing treatment for the infection.
Arrange private assessment safely, explain confidentiality limits, ask without judgment, and coordinate a safety plan and warm handoff.
Defer any safety assessment until the adolescent independently describes a commercial sex act.
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