Medical Conditions and Events That May Cause or Mimic Findings Associated With Child Abuse

Disclaimer: This is NOT a complete list of medical conditions, injuries, or events that may be, or have historically been, mistaken for signs of child abuse or neglect. Inclusion on this list does not mean that a particular finding is caused by a medical condition rather than abuse, nor does it suggest that child abuse and neglect do not occur. Child abuse and neglect are real and serious concerns that require appropriate investigation and intervention. This information is provided for educational and awareness purposes only and does not constitute legal or medical advice, diagnosis, or an opinion regarding any individual case.

1. Intracranial Hemorrhage

Medical conditions and events that may cause or contribute to intracranial hemorrhage include:

• Accidental choking or hypoxic episode

• Accidental head trauma

• Aneurysm

• Aplastic anemia

• Arteriovenous malformation (AVM)

• Benign enlargement of the subarachnoid spaces (BESS)

• Birth-related intracranial hemorrhage

• Birth trauma

  • Cesarean delivery

  • Forceps-assisted delivery

  • Prolonged or difficult labor

  • Vacuum-assisted delivery

• Bone marrow failure or infiltrative disorders

• Cerebral sinovenous thrombosis

• Coagulation disorders

• Congenital vascular abnormalities

• Disseminated intravascular coagulation (DIC)

• Factor deficiencies, including Factor XIII deficiency

• Fibrinogen disorders

• Hemophilia A

• Hemophilia B

• Hydrocephalus

• Hypertension

• Hypoxic-ischemic encephalopathy (HIE)

• Intracranial vascular malformations

• Late vitamin K deficiency bleeding

• Leukemia

• Liver disease associated with coagulopathy

• Macrocephaly

• Metabolic disorders associated with cerebral injury

• Platelet-function disorders

• Prematurity

• Ruptured aneurysm

• Ruptured vascular malformation

• Sepsis-associated coagulopathy

• Severe thrombocytopenia

• Stroke

• Thrombocytopenia

• Use or ingestion of anticoagulant medications

• Vitamin K deficiency

• Von Willebrand disease

Other Diagnoses Sometimes Considered in the Differential

• Glutaric aciduria type I

• Menkes disease

• Certain metabolic disorders

• Certain connective-tissue disorders

Important: The presence, location, age, extent, and pattern of intracranial hemorrhage must be interpreted together with the child's clinical presentation, medical history, imaging, laboratory findings, and history of trauma.

2. Retinal Hemorrhage

Medical conditions and events that may cause, contribute to, or be associated with retinal hemorrhage include:

• Accidental head trauma

• Accidental choking or hypoxic episode

• Anemia

• Aneurysm

• Arteriovenous malformations

• Birth-related retinal hemorrhage

• Birth trauma

  • Difficult or prolonged labor

  • Forceps-assisted delivery

  • Vacuum-assisted delivery

  • Cesarean delivery

• Blood dyscrasias

• Cardiopulmonary resuscitation in certain circumstances

• Carbon monoxide poisoning

• Cerebral aneurysm

• Coagulation disorders

• Disseminated intravascular coagulation (DIC)

• Endocarditis

• Extracorporeal membrane oxygenation (ECMO)

• Factor deficiencies

• Glutaric aciduria type I

• Hemophilia

• Hypertension

• Hypernatremia

• Hyponatremia

• Hypotension

• Hypoxia

• Hypoxic-ischemic encephalopathy

• Increased intracranial pressure

• Intracranial vascular abnormalities

• Leukemia

• Meningitis

• Papilledema-associated retinal findings

• Platelet disorders

• Prematurity

• Retinal hemangioma or other retinal vascular lesions

• Retinal infections

• Retinal disease

• Retinopathy of prematurity

• Retinal examination/procedures in premature infants

• Ruptured vascular malformations

• Sepsis

• Severe anemia

• Subacute bacterial endocarditis

• Thrombocytopenia

• Use of anticoagulant medications

• Vasculitis

• Vitamin K deficiency

• Von Willebrand disease

Important: Not all retinal hemorrhages are medically equivalent. Number, depth, location, distribution, associated retinoschisis, and other ocular and neurological findings are important when determining their significance..

3. Fractures

Medical conditions and events that may cause, contribute to, or increase susceptibility to fractures include:

• Accidental injury

• Alagille syndrome

• Bone cysts

• Bone tumors or lesions

• Birth trauma

• Cerebral palsy associated with decreased bone density

• Chondrodysplasias

• Chronic kidney disease-associated bone disease

• Congenital insensitivity to pain

• Congenital syphilis

• Connective-tissue disorders

• Copper deficiency

• Dysplastic bone abnormalities

• Ehlers-Danlos syndrome

• Genetic skeletal dysplasias

• Healing accidental fractures

• Hypophosphatasia

• Hypophosphatemic rickets

• Infantile cortical hyperostosis (Caffey disease)

• Infantile myofibromatosis

• Infections involving bone

• Inherited systemic hyalinosis

• Low bone mineral density associated with chronic illness

• Menkes disease

• Metabolic bone disease

• Metabolic bone disease of prematurity

• Neuroblastoma

• Nutritional deficiencies

• Osteogenesis imperfecta

• Osteomalacia

• Osteomyelitis

• Osteopenia

• Osteoporosis

• Physiologic periosteal reaction of infancy

• Prematurity

• Renal osteodystrophy

• Rickets

  • Nutritional rickets

  • Vitamin D-deficiency rickets

  • Genetic rickets

  • Renal/metabolic forms of rickets

• Scurvy/Vitamin C deficiency

• Skeletal dysplasias

• Steroid-associated bone fragility

• X-linked hypophosphatemia

Radiographic or Developmental Findings That May Require Careful Interpretation

• Accessory ossification centers

• Developmental variants

• Normal metaphyseal variants

• Nutrient foramina

• Physiologic periosteal reaction

• Radiographic positioning artifact

• Motion artifact

• Superimposition artifact

• Healing accidental injury

Medically Controversial or Disputed

• Temporary brittle bone disease

Temporary brittle bone disease should be clearly identified as controversial/disputed rather than presented as an established diagnosis.

4. Bruising or Bruise-Like Findings

Medical conditions and events that may cause increased bruising, bleeding, or skin findings that can resemble bruises include:

• Accidental injury

• Allergic reactions

• Aplastic anemia

• Bone marrow failure disorders

• Coagulation disorders

• Congenital dermal melanocytosis

  • Formerly called “Mongolian spots”

• Congenital insensitivity to pain

• Contact dermatitis

• Copper deficiency

• Disseminated intravascular coagulation

• Ehlers-Danlos syndrome

• Erythema multiforme

• Factor deficiencies

  • Factor II deficiency

  • Factor V deficiency

  • Factor VII deficiency

  • Factor VIII deficiency

  • Factor IX deficiency

  • Factor X deficiency

  • Factor XI deficiency

  • Factor XIII deficiency

• Fibrinogen disorders

• Glutaric aciduria type II

• Hemangiomas and vascular birthmarks

• Hemophilia A

• Hemophilia B

• Henoch-Schönlein purpura / IgA vasculitis

• Hermansky-Pudlak syndrome

• Hyperpigmented skin lesions

• Immune thrombocytopenia (ITP)

• Insect bites

• Leukemia

• Liver disease associated with coagulopathy

• Marfan syndrome

• Menkes disease

• Platelet-function disorders

• Post-inflammatory hyperpigmentation

• Purpura

• Seizure-related accidental injuries

• Severe infections causing coagulopathy

• Thrombocytopenia

• Use or ingestion of anticoagulants

• Vasculitis

• Vitamin C deficiency/scurvy

• Vitamin K deficiency

• Von Willebrand disease

Cultural, Traditional, or Therapeutic Practices That May Resemble Bruising or Injury

Certain traditional, cultural, or therapeutic practices can produce patterned skin findings and should be considered in the clinical history:

• Cupping

• Coining

• Gua sha

• Massage techniques producing petechiae or ecchymosis

• Suction therapies

• Traditional topical remedies

• Moxibustion

• Other culturally based healing practices that intentionally produce skin marks

The presence of these findings should still be evaluated medically to determine whether the history adequately explains the child's injuries.

5. Burns or Burn-Like Skin Findings

Medical conditions and events that may cause burns or skin findings that can resemble burns include:

• Accidental contact burns

• Accidental scald injuries

• Allergic contact dermatitis

• Bullous impetigo

• Chemical burns

• Chilblains/pernio

• Contact dermatitis

• Dermatitis herpetiformis

• Diaper dermatitis

• Drug eruptions

• Epidermolysis bullosa

• Erythema multiforme

• Fixed drug eruptions

• Friction burns

• Impetigo

• Insect-bite reactions

• Irritant dermatitis

• Mechanical abrasion

• Phytophotodermatitis

• Stevens-Johnson syndrome

• Staphylococcal scalded skin syndrome

• Toxic epidermal necrolysis

• Varicella/chickenpox

• Viral or bacterial blistering diseases

6. Failure to Thrive or Poor Weight Gain

Medical conditions, disorders, medications, and other medical factors that may contribute to poor growth or findings described as failure to thrive include:

• Gastrointestinal Conditions

• Celiac disease

• Chronic diarrhea

• Crohn's disease

• Food allergy

• Food-protein induced enterocolitis syndrome

• Gastroesophageal reflux disease (GERD)

• Inflammatory bowel disease

• Malabsorption disorders

• Short bowel syndrome

• Ulcerative colitis

Feeding and Swallowing Conditions

• Dysphagia

• Feeding disorders

• Oral-motor dysfunction

• Structural abnormalities affecting feeding

• Swallowing dysfunction

Endocrine and Metabolic Conditions

• Adrenal disorders

• Diabetes mellitus

• Genetic metabolic disorders

• Glutaric aciduria type I

• Hyperthyroidism

• Hypothyroidism

• Inborn errors of metabolism

• Pseudohypoaldosteronism

• Trifunctional protein deficiency

Cardiac and Pulmonary Conditions

• Chronic lung disease

• Congenital heart disease

• Cystic fibrosis

Neurologic and Genetic Conditions

• Cerebral palsy

• Developmental disabilities affecting feeding

• Dubowitz syndrome

• Genetic syndromes affecting growth

• Neuromuscular disorders

Other Medical Causes

• Cancer

• Chronic infection

• Chronic kidney disease

• Chronic liver disease

• Severe chronic neutropenia

• Increased metabolic demand due to chronic disease

• Medication adverse effects

7. Skin Findings That May Resemble Patterned Injury

Additional dermatologic findings that may sometimes be confused with trauma include:

• Atopic dermatitis

• Birthmarks

• Café-au-lait macules

• Congenital dermal melanocytosis

• Contact dermatitis

• Eczema

• Erythema nodosum

• Hemangiomas

• Hyperpigmentation

• Impetigo

• Insect bites

• Linear dermatitis

• Mastocytosis/urticaria pigmentosa

• Phytophotodermatitis

• Post-inflammatory hyperpigmentation

• Psoriasis

• Purpura

• Tinea infections

• Vasculitic lesions

9. Genital or Anal Findings That May Raise Concern for Sexual Abuse

• Accidental straddle injury

• Anal fissures

• Anal irritation associated with diarrhea

• Constipation-associated fissures

• Crohn's disease involving the perianal region

• Dermatologic diseases affecting the genital region

• Eczema

• Hemangiomas

• Labial adhesions

• Lichen sclerosus

• Perianal streptococcal dermatitis

• Pinworm infection

• Psoriasis

• Rectal prolapse

• Urethral prolapse

• Vulvovaginitis

• Yeast/candidal infections

Normal Anatomical Variants

Certain normal genital or anal anatomical findings may also require interpretation by clinicians specifically trained in pediatric examination.

Important: Suspected child sexual abuse requires specialized medical and forensic evaluation. The presence of a medical condition or anatomical variant does not independently establish whether abuse occurred.

10. Oral or Mouth Findings That May Be Mistaken for Trauma or Neglect

• Aphthous ulcers

• Accidental oral injury

• Bleeding disorders causing oral bleeding

• Dental eruption-related bleeding

• Gingivitis

• Hand-foot-and-mouth disease

• Herpes simplex infection

• Oral candidiasis

• Periodontal disease

• Self-injurious behaviors

• Stomatitis

• Vitamin deficiencies

11. Altered Mental Status, Seizures, Collapse, or Apparent Life-Threatening Events

Some medical conditions can produce sudden collapse, altered consciousness, seizures, apnea, or symptoms that may initially raise concern for inflicted head injury or poisoning:

• Accidental choking

• Arrhythmias

• Breath-holding spells

• Carbon monoxide exposure

• Electrolyte abnormalities

• Epilepsy/seizure disorders

• Hypoglycemia

• Hypernatremia

• Hyponatremia

• Hypoxia

• Inborn errors of metabolism

• Infection

  • Encephalitis

  • Meningitis

  • Sepsis

• Metabolic disorders

• Migraine variants

• Poisoning or accidental ingestion

• Reflux-associated choking events

• Syncope

• Sudden unexpected infant events

Important Medical Interpretation

A condition appearing on this list does not mean:

• The condition caused the child's particular injury.

• Testing for the condition is appropriate in every child.

• The presence of the condition excludes abuse.

• Every medical professional must rule out every condition listed before reporting suspected abuse.

• A single alternative diagnosis automatically explains multiple unexplained findings.

Instead, the purpose of this list is to demonstrate that findings associated with suspected abuse can have medical, developmental, accidental, genetic, hematologic, metabolic, infectious, dermatologic, vascular, nutritional, and other potential explanations.

When medically appropriate, evaluation should consider:

1. The child's complete medical and birth history.

2. Developmental abilities.

3. History of accidental injury or other events.

4. Family medical history.

5. Medications and supplements.

6. Laboratory findings.

7. Imaging and original imaging studies.

8. Reasonable differential diagnoses.

9. Relevant specialist consultation.

10. Whether multiple physicians interpret the findings differently.

11. Whether the proposed alternative explanation actually fits the type, pattern, severity, timing, and distribution of the findings.

The purpose of considering differential diagnoses is not to minimize or dismiss child abuse. It is to improve diagnostic accuracy so that children who are being abused are protected while children and families are not subjected to state intervention because a legitimate medical explanation was overlooked.