Pediatrics · Safety
Child Abuse & Neglect: Recognition and Mandatory Reporting
open a plain-language definition. Tap or click them, or press Enter on the keyboard.
On this page
Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current references. Reporting laws differ by state/jurisdiction — learn the rules where you practice.
1. Overview
Child maltreatment is any act or failure to act by a parent, caregiver, or other person in a custodial role that results in harm, potential for harm, or threat of harm to a child under 18 (CDC). The CDC describes four common types: physical abuse, sexual abuse, emotional abuse, and neglect (the most common). At least 1 in 7 U.S. children experiences abuse or neglect in a year, and this is likely an undercount.
Nurses are in every U.S. state. You report reasonable suspicion — you do not need proof, and you don’t investigate. Reports made in good faith are legally protected; failure to report can bring legal and licensing consequences.
Risk factors (abuse occurs in all groups — avoid bias): young child age, disability or special health needs, prematurity, caregiver substance use, mental illness, intimate partner violence, social isolation, financial stress, unrealistic expectations of the child, caregiver history of abuse. Infants and toddlers are at highest risk of fatal abuse.
2. Red Flags in the History
- History that doesn’t match the injury or the child’s developmental ability (e.g., “the 2-month-old rolled off the couch” with a skull fracture; a non-mobile infant with bruises)
- Changing or inconsistent stories, or different stories from different caregivers
- Delay in seeking care without a good reason
- Blaming a sibling or the child
- Repeated injuries, frequent ED visits at different facilities
- Caregiver seems unconcerned, hostile, or overly controlling of the child’s answers
3. Physical Abuse — Recognizing Patterns
| Finding | Accidental (typical) | Concerning for abuse |
|---|---|---|
| Bruises | Bony prominences in mobile children: shins, knees, forehead, elbows | TEN-4-FACESp rule: bruising on the Torso, Ears, Neck in a child < 4 years; any bruise in an infant < 4 months; Frenulum, Angle of jaw, Cheeks (fleshy), Eyelids, Subconjunctivae; patterned bruising |
| Patterns | Random | Shape of an object (loop cord, belt, hand print, bite marks), bruises in many stages of healing (bruise dating is unreliable — just document) |
| Burns | Splash pattern, irregular edges | Immersion burns with clear lines (“stocking/glove”), doughnut-shaped sparing of buttocks, cigarette burns (round, uniform), iron or grill patterns |
| Fractures | Toddler’s fracture, forearm fall | Posterior rib fractures, classic metaphyseal (“corner/bucket-handle”) fractures, fractures in non-ambulatory infants, multiple fractures of different ages, skull fractures with minor history |
| Oral | — | Torn frenulum in an infant |
Sentinel injuries: a small bruise or mouth injury in a young infant can be the first warning before severe abuse. Take them seriously.
: most often in infants < 1 year, often triggered by inconsolable crying. Signs range from subtle (vomiting, irritability, poor feeding, lethargy) to seizures, apnea, bulging fontanel, coma. Classic findings: subdural hematoma, retinal hemorrhages, and sometimes fractures — often without visible external injury.
Medical mimics to keep in mind (the provider evaluates): congenital dermal melanocytosis (Mongolian spots — document at birth), bleeding disorders, osteogenesis imperfecta, cultural practices such as coining or cupping (document; discuss respectfully), phytophotodermatitis, accidental injuries.
4. Other Forms
- Neglect: failure to meet basic needs — food (poor growth/failure to thrive that improves with feeding in the hospital), hygiene, clothing, supervision, shelter, medical/dental care, education; untreated illness; developmental delays. Distinguish poverty from neglect, connect families to resources, and still report when required
- Emotional abuse: name-calling, shaming, rejecting, threatening, withholding love. Signs: low self-esteem, withdrawal, aggression, depression, developmental or behavioral regression
- Sexual abuse: genital/anal injuries or bleeding, STIs in a prepubertal child, pregnancy in a young teen, pain with urination/defecation, age-inappropriate sexual knowledge or behavior, sudden behavior changes, nightmares, school problems. Disclosure is often delayed or partial
- (caregiver-fabricated illness; formerly Munchausen syndrome by proxy): caregiver fabricates or induces illness; symptoms happen only when the caregiver is present, don’t respond to treatment, or puzzle multiple providers
- Human trafficking: signs include a controlling companion, inconsistent stories, lack of ID, tattoos/branding, untreated injuries, many STIs
5. Priority Nursing Actions
- Safety first: treat injuries (ABCs), and protect the child from further harm. If immediate danger, follow facility security and law enforcement procedures
- Interview the child privately if age-appropriate, using open-ended, non-leading questions (“Tell me what happened”). Avoid “Did your dad hit you?” Use the child’s words. Formal forensic interviews are done by trained teams (e.g., Child Advocacy Center)
- Stay calm and supportive. Tell the child they did the right thing by telling, that it isn’t their fault. Do not promise to keep secrets — explain you must tell people whose job is to help keep them safe
- Interview caregivers separately; record each account
- Document objectively: exact quotes (in quotation marks), who said what, times, and a detailed description of injuries (size in cm, shape, color, location), body diagrams, and photographs per policy. Avoid conclusions (“abused”) — describe what you see and hear
- Report per state law and facility policy — usually to child protective services (CPS) and/or law enforcement — within the required timeframe (often immediately by phone, followed by a written report). Notify the provider and social work, but telling a supervisor does not replace your personal duty to report in many states
- Collaborate with the team: skeletal survey (children < 2), head imaging, eye exam, labs to rule out mimics, sibling screening
- Maintain a nonjudgmental, therapeutic relationship with the family; don’t confront or accuse
6. Prevention and Education
- Teach coping with infant crying (e.g., “Period of PURPLE Crying” programs): crying peaks around 6–8 weeks; it’s OK to place the baby safely in the crib and step away for a few minutes; never shake a baby
- Home visiting programs, parenting classes, respite, and support for stressed caregivers
- Safe sleep, safe storage of medications and firearms
- Help families with concrete needs (food, housing, child care) — economic support reduces maltreatment
- Childhelp National Child Abuse Hotline: 1-800-422-4453 (U.S.)
7. Memory Aids
- TEN-4-FACESp: Torso, Ears, Neck (< 4 yrs), any bruise < 4 months; Frenulum, Angle of jaw, Cheeks, Eyelids, Subconjunctivae; patterned
- “Those who don’t cruise rarely bruise” — bruises in non-mobile infants are red flags
- “Suspect, don’t investigate — report”
- “Quote it, measure it, picture it” — objective documentation
- “No secrets, no leading, no blame” when a child discloses
- AHT triad (classic): subdural hematoma, retinal hemorrhages, encephalopathy
8. NCLEX-Style Practice Questions
1. A 3-month-old is brought in with bruises on both cheeks. The parent says the baby “rolled into the crib rails.” What should the nurse do?
A. Accept the explanation — infants often bruise easily
B. Document objectively, notify the provider, and report suspected abuse per policy
C. Confront the parent about the injuries
D. Wait to see if more bruises appear before reporting
Answer: B. A 3-month-old is non-mobile and any bruising in an infant < 4 months (especially on the cheeks) is a red flag. The history doesn’t fit development. Nurses report reasonable suspicion; they don’t need proof or confrontation.
2. A 7-year-old says, “Promise you won’t tell anyone, but my uncle touches me.” What is the best response?
A. “I promise I won’t tell anyone.”
B. “Are you sure? Uncles sometimes give hugs.”
C. “Thank you for telling me. It’s not your fault. I need to tell people whose job is to help keep you safe.”
D. “Did your uncle touch your private parts?”
Answer: C. Support the child, don’t promise secrecy, and don’t ask leading questions (D) or doubt the child (B). Then report per law and policy.
3. Which findings are most suggestive of physical abuse? Select all that apply.
A. Bruises on the shins of a 3-year-old
B. Symmetrical burns on both feet with a clear line, like socks
C. Posterior rib fractures in a 4-month-old
D. A forehead bump on a toddler learning to walk
E. A loop-shaped bruise on the back
Answer: B, C, E. Immersion (“stocking”) burns, posterior rib fractures in infants, and patterned bruises suggest abuse. Shin bruises and forehead bumps in mobile toddlers are typical accidental injuries.
4. A 5-month-old is brought in for vomiting and lethargy with no fever. The parents say the baby “has been crying all week.” There are no external injuries. Which condition should the nurse be most concerned about?
A. Colic
B. Abusive head trauma
C. Teething
D. Viral gastroenteritis only
Answer: B. AHT often presents with nonspecific signs (vomiting, irritability, lethargy) and no visible injury; inconsolable crying is a common trigger. Report concerns so imaging and an eye exam can be done.
5. Which documentation is most appropriate when abuse is suspected?
A. “Child was clearly abused by father.”
B. “Bruise present on arm.”
C. “3 cm × 2 cm purple oval bruise on the left upper arm. Child states, ‘Daddy squeezed me.’”
D. “Mother appears to be a poor parent.”
Answer: C. Objective measurements, location, color, and the child’s exact words in quotes are best. Avoid conclusions or judgments (A, D) and vague notes (B).
References
Centers for Disease Control and Prevention. (2024). About child abuse and neglect. https://www.cdc.gov/child-abuse-neglect/about/index.html
Child Welfare Information Gateway. (n.d.). Mandatory reporting of child abuse and neglect. U.S. Department of Health and Human Services, Children’s Bureau. Retrieved October 15, 2026, from https://www.childwelfare.gov/
Christian, C. W., & the Committee on Child Abuse and Neglect. (2015). The evaluation of suspected child physical abuse. Pediatrics, 135(5), e1337–e1354. https://doi.org/10.1542/peds.2015-0356
Daley, S. F., Gonzalez, D., Bethencourt Mirabal, A., & Afzal, M. (2025). Child abuse and neglect. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459146/
National Council of State Boards of Nursing. (2026). 2026 NCLEX-RN test plan. https://www.nclex.com/test-plans.page
Pierce, M. C., Kaczor, K., Lorenz, D. J., Bertocci, G., Fingarson, A. K., Makoroff, K., Berger, R. P., Bennett, B., Magana, J., Staley, S., Ramaiah, V., Fortin, K., Currie, M., Herman, B. E., Herr, S., Hymel, K. P., Jenny, C., Sheehan, K., Zuckerbraun, N., … Leventhal, J. M. (2021). Validation of a clinical decision rule to predict abuse in young children based on bruising characteristics. JAMA Network Open, 4(4), e215832. https://doi.org/10.1001/jamanetworkopen.2021.5832