ESR Essentials: imaging of suspected child abuse—practice recommendations by the European Society of Paediatric Radiology
ESPR/ESR · 2024 · Europe
Source and licence
- Authors
- Gabrielle C Colleran, Maria Fossmark, Karen Rosendahl et al.
- Title
- ESR Essentials: imaging of suspected child abuse—practice recommendations by the European Society of Paediatric Radiology
- Journal
- European Radiology, 2024
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC11914366
Licence statement of the original publication
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Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
Key recommendations
- In the acute clinical setting of suspected abusive trauma in children under 1 year of age, the appropriate initial imaging protocol is a skeletal survey and an unenhanced brain computed tomography (CT) with 3-dimensional (D) reformats. In children 1–2 years of age, the CT head should be considered on a case-by-case basis. In children 2–5 years of age, both investigations should be considered on a case-by-case basislevel of evidence: low
- A limited follow-up skeletal survey (routinely including the chest and appendicular skeleton only) after 11–14 days has been shown to increase the sensitivity of initial radiographic imaging and is mandatory where abuse is suspectedlevel of evidence: low
- If the head CT is normal, but the child has abnormal neurology and/or a high index of clinical suspicion for physical abuse, brain and whole spine magnetic resonance imaging (MRI) should be performed within 2–5 dayslevel of evidence: low
Children younger than 1 year of age
- In the acute clinical setting of suspected child abuse, the appropriate imaging protocol is a skeletal survey and an unenhanced CT brain with 3-D reformats [4, 30–34]. If the head CT is normal but there is abnormal neurology, or a high index of clinical suspicion for physical abuse, a brain and whole spine MRI should be performed within 2–5 days, see flowchart. A limited follow-up skeletal survey (omitting the axial skeleton and the pelvis) after 11–14 days should be performed [27].
- Chest CT can be considered in children in this age group with negative skeletal survey and high clinical suspicion for child abuse, and when the radiographic diagnosis of rib fractures is indeterminate [19].
- Children with suspected injury to the abdomen should have a contrast-enhanced CT scan [35].
Children 1–2 years of age
- Initial and follow-up skeletal surveys and CT chest and abdomen are performed as for children below 1-year-old (see ‘Children younger than 1 year of age’).
- Neuroimaging is performed as for children above 2-years-old (see ‘Children above 2 years of age’).
Children above 2 years of age
- Children above 2-years-old who present with a history of falls or unexplained physical findings such as bruising will usually have a CT brain performed in the acute setting, with the advantage of its exquisite sensitivity for fracture. Where the history is more vague and the symptoms less specific, an MRI within 2–5 days may be the first investigation of the neuroaxis [5]. A skeletal survey is of less value in children above 2, and should be considered on a case-by-case basis. Alternatively, the radiographs may be tailored to the area(s) of suspected injury.
- All children with suspected injury to the chest or abdomen should have a contrast-enhanced CT scan [19, 35].
Abstract
Abstract: The goal of this paper is to provide a useful desktop reference for the imaging of suspected child abuse with clear, age-specific pathways for appropriate evidence-based imaging and follow-up.
We aim to provide a road map for the imaging evaluation and follow-up of this important and vulnerable cohort of patients presenting with signs and symptoms concerning for inflicted injury. As the imaging recommendations differ for children of different ages, we provide a flowchart of the appropriate imaging pathway for infants, toddlers, and older children, which allows ease of selection of which children should undergo skeletal survey, non-contrast computed tomography (CT) brain with 3-dimensional (D) reformats, and magnetic resonance imaging (MRI) of the brain and whole spine. For ease of review, we include a table of the common intracranial and spinal patterns of injury in abusive head trauma. We summarise search patterns, areas of review, and key findings to include in the report.
To exclude skeletal injury, infants and children under 2 years of age should undergo a full skeletal survey in accordance with national guidelines, with a limited follow-up skeletal survey performed 11–14 days later. For children over 2 years of age, the need for skeletal imaging should be decided on a case-by-case basis.
All infants should undergo a non-contrast-enhanced CT brain with 3-D reformats. If this is normal with no abnormal neurology, then no further neuroimaging is required. If this is abnormal, then they should proceed to MRI brain and whole spine within 2–5 days. Children older than 1 year of age who have abnormal neurology and/or findings on skeletal survey that are suggestive of inflicted injury should undergo non-contrast CT brain with 3-D reformats and, depending on the findings, may also require MRI of the brain and whole spine.
We hope that this will be a helpful contribution to the radiology literature, particularly for the general radiologist with low volumes of paediatrics in their practice, supporting them with managing these important cases when they arise in daily practice.
Key Points: The choice of initial imaging (skeletal survey and/or brain CT) depends on the age of the child in whom abuse is suspected.
A follow-up skeletal survey is mandatory 11–14 days after the initial survey.
If an MRI of the brain is performed, then an MRI of the whole spine should be performed concurrently.
Contents of the original publication
The section headings of the original.
- Key recommendations
- Introduction
- Craniospinal trauma
- How common is abusive head trauma (AHT) and how is it diagnosed?
- How does AHT present?
- Common injury patterns in AHT
- What do the reports need to include?
- Skeletal injuries
- Rib fractures
- Metaphyseal injury
- Long bone fractures
- Skull fractures
- Unusual fractures
- Fracture healing
- Differential diagnosis
- Visceral injuries
- What is the appropriate imaging pathway in cases of suspected physical abuse in children?
- Imaging of the neuroaxis
- Skeletal survey
- Recommendations
- Summary statement
- Patient summary
- Compliance with ethical standards
- Guarantor
- Statistics and biometry
- Informed consent
- Ethical approval
- Study subjects or cohorts overlap
- Methodology
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