Suspected Physical Abuse (SPA) Clinical Pathway

Pathway Background and Objectives

In 2013 there were close to 70,000 substantiated cases of child abuse and neglect in the United States. Child maltreatment is a significant medical problem. Cases of suspected physical abuse frequently present to the emergency department. It has been noted that there is variation in case evaluations among providers. There are also many providers who are unsure of how to evaluate cases of suspected physical abuse. There are guidelines set by the American Academy of Pediatrics for the evaluation of suspected cases of non-accidental trauma.

The objectives of this pathway are to:

  • Standardize the clinical practice in cases of suspected physical abuse that present to Connecticut Children’s
  • Standardize initial work-up and history taking
  • Provide clear guidelines for when to consult with the Suspected Child Abuse and Neglect (SCAN), Pediatric Surgery, Neurosurgery, Orthopedic, and Ophthalmology teams
  • Provide clear, evidence based guidelines for ordering laboratory and radiographic testing when abuse is suspected
  • Decrease the ordering of unnecessary imaging studies
  • Reduce bias in the evaluation of suspected child physical abuse cases

Algorithm  Educational Module

  • Percentage of patients with suspected physical abuse who have SCAN consult order
  • Percentage of patients < 2 years old with suspected physical abuse who have skeletal survey ordered
  • Percentage of patients with suspected physical abuse who have utilization of the pathway order set
  • Length of stay (days) for admitted patients
  • Percentage of admitted patients who had pediatric surgery consult order
  • Percentage of patients with maltreatment ICD-10 code applied
  • Anderst J, Carpenter S, Abshire TC, Kilough E. Evaluation for Bleeding Disorders in Suspected Child Abuse. Pediatrics. 2022 Sep; 150(4):e2022059276.  
  • Baxter AL, Lindberg DM, Burke BL, Shults J, Holmes JF. Hepatic enzyme decline after pediatric blunt trauma. Child Abuse Negl. 2008 Sep;32(9):838-45. 
  • Bennett, CE, Christian CW. Clinical evaluation and management of children with suspected physical abuse. Pediatric Radiology. 2021 May;51(6)853-860.
  • U.S. Department of Health & Human Services; Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child Maltreatment 2020. Available from https://www.acf.hhs.gov/cb/data-research/child-maltreatment.
  • Christian CW; Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse. Pediatrics. 2015 May; 135(5):e1337-1354.
  • Flaherty EG, Perez-Rossello JM, LevineMA , Hennrikus WL; The American Academy of Pediatrics Committee on Child Abuse and Neglect, Section on Radiology, Section on Endocrinology, and Section on Orthopaedics; The Society for Pediatric Radiology. Evaluating children with fractures for child physical abuse. Pediatrics. 2014 Feb; 133(2):e477–e89.
  • Henry MK, Feudtner C, Fortin K, Lindberg DM, Anderst JD, Berger RP, Wood JN. Occult Head Injuries in Infants Evaluated for Physical Abuse. Child Abuse & Neglect. 2020 May;102:104431–38. 
  • Lindberg D, Makoroff K, Harper N, Laskey A, Bechtel K, Deye K, Shapiro R; ULTRA Investigators. Utility of hepatic transaminases to recognize abuse in children. Pediatrics. 2009 Aug;124(2):509-16.
  • Lindberg DM, Shapiro RA, Blood EA, Steiner RD, Berger RP. Utility of Hepatic Transaminases in Children with Concern for Abuse. Pediatrics. 2013 Feb; 131(2):268-275. 
  • Narang SK, Fingarson A, Lukefahr J; Council on Child Abuse and Neglect; Sirontnak AP, Flaherty EG, CAPT Gavril AR, Gilmartin ABH, Haney SB, Idzerda SM, Laskey A, Legano LA, Messner SA, Mohr B, Moles RL, Niewnow S, Palusci VJ. Abusive head trauma in infants and children. Pediatrics. 2020 April;145(4):e20200203. Retrieved from https://doi-org.ezproxy.lib.uconn.edu/10.1542/peds.2020-0203. 
  • Rubin DM, Christian CW, Bilaniuk LT, Zazyczny KA, Durbin DR. Occult Head Injury in High-Risk Abused Children. Pediatrics. 2003 Jun;111(6):1382-1386. 
  • Sheets, L. K., Leach, M. E., Koszewski, I. J., Lessmeier, A. M., Nugent, M., & Simpson, P. (2013). Sentinel injuries in infants evaluated for severe physical abuse. Pediatrics, 131. doi: 10.1542/peds.2012-2780

The clinical pathways in the above links have been developed specifically for use at Connecticut Children’s and are made available publicly for informational and/or educational purposes only. The clinical pathways are not intended to be, nor are they, a substitute for individualized professional medical judgment, advice, diagnosis, or treatment. Although Connecticut Children’s makes all efforts to ensure the accuracy of the posted content, Connecticut Children’s makes no warranty of any kind as to the accuracy or completeness of the information or its fitness for use at any particular facility or in any individual case.