Clinical Scorecard: Key Imaging Guidelines for Evaluating Suspected Child Abuse: Recommendations from the European Society of Paediatric Radiology

At a Glance

Key Highlights

• Initial imaging for suspected abuse in children under 1 year includes skeletal survey and unenhanced brain CT with 3D reformats.
• A limited follow-up skeletal survey after 11–14 days is mandatory to increase sensitivity of detecting injuries.
• If head CT is normal but clinical suspicion remains high, brain and whole spine MRI should be performed within 2–5 days.

Guideline-Based Recommendations

Diagnosis

• Use skeletal survey and unenhanced brain CT as initial imaging in children under 1 year with suspected abuse.
• Consider CT head on a case-by-case basis in children aged 1–2 years; similarly for children 2–5 years.
• Perform limited follow-up skeletal survey including chest and appendicular skeleton after 11–14 days.
• If CT is normal but neurological signs or suspicion persist, perform brain and whole spine MRI within 2–5 days.

Management

• Multidisciplinary assessment triggered when history or injury mechanism is inconsistent with clinical findings.
• Radiologists should carefully assess parietal skull, parafalcine region, and bridging veins for fractures and hemorrhages.
• Identify injury patterns such as multifocal, bilateral, or interhemispheric subdural hemorrhages suggestive of AHT.

Monitoring & Follow-up

• Follow-up skeletal surveys improve detection sensitivity and are mandatory in suspected abuse cases.
• MRI can detect hypoxic-ischaemic injury, cerebral edema, and retinal hemorrhages which increase specificity for AHT.

Risks

• High risk of over- and under-diagnosis with serious child and family consequences and high litigation rates.
• Skull fractures from accidental falls are common and have low positive predictive value for abuse.
• Dating of injuries should not rely solely on imaging density or intensity but on comprehensive clinical and imaging correlation.

Patient & Prescribing Data

Children under 5 years with suspected physical abuse, particularly infants under 1 year

Imaging protocols tailored by age and clinical presentation improve diagnostic accuracy and guide multidisciplinary management.

Clinical Best Practices

• Perform initial skeletal survey and unenhanced brain CT with 3D reformats in infants under 1 year.
• Use follow-up skeletal surveys routinely after 11–14 days to detect evolving injuries.
• Employ brain and whole spine MRI when CT is normal but clinical suspicion remains high.
• Focus imaging assessment on common injury sites: parietal skull, parafalcine region, and bridging veins.
• Avoid relying solely on imaging characteristics to date injuries; integrate clinical and imaging findings.

References

• European Society of Paediatric Radiology Guidelines
• Incidence and impact of abusive head trauma