Child maltreatment: signs that should raise concern
- Finding
Injuries, patterns and accounts that suggest physical abuse of a child and oblige the doctor to investigate, protect and report.
What it is
Child maltreatment includes physical, sexual and psychological abuse, neglect and exploitation of anyone under 18. Law 1098 of 2006 (art. 18) defines it broadly, including carelessness, omission and negligent treatment. The doctor does not need certainty to act: reasonable suspicion is enough. In physical abuse, warning signs combine three elements: an injury that does not fit the account or the child's developmental stage, an injury pattern typical of inflicted harm, and caregiver or child behaviour that does not fit.
How to tell it apart
- Accident: a coherent, stable account, an injury that fits the age, on bony prominences, and timely care.
- Conditions that mimic abuse: bleeding disorders, osteogenesis imperfecta, congenital pigmented spots and cultural practices; exclude them before concluding.
- TEN-4-FACESp showed a sensitivity of about 96 % and a specificity of about 87 % in bruised children under 4 (Pierce, 2021); it is a screening tool, not a diagnosis.
- The colour of a bruise cannot date it reliably.
How to recognise it
- Inconsistent account: the mechanism does not explain the injury, changes with each telling, or a young sibling is blamed.
- Injury that does not fit development: a baby who is not yet mobile rarely has bruises.
- Bruises in protected areas per TEN-4-FACESp: torso, ears, neck; frenulum, angle of jaw, cheeks, eyelids, subconjunctivae; any up to 4.99 months; or patterned.
- Bruises shaped like an object or a hand, human bites, immersion burns with sharp margins, or small round burns.
- Suggestive fractures: classic metaphyseal lesions, posterior rib fractures, multiple fractures at different stages of healing.
- Delay in seeking care, a caregiver who shows no concern or blames the child, and growth failure without another cause.
How it forms
- Inflicted injuries tend to be on soft, protected areas; accidental falls injure bony prominences (forehead, knees, elbows, shins).
- Classic metaphyseal lesions result from twisting and pulling forces on immature bone, as when a limb is shaken or yanked.
- Posterior rib fractures are associated with compression of the chest when the child is gripped with the hands.
Accidental injury versus an injury that should raise concern
| Feature | More typical of accident | Should raise concern |
|---|---|---|
| Bruise site | Forehead, knees, shins, elbows | Torso, ears, neck, cheeks, eyelids, frenulum |
| Age and development | Child who already walks | Baby who is not yet mobile |
| Fracture | Supracondylar humerus in a child at play | Classic metaphyseal, posterior rib, several of different ages |
| Account | Coherent with the mechanism and stable | Absent, changing or not explaining the injury |
Next step: what to do and document
- Treat and protect: if the child is in danger at home, admit the child or activate ICBF protection at once.
- Investigate by age: in children under 2 with suspected physical abuse, a full skeletal survey and a search for intracranial injury.
- Document injuries with measurements, diagrams and, with authorisation, photographs; record each informant's verbatim account separately.
- Report to the competent authority and notify the ICBF; in sexual abuse, within 24 hours (Law 1146 of 2007, art. 15). See mandatory reporting.
- Official text checked on 2026-11-05 at funcionpublica.gov.co.
Common mistakes
- Accepting without analysis a mechanism that does not explain the injury.
- Overlooking a small bruise in a baby: it may be a sentinel injury that precedes severe injuries.
- Trying to date bruises by their colour.
- Waiting for certainty before reporting: the law asks for suspicion to be reported.
Test yourself
Think of the answer, then tap the question to see it.
What does the TEN-4-FACESp rule stand for?
Bruising on the torso, ears or neck (TEN); any bruise in infants up to 4.99 months (4); on the frenulum, angle of jaw, cheeks, eyelids or subconjunctivae (FACES); or patterned (p).
Which fractures are highly suggestive of abuse in an infant?
Classic metaphyseal lesions, posterior rib fractures and multiple fractures at different stages of healing, without major trauma to explain them.
A 3-month-old has a bruise on the cheek and nobody knows how it happened; what should be done?
Suspect abuse: investigate (including a skeletal survey), document, protect the baby and notify the authorities and the ICBF.
Can a bruise be dated by its colour?
Not reliably: the colour change varies with the person, the depth and the site.
Elsewhere in DurgiPedia
Connections
Educational content on forensic and legal medicine; not legal advice and no substitute for the technical guides of Colombia's National Institute of Legal Medicine and Forensic Sciences. Laws change: each page links the official text and says when it was last checked. For a real case, follow the guide in force and ask the competent authority.
Sources: Validation of a clinical decision rule to predict abuse in young children based on bruising characteristics (Pierce MC et al.) (JAMA Network Open (PMC), 2021); Child Protection Evidence: Fractures (systematic review) (Royal College of Paediatrics and Child Health, 2020); Child maltreatment (fact sheet) (World Health Organization, 2026); Ley 1098 de 2006, Código de la Infancia y la Adolescencia (arts. 18 y 46) (Función Pública, Gestor Normativo, 2006); Ley 1146 de 2007, prevención de la violencia sexual y atención integral de niños, niñas y adolescentes abusados sexualmente (art. 15) (Función Pública, Gestor Normativo, 2007).
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Representative model, for educational purposes only.