GPAtlas🧭 When to suspect
Child maltreatment is a differential diagnosis, not a verdict. In primary care you rarely need to prove abuse:
• Recognise the alerting features.
• Hold maltreatment in mind as one possible explanation.
• Act on a reasonable suspicion.
NICE uses two deliberate verbs:
• “suspect”: the evidence is strong enough to prompt referral and investigation.
• “consider”: maltreatment belongs in the differential and should be actively explored or excluded.
The features that should raise concern are:
• An injury that does not fit the developmental stage of the child.
• A history that is absent, vague, inconsistent, or changes between tellings.
• An unexplained delay in seeking care.
• An account that is incompatible with the mechanism.
• Injuries in a pattern or distribution typical of inflicted harm.
In infancy, any injury in a child who is not independently mobile must prompt suspicion of maltreatment.
| Category | Features that may alert you |
|---|---|
| Physical abuse | Bruising, fractures, burns, head or visceral injury with an absent, unsuitable, or developmentally implausible explanation. |
| Emotional abuse | • Persistent criticism, rejection or scapegoating • Developmental or behavioural changes (fearfulness, withdrawal, over-compliance, aggression) |
| Sexual abuse | • Genital, anal or perianal injury or symptoms without medical cause • Age-inappropriate sexualised behaviour or knowledge • Disclosure |
| Neglect | • Faltering growth, poor hygiene, untreated conditions, repeatedly missed appointments, inadequate supervision • Balance against material poverty |
| Fabricated or induced illness (FII) | • Reported symptoms that are not observed, inconsistent with investigations, or that resolve when the carer is absent • Escalating help-seeking |
The 2025 NICE update added a long-awaited definition.
• A child is now considered independently mobile if they can do any of the following: crawl, bottom-shuffle, pull to stand using furniture, stand unaided, cruise (move about holding onto furniture), climb, walk with a push-along walker, or walk unaided.
• Sitting or rolling alone does not count as independent mobility.
• A child under 12 weeks should never be regarded as independently mobile.
• Bruising, petechiae, lacerations, abrasions, scars, or burns in a child who has not reached any of those milestones should make you suspect maltreatment.
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