GPAtlas🧭 When to suspect
Child maltreatment is a differential diagnosis, not a verdict. In primary care the task is rarely to prove abuse – it is to recognise the alerting features, hold maltreatment in mind as one possible explanation, and act on a reasonable suspicion. NICE uses two deliberate verbs: “suspect” (the evidence is strong enough to prompt referral and investigation) and “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, or injuries in a pattern or distribution typical of inflicted harm. The single most important rule in infancy is that 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. Critically, sitting or rolling alone does not count as independent mobility, and a child under 12 weeks should never be regarded as independently mobile. The clinical corollary is direct: bruising, petechiae, lacerations, abrasions, scars, or burns in a child who has not reached any of those milestones should make you suspect maltreatment.
Source: NICE CG89 · NICE NG76
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