This chapter discusses the roles and functions of pointing in caring for preverbal children primarily in Western cultures seeking to raise verbally expressive, independent children. The chapter describes how preverbal children can use pointing to elicit sensitive and responsive care from caregivers, therefore supporting developmental outcomes in many domains (language, social, cognitive). It examines pointing within cultural contexts in which it occurs most, contrasting Western caregiving (distal style, prioritizing object labeling) with non-Western cultures (proximal style, favoring tactile interactions). The chapter underscores the necessity to extend research on infants’ pointing beyond the lab to capture caregiver–child interactions in real-world settings, providing an ecologically valid perspective on gestures in children’s everyday lives. It argues for an inclusive research approach that explores infant pointing beyond Western cultures, which so far dominate the literature on this topic.

This chapter describes a case of a 7-month-old male who was brought to the emergency department after being found unresponsive and not breathing by his mother. The patient was cyanotic and limp, and CPR was initiated by EMS. The chapter outlines the PALS resuscitation protocol, including advanced airway, chest compressions, and addressing reversible causes of cardiac arrest. The patient was pronounced dead after significant and adequate resuscitation, and the family was provided with psychosocial support. The diagnosis was sudden unexpected death in infancy, and blood and urine were collected for postmortem testing. The chapter provides important information on the management of pediatric cardiac arrest and the importance of offering support to families in the event of sudden infant death.

Injuries to the scalp and cranium are often encountered in children who suffer abusive head trauma. Various imaging modalities, such as radiography, CT and MRI, contribute to accurately diagnosing these injuries and reliably differentiating them from normal variants. A significant challenge in both radiographic and clinical evaluations of skull fractures and extracranial soft tissue injuries is the resemblance between accidental and nonaccidental injuries. Thus, a comprehensive approach that combines imaging findings with the patient’s history, physical examination and laboratory results is essential in each case. This chapter presents vital information on the developmental anatomy of the cranium and scalp and how these relate to traumatic injuries. It also reviews the imaging features of typical abusive injuries, their association with specific mechanisms of trauma and the appropriateness of various imaging modalities.

This chapter reviews the normal anatomy, fractures and challenges of the upper extremity frequently encountered in child abuse imaging. Specifically, fracture types of the humerus, the elbow and the forearm are examined with attention to imaging techniques and protocols, particularly radiography and ultrasound.

This chapter reviews the imaging approach in suspected child physical abuse, including differing presentations of child physical abuse as well as recommendations for screening children at risk. Imaging strategy of the skeleton, including radiography, chest CT, ultrasound, whole-body MR and radionuclide bone imaging is reviewed.

The differential diagnosis for multiple fractures in infants and young children includes disorders of calcium and phosphorus metabolism. Conditions such as nutritional vitamin D deficiency rickets, metabolic bone disease of prematurity and congenital rickets may present with metaphyseal changes and fractures, but these typically differ from those seen in abusive trauma. Specialized laboratory studies and imaging tests, as well as potential consultations with endocrinologists, are essential to differentiate between metabolic bone diseases and abuse.

Visceral injuries are important manifestations of child abuse. This chapter reviews mechanisms, clinical presentation and imaging of inflicted injuries involving the neck, thorax, abdomen and pelvis. Because most visceral injuries can be plausibly explained as accidental, the significance of the injuries noted radiologically must be assessed in conjunction with the clinical context, including age and ambulatory status of the child, and other imaging findings, particularly skeletal findings that may be more specific for abuse.

Pelvic fractures in children resulting from abuse are rare but strong indicators of severe trauma. These injuries, especially in infants, are subtle and usually involve the superior pubic rami. In older children, they often occur in cases of significant blunt trauma or sexual abuse. Pelvic fractures are frequently associated with other signs of abuse, particularly other fractures around the hips. The anteroposterior view of the pelvis in the initial skeletal survey should be examined with care. Due to the rarity of pelvic fractures, it is reasonable to exclude the frontal view of the pelvis in the follow-up skeletal survey. Cross-sectional imaging may be beneficial in selected cases.

A fundamental dilemma in both the radiology reading room as well as the courtroom is whether a potential abusive head or spinal injury may be mistaken for other entities – both pathological processes and also normal anatomical or physiological variants.

A number of differential diagnoses, or mimics, for abusive head trauma may be apparent radiologically, but many may not be. Striving to achieve a medical “diagnosis” of an abusive injury requires the interplay between the radiologist and numerous other clinical specialties. The wide differentials which we discuss include accidental trauma, coagulopathies – both congenital and acquired, metabolic disorders, sepsis and vascular malformations, with all needing to be excluded before reaching a conclusion of nonaccidental trauma.

The experienced radiologist and clinician working in the challenging field of child protection also recognises that it is not always possible to reach a clear-cut decision and learning to communicate levels of uncertainty is essential. Part of this process is to always be alert to diagnostic mimics that may mislead the inexperienced and unwary.

Abusive head trauma (AHT) is a leading cause of traumatic death in infants, often resulting in severe brain injuries with lifelong consequences. It can cause cognitive, sensory and behavioral impairments, which may not fully emerge until later in childhood. AHT injuries are typically classified as primary (direct mechanical damage, such as contusions and lacerations) or secondary (indirect effects like hypoxic-ischemic injury and cerebral edema).

Infants are particularly vulnerable due to factors like poor neck control, larger head size and incomplete brain development. Neuroimaging, especially MRI and diffusion-weighted imaging, is essential for diagnosing these injuries and tracking their evolution, as some manifestations develop over days or weeks. Mechanisms of cell death, including necrosis, apoptosis and autophagy, play a key role in the progression of brain damage.

Differentiating AHT from accidental trauma is challenging. Certain patterns, such as subdural hemorrhages with ischemic injury, strongly suggest abuse. Comprehensive imaging, clinical evaluation and follow-up are crucial for documenting injury progression and understanding its impact on the developing brain.