The majority of childhood injuries are accidental, but an inflicted injury missed or improperly evaluated can escalate to child fatality. [1, 2, 3] The emergency medicine (EM) provider must be familiar with how inflicted injuries present and how to intervene. Intervention can save the child’s life in the same way protecting an airway or administering antibiotics for meningitis can save a child’s life.
In the United States, medical providers are mandated reporters of child abuse. The EM provider is obligated by law to report when there is a reasonable suspicion of child abuse. The provider cannot be held legally responsible for reporting in good faith if the suspicion cannot be proven, but he or she can be held legally responsible if they do not report suspected child abuse when there is a reasonable suspicion of such. Mandated child abuse and neglect reporting laws vary from state to state; it is the physician’s responsibility to know the law in his or her state.
The EM provider must approach each suspected victim systematically. The first priority is appropriate medical care for the patient. The other steps include a thorough history, a complete physical examination, consultation with a social worker and/or child abuse pediatrician, and making a report to Child Protective Service (CPS) agencies. One must carefully and clearly document all historical information (and sources), as well as any injury (drawing, diagrams, and/or photographs). It is not required that the EM provider diagnose child abuse with 100% confidence, but to reasonably suspect child abuse and initiate referral for subsequent investigation while providing medical care for the patient.
Child abuse is a challenging diagnosis to manage in the emergency department (ED). It is best managed systematically, with a multidisciplinary team, and with established guidelines to maintain objectivity and thoroughness. Local and institutional resources such as social workers, child abuse physicians, pediatric radiologists, CPS, and law enforcement should be consulted early in the evaluation when possible. Institutional child abuse protocols facilitate the physician’s ability to objectively focus on the needs of the individual patient.
While each state may have slightly different definitions of child abuse and neglect, the Child Abuse Prevention and Treatment Act (CAPTA), which was originally enacted by Congress in 1974, defines child abuse and neglect as, at a minimum: “Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act, which presents an imminent risk of serious harm.” 
Child abuse may occur for a multitude of reasons. Risk factors exist within society (eg, poor familial support systems, poverty, inadequate/overcrowded housing), within families (eg, depression, poor role models, drug abuse), and within the child (eg, medically fragile, prematurity, behavioral problems). It has been proposed that abuse requires a parent who is capable of abuse, a child who is actively or passively a target, and a crisis that triggers an inappropriate response. 
The 4 overlapping categories of child abuse are (1) physical abuse, (2) sexual abuse, (3) psychological abuse, and (4) neglect. Each has unique characteristics and requires individual approaches to diagnosis and management.
Physical abuse is characterized by physical injury (eg, bruises, fractures, tissue disruption) resulting from hitting, punching, pinching, kicking, biting, burning, shaking, or otherwise harming a child. Sometimes, the injury is inflicted in the course of physical punishment. From both a legal and medical standpoint, the intent of the abuser (to inflict injury or not) is not relevant to the diagnosis. Pathophysiology is unique to each type of injury.
Sexual abuse is described in Child Sexual Abuse.
Neglect is the most common type of child maltreatment in the United States (78.5%)  and is caregiver failure to meet basic nutritional, medical, educational, and emotional needs of a child. Neglect is legally reportable. Nutritional neglect is likely the most common form of neglect that recognized in the ED, typically in the form of failure to thrive (FTT). Nutritional neglect associated with FTT is not diagnosed in one visit. The EM provider should refer to specialists for further evaluation either on admission or as an outpatient. Risk factors for neglect include poverty, poor support systems, parenteral mental health issues or mental disability, parenteral substance abuse, poor parenting skills, or complex child physical/medical/psychological needs.
Medical child abuse (previously known as Munchausen-by-proxy) involves a complex dynamic of a parent fabricating a child’s illness and then presenting persistently, often to an ED, for care. The perpetrator is most often the mother who appears very knowledgeable about the child’s condition. The symptoms are often unusual and do not generally respond to treatment. Presentations are varied, but can include bleeding/bruising (warfarin, dye, exogenous blood), seizure (poison, suffocation, lying), apnea (lying, suffocation), infection (line contamination), diarrhea (laxative), vomiting (ipecac), and altered mental status (drug exposure). Older children often internalize the parent’s projection of their illness and believe they are sick. The outcome can be fatal. When children are brought repeatedly for care for unusual symptoms that do not respond to medical therapy, it is reasonable to consider this diagnosis and consult with a child abuse pediatrician.
In 2011, 3.4 million referrals were made to child protective authorities in the United States; 8.4% of the referrals were from medical personnel.  The rate of child maltreatment in the United States was 9.1 cases per 1000 children.  Seventy-eight percent of child maltreatment reports were from neglect, 17.6% from physical abuse, and 9.1% from child sexual abuse.  The overall child fatality rate was 2.1 deaths per 100,000 children.  Women represented 53.6% of perpetrators.  From 2000-2008, almost 340,000 children were treated in US EDs for inflicted injury, or 1.3% of all pediatric ED visits. 
Child maltreatment is a global problem. Accurate incidence is difficult to determine, owing to lack of good studies in many areas of the world.
The child who is maltreated may experience immediate pain, fear, humiliation, injury of varying severity, and loss of self-esteem. Apart from the potential physical sequelae (eg, death, traumatic brain injury, disfigurement), long-term health consequences of child maltreatment and adverse childhood experiences include increased risk for substance abuse, self-injurious and suicidal behavior, depression, anxiety, criminal behavior, cardiovascular disease, diabetes, cancer, premature mortality, low mental well being and life satisfaction, obesity and other mental health problems. [8, 9, 10, 11, 12, 13]
Mortality increases with recurrent episodes of inflicted trauma.  In 2010, homicide was the third leading cause of death in aged children 1-4 years  and 81.6% of fatalities from child abuse were in children younger than 4 years. 
Child maltreatment is found in every race, ethnicity, culture, and socioeconomic status. It is important for clinicians to approach all children in the same manner regardless of background.
The sexes are equally affected by child maltreatment, but homicide rates are slightly higher in males. 
Child maltreatment can occur at any age, but the highest rate of victimization is in children younger than 1 year, at 21.2 cases per 1,000 children.  Children younger than 4 years represent the majority of childhood fatalities. The incidence of physical abuse decreases during early school years and increases again during adolescence.
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