Child abuse is a hidden epidemic. More than 1 million children are abused in some form every year in the United States. Thousands will die annually from abuse.¹ Many more go undetected and are unrecognized in offices, clinics, hospitals, and emergency departments throughout the country. Emergency physicians are on the front lines and may be the last (or only) safety net for an abused child.

Presentations to the emergency department are sometimes obvious, but many are subtle and go unrecognized. Failure to detect or investigate potential abuse can lead to catastrophic consequences. Children who are physically abused once are likely to be abused again. Studies have shown that unrecognized abuse has up to a 50% chance of recurrence and up to a 10% chance of leading to death.^2-4

Even when investigated or detected, disastrous outcomes might occur if the child is not removed from the potentially harmful environment. With a high index of suspicion and a low threshold for reporting and intervention, emergency physicians can save a life by identifying child abuse and stopping it from happening again.

The History and Physical

There are many challenges when considering the diagnosis of abuse. As most abuse occurs in children who have limited or no verbal skills, the history is often entirely dependent on the caregiver.^5-9 Two common scenarios take place. First, the caregiver may be unaware there has been harm done to the child. They may be bringing in their child after they observed something nonspecific at home, such as respiratory distress or vomiting, after a babysitter, friend, or family member took care of the infant.

The other situation, which is often more challenging, is when the caregiver committed or witnessed the abuse. In such cases, the caregiver will frequently mislead the clinician and/or omit information.

Because subtle presentations for physical abuse are common, especially in the preverbal infant or child, performing a thorough history and physical examination and being alert for suspicious findings are essential for detecting abuse. Injuries that are implausible, inconsistent with mechanism, or accompanied by a changing or vague history should raise suspicion and be investigated further.