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INTRODUCTION AND EPIDEMIOLOGY
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Child maltreatment is, unfortunately, a common occurrence. In the United States, over 650,000 children suffer some form of child abuse or neglect each year, and approximately 12% of these children will present to a hospital with injuries.1 It is estimated that between 2% and 10% of children visiting the ED are victims of child abuse or neglect.2 Therefore, emergency physicians are in a unique position to identify nonaccidental injuries and potentially prevent further abuse. Child maltreatment takes many forms including neglect (68%), physical abuse (16%), sexual abuse (8%), and emotional abuse and medical child abuse (8%)1 (previously called Munchausen syndrome by proxy).
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Child neglect is the most common form of child maltreatment and the most difficult to evaluate and manage; it contributes to as many as 50% of fatalities from child maltreatment.3 Neglect occurs when a caregiver fails to meet a child's basic needs in provision of food, shelter, clothing, health care, education, supervision, and nurturance.3,4,5 Further, this failure either results or is very likely to result in serious impairment of a child's health or development. While many types of neglect may occur, seldom does any one form exist on its own. Carefully consider each neglect risk factor individually, identifying whether there is overt historical or physical evidence of each subtype of neglect (Table 148-1).
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Given that neglect is rarely a single act, but is rather an accumulation of harm over time, the often brief, single encounter of an ED assessment cannot provide the comprehensive assessment required. The goals of the ED encounter are to recognize when child neglect may be at issue, to clearly document the presenting concerns, and to trigger the appropriate multidisciplinary team approach for the investigation and management of these complex cases. The recognition of child neglect in the ED requires knowledge of the multiple risk factors associated with neglect (Table 148-2).4,5,6,7 Poverty, parental substance abuse, and mental health issues are three of the most common risk factors for child maltreatment and neglect.4,6 Although not all poor families are neglectful, poverty has an overwhelming effect on the parents' ability to provide basic care for their children and ...