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ED visits for child abuse drop during pandemic; hospitalizations increase

March 1, 2021











The U.S. child welfare system depends on reports made by caregivers, teachers and medical professionals.

During public health emergencies, limitations to the nation’s reporting system become evident, as children have fewer face-to-face interactions with their teachers and are less likely to attend doctor’s appointments. In addition, a decrease in home investigations and mandatory court appearances during the COVID-19 pandemic has limited monitoring of the approximately 3.5 million children in the child welfare program.

According to some officials in child protection agencies, reporting of suspected child abuse in the U.S. has declined by 20%-70%, due to fewer in-person interactions outside the home.

The COVID-19 pandemic has caused significant stressors on families, all of which can increase the risk of child abuse and neglect. These include loss of income, an increase in parental responsibilities during nationwide school closures, an increase in substance abuse and exacerbation of parental mental health conditions. Since child protective services are not provided prevention tools and rely on a reactionary approach, child abuse and neglect cases often are identified following an insult to the child.

A recent report in MMWR evaluated child abuse and neglect trends in U.S. emergency departments (ED) before and during the COVID-19 pandemic.

Study findings

Investigators compared ED visits related to suspected or confirmed abuse and neglect in children younger than 18 years between January 2019 and September 2020 using the National Syndromic Surveillance Program’s BioSense Platform.

Most reports came from an average of 2,970 facilities per week from 47 states and the District of Columbia. Visits were documented as suspected or confirmed cases of physical, sexual or emotional abuse or neglect based on syndrome definitions, chief complaint search terms, diagnosis codes and negations.

In the weeks following the president’s Proclamation Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak on March 13, 2020, the volume of ED visits declined by 72% among children 10 years and younger and 71% for those older than 10 compared to 2019. Total number of ED visits related to child abuse and neglect also declined beginning that same week, reaching a nadir between March 29-April 4, 2020.

From March 29-April 25, ED visits for patients younger than 18 years declined by an average of 53% compared to the same period in 2019. The proportion of ED visits related to child abuse and neglect per 100,000 ED visits concurrently increased in all age groups from 2.1% in 2019 to 3.2% in 2020 (p<0.001). This may be related to the overall decrease in total number of ED visits following the president’s national emergency declaration.

What is most concerning, however, is that the proportion of ED visits related to child abuse and neglect ending in hospitalization significantly increased for all age groups between 2019 to 2020 (see figure).

Percentage of visits related to child abuse/neglect ending in hospitalization

Source: National Syndromic Surveillance Program
















While overall cases decreased, severity of injuries worsened or stabilized, raising concerns that child abuse may be under-reported. This may have many negative consequences on children’s mental and physical health, and prevention strategies are paramount.

Strategies for the future

Several states have adopted new approaches to conduct investigations into child abuse and neglect safely during the COVID-19 pandemic. Some states’ child protection agencies have increased virtual visits; however, this approach may limit thorough investigations often needed by social workers for high-risk children. Other states have invested in providing personal protective equipment (PPE) for in-person visits. However, PPE shortages like those in cities such as New York may put workers at risk.

Strategies to improve surveillance and identification of child abuse and neglect are needed. The Centers for Disease Control and Prevention’s technical package for preventing child abuse and neglect ( emphasizes limiting home stressors such as by improving family economic support and promoting family-friendly work policies.

The Families First Coronavirus Response Act signed into law on March 18, 2020, increased funding for child welfare-related programs, including Medicaid and the Foster Care, Prevention, and Permanency program. In addition, the CARES Act signed into law on March 27, 2020, expanded unemployment benefits, income support and increased funding for several supplemental nutrition programs, like the Special Supplemental Nutrition Program for Women, Infants, and Children. In addition, $45 million was distributed to state child welfare services.

Although the additional funding for these programs has provided necessary relief, there still are significant needs that must be addressed to limit harm to children. Visits to a pediatrician may be one of the few face-to-face interactions a child has outside the home during this public health emergency. Therefore, pediatricians should be diligent in assessments and report any signs of abuse or neglect.


Official reporting of child abuse and neglect has declined by what percentage since the beginning of the COVID-19 pandemic?

A.  5%-10%

B.  15%-20%

C.  20%-70%

D.  85%-97%

Answer: C

Dr. Teherani is a post-graduate training fellow in pediatric infectious diseases at Emory University School of Medicine and Children’s Healthcare of Atlanta (CHOA). Dr. Pickering is adjunct professor of pediatrics at Emory University School of Medicine and CHOA.

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