Child abuse in all its forms -- physical abuse, sexual abuse, emotional abuse, and neglect -- can produce serious illness in the victim. Types of abuse injuries that may lead to admission to a PICU include head trauma, abdominal trauma, thoracic trauma, asphyxiation, intentional intoxication (Munchausen by Proxy syndrome), burn injuries, and severe medical neglect. A child admitted to a PICU is first medically stabilized. This should be followed by a systematic evaluation of the child, including a complete medical history, a physical examination, diagnostic studies, and consultation. Histories obtained from the parents and other caregivers must be accurately documented. Recording exact words in the medical record can be helpful to physicians, social workers, law enforcement officers, and prosecutors. Since the medical record often becomes a medical-legal document, it is essential that all evidence of abuse be accurately and appropriately documented. This may involve the taking of color photographs or the use of drawings. All appropriate child abuse forms should be completed. When abuse is suspected by the PICU team, this must be reported to an appropriate agency in accordance with State law. Intervention to protect the abused child and siblings who may be at risk for injury requires that the attending physician be able to say with "reasonable medical certainty" that the child was abused. Consultations with child abuse and other specialists, as well as specific training in forensic medicine, strengthen the physician's judgment. Five relevant case vignettes with follow-up questions are provided. 2 references