Summary Background The need for an effective system of child protection, which is able to detect children at risk of physical abuse, has never been more urgent. The level of reporting of non-accidental injury (NAI) in young children is lower than would be expected from official statistics, which means that Accident and Emergency (A&E) nurses and clinicians have a special responsibility to improve detection of possible abuse, in what has become a very challenging area of medicine. Aims: In this paper, we review the main issues facing clinicians and nurses in the identification of children at risk of NAI and discuss the policy implications affecting A&E departments. In particular we ask the question: what are the factors that influence the identification and reporting of suspected NAI in young children and how can the under-recognition of NAI be improved? Conclusion We conclude that organisational changes, such as the creation of a shared national database and improved training for A&E staff so that they are aware of social as well as clinical risk factors, are needed to address the under-reporting of non-accidental injury in young children.