1. Sentinel Injuries in Physical Abuse
Leslie Strickler DO FAAP
Associate Professor of Pediatrics
University of New Mexico Children’s Hospital
Medical Director, Child Abuse Response Team (CART)

2. Objectives Define sentinel injury
Identify common presentations of sentinel injury
Sentinel injury case review
Review recommended medical evaluation in presentations of sentinel injuries

3. Definitions of Sentinel Injury
A visible or otherwise detectable minor injury in a pre- mobile infant that is poorly explained therefore concerning for child abuse
Often clinically insignificant from a treatment perspective
Heal quickly and completely without direct sequelae

4. Definition of sentinel injury
An injury recognized retrospectively as being an indicator of abuse
Typically involves pre-mobile infants
Is recognized by caretaker, and often includes history inconsistent with cause or severity of injury
An injury associated with a higher rate of diagnosis of abuse

5. Types of Sentinel Injury
Sentinel Injury breakdown
80% bruises
Including subconjunctival hemorrhage
11% Intraoral injury
7% fracture
Sheets, L. et al. Sentinel Injury in Infants Evaluated for Child Physical Abuse. Pediatrics 2013;131:

6. Frequency and Significance of Sentinel Injury
Retrospective Case Control
401 infants <12 months pf age evaluated by hospital based child abuse team
Of 200 diagnosed as abused, 27.5% had sentinel injuries
Of 100 indeterminate for abuse, 8% had sentinel injuries
Of 101 non-abused infants, 0% had sentinel injuries
Sheets, L. et al. Sentinel Injury in Infants Evaluated for Child Physical Abuse. Pediatrics 2013;131:

7. Case 1
4-month-old female, presented to UNM pediatric urgent care clinic with CC of right arm redness and decreased use/movement discovered by parents after waking from sleep. No trauma reported.
AL case presentation

8. Case 1
Exam noted discomfort on abduction and flexion of right shoulder and swelling of right upper arm
X-ray: acute transverse fracture of right humeral diaphysis
No other injuries on skeletal survey and head CT
Bruising to pad of right index finger identified on CART exam

9. Acute humerus fracture
Acute humeral fracture

10. Bruising to pad of right index finger

11. Case 1
Medical record review revealed visit to UNM Pediatric Emergency Department approx. 2 weeks prior for small bleeding cut under tongue noted by father after infant woke from a nap.
This history was not independently disclosed by parents during CART consultation

12. Case 1 Prior ED Course
No history of trauma other than parental report that infant puts things in her mouth due to teething
No PO intake by infant since injury noted
ED exam noted small linear laceration inferior to tongue, anterior to frenulum without active bleeding. No other injuries on exam.
Differential Diagnosis: Mouth laceration, NAT
Discharged without PO challenge due parental persistence in desiring to go home
No Referral to protective services or child abuse pediatrician

13. Case 2
3-month-old male, presented to community ED after father reported noting a “pop” after infant’s arm inadvertently became stuck behind his back during swaddling.
JL case presentation

14. Case 2
X-ray identified acute oblique mid to distal diaphyseal fracture of the left humerus.
Father then changed history stating he fell while holding the baby, and the baby’s arm was outstretched.
CYFD/Law Enforcement notified and infant transferred to UNM for CART consult

15. Acute humerus fracture
Acute humeral fracture

16. Case 2
CART exam notable for healed transection of superior labial frenulum, left upper arm swelling, and multiple linear petechial bruises on the left leg
No additional injuries identified on skeletal survey and head CT

17. Healed tear of superior labial frenulum

18. Linear petechial bruise (medial left knee)

19. Linear petechial bruises (left anterior thigh)

20. Multiple linear petechial bruises (posterior left thigh)

21. Case 2
CART medical record review revealed UNM Peds ED visit approx. 2 weeks prior and admission for fussiness, poor feeding, and intermittent bleeding of a “lesion” on the mucosa of the central upper lip, pointed out by father to clinicians.
No trauma history was reported
3 day admission with initial IVF requirement
Discharge without clear “inciting” event identified, no referral to protective services or child abuse pediatrician

22. Case 3
2 month infant admitted to community hospital with fever and Streptococcus pneumonia bacteremia and meningitis.

23. Case 3 Fever recurred near day 10 of antibiotic treatment
Chest x-ray obtained which revealed a healing clavicle fracture
Same fracture was recognized in retrospect on chest x-ray obtained at admission
Infant transferred to UNM due to concern for physical abuse

24. Case 3 History Skeletal survey Multiple healing rib fractures
One corner metaphyseal fracture
Scapular fracture
Fractures of phalanges
Physical Exam
Healing tear of superior labial frenulum
History
Mother reported frequent intra-oral bleeding on ROS

25. Babygram 3/29/16

26. Skeletal Survey: L 5-8 rib fractures

27. Skeletal Survey 4/8/16: distal femur corner metaphyseal fracture

28. Healed tear of superior labial frenulum

29. Case 3 Medical Record Review
urgent care visit 2 weeks prior to meningitis diagnosis for bruising of tongue, and abrasion to palate and lower inner lip.
Variable traumatic histories provided including infant striking face on father’s shoulder and infant’s tooth causing oral injury
*Infant was edentulous
Reported epistaxis 2 days prior to meningitis diagnosis
*Streptococcus Pneumonia is typical nasopharyngeal flora

30. Clinical course at UNM
Prolonged S. pneumoniae meningitis course complicated by ventriculitis and empyema requiring PICC line and extended parenteral therapy

31. Oral/Nasal Injuries
History: unexplained epistaxis, hematemesis, choking/gagging, feeding difficulty, or respiratory distress
Perform a thorough intra-oral/nasopharyngeal examination for history of oral bleeding or epistaxis in a young infant
Mechanisms: direct blow to mouth or forced insertion of object into mouth or nose
Refer to a Child Abuse Pediatrician!
Maguire S. Diagnosing abuse: a systematic review of torn frenum and other intra-oral injuries. Arch Dis Child, 2007; 92:
Walton L. Nasal bleeding in non-accidental injury in an infant. Arch Dis Child, 2010; 95:54-54.

32. Oral Injury: Acute Sublingual Laceration
Noted during admission exam for 2 mo infant with bronchiolitis
Mother reported accidentally cutting mouth with bulb syringe
Numerous bruises and abrasions on physical exam
Multiple fractures on SS
Unexplained, unreported bruise to scrotum with testicular hematoma at 1 month WCC
Note the blood on the outer edges

33. Healing sublingual laceration
Note the triangular/diamond shape of the sublingual frenulum

34. Healing Superior Labial Frenulum Tear
Note the diamond shape to the frenulum, as contrasted with the prior image

35. Medical Evaluation in Sentinel Injury
Detailed medical history and history of injury/presentation
Thorough medical examination with attention to skin, oral cavity, neurologic, and palpatory musculoskeletal exam

36. Medical Evaluation in Sentinel Injury
IMAGING
SKELETAL SURVEY (SS)
11-13% of children <2 years of age evaluated for suspected abuse have occult injury on SS
25-30% of children <2 years of age with a clinical diagnosis of physical abuse have occult injury on SS
Belfer, RA et al. Use of the skeletal survey in the evaluation of child maltreatment. Am J Emer Med ; 19(2):
Day, F et al. A retrospective case series of skeletal surveys in children with suspected non-accidental injury. J Clin Forensic Med ; 13(2): 55-59

37. Medical Evaluation in Sentinel Injury
NEUROIMAGING (Non-contrast Head CT or MRI)
Approx % of neurologically normal children < 2 years of age with high risk presentation for abuse have occult head injury identified on imaging.
Laskey, A et al. Occult head trauma in young suspected victims of physical abuse. J Pediatr ;144:
Rubin, D et al. Occult head injury in high risk abused children. Pediatrics ;111:

38. Clinical Pearls
Further explore any history or sign of injury in pre-mobile infants
If it doesn’t cruise, it shouldn’t bruise, break, or bleed from it’s mouth or nose!
Perform detailed oral cavity exam on all infants presenting with history of bleeding/injury, difficulty feeding, difficulty breathing, hemoptysis, hematemesis, or epistaxis
Refer unexplained injury in pre-mobile infants
Protective Services
Law Enforcement
CART

39. Parting Thoughts Child Abuse is an under-reported national epidemic
Children in New Mexico are disproportionately affected
Ignoring abuse will not make it go away
Severity escalates with time
Report suspicion, refer for evaluation
Accurate diagnosis is prevention!

40. Thriving New Mexico Child!