Overview
Definition:
Sentinel injuries are minor, early signs of physical abuse that may precede more severe injury
Bruising patterns, particularly in non-ambulatory infants, are highly significant indicators of potential abuse due to their location, size, shape, and multiplicity.
Epidemiology:
Child abuse and neglect are significant public health issues
Bruising is the most common sign of physical abuse in children, especially infants under one year of age
In non-ambulatory infants, any bruising should be considered suspicious for abuse.
Clinical Significance:
Prompt recognition of sentinel injuries and specific bruising patterns is crucial for timely intervention, protection of the child, and appropriate legal reporting
Failure to identify these signs can lead to severe, life-threatening injuries or fatalities.
Clinical Presentation
History Points:
Inquire about the mechanism of injury with specific, open-ended questions
Note discrepancies between the reported history and the observed injury
Assess parental stress, mental health, and substance use history
Obtain a detailed developmental history, especially regarding mobility.
Physical Examination Findings:
Perform a thorough, head-to-toe examination, including internal surfaces of the mouth, ears, and genitals
Document the location, color, size, shape, and pattern of all bruises
Note any associated injuries such as fractures, burns, or head trauma.
Bruising Characteristics:
Location: Bruises on the trunk, ears, neck, and buttocks are highly suspicious in infants
Size and shape: Linear, oval, or irregularly shaped bruises can be indicative of inflicted trauma
Color: While color changes with time (red/purple to blue/green to yellow/brown), the pattern is more important
Multiplicity: Multiple bruises in various stages of healing are a red flag.
Diagnostic Approach
History Taking:
Elicit a detailed account of how the injury occurred from all caregivers present
Ask about prior injuries or concerns for the child's safety
Assess for any history of domestic violence or parental substance abuse
Document inconsistencies in the history meticulously.
Physical Examination:
A comprehensive physical examination is paramount
Pay close attention to areas not typically injured during normal play, such as the face, ears, neck, abdomen, and genitalia
Use a standardized approach to document all findings, including diagrams and photographs if indicated.
Investigations:
Skeletal survey: Recommended for all infants under 2 years with bruising concerning for abuse
Consider Doppler ultrasound for suspected internal injuries
Other investigations may include a complete blood count (CBC) with coagulation studies if a bleeding disorder is suspected, although this is rare as a primary cause of bruising in abuse cases.
Differential Diagnosis:
Accidental trauma: Falls from low heights or play-related injuries
Coagulation disorders: Hemophilia, von Willebrand disease, idiopathic thrombocytopenic purpura (ITP) - typically present with petechiae, purpura, or spontaneous bleeding, not localized patterned bruises
Osteogenesis imperfecta: Can present with fractures, but bruising is less common
Meningococcemia: Can cause purpuric lesions, but typically associated with systemic illness.
Management And Reporting
Immediate Actions:
Ensure the child's safety
If abuse is suspected, the child must be protected, which may involve removal from the home
Provide necessary medical care for any injuries.
Medical Management:
Treat specific injuries as indicated (e.g., pain management for fractures, wound care)
If a bleeding disorder is suspected, consult hematology.
Reporting Obligations:
In India, healthcare professionals are mandatory reporters of suspected child abuse
Report suspicions to the Child Welfare Committee (CWC) or the police immediately as per legal guidelines.
Documentation:
Meticulous documentation is critical
This includes detailed notes, diagrams of injuries, and high-quality photographs
Accurate records are essential for legal proceedings and child protection.
Sentinel Injuries Patterns And Age
Infants Under 1 Year:
Any bruising is suspicious
Classic locations include the face, ears, neck, trunk, and buttocks
Injuries from grabbing, slapping, or shaking are common.
Toddlers 1 To 3 Years:
Bruising may occur on extremities and trunk
Patterns can suggest impact with objects, biting, or pinching
They are more mobile, so accidental falls are more common, but vigilance for abuse remains high.
Older Children:
Bruising may be more generalized, but specific patterns (e.g., human bite marks, handprints, object shapes) are highly indicative of abuse
Document location carefully.
Key Points
Exam Focus:
Understand that in infants <1 year, any bruise is suspicious
Key patterns to recognize include handprints, finger marks, loop marks, and bite marks
The skeletal survey is a critical investigation for suspected abuse.
Clinical Pearls:
Documenting the color of a bruise can be helpful for approximate age estimation, but pattern and location are more significant indicators of abuse
Always consider the developmental stage of the child when evaluating bruises
If the history doesn't fit the injury, consider abuse.
Common Mistakes:
Attributing all bruises in infants to accidental causes without thorough investigation
Failing to perform a complete skeletal survey when indicated
Inadequate documentation of physical findings and historical inconsistencies
Delaying reporting to authorities.