Leslie Strickler DO FAAP Associate Professor of Pediatrics University of New Mexico Childrens Hospital Medical Director Child Abuse Response Team CART Objectives Define sentinel injury Identify common presentations of sentinel injury ID: 933316
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Slide1
Sentinel Injuries in Physical Abuse
Leslie Strickler DO FAAPAssociate Professor of PediatricsUniversity of New Mexico Children’s HospitalMedical Director, Child Abuse Response Team (CART)
Slide2Objectives
Define sentinel injuryIdentify common presentations of sentinel injurySentinel injury case reviewReview recommended medical evaluation in presentations of sentinel injuries
Slide3Definitions 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
Slide4Definition 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
Slide5Types of Sentinel Injury
Sentinel Injury breakdown80% bruisesIncluding subconjunctival hemorrhage
11
% Intraoral injury
7
%
fracture
Sheets
, L. et al. Sentinel Injury in Infants Evaluated for Child Physical Abuse. Pediatrics
2013;131:701-707.
Slide6Frequency and Significance of Sentinel Injury
Retrospective Case Control401 infants <12 months pf age evaluated by hospital based child abuse teamOf 200 diagnosed as abused, 27.5% had sentinel injuriesOf 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;131:701-707
Slide7Case 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.
Slide8Case 1
Exam noted discomfort on abduction and flexion of right shoulder and swelling of right upper armX-ray: acute transverse fracture of right humeral diaphysisNo other injuries on skeletal survey and head
CT
Bruising to pad of right index finger identified on CART exam
Slide9Acute
humerus
fracture
Slide10Bruising to pad of right index finger
Slide11Case 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
Slide12Case 1 Prior ED Course
No history of trauma other than parental report that infant puts things in her mouth due to teethingNo PO intake by infant since injury notedED 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
Slide13Case 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.
Slide14Case 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
Slide15Acute
humerus
fracture
Slide16Case 2
CART exam notable for healed transection of superior labial frenulum, left upper arm swelling, and multiple linear petechial bruises on the left legNo additional injuries identified on skeletal survey and head CT
Slide17Healed tear of superior labial frenulum
Slide18Linear petechial bruise (medial left knee)
Slide19Linear petechial bruises (left anterior thigh)
Slide20Multiple linear petechial bruises (posterior left thigh)
Slide21Case 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
Slide22Case 3
2 month infant admitted to community hospital with fever and Streptococcus pneumonia bacteremia and meningitis.
Slide23Case 3
Fever recurred near day 10 of antibiotic treatmentChest x-ray obtained which revealed a healing clavicle fractureSame fracture was recognized in retrospect on chest x-ray obtained at admissionInfant transferred to UNM due to concern for physical abuse
Slide24Case 3
Skeletal surveyMultiple healing rib fracturesOne corner metaphyseal fractureScapular fractureFractures of phalanges
Physical Exam
Healing tear of superior labial frenulum
History
Mother reported frequent intra-oral bleeding on ROS
Slide25Babygram 3/29/16
Slide26Skeletal Survey: L 5-8 rib fractures
Slide27Skeletal Survey 4/8/16: distal femur corner metaphyseal fracture
Slide28Healed tear of superior labial frenulum
Slide29Case 3
Medical Record Reviewurgent 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
Slide30Clinical course at UNM
Prolonged S. pneumoniae meningitis course complicated by ventriculitis and empyema requiring PICC line and extended parenteral therapy
Slide31Oral/Nasal Injuries
History: unexplained epistaxis, hematemesis, choking/gagging, feeding difficulty, or respiratory distressPerform 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:
1113-1117.
Walton
L. Nasal bleeding in non-accidental injury in an infant
.
Arch Dis Child, 2010;
95:54-54.
Slide32Oral Injury: Acute Sublingual Laceration
Noted during admission exam for 2 mo infant with bronchiolitis Mother reported accidentally cutting mouth with bulb syringeNumerous bruises and abrasions on physical examMultiple fractures on SS
Unexplained, unreported bruise to scrotum with testicular hematoma at 1 month WCC
Slide33Healing sublingual laceration
Slide34Healing Superior Labial Frenulum Tear
Slide35Medical Evaluation in Sentinel Injury
Detailed medical history and history of injury/presentationThorough medical examination with attention to skin, oral cavity, neurologic, and palpatory musculoskeletal exam
Slide36Medical Evaluation in Sentinel Injury
IMAGINGSKELETAL 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
i
njury on SS
Belfer, RA et al. Use of the skeletal survey in the evaluation of child maltreatment. Am J Emer Med. 2001; 19(2):122-124
Day, F et al. A retrospective case series of skeletal surveys in children with suspected non-accidental injury. J Clin Forensic Med. 2006; 13(2): 55-59
Slide37Medical Evaluation in Sentinel Injury
NEUROIMAGING (Non-contrast Head CT or MRI)Approx. 30-40% 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. 2004;144:719-722
Rubin, D et al. Occult head injury in high risk abused children. Pediatrics. 2003;111:1382-1386.
Slide38Clinical Pearls
Further explore any history or sign of injury in pre-mobile infantsIf 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
Slide39Parting Thoughts
Child Abuse is an under-reported national epidemicChildren 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!
Slide40Thriving New Mexico Child!