Injuries, other than abrasions, are rare in precruising infants. In this population, a history or observation of a sentinel skin injury, intraoral injury, or musculoskeletal injury without a plausible explanation, is concerning for physical abuse. A precruising infant with a sentinel injury should be medically evaluated for occult injury and predisposing medical conditions, as well as reported to authorities for further investigation. Early identification of sentinel injuries and appropriate interventions can prevent further abuse.
Key points
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A sentinel injury is a visible, minor injury in a precruising infant that is poorly explained and therefore concerning for physical abuse.
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Sentinel injuries are common in abused infants and rare in nonabused infants.
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A history of a sentinel injury in an infant with suspected abuse should increase the level of concern for maltreatment.
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Identification of a sentinel injury, reporting, and intervention may prevent further abuse.
Introduction/characterize the issue/problem
A 7-week-old infant presented to an emergency room by ambulance after an episode of pallor, vomiting, and decreased responsiveness. Physical examination was significant for an ill-appearing infant with a weak cry. The head computed tomography (CT) showed bilateral, thin, acute, convexity subdural hemorrhages, and the skeletal survey showed acute and healing rib fractures, as well as a classic metaphyseal lesion and acute spiral fracture of the right tibia. Extensive retinal hemorrhages were also noted on dilated funduscopic examination. Following a comprehensive evaluation by the hospital-based child protection team, the child was diagnosed with abusive head trauma and fractures. In the medical history, the father reported a bruise adjacent to the infant’s mouth 2 weeks before admission, which he attributed to the infant bumping her head on her pacifier while he held the infant to his chest ( Fig. 1 ). The father eventually confessed to abusing the infant on multiple occasions. If this initial sentinel injury had been identified as concerning for abuse and appropriate safety measures used, the subsequent severe injuries may have been prevented.
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