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When Bruises Don't Add Up: Recognizing Sentinel Injuries in Infants | Grand Rounds Episode · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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This is Pediatrics Now, brought to you by the Department of Pediatrics at UT
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Health San Antonio and University Health's new Women's and Children's Hospital.
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Today, I'm bringing you grand rounds. Let's listen in.
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Sentinel injuries, and most of them were not reported, and no evaluation for
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abuse was done, no work done.
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As I said, these injuries or sentinel injuries are not minor.
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They are early warnings that can tell us to evaluate and to check for injuries
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or evaluate early in life.
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As clinicians, as providers, we
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face several barriers in recognizing and acknowledging sentinel injuries.
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So we might think that abuse of an infant is something that's unthinkable,
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that injuries are minor and they are trivial.
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It could be also lack of awareness of what does the bruising significance.
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And there's also bias. Families are perceived to be at low risk of harming their babies, their infants.
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And there's also the ABA bias. And we think that could be anything but abuse.
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I'm going to talk a little bit more about this. So what's ABA bias?
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It's a very uncommon bias.
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It's hard to understand how someone could hurt a young child.
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It's much easier to understand that accidents happen, and especially when a
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bruise is very small or the injury is very minor.
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Providers may also not want to report because they have a good relationship
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with the family or because they have a good feeling about the caregiver.
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Those are all reasons for this bias. And also sometimes because it's less work.
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So we're going to face our first case.
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So here we get a four-week-old presented to the PCP due to upper respiratory symptoms.
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Physical exam showed a subconjunctival hemorrhage.
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And the EMR was documented by the provider that the infant had the subconjunctial
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hemorrhage caused by the baby himself crying.
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So maybe the patient presented to the ED four weeks later due to blood also
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in their mouth, so four weeks after.
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And the physical exam showed a frenelum tear as well as a bruise under the top.
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So here we can see a very subtle subconjunctal hemorrhage on the medial part of the right eye.
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So this, at four weeks old, was a sentinel injury.
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And a baby this age could not have caused, or a kid could not have caused this injury to himself.
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So this, at four weeks old, just needed a complete workup to rule out child abuse or to the workup.
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And then the daily percentage four weeks later with a frontalum tear and also a bruise here,
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like we can see on the left side of the tongue.
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So in this time, we were consulted for the second time when he was eight weeks old.
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And we were doing a skeletal survey and a head CT and all the workup.
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The head CT was negative. The skeletal survey showed classic metafysel fractures
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on lower extremities, which are also fractures, highly specific for abuse.
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So this is a good example of a missed sentinel injuries at four weeks old,
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and then at eight weeks old, we have additional injuries.
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So we need to talk also what is not a sentinel injury.
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So some superficial abrasions or temporary redness to the skin in infants is not a sentinel injury.
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This may occur during normal care and handling of an infant.
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Examples of this can be infant scratches to the cheek with their nails,
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compression from an article of clothing or blood pressure cuff that results within hours.
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The term sentinel applies only to visible skin findings and does not include
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occult injuries, for example, rib fractures or any abdominal trauma.
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It may have happened, so you cannot, those skin findings are not visible physical
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exams, so those are not sentinel injuries.
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And then it's important to emphasize that it's not a sentinel injury,
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a cutaneous injury in an infant or a child who is already cruising or walking.
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I want to start talk about physical abuse.
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So when we start talking about physical abuse, to know which to differentiate
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between abusive from accidental bruises,
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so we need to start thinking about how children interact with the world.
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If you've seen children playing and during normal childhood play,
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how do they injure themselves?
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What part of their bodies come in contact with the world?
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And also very important, how do injuries change with mobility?
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And how do they usually fall? All of that. So, that's all questions that we
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need to take into consideration when evaluating bruises.
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We're going to start talking about areas that are common for accidental bruises.
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So, the forehead, nose, chin, elbows, the hips, which are areas that are in bony prominences.
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Also the knees and the shins.
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And we have also sort of a couple of examples of accidental bruises,
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so bruises on the lower extremities.
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Here we can see even a cluster of bruises, but due to the area where it's located,
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it's It's an area that's commonly injured in mullet children.
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Cabruces on the arms and also forearms and then also bruises on the elbows.
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There's other um examples of of
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bruises specifically this was a recent very recent case
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of mine this child was playing around with this child had maybe remember had
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like four or five siblings they were playing around and um the child felt forward
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while playing outside in the cord.
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The part that was also concerning and why they called us was because there was
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this bruise that also has an abrasion.
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And then there was this linear also abrasion on the nose, on the bridge of the
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nose. So this area is also very common.
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It's an area commonly injured by children while they're playing.
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And also here in the chin, this is also another area that it's very common for accidental bruises.
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Now we're going to talk about pen for face-to-speak. This is one of the most
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helpful tools when we evaluate bruising.
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This is a clinical decision rule or aid that is designed to identify bruising
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patterns that are more concerning for abuse, particularly in younger children.
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So the pen specifically means to torso, ears, and neck.
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These are locations that when accidental bruises is very uncommon especially in,
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young children the 4 refers to any bruising in any child less than 4 months old,
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at that age less than 4 around that age children are not mobile so the bruising
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is not expected and should raise concern,
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And then the expanded phases P includes additional areas or high-risk areas
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that are not commonly injured during an accident, like accidental bruising.
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So that will be the phrenolum, angle of the jaw, cheeks, the eyelids, and subconjunctivate.
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So the important part here to remember,
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or the key idea, is not that every bruise in this area is abused.
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So that's the first thing that we need to think.
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But that these findings should prompt a more careful examination and deconsideration
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of abuse and get more history,
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get more evaluation to evaluate, to see how that goes.
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Um.
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So areas of sorry we're going to talk about areas uh
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that are uh concerning for
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abusive uh injuries so the chest so that
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these are all um many of these areas are
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like the abdomen the buttocks the cheeks
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are fleshy areas that don't overlie bony prominences uh like the abdomen genitals
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buttocks the ears the ears are areas that are also protected on the side of
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the head They shouldn't be injured during accidental injuries.
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Any intraoral injury, the angle of the jaw, as I mentioned earlier, and the eye.
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So here there are examples of injuries that are concerning for abuse so there's our,
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bruises or this is this can be this should be
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described as a cluster of bruises different cluster of
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bruises on the chest and the
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abdomen these are areas that are that no
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bone is underneath underneath it so there's
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no bony prominences and they are and are areas
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that are also commonly protect the children put their
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hands or extend their hands to be
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able to protect their abdomen and chest and also here on this other pictures
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here this is a an infant and we can see there's multiple bruises and most of
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these bruises important part here is that they are patterned You can see that there's,
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these are curvilinear bruises,
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multiple curvilinear bruises around the back.
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These are other areas that are concerning for abuse.
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The ear, and see here in the ear, it can be impact to that area.
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That is not very common to happen on accidental injuries.
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It could also, it could also, the mechanism for ear bruise can be an impact
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to the area or also crushing forces.
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Any pinching to that area could also cause the bruises.
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And these are other pictures showing concerning bruises.
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So in all of these pictures, we need to also get a history and get the context of the picture.
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So, for example, this infant with a facial bruise,
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this could potentially happen during a motor vehicle accident or a high-velocity impact.
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But if there's no explanation for that, no history for that,
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for example, in this child, then and the rest of the work of,
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fagulopathy work of bleeding disorder work of is negative,
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then this injury would be concerning for abuse because there's no history explaining
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this bruised on a protected area like the face.
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Then here we also have this bruise on the abdomen.
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This is a small baby. this was also a recent case, baby two or three months
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old with this pattern linear bruise on the abdomen with no explanation and all the work of normal.
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So all of this, also these two bruises would be concerning for surgical abuse.
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These are other examples of other bruises, so on the cheek,
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and then here what I wanted to show here is another example of a bruise related
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to tenfold faces, so on the angle of the jaw, which also would be concerning.
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Also another picture of injuries concerning
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for abuse related to 10-4 phases this is another i like to show these pictures
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too because this is a very subtle subconjunctive hemorrhage that could be easily
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missed on a normal physical exam and also this same child had this,
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This is her right eye, and then on the upper eyelid, she had this bruise on her upper eyelid.
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And now additional pictures concerning for abuse, but these ones are pattern bruises.
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So we can see here all of these different pattern, loop-shaped pattern bruises.
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So in this picture, you can see that there's multiple pattern injuries,
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but just by having just one, that will be also just concerning for physical abuse.
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And then here we also see another pattern injury in the abdomen of another baby
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similar to the picture that we saw earlier.
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So now we're going to talk about mimics. When it looks like abuse, but it is not abuse.
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So most continuous mimics can be identified with history and physical exam.
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There was a study done around 3,000 children evaluated for physical abuse.
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And from all of them,
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2.4% of them had cutaneous mimics, and 81% that had that 2.4% were diagnosed
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just by the history and the physical exam.
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Now, it's important when there's any consideration or any concern that this can be a mimic,
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the injuries, to consider additional diagnostic testing and then also referrals
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to specialists including dermatology,
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ID, and that might be helpful for patients.
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And to get to the bottom to see if it's a mimic or not.
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So we're going to talk today about skin
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conditions we're going to also talk about common
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bleeding disorders and also we're going to talk about other conditions like
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iotrianic bruises henna schlein purpura urticaria pigmentosa neuroblastoma garment
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lines and also stretch marks.
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I'll show pictures and how all of this and the skin conditions and the common
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brain disorders can mimic abuse.
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So, the first one, CDMs, or congenital dermal melanocytosis.
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So, it's very, it depends on the, it's more common in African American,
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then more common in Asians, and then Hispanic and Caucasian patients.
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As we all know, they usually fade during childhood, but it may persist into
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adulthood. hood, it's usually on the lumbosacral area, but we've seen on the
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upper back, shoulders, even on the feet.
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They are caused by their mole melanocyte deposition and the difference is they're
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benign, they're flat blue-gray color patches.
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We also see hemangiomas or benign vascular lesions that can appear red,
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purple, or bruise-like.
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They follow a predictable course, so they grow in infancy, and then they have a gradual involution.
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And the clues are that they have well-defined borders and the persistent and
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the evolution over time.
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So this one is a one that's more diffused, but specifically this example is right here.
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This one here might be also easily missed by a bruise, also because of the location.
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This is the ear. This will be the cheek. and here this is the lower extremity
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and this could also be missed for a bruise.
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We also have phytophotodermatitis. So this is a case of a 20-month-old with
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skin lesions noted the day after a barbecue at family picnic.
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Mom was preparing margaritas and the shot was playing nearby with family members
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and also there was prolonged sun exposure.
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So you can see here in this area the outline of mother's fingers.
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That's because she was holding her hand. Sorry, let's see, a boy.
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So phytophotodermatitis, also a phototoxic reaction from plant and exposure plus sunlight.
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The lesions are often irregular, often linear, streaked, and they have erythema
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and blistering, and later it can show hyperpigmentation.
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And the clues specifically for this findings is the exposure history to the
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sun and the distribution and also the reaction also with any citrus,
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as I said before, any oranges, grapefruit,
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or any other parsley, parsley, figs, carrots, all of these ones could cause the reaction.
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So, now we're going to talk about common bleeding disorders.
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So, ITP is a very common bleeding disorder that can be mistaken or can be misleading for abuse.
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There can be multiple bruises in different areas, often without clear trauma history.
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They may appear widespread. maybe they can be accompanied by petechiais and
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also mucosal bleeding and the pattern and the number of bruises may not correlate
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also with the history you can see bruises,
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similar to this one in ITP there's also bruises similar more severe like this one so it could also be,
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misleading for abuse.
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You also see with hemophilia, which there's bleeding after minimal or no trauma.
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It may involve the joints and look more severe because it includes joints,
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muscle, or any mucosal site.
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And the pattern of the injury may
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not match the reported mechanism or the reported history by the parents.
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We also see it a lot with mimics with von Wilbrand disease, which causes easy bruising,
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frequently with neocosal bleeding, epistaxis, gingival bleeding,
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and the bruises may be diffuse,
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multiple around the body, and also very recurrent, and can occur in locations
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that are not typically prone to accidental bruising, which that would raise concern for abuse.
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So in this picture, as we can see, all of this diffuse bruising on the back. This is an older child.
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If there's no actual history to explain this bruising, someone can see this
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bruise and and be concerned because of the extent of the bruise on the back.
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Other, now we're going to talk about other conditions that can be mimics of bruises.
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We're going to talk about iatrogenic bruises. So these are very common bruises in young children.
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Bruises caused by any medical intervention. Children that are difficult,
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that have the difficult access or frequent hospitalization, chronic illness or ICU things.
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They may appear hours after procedures and can look more extensive than expected.
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And the important part that we always try to say to the medical team,
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so to document the procedure, the timing, and if there's any injuries documented on the medical record,
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if there's anything happening with the IV placement or blood draws,
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that should always be documented.
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These are examples of some bruises done are for blood pressure cuffs or here
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by blood rust, this area,
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or also blood rust on this area.
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We have hematoline purpura, which are bruised like purpura or ecchymosis,
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often sound symmetrically on lower extremities.
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The lesions can appear like ecchymosis and purpura, and they also may be accompanied
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by abdominal pain or joint pain.
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And the important part is the distribution, the symmetry that could kind of
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help us distinguish from abusive bruises.
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Also, if there's any additional symptoms, any systemic symptoms,
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that also can help with differentiating.
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These are other pictures of Henosho and Purpuruk, but also mimic bruises on
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the lower extremities. These are infants.
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And then there's also Urticaria pigmentosa, which is our tan round macules,
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papules, that can appear bruised-like.
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They are caused by mast cell accumulation on the skin.
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And also here it's important, that's why it's important to have the history
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and the physical exam because these lesions articulate with rubbing and they can be persistent.
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There's a lot of lesions around the body and they, so that will be an important
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differentiation from an abusive bruise.
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Another mimic would be neuroblastoma. So this can be, this can show bruised
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like, or bluish bruised like lesions around the periorbital area without any history of trauma.
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So that will be the part that will be concerning, that there will be no history
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to explain these findings.
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They may appear like ecchymosis under the eyes or around the eyes.
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But the important part here is that they can be systemic symptoms,
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so they can, there's going to be an abdominal mass, weight loss,
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irritability, other symptoms that could tell us.
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And these are unexplained, persistent lesions.
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So that's why we should consider other causes besides trauma or abuse.
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There's another interesting one, garments band lines. So these are linear skin
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marks caused by pressure or friction from tight clothing.
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So it can be elastic, waistbands.
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We've seen it with socks. We've seen it with diapers.
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They appear as very well-defined. I'm going to show you pictures now on the next slide.
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Appear well-defined, often symmetric lines, often also circumferential that
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may resemble pattern injuries.
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Typically located where clothing applies consistent pressure,
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like the waist or the thigh or the ankle or lower extremities.
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And the key features include sharp borders, symmetry, and then obviously now
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the correlation with the skin, or that's the important part of the history.
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Garment. So now here, these are pictures of the garment pant line.
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So here is like the lower extremity, also here lower extremity.
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This one, it's another one. And all of this one were caused by clothing,
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clothing that was applying pressure.
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So you can see that they can also easily be mistaken for bruises.
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Thank you.
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And then we have stretch marks uh so this could also be uh,
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misleading for for abuse so these are linear hyperpigmented
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or hypopigmented lines that also may resemble bruises or scars um they're often
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linked to rapid growth obesity or uh pregnancy changes in in weight or um steroid
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use um they're common in the abdomen the size, buttocks,
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and like this, the specific findings on the back.
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And they have chronic appearance, and that's when also the history may help
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distinguish between an acute injury, abuse, or dysmimic.
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So what do you hear? That's why I've been stressing the part of the history.
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So when we see all of these injuries, it's important to ask if there's a clear explanation.
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The important part is here, it's clear.
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Was the event witnessed by any caregiver or anyone?
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And important also is the child's verbal, to ask the child always what happened.
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Does the history fit the child's developmental abilities?
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Does the explanation match the injury pattern and the location where the injury is?
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Is there any family history of bleeding, easy bruising, or that's why work can be done?
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And then also, are there any systemic symptoms that suggest that there's any
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other medical cause, any underlying medical cause that could have been causing this injury?
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So these are all questions that we should consider.
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So we have here case number two. So this is a three-month-old that was brought
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in to the ED for this marks that we can see here on the lower extremities,
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on the back of the lower extremities, and on the right arched chest.
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Caregivers noticed the bruises or the discoloration while changing clothes and
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they denied any trauma falls or any injuries.
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They didn't have any history to explain.
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They also reported that the child had increased fuzziness over the past day,
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was feeling well, no vomiting, no fever, but was more fuzzy.
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And then important questions that were asked during the history taking was a
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development. And then the child is non-mobile.
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He's not yet rolling. And it's cared for at home by mother and maternal grandparents.
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So the child doesn't go to daycare.
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There have been no recent procedures,
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no accidental events, and no family history of bleeding disorders.
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So our question in this case would be, what are the next steps?
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So, in this specific case, we have a three-month-old infant who is non-mobile,
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and then on, so we have the history with no history,
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the development, and then when we go to the physical exam,
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if we start with the auto on the top,
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we have pattern injuries on the lower extremities, multiple pattern injuries,
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and also the important part in this case is the location of the bruise.
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Also here in this area, you see multiple linear abrasions, but also the concerning
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part here would be the location of the injury.
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So what are the next steps in this shell? This child should.
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Due to the age, should get a skeletal survey, should get a head CT to evaluate,
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and then also should get a complete bleeding workout.
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So this is the AAP, the recommended approach that AAP provides to evaluate bruising
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when there is concern for possible abuse.
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And this specifically guides when to consider a bleeding disorder workout.
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So if we see on the top,
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the first part is to determine whether these findings are clearly explained
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by abusive trauma or if they're a well-documented accidental mechanism.
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If there are features that are highly concerning, such as pattern bruising,
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as we talked earlier, or bruising in locations like the ears,
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necks, or the genital area.
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Then a bleeding disorder is not necessary if these findings are not explained
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by an underlying agulopathy.
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However, on the other side, if there is no explanation,
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particularly in a non-mobile child or when bruising is in concerning locations,
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then a hematologic or a consult to a pediatric hematologist should be done.
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A hematologist should be considered.
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So when to do additional workup. So skeletal surveys are recommended in all
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children less than two years old when there's concern for physical abuse,
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specifically the highest yield would be when children are less than 12 months old.
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Also in any non-mobile infant with bruises,
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any infant with unexplained or suspicious fractures or injury or inconsistent
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or absent or changing history.
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And also any high-risk situation. This would mean any sibling or household contact of any abused child.
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So that's called sibling risk assessment. So when there's any concern for any child,
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we evaluate any child that is living in the same household that is less than
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two years old. So that's part of the evaluation.
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And then head CTs should be done in infants less than six months old with concerns for physical abuse.
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There's a low threshold even when they're asymptomatic.
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Any infant less than six months old with neurologic symptoms,
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any vomiting, seizures, alter mental status.
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And then any infants with any high-risk findings concerning bruising patterns, any pattern injuries,
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or any bruises in locations that are not commonly injured in accidental injuries.
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So the takeaway points, early recognition matters.
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Sentinel injuries are subtle, and cell findings may be the first opportunity
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to identify and prevent further or more severe harm in the future.
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Injury interpretation or to
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interpret the injury requires careful correlation with the exam findings.
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That's very important to do the physical exam and also ask the child's development
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and the reported mechanism by the caregivers.
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Most cutaneous mimics can be identified through a thorough history and physical exam.
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And important to stay objective and vigilant and balance bias with maintaining
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a high index of suspicion to ensure the safety of our patients.
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And also very, very important that when in doubt, you can always seek support.
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Here at the Center for Miracles, we are always available for consultation.
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And you guys can reach out with any questions or concerns.
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Here on the lower part, it's our on-call phone number. Anyone write it down.
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This on-call phone number, there's always someone is going to answer this phone.
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There's someone 24-7, 365 days a year, and we're always willing to help.
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Let me switch here. Any questions?
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Thank you so much, Dr. Reyes-Ruiz, for that excellent presentation.
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We do have a question in the chat box from Dr. Francis.
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Is coining a form of abuse or just an acceptable cultural event?
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So I was, that's something that I was going to, I thought about a lot to add
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on this presentation and didn't add the cultural.
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So that's a really difficult question to respond.
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During these cases, we need to take in consideration the cultural practices.
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And so that will be something that you should discuss with the family,
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take into consideration with the family.
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And also when parents move here, they follow their cultures,
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but they should also follow here the rules as well.
40:43
Loss here in the US. It's something that you should discuss with the families.
40:48
And also, if it becomes a pattern, then it also gets,
40:52
if you inform the family and tell them about the negative consequences and anything
40:58
that could happen, and then it also becomes a pattern, then that could also raise more concern.
41:07
Thank you for listening to that fascinating talk. Don't forget to click on the
41:11
link in this podcast for free credit that may include CME, MOC,
41:16
or ethics credit, depending on our topic or podcast.
41:19
Our sister podcast is Pediatrics Now for Parents. That's also found wherever you get your podcasts.
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I'm Holly Wehmut. I'll see you soon.