Overview
Definition:
Sentinel bruises in non-mobile infants refer to minor, often inexplicable bruises that may precede more severe inflicted injuries
These bruises, particularly in infants too young to ambulate or actively explore their environment, can serve as a critical warning sign of potential child abuse or neglect.
Epidemiology:
Bruising is common in mobile infants, but in non-mobile infants (under 12-18 months), any bruise should raise suspicion
Studies indicate a significant percentage of abused infants present with bruises, with sentinel lesions potentially preceding major trauma in some cases
Incidence data varies, but recognizing these signs is paramount for early intervention.
Clinical Significance:
The presence of sentinel bruises in a non-mobile infant is a medical emergency and requires a high index of suspicion for abuse
Failure to recognize and appropriately investigate these findings can lead to devastating outcomes, including severe injury or death
Early identification and intervention are crucial for protecting the child and addressing the underlying family dynamics.
Clinical Presentation
Symptoms:
Parental reports may be vague or contradictory
Common presentations include: Unexplained bruises discovered during routine examination or bathing
History of minor falls or bumps that do not correlate with the injury
Irritability or fussiness without clear cause
Feeding difficulties
Fever or lethargy (in cases of more severe trauma).
Signs:
Physical examination should be meticulous and systematic
Look for: Bruises in various stages of healing (indicating multiple incidents)
Bruises on unusual locations for accidental injury (e.g., trunk, ears, neck, buttocks, inner thighs)
Bruises with patterns suggestive of inflicted injury (e.g., handprints, linear patterns, strap marks)
Petechiae or ecchymoses
Signs of associated trauma: fractures, retinal hemorrhages, subdural hematomas, internal injuries.
Diagnostic Criteria:
There are no definitive diagnostic criteria for sentinel bruises per se
The diagnosis is primarily based on clinical suspicion, age of the infant, mechanism of injury (or lack thereof), and the pattern/location of the bruises
A multidisciplinary approach involving pediatrics, child protection services, and social work is essential for comprehensive evaluation.
Diagnostic Approach
History Taking:
Obtain a detailed history from all caregivers
Key points to elicit: Developmental milestones and mobility
Daily routine and supervision
Any reported falls or accidents, no matter how minor
Any unusual events or stressors within the family
Previous injuries or concerns raised by healthcare providers
Substance abuse or mental health issues of caregivers
Red flags: Inconsistent histories, blame shifting, evasiveness, lack of concern for the infant's well-being, history of abuse within the family.
Physical Examination:
Perform a complete head-to-toe physical examination
Document all findings meticulously, including the location, size, color, and shape of any bruises
Use a standardized diagram for documentation
Examine the infant in a well-lit, warm environment
Pay close attention to: Skin for any lesions, bruises, burns
Eyes for retinal hemorrhages or strabismus
Head and neck for any signs of trauma
Skeletal survey to rule out occult fractures
Genitalia and perianal area for signs of abuse.
Investigations:
Radiological: Skeletal survey (X-rays of long bones, skull, spine, pelvis) is crucial to detect occult fractures, which are highly indicative of abuse
Consider follow-up imaging like CT scans or MRI of the head and abdomen if there are signs of significant trauma or concern for internal injuries
Laboratory: Complete blood count (CBC) to assess for anemia or infection
Coagulation profile (PT, PTT, INR) to rule out bleeding disorders if bruising is extensive or unexplained
Liver function tests (LFTs) and renal function tests (RFTs) may be indicated based on clinical suspicion
Urinalysis
Consider toxicology screen in specific circumstances
Genetic testing for bleeding disorders if coagulation studies are normal but suspicion remains high.
Differential Diagnosis:
While child abuse is the primary concern, other conditions can mimic bruises: Bleeding disorders (e.g., hemophilia, von Willebrand disease, idiopathic thrombocytopenic purpura)
Henoch-Schönlein purpura (though typically purpuric rash on lower extremities)
Osteogenesis imperfecta (can present with fractures and bruising)
Osteoporosis
Certain infections (e.g., meningococcemia with purpura fulminans)
Accidental trauma (must be carefully evaluated for plausibility based on infant's developmental stage and history)
Other rare genetic conditions.
Management
Initial Management:
Immediate removal of the child from the abusive environment is paramount
This typically involves alerting child protective services (CPS) and hospital medical staff designated for child abuse cases
Ensure the infant is medically stable and address any immediate life threats
Secure evidence meticulously, including photographs of bruises if appropriate and legally sanctioned.
Medical Management:
Management focuses on treating any associated injuries (e.g., fractures, head injuries, internal bleeding)
Supportive care is vital: pain management, hydration, nutrition
If a bleeding disorder is diagnosed, specific management will be initiated (e.g., factor replacement)
No specific pharmacological treatment for the bruises themselves beyond addressing underlying causes.
Surgical Management:
Surgical intervention is indicated for associated injuries such as significant intracranial bleeding requiring evacuation, repair of lacerations, or management of abdominal injuries (e.g., splenic or hepatic tears)
Orthopedic surgery may be required for complex fractures.
Supportive Care:
Close monitoring of vital signs and neurological status
Nutritional support to ensure adequate growth and development
Psychological support for the infant and any siblings
Collaboration with social workers and child protection agencies is essential for ongoing care and safety planning.
Complications
Early Complications:
Immediate complications include severe head injury (subdural hematoma, diffuse axonal injury), long bone fractures, abdominal organ damage, retinal hemorrhages, and death
Infection can arise from open wounds or fractures.
Late Complications:
Long-term sequelae can include developmental delays, cognitive deficits, behavioral problems, learning disabilities, physical disabilities from fractures, chronic pain, and psychological trauma (PTSD)
Re-victimization is a significant concern if safety plans are inadequate.
Prevention Strategies:
Primary prevention involves public education on infant safety and child abuse prevention
Secondary prevention involves early identification of at-risk families and providing support services
Recognizing sentinel bruises and acting promptly is a critical tertiary prevention strategy to avert severe harm.
Key Points
Exam Focus:
Any bruise in a non-mobile infant is suspicious for abuse
Skeletal survey is mandatory for occult fractures
Differential diagnosis includes bleeding disorders
Always involve child protective services
Meticulous documentation is crucial.
Clinical Pearls:
Trust your instincts
If a history doesn't fit the injury, investigate thoroughly
Document even minor findings with diagrams and descriptions
Always examine the infant in a well-lit area, unclothed
Consider the developmental stage when assessing the plausibility of accidental injury
Remember to examine the eyes for retinal hemorrhages and ears/neck for bruising.
Common Mistakes:
Dismissing bruises in non-mobile infants as accidental without thorough investigation
Inadequate or incomplete history taking from caregivers
Failing to perform a complete physical examination and skeletal survey
Not involving child protective services in a timely manner
Lack of meticulous documentation, which can impede legal or protective actions.