Red Flag Injuries for Child Abuse

William T. Basco, Jr, MD, MS


January 05, 2016

Testing for Abuse in Children With Sentinel Injuries

Lindberg DM, Beaty B, Juarez-Colunga E, Wood JN, Runyan DK
Pediatrics. 2015;136:831-838

Sentinel Injuries of Abuse

It can be difficult, on the basis of history or interactions with patients and families, to determine which children should have a comprehensive evaluation for abusive injury. This study sought to determine whether specific injury types were more or less likely to be associated with abusive injury, in the hopes of identifying "red flag" injuries for providers to focus on.

The data in this study were obtained from 18 children's hospitals that participate in the Pediatric Health Information System (PHIS). Using data from 2004 to 2011, 30,355 children aged < 24 months with a putative sentinel injury (one that might indicate abuse) were identified. More than 89% of the children had only one putative sentinel injury, 7.6% had two such injuries, and the remainder had three or more. The candidate injuries evaluated for this study were bruising; burns; oropharyngeal injury; intracranial hemorrhage; abdominal trauma; genital injury; subconjunctival hemorrhage; isolated skull fracture; and fractures of the humerus, ribs, radius, ulna, or fibula.

The frequency of diagnosis of abuse in children with a sentinel injury varied with the age of the child, ranging from a low of 3.5% for burns in infants aged < 6 months to a high of 56.1% for rib fractures in children aged < 24 months. Sentinel injuries that were associated with abuse < 10% of the time in the entire cohort included burns (3.5%), isolated skull fracture (4.3%), and subconjunctival hemorrhage (8.6%). Sentinel injuries associated with abuse in 11%-20% of the cohort included oropharyngeal injuries, fractures of the long bones of the arms and legs, and genital injuries. Injuries associated with abuse in more than 20% of cases were intracranial hemorrhages (26.3%) and abdominal trauma (24.5%). Only 46% of the visits by a child with at least one of the putative sentinel injuries resulted in a skeletal survey.

The study concluded that several injury types (rib fractures, intracranial hemorrhage, and abdominal trauma) are associated with abusive injury > 20% of the time. They suggest that further work is needed to systematize the evaluation of patients with putative sentinel injuries.


These data serve to remind practitioners of some of the putative sentinel injuries for abuse of children. I'm struck that so many injuries were associated with abuse more than 10% of the time, although only three injury types were associated with abuse more than 20% of the time.

The more difficult question, which the study authors allude to, is whether the risk associated with any particular injury is low enough to warrant forgoing a more comprehensive workup. For example, if the chance that a burn is associated with abuse in only 1% of children, is that low enough, without other historical or physical features, to justify avoiding additional workup?

Variability in practice points out a bigger dilemma. Given that several of these findings are associated with evidence of abuse at high enough frequencies to warrant further inquiry, variability in the decision to obtain a skeletal survey may not be acceptable. From a quality standpoint, I agree that we would do well to focus on completing a comprehensive workup when one of the high-concern injuries is present rather than to trying to decide whether any injuries have a low enough association with abuse to avoid additional workup.


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