TOPLINE:

A study found that only 0.7% of children who visited the emergency department (ED) for sentinel injuries experienced a serious abusive injury within 12 months of the index visit.

METHODOLOGY:

• Researchers conducted a retrospective analysis of 23,919 children aged 0-24 months (median age, 5 months; 53% boys; 48.2% White, 23.2% Black, and 15.3% Hispanic) who presented to the ED with sentinel injuries between 2014 and 2019.
• Sentinel injuries included bruising and oropharyngeal injuries in children younger than 6 months; extremity fractures and traumatic brain injuries in children younger than 12 months; and rib fractures, subconjunctival hemorrhage, or genital, thoracic, or abdominal injuries in children younger than 24 months.
• The primary outcome was a serious abusive injury, defined as an injury — including fracture, traumatic brain injury, burn, abdominal injury, or thoracic injury — requiring hospitalization or resulting in death.
• Secondary outcomes were any serious injury, a child abuse diagnosis at the index ED visit, a child abuse diagnosis within 12 months of the index ED visit, a child abuse diagnosis leading to any admission within 12 months of index ED visit, and death.

TAKEAWAY:

• At 12 months after the initial visit, 1.8% of patients experienced a serious injury and 0.7% experienced a serious abusive injury; the mortality rate was 0.05%.
• Child abuse was diagnosed in 4.8% of patients at the initial ED visit and in an additional 0.6% within 12 months.
• Among patients diagnosed with abuse at the index visit, 8.3% experienced a subsequent serious injury.
• At the initial ED visit, the most common sentinel injuries were bruising (39.1%) and fractures (21.5%); 20.9% of patients had multiple injuries, and 88% were discharged home.

IN PRACTICE:

"Our study contributes to the current body of literature on child physical abuse by providing insight into the implications of sentinel injuries for child abuse recognition," the authors wrote. "Although current ED practice should not change based on our study, further studies are needed to refine our understanding of the risks associated with specific sentinel injuries and injury patterns," they added.

SOURCE:

The study was led by Stephanie Mitrano, MD, Massachusetts General Hospital, Harvard Medical School, Boston. It was published online on September 3, 2025, in Annals of Emergency Medicine.

LIMITATIONS:

The study relied on diagnosis codes without a clear gold standard for abuse or injury severity, which likely underestimated or missed cases. It included only ED and hospital visits within the same state and excluded outpatient encounters, potentially overlooking abuse diagnoses made outside the ED. It lacked clinical details such as bruise location, developmental milestones, injury-history consistency, and documentation of child protective or social work referrals, limiting assessment of the specific abuse risk for each injury type.

DISCLOSURES:

One author provided paid expert witness testimony and conducted medical record reviews in cases with concern for physical abuse, and another received author royalties from UpToDate.com for pediatric trauma content. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.