Identifying abuse or non-accidental trauma in children

Ignoring 'sentinel injuries' in child can lead to more abuse, and life-threatening situation

Dr. Jada Ingalls discusses sentinel injuries investigation and non-accidental trauma for the Called to Care podcast

Episode Transcript

Courtney Collen (Host): Hello, welcome to our new medical series ‘Called to Care’ by Sanford Health. I’m your host, Courtney Collen, with Sanford Health News. Called to Care brings forward medical experts who can give fellow clinicians some advice and guidance they can use in their primary care practice and information about when it’s time to refer patients and families to more specialized care.

Joining me for six episodes, focusing on children’s care is Joseph Segeleon, MD. He’s the vice president and medical officer for Sanford Children’s Hospital and a leader in pediatric critical care. Good to have you here, Dr. Segeleon.

Dr. Joseph Segeleon: Good to see you as well, Courtney.

Host: You have narrowed down six timely topics for us. In this specific episode, we’re talking about sentinel injuries and non-accidental trauma. Dr. Segeleon, tell us why you chose this specific topic.

Dr. Segeleon: Unfortunately, in our society and every provider out there knows this, we do see child abuse and almost more importantly, we have this sneaky suspicion that we miss child abuse. So I really thought it would be valuable if we got an expert to give us some advice and some support for how we go about handling this issue.

Host: Yeah. Well, let’s welcome Dr. Jayda Ingles to our conversation. Welcome.

Dr. Jada Ingalls: Thank you,

Dr. Segeleon: Dr. Ingalls. Thanks again for coming and agreeing to talk. We’re excited to have you here today, and I know our providers are going to really find it valuable. I think first of all, I’d like to ask you is what kind of training does a child abuse physician have?

Dr. Ingalls: Sure. So as always, we go through medical school graduate from that, we then match into a pediatric residency, which is three years of training. And then after that, you will apply and match into a child abuse pediatrics fellowship, which is also three years of training.

Dr. Segeleon: Great, thank you. You know, as a pediatric critical care physician, my entire career I’ve obviously seen sometimes just tragic and horrific consequences of child abuse, knowing that most of the providers that are going to be listening to this podcast are outside providers or rather outpatient providers. I know a lot of them often worry about missing child abuse and what signs and symptoms will help me identify the child who could be at-risk. So could you give us a little bit of a overview and some specifics on what do providers look for that makes them suspicious that a child may be being abused or neglected?

Dr. Ingalls: Sure. I always think that one of the most important topics for anybody who sees children in a medical setting to know about is what we call ‘sentinel injuries’. Sentinel injuries are relatively minor injuries from physical abuse, that if they’re not recognized and intervention does not occur to keep a child safe, typically physical abuse will become worse over time and then you can end up with a more life-threatening injury.

Dr. Segeleon: What specific patterns should I look for? So, these are minor injuries that sort of portend to something more significant in the future?

Dr. Ingalls: Yeah, so we typically use a pneumonic that’s called 10-4 Faces-P as a reminder of what are the types of injuries that are part of Sentinel injuries. So 10 stands for bruising or injury to the torso, ears and neck in any child under four years of age. When they’ve done studies that have looked at where on the body do children normally get bruises from accidental injury versus from physical abuse, it’s very unusual for children to get accidental bruising on the neck and specifically on the ears, and then the torso being the chest, abdomen and back. So, those are areas we look for. Also the ‘four’ stands for any bruising in an infant, less than four months of age. So, the reason that’s important is because infants under four months, can’t roll. So they’re not going to be able to have an injury that a caregiver doesn’t know if they’ve managed to wiggle off of a couch or something and got a bruise from falling, then a caregiver is expected to know that fall occurred. They left them in one place and found them in another place. Also, we look at the ‘F’ is for frenulum. So there are three frenulum, or frenna in the mouth. So there’s two labial frenulum. So one on the upper lip, one on the lower lip and then the sublingual that’s under the tongue. So whenever I do exams, I always flip up both lips, make sure the frenulums are in tact, lift up the tongue, look under there. If you see any kind of bruising, laceration, injury to that area is often a sign that an infant has had a bottle or a spoon shoved in their mouth. Or sometimes we’ll see it with smothering or suffocation where someone places a hand over the child’s mouth and they’re vigorously moving their head back and forth and attempt to breathe and that tissue gets torn. And the other area that we look at in terms of bruising to the face would be the angle of the jaw. So around your mandible, if someone grabs a child’s chin or face and is yelling at them can leave two circular bruises around that area. Cheeks, if there’s bruising along like the fatty part of the cheek, that’s an area that’s harder to bruise. So, anywhere that has more fat is not a usual place for an accidental bruise. Eyelid bruising is also concerning. So your orbital rim should be protecting your eyelids. So if we’re seeing bruising on the eyelid itself, that’s concerning. In infants under a year, subconjunctival hemorrhages can be concerning. So sometimes we’ll see those if somebody has squeezed a baby and you’re increasing their intrathoracic pressure and the vessels will break, you want to always be careful though that it’s not something that happened with birth, go back, review the documentation from the newborn nursery or parents have pictures from that time because that could be a birth-related finding as well, and then pattern injuries. So pattern injuries of the skin, whether that’s pattern bruising, pattern burn, things of that nature. We think about belt marks, loop marks, hand slaps, those type of things.

Dr. Segeleon: You said something interesting about ears. Could you be a little bit more specific about ear bruising?

Dr. Ingalls: Sure. So ear bruising in kids especially if they’re not mobile is very highly specific for physical abuse because, and by not mobile, I mean not ambulatory, not completely walking independently. And so the way that we see ear bruising in children, when it’s caused by abuse is typically it could be an open-handed slap to the side of the head or a punch or a kick or strike with an object to the side of the head where the ear gets crushed between the object that’s striking the child’s head and the actual skull. And so in order to make sure that you see all of the ear bruising and my routine practice, even when I was a resident and I became aware of this, anytime I went to do an ear exam, I would flip the ear forward to shine the light back there. Because, sometimes it will only be on the back surface of the ear or it could even be on the scalp that’s budding the ear.

Dr. Segeleon: Okay. Thank you. You know, I can’t tell you as, as a intensivist, how many times I’ve seen children injured from child abuse and a common explanation is, ‘the child fell off the couch’. That just seems to be a common refrain that we hear. Can you expand a little bit on what’s kind of accidents are innocent and how, particularly if the injury seems much more than the history, what should we be looking for for the listeners out there? What should they be looking for as far as red flags?

Dr. Ingalls: Sure. So yeah, certainly we know that accidental falls can occur. When I think about accidental, these would be in the category of short falls and by short falls, that means something that’s less than six feet in most cases. And that is where a couch fall would fall into. So when we talk about short falls and there have been studies that have even been done on kids that are admitted to the hospital and have a shortfall, whether it’s from the bed in the room, the couch in the room or the crib in the room. And when you look at those studies, the most common outcome of a short fall at home is going to be no injury at all. Most kids are perfectly fine. If you look at the next level, then you’re talking about, well, maybe they have a bruise on the scalp. Maybe they have a scalp hematoma that’s palpable then after that would be a skull fracture. And then sometimes after that you could have a subdural bleed underneath of the skull fracture, sometimes subarachnoid. And then kind of when you’re getting into things that are more concerning would be a parenchymal injury. We don’t expect a parenchymal brain injury from a short fall without a specific reason. In short falls, that could be a whole talk in and of itself. But I think, you know, for me, when I come in and I’m thinking about the history and is possible, I always want to know the child’s developmental capability, right? So if somebody says they left them all the way in the back of the couch or in the middle of the bed, is that baby able to roll? Are they able to crawl? Would it be possible asking the parents ‘how high is the bed?’ Cause not everybody has it on a, on a frame could just be lying on the floor. Is there anything on the floor or in the pathway of the fall that the child could have struck their head on? Is there a nightstand, are there objects on the floor toys, other things like that?

Dr. Segeleon: Thank you. Yeah. I think a fair generalization is that if the injury out weighs or seems much more significant than the mechanism, that’s probably a reason to be suspicious?

Dr. Ingalls: It is. And also if the history that’s given to you is not consistent with what the child’s developmental capabilities are, is always a red flag.

Dr. Segeleon: Yeah. Great. Thank you. It good, very good advice. I know as an intensivist when we saw impact injuries, particularly if it was an impact with a skull fracture, we would very often know that there was a mechanism of injury, but of course subdural bleeds that were bilateral, especially in constellation with retinal hemorrhages would be much more concerning. And I know that’ll be a topic for probably another day. So familiar I’m in the outpatient world. And I am seeing children that I have a suspicion that I’m concerned, what, what should I do? Who should I go to do I have to go to … and a lot of times providers are concerned with what if I’m wrong? What if I accused this family that has been coming to see me and I’m wrong? Can you, can you expand a little bit on that for me please?

Dr. Ingalls: Sure. So I think anytime that you have a concern, it can be uncomfortable, especially if you are in a primary care provider because the family trusts you, you may have taken care of all of the kids, even other generations of the family. And you want to, you can be concerned that they may not return to you if you have to make a report. And that is absolutely a legitimate concern. I think we have to always weigh it against the, what is the risk to the child? What if I don’t report this and this child goes home, the abuse gets worse and this becomes a near fatality with permanent disability or death. And so I think you have to consider your responsibility to the child’s safety, but also what is the mandated reporting laws in your state? And so all 50 States have requirements that if you have a suspicion for abuse of a child, that you have to report it, usually that report goes through child protective services in your respective state.

I, for one always think that it is best to tell the family if you’re going to make that report. It is difficult conversation to have, I think families take it better when they are, when they’re told that any, you know, you can try to make it so that they don’t feel like you’re exactly calling them out. Our role is never to say ‘who caused the injury?’ All we say is that there is an injury I’m concerned about. And what I tell them is that legally by the state’s requirements, as a mandated reporter, I have to make a report. Whenever I see this particular finding, that doesn’t mean that I’m saying that ‘you did it’. It’s just saying that somebody else needs to investigate it to find out what happened. We also want to make sure that, you know, we’re telling families there could be additional workup that sometimes a specialist like a child abuse pediatrician has to come in and see if there could be other alternatives, you know, medical conditions that could lead to some of these things.

But usually, I end the conversation stating that I know the family loves the child and they want their child to be safe. We want the same thing. Sometimes the conversation goes very well. Parents understand some of them are even mandated reporters in their jobs. And sometimes it doesn’t always go as pleasant as we would like it to. But at least we’ve told them upfront and then they know that CPS will be contacting them. And it also turns into I think less surprised. I never think it’s fair for a family to just get a phone call or a knock at the door from CPS and not been told that we made that report.

What happens if you make a report and you’re wrong? For you personally, as long as you’re making a report in good faith, you’re protected by the seat statute.

You’re not going to be in trouble. You’re not going to be getting you know, any century because you made a report in good faith. It’s also, I think, important to remember that the system does not 100% rely on us. So you make the report to CPS. The CPS intake worker looks at it, reviews it, the information with the supervisor, and then CPS decides whether or not they’re going to open or not. The vast majority of reports that are made to CPS go through that initial screening process and are never opened. So, you could make a report and the family is never contacted by CPS. If they do decide to open there’s two pathways that it goes into. So it either goes into an active investigation, which is rare and less common, or it goes into family assessment, which is more like what kind of services and support can we offer the family and is not a punitive route

Dr. Segeleon: I know that is something that’s on provider’s minds because you you’re often not a hundred percent sure. So that’s great information. You know, many, many, many years ago, I was a pediatrician for two years actually on the east coast. And I recall during those two years being very concerned about missing a case. You come out of pediatric residency and you understand, and you realize, unfortunately, the child abuse is much more common than is talked about. And I know that a number of my colleagues out in outpatient medicine, we do worry about missing that case and missing those children that are being abused.

Dr. Ingalls: I think it’s always, you know, you can always recognize too, that whatever system you’re working in or what, whoever you’re near, if there is a child abuse center nearby, you can call that clinic at any time and get a child abuse pediatrician to talk through with you what you’re seeing to let you know, if it’s something that they’re also worried about, sometimes that can give you reassurance, or if, you know, occasionally we’ll see things that someone’s worried about. They’re able to send pictures through MyChart, through the haiku app and we can say, ‘oh no, we recognize this as a particular skin condition or something else that someone may not be familiar with’. So I would encourage people also to consider that, to reach out either appear to the care clinic in Fargo or to child’s voice in Sioux falls. We’re always willing to help.

Dr. Segeleon: Great. Thank you. The other thing I wanted to ask you is, you know, a lot of times as an outpatient physician, you’re looking at kids do fall and kids get in injuries. And so frequently it’s broken bones, you know, there’s fractures. Are there specific things that you see on an x-ray that should alert you?

Dr. Ingalls: Sure. So there are some fractures that are highly specific for physical abuse. Those would be post your rib fractures and also any, any fracture in a child that is non-ambulatory, not walking yet.

Dr. Segeleon: Great. Thank you. That’s very helpful. So as you alluded to there’s now a child abuse center and you’re the first child abuse specialist I believe in North Dakota. Is that correct?

Dr. Ingalls: So Dr. Arnie Graf was here for a while and he had left to go to the Mayo Clinic. So I am picking up where he left off, I believe approximately six to seven years ago.

Dr. Segeleon: Oh, well, fantastic. We are so fortunate to have you here in this region, in this community. Why and when would I, as an outside provider, refer someone specifically to your center and how do I go about doing that?

Dr. Ingalls: Sure. So I think you know, we see at our center, any children where there are concerns for physical abuse, sexual abuse and neglect, we can even see kids where their concerns for psychological abuse. And we see cases of torture as well. So anything that you are concerned about, certainly you could make a referral through the the Epic system. There is an order for child advocacy is the way that you would usually find it for us. I believe there is an order also for a child’s voice. And then it’s as simple as just putting an order through the chart. If it’s something that can wait, you know, another week or two to schedule, that would be something like, you know, maybe parents have concerned about some sexualized behaviors or something like that. If it’s something you’re not sure whether it can wait or it needs to be seen sooner, you can always call us just directly at the phone number for the clinic or through one call.

We take calls both ways, most physical abuse concerns. I like to know about sooner rather than later, if there’s still skin injury, that’s visible because I would like to have high quality pictures of that that could be taken in my clinic or in the ER in the hospital. And also I want to help providers and get history from them to determine where is the most appropriate place to send this child? Is this a child that needs to go? Are they within the timeframe for a sexual assault kit? They need to go to the ER, is that a child that has a physical abuse injury that may be gone by the time I see them in a week or two, and maybe they need to go to the ER as well. So I personally always just appreciate getting a phone call. I know that takes some time out of the provider’s day, but I think it helps us direct the child to the right place.

Dr. Segeleon: So if I’m a provider and I have maybe just a question or a concern, it would be okay to give you a call and kind of get your advice on a case?

Dr.  Ingalls: For sure. We’re here all the time. We’re happy to take phone calls. We do multiple calls a day. We want to make sure that these kids are safe, that you feel comfortable with the clinical decisions that you’re making.

Dr. Segeleon: Thank you so much. It’s really been great to have you here. And it’s been you’re just a great information source and really helpful.

Host: Dr. Ingalls, thank you so much for your expertise on cases of non-accidental trauma and giving us more insight on when it’s time to make report and refer to a child abuse specialist like you. Our Called to Care Podcast series, focusing on children continues with topics from appendicitis to joint pain right here with our own Sanford health experts.

Dr. Ingalls, Dr. Segeleon, thank you so much for being here. We’ll see you soon.

Posted In Children's, Physicians and APPs

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