In more than two decades as a child-abuse pediatrician, Dr. Lynn Sheets has noticed a trend.
Often, when a seriously abused child arrives, perhaps with broken bones or head trauma, she looks back at medical records and finds that the same child often sustained minor bruises as an infant.
“That piqued my interest,” says Sheets, an associate professor of pediatrics at the Medical College of Wisconsin. Colleagues around the country noticed the same thing. “There are many cases where a child would have, say, a bruise on his cheek and the mother would say, It’s from bumping into a pacifier. Then several weeks later, that child would come in having been beaten or slammed or even killed.”
Those observations led Sheets to investigate the association between bruises in babies considered too young to be hurting themselves and later abuse. The results of her study, published this week in the journal Pediatrics, found that fairly minor injuries like bruises can forecast more severe abuse, a phenomenon known as sentinel injuries.
Sentinel injuries are unexpected injuries that occur in babies who can’t yet cruise — before they can pull to a stand and take a few steps while holding on to something. “Babies who are not yet cruising shouldn’t be bruising,” says Sheets, who is medical director at the Child Protection Center, Children’s Hospital of Wisconsin. “We already knew that, but what we didn’t know is that babies who’ve been horribly abused often have a previous history of bruising.”
Sheets and her colleagues looked at three groups of babies under 1 year of age: infants who were abused, those who were evaluated but were found not to have been abused and babies where it was impossible to know whether injuries had resulted from abuse.
Of 401 babies studied, 200 were substantiated as abused, with 27.5% of them having previous documentation of minor bruises. Those babies whose injuries were not associated with abuse had zero prior reports of sentinel injuries; 8% of babies in the undetermined group had a history of minor injuries.
While the connection seems unsurprising, it’s important for helping doctors to navigate the challenging thickets of determining when abuse is occurring among the youngest victims. “If we can call them what they are — ‘sentinel’ injuries, or warning injuries — it helps people think differently about them,” says Sheets.
Providers should also be alert to implausible explanations that could hide the first signs of abuse, such as bumping and bruising in a precruising baby that’s explained as the infant banging her leg on the crib.
Babies, says Sheets, are actually pretty hard to bruise. They roll over into crib slats and swings all the time, and such bumping with their own body weight typically shouldn’t leave a mark. “It’s about heightening awareness,” she says.
From a public-health perspective, it’s also about saving money: each case of child abuse carries with it an estimated $210,000 lifetime price tag, and identifying cases early or monitoring cases of suspected abuse could help to alleviate some of these costs.
To cut down on abuse, it’s helpful to understand that crying is the primary trigger that sets some parents off. Online campaigns such as the Period of Purple Crying teach parents that crying — lots of it, especially early on — is a normal developmental stage. “If we can identify abuse early,” says Sheets, “that in and of itself may help families get additional resources to deal with the stress of a new baby.”