Neglect and Child Physical Abuse Presenting with Sentinel Injuries in Children Four Years and Younger in the Emergency Department

Originally approved October 2023


The American College of Emergency Physicians (ACEP) acknowledges the crucial role of healthcare professionals in identifying and treating child maltreatment. Infants and children presenting to the emergency department (ED) may exhibit subtle signs of neglect and physical abuse, requiring careful evaluation, coordination with specialists, and judicious reporting to child protection agencies.

• Child maltreatment has far-reaching consequences, including long-term health impacts and increased risks of chronic illnesses, mental health disorders, addiction, and shorter life expectancy.
• Neglect and child physical abuse are leading causes of death and disability in children. In 2019 alone, over three million reports of suspected child maltreatment were received in the United States, with approximately 656,000 confirmed victims. Young children, in particular infants and pre-verbal children, are highly vulnerable. Tragically, child abuse claims the lives of an estimated 1,840 children annually in the United States. Forty-five percent of all child fatalities were children under the age of one.
• Signs of neglect can include poor supervision, care, nourishment, or hygiene. Both neglect and sentinel injuries, or seemingly minor trauma, can serve as indicators for potential more serious injuries. A validated clinical decision rule to help screen children under four years of age with bruising to identify when a bruise is more likely to be caused by abuse than accidental injury, such as TEN-4-FACESp which stands for bruising to the Torso, Ears, Neck, Frenulum, Angle of the jaw, Cheeks, Eyelids or Subconjunctivae, “4” represents infants four months and younger with any bruise, anywhere, and “p” represents the presence of patterned bruising, aid in distinguishing abusive from non-abusive trauma based on the characteristics of bruising. Recognition of neglect and sentinel injuries provides an opportunity to intervene and prevent further harm.
• Previous studies highlight missed opportunities in identifying sentinel injuries. 1/3 to 1/2 of children who are severely injured or die due to physical abuse have been previously evaluated by healthcare professionals shortly prior to their deaths for seemingly minor visible injuries which were likely caused by abuse, but the diagnosis of abuse was not recognized. Recognizing signs of child abuse, such as sentinel injuries is essential for prompt evaluation of child abuse, regardless of social risk factors or protective factors.
• When a sentinel injury is identified, physicians should pursue further evaluation to assess additional injuries and underlying medical conditions. Guidelines from the American Academy of Pediatrics, American College of Surgeons, and American College of Radiology offer detailed approaches to evaluation for different clinical presentations.
• The use of electronic medical records (EMRs) can facilitate standardized care, guideline adherence, and improved outcomes. Strategies such as universal screening for child abuse, clinical decision support triggers, and child abuse-specific order sets can be implemented within the EMR system.