Sentinel Injuries in Emergency Departments and Subsequent Serious Injury in Children - 04/09/25

Doi : 10.1016/j.annemergmed.2025.07.033

Stephanie M. Mitrano, MD ^a,^⁎ , Kenneth A. Michelson, MD, MPH ^c, Michael C. Monuteaux, ScD ^b, Daniel M. Lindberg, MD ^d, Caitlin A. Farrell, MD ^b, Joyce Li, MD, MPH ^b
^a Division of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
^b Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
^c Division of Emergency Medicine, Ann & Robert Lurie Children’s Hospital of Chicago, Chicago, IL
^d Departments of Emergency Medicine and Pediatrics, University of Colorado Anschutz Medical Center, Aurora, CO

^∗Corresponding Author.

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Thursday 04 September 2025

Abstract

Study objective

Sentinel injuries in young children are minor injuries that can raise suspicion of physical abuse. Although early identification is critical, widespread screening of patients can incur unintended harm to both children and their families. We determined the frequency of serious abusive injury within 12 months following an emergency department (ED) encounter for a sentinel injury.

Methods

Using the Healthcare Cost and Utilization Project State ED and Inpatient Databases, we identified children 0 to 24 months of age with an ED diagnosis of a sentinel injury between 2014 and 2019. Our primary outcome was serious abusive injury (admission for serious injury or death with a child abuse diagnosis) within 12 months of a sentinel injury ED visit.

Results

Among 23,919 children with a sentinel injury ED visit (median age 5 months, 53% boys), bruise or fracture was diagnosed in 14,501 children (60.6%). In the 12 months following the sentinel injury visit, serious abusive injury was diagnosed in 176 (0.7%) patients. At the index ED encounter, abuse was diagnosed in 1,156 children (4.8%); 96 (8.3%) of these patients had an additional serious abusive injury diagnosed within 12 months.

Conclusion

Subsequent diagnosis of a serious abusive injury was uncommon after an initial ED sentinel injury diagnosis. Of all children in whom abuse was diagnosed during the study period, the majority of patients were diagnosed at the sentinel injury ED visit, with nearly 1 in 12 at risk for subsequent serious injury. Prospective studies are needed to further risk-stratify children with sentinel injuries.

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Keywords : Physical child abuse, Nonaccidental trauma, Pediatric emergency medicine, Sentinel injuries

Plan

Introduction

Background

Importance

Goals of This Investigation

Materials and Methods

Study Design

Selection of Participants

Characteristics of Study Subjects

	Please see page XX for the Editor’s Capsule Summary of this article.
	Supervising editor: Benjamin T. Kerrey, MD, MS. Specific detailed information about possible conflict of interest for individual editors is available at editors.
	Author contributions: SMM and JL conceived the study, designed the methodology, and obtained IRB approval. MCM and KAM supervised the conduct of the data collection. KAM acquired and cleaned the data set. MCM and KAM provided statistical advice on study design and SMM and MCM analyzed the data. DML and CAF provided expert opinion on the topic and assisted with study design. SMM drafted the manuscript, and all authors contributed substantially to its revision. SMM takes responsibility for the paper as a whole.
	Data sharing statement: From the date of publication, due to an existing data use agreement with the supplier, the data may only be obtained from Healthcare Cost and Utilization Project (HCUP) directly (hcup-us.ahrq.gov). Data dictionary is also available directly from HCUP. We can share analytic code upon reasonable request. Please contact Stephanie Mitrano at smitrano1@mgb.org.
	All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
	Funding and support: By Annals’ policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). Dr. Lindberg has provided paid expert witness testimony and medical record review in cases with concern for physical abuse. Dr. Farrell receives author royalties from UpToDate.com for pediatric trauma content. Dr. Li has received payment for giving lectures on emergency medicine topics for Northwest Seminars, reimbursement for travel from the American College of Emergency Physicians for educational presentations at the national assembly and honorariums for writing articles for pediatric emergency medicine practice. Dr. Michelson received funding through award K08HS026503 from the Agency for Healthcare Research and Quality.
	Presentation information: This study was presented at the Pediatric Academic Societies Meeting 2024 on May 4th in Toronto, Canada.