Child maltreatment recognition and response — formative SAQs

SAQ 1 (10 marks)

A 3-month-old infant who does not yet roll is brought to the emergency department with a single small bruise on the pinna and a small bruise over the cheek, attributed to a feed-bottle knock. The infant is otherwise well. [8]

1. Define a sentinel injury and explain why this presentation qualifies as one. (3) [8] [9]
2. Outline the recognition-to-response bundle you would run, naming each step and stating which steps must NOT wait for the others. (5) [2] [9]
3. State when you would make a mandatory report, and the principle on which reporting rests. (2) [2]

Model answer

A sentinel injury is a visible, minor injury in a pre-mobile infant whose stated mechanism does not adequately explain it. This presentation qualifies because the infant does not yet roll or move independently, yet has bruising on the pinna and cheek — sites that an infant at this developmental stage cannot injure through its own movement, and a feed-bottle knock does not plausibly produce a pinna bruise. Among infants evaluated for physical abuse, roughly one in three with such an injury has occult abuse found on workup, and the sentinel injury may precede a fatal or disabling event. [8] [9]

The recognition-to-response bundle runs in parallel, not in series: (1) stabilise and treat any physiological threat using an ABCDE approach; (2) examine top-to-toe in a trauma-informed way and document every injury on a body map with measured size, colour, pattern and photographs with a scale; (3) investigate with a skeletal survey with dedicated views and a coagulation screen, repeating the survey at 11 to 14 days; (4) report to child protection; (5) refer to the multidisciplinary child-protection team and arrange a case conference; and (6) build a written safety plan and arrange follow-up. Documentation and reporting must NOT wait for completion of the workup — they proceed at the same time. [2] [9]

A mandatory report is made when the clinician forms a reasonable belief that the child has suffered or is at risk of significant harm. Reporting rests on reasonable belief of risk, not on diagnostic certainty, so the report is made now and the workup proceeds in parallel. [2]

SAQ 2 (10 marks)

A 2-month-old infant presents with apnoea, seizures and a reduced conscious state. CT brain shows a subdural haemorrhage. [12]

1. List the core components of the workup for suspected abusive head trauma. (5) [12] [14]
2. Describe the retinal findings that are highly suggestive of abusive head trauma and distinguish them from birth-related haemorrhage. (3) [12] [14]
3. Name the PredAHT features and explain how the tool is used. (2) [12]

Model answer

The workup combines stabilisation with objective evidence-gathering: full ABCDE stabilisation with neuroprotection, seizure control and management of raised intracranial pressure; non-contrast CT brain as first-line (already performed) with MRI brain once stable for parenchymal, diffuse-axonal and dating detail; specialist indirect ophthalmoscopy for retinal haemorrhages; a full skeletal survey with dedicated views (repeated at 11 to 14 days); a coagulation screen to exclude a bleeding diathesis; and a metabolic workup to exclude mimics such as glutaric aciduria. Admission to a monitored bed and a mandatory report run in parallel. [12] [14]

Retinal haemorrhages that are extensive, multilayered and extending to the retinal periphery are highly suggestive of abusive head trauma. They are distinguished from birth-related haemorrhages, which are typically few, confined to the posterior pole, unilateral or bilateral, and resolve within the first weeks of life; a single resolving dot or a few posterior-pole flame haemorrhages in a neonate do not carry the same specificity. Indirect ophthalmology by a specialist documents the pattern reliably. [12] [14]

PredAHT combines six features — head or neck bruising, subdural haemorrhage, hypoxic-ischaemic injury, retinal haemorrhage, rib fracture, and long-bone fracture — to estimate the probability of abuse. It is used as decision support alongside exclusion of mimics and multidisciplinary review, not as a standalone diagnosis. [12]