Case 16

A 2-month-old baby girl was brought to the emergency department by her father. He stated he witnessed her gasp for air, vomit and then go limp. On arrival, she was stable and appeared ‘back to baseline’ according to her father. However, bruising was noted under her right eye and lateral to the left eye as shown in Image 16. Her parents then reported that her 13-month-old sister was jumping on the bed and hit her in the face with her bottle. There was no other reported trauma. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig16.jpg"/>

What is your diagnosis?

How would you further evaluate this child?

36Other than facial bruising, this baby’s physical examination was completely normal. However, the history of trauma provided by the parents did not seem sufficient to explain the injuries present. Bruising in young infants who are non-ambulatory is extremely rare. In their landmark study, Sugar et al. identified bruising in only 0.6% of infants younger than 6 months of age presenting for well-child care. ¹ Furthermore, facial bruising (excluding the forehead), even in ambulatory toddlers, was exceedingly rare. As a result, it is important for clinicians to have a high index of suspicion for child abuse when a young, pre-ambulatory infant presents with unexplained or poorly explained bruising, particularly to the face. The diagnosis in this child was physical abuse.

Current recommendations suggest that for infants with facial bruising, the workup should include a skeletal survey, head imaging, trauma screening, laboratory studies, and a retinal examination. ² As a result, the hospital child protection team recommended these studies and a referral to Child Protective Services for this infant. The baby’s skeletal survey was negative for any acute or healing fractures. However, unilateral retinal haemorrhages were identified and a head CT scan revealed bilateral subdural haematomas. A diagnosis of child physical abuse was made and the child ultimately was discharged to a foster home. This case highlights the importance of thoroughly evaluating all bruising in young infants. While this baby had already suffered abusive head trauma when the bruise was noted, bruising has been reported as a frequent sentinel event in infants presenting with confirmed child physical abuse. In a study by Sheets et al., 27.5% of abused infants were found to have had a previous sentinel injury, of which bruising accounted for 80%. ³ It is clear that for many patients, early detection of bruising as an indication of abuse plays an important role in the prevention of abuse escalation.