Original Title: Lésions sentinelles : signes suggestifs de blessures infligées chez les bébés non ambulants

Authors' objectives: The Association des médecins en protection de l’enfance du Québec (AMPEQ) has observed that, despite existing guidelines, practices for identifying sentinel injuries in infants vary considerably, and missed opportunities to prevent serious injuries are still being observed. In this context, the Association asked the Institut national d'excellence en santé et en services sociaux (INESSS) to produce a clinical tool based on best practices to promote the recognition of sentinel injuries in primary care settings and to specify the clinical approaches to be followed. The work has also received approval by the directors of the directions de la protection de la jeunesse (DPJ) (Youth Protection Directorates - DYP) and by the programme-service Jeunes en difficulté (DPJe) (Youth in Difficulty Program), as well as by the directrice nationale de la protection de la jeunesse (DNPJ) (National Director of Youth Protection).

Authors' results and conclusions: RESULTS (#1 A SENTINEL INJURY IS A VISIBLE INJURY IN A PRECRUISING INFANT, OR ONE REPORTED BY A PARENT, THAT APPEARS CLINICALLY UNSIGNIFICANT AND IS UNEXPLAINED.): Bruises, subconjunctival hemorrhages, and intraoral injuries are identified as the main possible sentinel injuries to watch for in precruising infants. (#2 IT IS IMPORTANT TO REMAIN ALERT AND WATCHFUL FOR THE FOLLOWING INJURIES WHENEVER IN CONTACT WITH A PRECRUISING INFANT): Without plausible explanations, these injuries must be investigated: • Any bruise (regardless of color, shape, or location) – however, it is important to differentiate it from various skin conditions (e.g., birthmarks, hemangiomas, hyperpigmentation, or hypopigmentation). (#3 IN ORDER TO DETERMINE THE UNEXPLAINED NATURE OF THE INJURY, IT IS IMPORTANT TO CONSIDER THE CONSISTENCY BETWEEN THE INJURY NARRATIVE, THE CLINICAL SIGNS OF THE SENTINEL INJURY, AND THE BABY'S STAGE OF MOTOR DEVELOPMENT): It is recommended that the history be obtained from the parent in a nonsuggestive manner and that attention be paid to certain elements of the story that seem inconsistent with an accidental injury (e.g., lack of narrative, vague, imprecise, or hypothetical story). (#4 A COMPREHENSIVE MEDICAL EVALUATION, INCLUDING A MEDICAL HISTORY AND A COMPLETE PHYSICAL EXAMINATION, IS NECESSARY TO IDENTIFY MEDICAL HISTORY AND DETECT ANY OCCULT INJURIES.): The physical examination includes an assessment of the baby's general condition, a visual inspection of the body, palpation of all areas of the body to identify other injuries, and a neurological examination. (#5 ADDITIONAL EXAMINATIONS ARE ALSO NECESSARY IN CASES OF POTENTIAL SITUATIONS OF ABUSE TO IDENTIFY OR RULE OUT THE PRESENCE OF UNDERLYING MEDICAL CONDITIONS, BUT ALSO TO DETECT AND DOCUMENT OCCULT INJURIES): If any sentinel injuries are present, a general assessment including a complete blood count is recommended. In addition, if bruising is present, additional laboratory tests to screen for possible hemostasis or coagulation disorders are also indicated. (#6 ANY SITUATION MUST BE REPORTED TO THE DYP AS SOON AS THERE IS REASONABLE CAUSE TO BELIEVE THAT THE BABY'S SAFETY OR DEVELOPMENT IS OR COULD BE COMPROMISED): Discussing the report and the steps of the clinical assessment with the parent in a caring manner can facilitate their cooperation. However, it is not mandatory to inform the parent that a report is or will be made. (#7 DEPENDING ON CLINICAL JUDGMENT AND LOCAL ORGANIZATION OF HEALTHCARE SERVICES, SPECIALIZED CONSULTATIONS (OPHTHALMOLOGY, HEMATOLOGY, RADIOLOGY, GENERAL PEDIATRICS, OR PEDIATRICS SPECIALIZED IN ABUSE) MAY BE INDICATED TO): • complete the assessment; • consider differential diagnoses; • ensure appropriate care of the baby. (#8 THE MAIN OBSTACLES TO IMPLEMENTING THE RECOMMENDATIONS OF THE CLINICAL TOOL ON SENTINEL INJURIES RELATE TO LACK OF TIME DURING CONSULTATIONS, HEALTH PROFESSIONALS' FEAR OF MAKING PREMATURE REPORTS TO THE DYP, AND LACK OF TRAINING AND CLINICAL SUPPORT): To address these issues, it is proposed that INESSS’ clinical tool be integrated into care platforms, that professionals' skills in communicating with families be strengthened, and to have a better framework for referrals to the DYP. CONCLUSION: The clinical tool developed through this current work aims to support primary care professionals in Quebec by providing a clear, evidence-based framework for recognizing sentinel injuries and guiding clinical decision-making. It promotes a balanced, respectful, and caring approach toward families, the strengthening of collaboration among professionals, and the improvement of the consistency of interventions. Thus, it contributes to protective practices adapted to precruising infants.

Authors' methods: Practice guidelines and expert consensus statements published between 2019 and 2025 were identified in targeted databases and grey literature. Documents were selected based on pre-established criteria and their quality was assessed using the AGREE GRS tool. An advisory committee of experts from various fields validated the scientific evidence and participated in the development of recommendations. The work was then presented to a monitoring committee composed of representatives from the ministère de la Santé et des Services sociaux (MSSS), Santé Québec, associations, and professional orders. Finally, external validation of the work by external readers who are specialists in the field of interest and future users was also carried out at the end of the project.

Project Status: Completed

Year Published: 2026

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/lesions-sentinelles-signes-suggestifs-de-blessures-infligees-chez-les-bebes-non-ambulants.html

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)