Child physical abuse often presents first with injuries that appear minor, but missing these early warning signs can have devastating consequences. Two recent CMAJ papers examine how sentinel injuries in infants may signal escalating risk and how patterns of severe maltreatment shifted during the COVID-19 pandemic. Together, they offer practical guidance on when clinicians should escalate concerns and highlight system factors that shape risk for vulnerable children.

Dr. Megan Cooney, a child maltreatment pediatrician at Health Sciences Centre Winnipeg and co-author of “Five things to know about sentinel injuries and indicators of child physical abuse”, explains why medically minor injuries in pre-cruising infants require careful scrutiny. She notes that more than one quarter of children who experience catastrophic abuse had previously been seen for minor injuries. Any unexplained or poorly explained injury in a non-cruising infant should raise concern. She also reviews the validated TEN-4-FACESp clinical decision rule to help clinicians identify bruising patterns that warrant further action.

Dr. Matthew Carwana, a pediatrician at BC Children’s Hospital and clinical investigator at the BC Children’s Hospital Research Institute, discusses findings from “Hospital admissions for maltreatment among children younger than 2 years during the COVID-19 pandemic in Canada”.  He describes an early drop in maltreatment hospitalizations during the first 16 weeks of the pandemic, followed by a return to expected levels. However, ICU admissions rose above baseline for roughly the following year, raising concern that children may have been presenting with more serious injuries. Carwana suggests reduced early detection and loss of family and community supports during periods of isolation may have contributed.

For physicians, the message is to remain objective and act early. Injuries in pre-cruising infants should be treated as potential red flags, validated tools such as TEN-4-FACESp can support clinical judgment, and concerning cases should prompt timely reporting to child welfare agencies rather than waiting for certainty.

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