5-week-old with blood under the tongue

A 5-week-old infant presented with blood under his tongue. | Image credit: Contemporary Pediatrics

Presenting symptoms 

A 5-week-old male infant was brought to his pediatrician for evaluation of intermittent small amounts of blood under his tongue. The parents first noticed the bleeding 2 weeks prior and reported it had occurred on 2 or 3 occasions. The baby was otherwise healthy, feeding well, and achieving appropriate developmental milestones. On examination, the pediatrician noted an absent sublingual and lower labial frenulum but no other abnormalities in the oral cavity (Figure). The parents denied any trauma or forceful feeding practices. Despite the seemingly innocuous presentation, concerns were raised about the possibility of nonaccidental trauma (NAT), given the historical association of frenulum injuries with abuse (Table).

Figure. A 5-week-old infant presents with blood under his tongue.

Case overview 

The absence of the frenula led to a referral to a child abuse pediatrician (CAP).¹ The CAP considered the torn frenula as possible "sentinel injuries," commonly associated with physical abuse in infants.¹ However, a careful evaluation revealed no signs of other injuries or trauma, and imaging studies confirmed no abnormalities elsewhere. Despite the CAP’s concerns, the pediatrician’s clinical judgment, coupled with a review of relevant literature, suggested that torn frenula might occur in nonabusive contexts, often secondary to natural processes such as vigorous sucking, accidental trauma during routine infant care, or congenital absence.^2,3

Table. Differential Diagnosis

This case underscores the challenge of distinguishing accidental from inflicted injuries and emphasizes the importance of a thorough differential diagnosis to avoid misdiagnosing innocent findings as markers of abuse.⁴

Analysis of the case

Initial evaluation

The torn frenula raised initial concerns due to their well-documented association with NAT. However, the absence of corroborative findings, such as additional bruising, other fractures, or inconsistencies in the parents' accounts, necessitated a more comprehensive evaluation.⁵ Imaging studies, including detailed skeletal surveys, ruled out fractures or other injuries that might suggest NAT. Additionally, the history of mild intermittent bleeding without significant trauma pointed toward a localized issue rather than systemic or inflicted pathology.

Diagnostic testing

Comprehensive coagulation studies were performed and effectively excluded a bleeding diathesis as the underlying cause. A review of the birth and feeding history was undertaken, revealing no episodes of forceful feeding, oral trauma, or other incidents that could reasonably account for the observed findings. This detailed history-taking further diminished the likelihood of inflicted injury.

Special considerations

The pediatrician conducted a literature review to assess the prevalence and etiology of frenulum injuries in infants. Studies indicate that such injuries may occur as a result of routine infant care practices, such as bottle-feeding or pacifier use, and are often mistaken for indicators of abuse.² Additionally, congenital absence of frenula, while rare, has been documented as an anatomical variant.³ This rare congenital presentation could plausibly explain the findings in this case.

Consultations

To gain further insights, peer consultations were sought from otolaryngology and pediatric dental specialists. These specialists supported the hypothesis that the presentation was consistent with anatomical variation rather than inflicted trauma. Their expertise bolstered the conclusion that the frenulum findings were not indicative of abuse but rather a benign and possibly congenital condition.

Discussion 

The frenulum is a thin band of tissue connecting the lips or tongue to the oral cavity. It is particularly vulnerable to minor trauma during routine infant activities such as feeding, sucking, or the use of pacifiers.⁶ In infants, frenulum injuries may occur naturally due to anatomical tension, particularly in cases where congenital variations in oral anatomy exist. Minor trauma from routine care, such as inserting a bottle or a pacifier, can also result in injuries that might resemble trauma but are benign in origin. Additionally, the physiological fragility of neonatal tissues contributes to the potential for spontaneous injury without significant external force.

The torn frenula in this case presented a significant diagnostic dilemma. While sentinel injuries, such as torn frenula, are often red flags for NAT, they are not pathognomonic and must be assessed within the broader clinical context.⁶ Mislabeling innocent findings as abuse has profound ramifications for families, emphasizing the need for a balanced, evidence-based, and multidisciplinary approach to such cases.

Implications for clinical practice

This case underscores the critical need for clinicians to distinguish between injuries with high specificity for abuse and those that arise from benign or accidental processes.⁷ The clinical context, including the absence of additional injuries, inconsistencies in parental history, or other red flags, plays a pivotal role in making this distinction. Overreliance on isolated findings such as torn frenula can lead to misdiagnoses, unnecessary investigations, and undue stress for families.

To avoid such pitfalls, clinicians should adhere to evidence-based protocols, reserving routine imaging or invasive testing for scenarios where there is substantial supporting evidence of abuse. Furthermore, interdisciplinary collaboration—drawing on expertise from pediatricians, otolaryngologists, and dental specialists—can provide a more nuanced understanding of the injury and prevent hasty conclusions. In this case, the absence of corroborative signs of trauma, coupled with the knowledge of the natural vulnerability of frenula, supports the conclusion that the findings were benign and not indicative of NAT.

Final diagnosis 

Congenital absence of the sublingual and lower labial frenula, with possible mild trauma during routine infant care, resulting in intermittent minor bleeding episodes.

Treatment, prognosis, and follow-up 

No intervention was required. The family was reassured about the benign nature of the findings. Follow-up visits confirmed normal growth and development, with no recurrence of bleeding or new findings suggestive of abuse or systemic illness.

Conclusion 

This case serves as a reminder of the importance of considering benign etiologies for findings traditionally associated with abuse. A thorough history, careful examination, and evidence-based approach are essential to prevent unnecessary interventions or misdiagnoses. Clinicians should remain vigilant but avoid overinterpreting isolated findings in the absence of corroborative evidence.

References

1. Kepron C, Walker A, Milroy CM. Are there hallmarks of child abuse? II. non-osseous injuries. Acad Forensic Pathol. 2016;6(4):591-607. doi:10.23907/2016.057
2. Yee R, Kwek VYX, Chng CK, Rajasegaran K, Welbury R. Frenal tears: accidental or non-accidental? Singapore Med J. 2023;64(7):459-461. doi:10.11622/smedj.2021011
3. Fahmy, MAB. Frenulum anomalies and diseases. In: Normal and Abnormal Prepuce. Springer, Cham; 2020. https://doi.org/10.1007/978-3-030-37621-5_32
4. Henry MK, Wood JN. What's in a name? sentinel injuries in abused infants. Pediatr Radiol. 2021;51(6):861-865. doi:10.1007/s00247-020-04915-7
5. Sarkar R, Ozanne-Smith J, Bassed R. Systematic review of the patterns of orofacial injuries in physically abused children and adolescents. Trauma Violence Abuse. 2021;22(1):136-146. doi:10.1177/1524838019827617
6. Lee JJ, Sarangam M, Feldman KW, Tieder JS. Riga-Fede disease: a case of sublingual trauma not associated with abuse. Pediatr Emerg Care. 2021;37(12):e1735-e1737. doi:10.1097/PEC.0000000000001922
7. George CLS, Theesfeld SSN, Wang Q, Hudson MJ, Harper NS. Identification and characterization of oral injury in suspected child abuse cases: one health system's experience. Pediatr Emerg Care. 2021;37(10):494-497. doi:10.1097/PEC.0000000000001715