Abstract
Bruising caused by physical abuse is the most common antecedent injury to be overlooked or misdiagnosed as nonabusive before an abuse-related fatality or near-fatality in a young child. Bruising occurs from both nonabuse and abuse, but differences identified by a clinical decision rule may allow improved and earlier recognition of the abused child. To refine and validate a previously derived bruising clinical decision rule (BCDR), the TEN-4 (bruising to torso, ear, or neck or any bruising on an infant <4.99 months of age), for identifying children at risk of having been physically abused. This prospective cross-sectional study was conducted from December 1, 2011, to March 31, 2016, at emergency departments of 5 urban children's hospitals. Children younger than 4 years with bruising were identified through deliberate examination. Statistical analysis was completed in June 2020. Bruising characteristics in 34 discrete body regions, patterned bruising, cumulative bruise counts, and patient's age. The BCDR was refined and validated based on these variables using binary recursive partitioning analysis. Injury from abusive vs nonabusive trauma was determined by the consensus judgment of a multidisciplinary expert panel. A total of 21 123 children were consecutively screened for bruising, and 2161 patients (mean [SD] age, 2.1 [1.1] years; 1296 [60%] male; 1785 [83%] White; 1484 [69%] non-Hispanic/Latino) were enrolled. The expert panel achieved consensus on 2123 patients (98%), classifying 410 (19%) as abuse and 1713 (79%) as nonabuse. A classification tree was fit to refine the rule and validated via bootstrap resampling. The resulting BCDR was 95.6% (95% CI, 93.0%-97.3%) sensitive and 87.1% (95% CI, 85.4%-88.6%) specific for distinguishing abuse from nonabusive trauma based on body region bruised (torso, ear, neck, frenulum, angle of jaw, cheeks [fleshy], eyelids, and subconjunctivae), bruising anywhere on an infant 4.99 months and younger, or patterned bruising (TEN-4-FACESp). In this study, an affirmative finding for any of the 3 BCDR TEN-4-FACESp components in children younger than 4 years indicated a potential risk for abuse; these results warrant further evaluation. Clinical application of this tool has the potential to improve recognition of abuse in young children with bruising.
Highlights
Bruising is the most common injury from physical child abuse[1,2] and the most common injury to be overlooked or misdiagnosed as nonabusive before an abuse-related fatality or near-fatality in a young child.[3,4,5] Several studies[4,5,6] identified bruises as the preceding injury to abusive head trauma
The resulting bruising clinical decision rule (BCDR) was 95.6% sensitive and 87.1% specific for distinguishing abuse from nonabusive trauma based on body region bruised, bruising anywhere on an infant 4.99 months and younger, or patterned bruising (TEN-4-FACESp)
In this study, an affirmative finding for any of the 3 BCDR TEN-4FACESp components in children younger than 4 years indicated a potential risk for abuse; these results warrant further evaluation
Summary
Bruising is the most common injury from physical child abuse[1,2] and the most common injury to be overlooked or misdiagnosed as nonabusive before an abuse-related fatality or near-fatality in a young child.[3,4,5] Several studies[4,5,6] identified bruises as the preceding injury to abusive head trauma. Failure to recognize bruising caused by physical child abuse is a missed opportunity and an error in medical decision-making that contributes directly to poor patient outcomes.[7,8,9,10] Published evidence confirms that measurable differences exist between bruising from nonabusive and abusive injury in infants and young children.[10,11,12,13,14,15,16,17,18,19,20,21,22,23] An evidence-based screening tool may prevent these high-stakes failures Modeling these differences into an easy-to-use clinical decision rule may prevent further abuse through improved recognition. Such a rule is especially critical for infants and young children who are at the highest risk of serious, potentially fatal abuse[2] and who are too young or afraid to state what happened
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