Tool Predicts Whether One Bruise in Pediatric ED Signals Abuse
The ability of a single bruise to predict abuse when a child enters an emergency department (ED) has been unknown, but new research indicated that a validated screening tool is highly effective in helping clinicians make that prediction when one bruise is the only skin finding. In a sample of children with one bruise who
The ability of a single bruise to predict abuse when a child enters an emergency department (ED) has been unknown, but new research indicated that a validated screening tool is highly effective in helping clinicians make that prediction when one bruise is the only skin finding.
In a sample of children with one bruise who entered a pediatric ED, the TEN-4-FACESp bruising clinical decision rule (BCDR) screening tool performed with 81.5% sensitivity and 87.6% specificity for abuse. “Even one BCDR-positive bruise indicated increased risk for abuse,” the authors wrote.
Findings of the study, led by Audrey Raut, MD, MSCI, in the Division of Child Abuse Pediatrics at Lurie Children’s Hospital of Chicago, Chicago, were published in Pediatrics.
Editorialists wrote in an accompanying commentary that the findings show that disregarding one bruise in an atypical or concerning body region could result in missing a sign of abuse and a chance for intervention.
Bruising is the most common sign of child physical abuse and also the most likely injury to be overlooked or misdiagnosed before an abuse-related death or injury in a young child, the researchers reported.
Tool Already Validated for More Than One Bruise
The tool was already validated as a screen that uses information about which region of a child’s body was bruised, age, and pattern of bruising to predict abuse in children younger than 4 years of age. The acronym stands for bruise locations — Torso, Ears and Neck (TEN) and Frenula, Angle of jaw, fleshy Cheek, Eyelids, Subconjunctiva (FACES). The 4 is for any bruise anywhere on an infant 4.99 months of age or younger, and p is for presence of a pattern of bruising (such as slap, grab, or loop marks). It has been shown to predict abuse with 95.6% sensitivity and 87.1% specificity in children younger than 4 years. But there were no specified number of bruises in the validation study.
Researchers wanted to evaluate the accuracy of the BCDR in predicting abuse when only one bruise was visible and also to identify other characteristics that would differentiate abuse from accidental injury in young children with a single bruise.
Patients included in this secondary analysis were those from the BCDR validation study whose only skin finding was one bruise (including petechiae, subconjunctival hemorrhage, or frenulum injury).
Cases were previously classified as abuse, accident, or indeterminate by an expert panel. Of 349 patients with a single bruise, 27 were classified as abuse. The researchers compared demographics, clinical characteristics, bruising regions, and psychosocial risk factors (such as prior law enforcement involvement or prior Child Protective Services involvement) between abuse and accident groups.
Factors That May Differentiate Abuse
Most cases (92.3%) were determined to be accidental, consistent with previous research. Raut’s team found that patients with abusive injuries were younger, less likely to present with an injury complaint but more likely to have a bruise in a BCDR-positive region, have a lower Glasgow Coma Score, and have psychosocial risk factors.
“Positive BCDR results may therefore improve recognition of abuse among young children with a single bruise in the pediatric ED, although negative BCDR results must be interpreted with caution given the higher rate of false negatives in this analysis compared with the validation study,” the authors wrote.
Editorialists Tagrid M. Ruiz-Maldonado, MD, MS, with the Department of Pediatrics, Center for Safe and Healthy Families, University of Utah, Primary Children’s Hospital in Salt Lake City, Utah, and Suzanne B. Haney, MD, MS, Children’s Nebraska, in Omaha, Nebraska, wrote that clinical decision support tools, such as TEN-4-FACESp, help distance clinical decision-making from emotional responses.
Providers are well aware that making the wrong call can result in a child wrongly being removed from loving caregivers or being returned to an unsafe environment, they wrote. In some situations, providers’ diagnoses may also be acted on by outside agencies, such as law enforcement and Child Protective Services.
“TEN-4-FACESp is an effective risk-prediction tool that has revolutionized medical providers’ approach and understanding of seemingly minor injuries in childhood,” they wrote.
They pointed out, however, that TEN-4-FACESp “is not a diagnostic tool. Child abuse pediatricians are pivotal in providing input that clinical decision support tools are not built to provide,” they noted. “This study carries great relevance for general pediatricians and all other pediatric subspecialties.”
The TEN-4-FACESp bruising clinical decision rule (BCDR) validation study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The authors reported no relevant financial relationships. Ruiz-Maldonado and Haney reported that their institutions have been paid in cases of suspected child abuse and neglect where they have testified. Haney is a member of the editorial board for Pediatrics.
Marcia Frellick is an independent healthcare journalist based in Chicago.
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