Human InterestInjuriesPreventive Medicine


It was very difficult for me, but many years ago I accused a mother of physically abusing her children. She was in her late 20’s, had two children, a boy and a girl, and worked full time. She was always nervous, unsure of herself, and unfocused. Her children weren’t sick any more than normal, but they had more than the usual number of physical injuries; not just bumps and bruises, but fractures—FRACTURES, Broken bones. 

This incident happened many years ago so specific details are blurry, but I do remember when I saw them, the kids were often unbathed and had bruises everywhere. The final straw was when the daughter was brought in with a broken/fractured humerus (upper arm bone). That’s an unusual fracture for a 2 year old, so I told the mother I was concerned the children were being abused. I warned her that I was going to report my concerns to the local police, which I did. I immediately got an angry visit from her husband. 

An investigation ensued which resulted in the temporary separation from her children. Unfortunately, I don’t recall the final conclusion of the case, but I think she was found guilty of abusing both children. After my accusations, I never saw the parents or children again so what happened later is unknown. 

Fortunately, this type of situation was not common in my practice. Situations just like it can, and do, occur all the time, though. To help family doctors prepare for these situations, the American Academy of Family Physicians, AAFP, publishes informative “Point-of-care Guides” in their journal, American Family Physician. One such article just appeared in the June 2022 issue. It is titled “Bruising Characteristics to Predict Child Abuse.” It was written by two U.S. Army family physicians and is the source of information presented in this blog post.

The authors report that in children 4 years and younger, as a result of child abuse, there are 3.5 deaths per 100,000 children per year. “Bruising is the most common injury of child abuse….[it is] overlooked or mis-diagnosed before the death of a child due to abuse.” It’s not just bruising per se, it’s the amount and location. Bruising of the shins and forehead are common in children just learning to walk, but bruising in other areas is a red flag.

The TEN-4 Bruise Clinical Decision Rule of 2010 was a “case-control study” of children admitted to a pediatric ICU with trauma. It was found that “a bruise on the torso (abdomen, back, buttocks, chest, hip, genital area), ear, neck, or any bruise on a child younger than 4 months is suspicious.” 

The TEN-4 Rule was “refined” in 2021 and renamed the TEN-4-FACESp Bruise Clinical Decision Rule. Of the 21,123 children under 4 years of age screened for bruising at five urban children’s hospitals, 2161 were selected for study. Only Eighty-one percent of those screened using the old criteria were abuse victims. The test was not sensitive enough so new criteria were established—bruising under the tongue, the jaw, facial cheek, eyelids, and whites of the eyes. The pattern of bruising—bite, slap, grab, squeeze—was important, too. These additions increased accuracy (sensitivity) to 96%. So adding additional bruising sites to the criteria increased the likelihood of determining child abuse. 

Now, in the course of an examination, if bruising is noted in three of the areas mentioned in the TEN-4-FACESp Rule, the child must be suspected of abuse and the case reported. 

Of course, broken bones, cigarette burns, or unconsciousness throw the case into a different realm of probability altogether. The family doctor, pediatrician, or ER physician must be alert to these findings and report them immediately. Vigilance and a high “index of suspicion” on the part of the family doctor prevent future abuse and permanent harm to the victims. 

Reference: Point-of-care-Guides Saguil A, Salinas R. Bruising Characteristics to Predict Child Abuse Am Fam Phys 2022 June;105(6):661-662.

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