Can TEN4 distinguish bruises from abuse, inherited bleeding disorders or accidents?

Area of Science:

• Pediatrics
• Forensic Medicine
• Medical Diagnostics

Background:

• Bruises in young children can indicate abuse, accidents, or inherited bleeding disorders (IBDs).
• The TEN4 categorization system (torso, ear, neck bruises, or any bruise in infants <4 months) aims to differentiate these causes.
• Previous studies suggested high accuracy for TEN4, but its utility in real-world scenarios requires further evaluation.

Purpose of the Study:

• To evaluate the effectiveness of the TEN4 categorization in differentiating between abuse, accidents, and IBDs in children.
• To assess the diagnostic accuracy of TEN4 for identifying abuse versus accidental injuries and IBDs.

Main Methods:

• A prospective comparative longitudinal study was conducted.
• Data from 328 community children, 106 children with IBD, and 342 abuse cases were analyzed.
• Likelihood ratios (LRs) were calculated for bruise number and location (TEN4 criteria) in different age groups (pre-mobile vs. mobile) and compared across abuse, accident, and IBD groups.

Main Results:

• Any bruise in pre-mobile children increased the likelihood of abuse/IBD over accidental injury.
• Multiple bruises, especially in TEN4 locations, increased the likelihood of abuse/IBD in mobile children.
• The TEN4 system showed an estimated sensitivity of 69% and specificity of 74% for abuse in children under 48 months, which is lower than previously reported.
• TEN4 did not differentiate between abuse and IBD.

Conclusions:

• A positive TEN4 screen warrants further child protection investigation in pre-mobile children with any bruise and mobile children with multiple bruises.
• The TEN4 system is not sufficient to distinguish between abuse and IBD; IBD must be excluded in suspected cases.
• The study highlights a need for caution, as the estimated sensitivity and specificity of TEN4 were lower than anticipated.