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Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics
Mary Clyde Pierce1,2, Kim Kaczor1, Douglas J Lorenz3
1Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
Insights
The refined TEN-4-FACESp bruising clinical decision rule (BCDR) accurately identifies physical abuse in young children. This tool aids in earlier recognition of child abuse, potentially preventing severe outcomes.
Area of Science:
- Pediatrics
- Forensic Medicine
- Child Abuse Recognition
Background:
- Bruising in young children is frequently overlooked or misdiagnosed, often preceding abuse-related fatalities.
- Distinguishing abusive from non-abusive bruising is critical for timely intervention.
Purpose of the Study:
- To refine and validate the TEN-4 bruising clinical decision rule (BCDR) for identifying children at risk of physical abuse.
- To improve the early recognition of child abuse through a validated clinical decision tool.
Main Methods:
- Prospective cross-sectional study in emergency departments of 5 urban children's hospitals (2011-2016).
- Inclusion of children younger than 4 years with bruising, identified via deliberate examination.
- Refinement and validation of the BCDR using binary recursive partitioning analysis on bruising characteristics.
Main Results:
- The study enrolled 2161 children; 410 (19%) were classified as abuse by expert consensus.
- The refined BCDR (TEN-4-FACESp) demonstrated 95.6% sensitivity and 87.1% specificity for distinguishing abuse.
- Key indicators included torso, ear, neck, frenulum, jaw angle, cheeks, eyelids, subconjunctivae bruising, infant bruising (<4.99 months), or patterned bruising.
Conclusions:
- The TEN-4-FACESp rule effectively identifies children at risk for abuse.
- Clinical application of this tool can enhance the recognition of abuse in young children presenting with bruising.
- Early identification through this BCDR may lead to improved outcomes and prevention of severe harm.
Importance:
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.
Objective:
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.
Design, Setting, And Participants:
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.
Exposures:
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.
Main Outcomes And Measures:
Injury from abusive vs nonabusive trauma was determined by the consensus judgment of a multidisciplinary expert panel.
Results:
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).
Conclusions And Relevance:
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.
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