Mary Clyde Pierce1,2, Kim Kaczor1, Douglas J Lorenz3, Gina Bertocci4, Amanda K Fingarson2,5, Kathi Makoroff6, Rachel P Berger7, Berkeley Bennett8,9, Julia Magana10,11, Shannon Staley12,13, Veena Ramaiah12, Kristine Fortin2,5,14, Melissa Currie15, Bruce E Herman16, Sandra Herr17, Kent P Hymel18, Carole Jenny19, Karen Sheehan1,2, Noel Zuckerbraun7, Sheila Hickey20, Gabriel Meyers8, John M Leventhal21. 1. Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois. 2. Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois. 3. Department of Bioinformatics and Biostatistics, School of Public Health and Information Sciences, University of Louisville, Louisville, Kentucky. 4. Department of Bioengineering, J.B. Speed School of Engineering, University of Louisville, Louisville, Kentucky. 5. Division of Child Abuse Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois. 6. Mayerson Center for Safe and Healthy Children, Cincinnati Children's Hospital, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio. 7. Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania. 8. Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. 9. Department of Pediatrics, The Ohio State University, Nationwide Children's Hospital, Columbus. 10. Department of Pediatrics, University of California San Diego School of Medicine, La Jolla. 11. Department of Emergency Medicine, University of California, Davis Medical Center, Sacramento. 12. Department of Pediatrics, University of Chicago, Chicago, Illinois. 13. Division of Pediatric Emergency Medicine, Advocate Children's Hospital, Oak Lawn, Illinois. 14. Division of General Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia. 15. Norton Children's Pediatric Protection Specialists Affiliated with the University of Louisville School of Medicine, Louisville, Kentucky. 16. Department of Pediatrics, University of Utah School of Medicine, Salt Lake City. 17. Division of Pediatric Emergency Medicine, University of Louisville, Louisville, Kentucky. 18. Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania. 19. Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle. 20. Department of Social Work, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois. 21. Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut.
Abstract
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.
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.
Authors: Kent P Hymel; Wouter Karst; Mark Marinello; Bruce E Herman; Terra N Frazier; Christopher L Carroll; Veronica Armijo-Garcia; Matthew Musick; Kerri Weeks; Suzanne B Haney; Afshin Pashai; Ming Wang Journal: Child Abuse Negl Date: 2022-01-22
Authors: Devon M Kratchman; Porcia Vaughn; Ligia Batista Silverman; Kristine A Campbell; Daniel M Lindberg; James D Anderst; Angela N Bachim; Rachel P Berger; Kent P Hymel; Megan Letson; John D Melville; Joanne N Wood Journal: Child Abuse Negl Date: 2022-06-27
Authors: Gunjan Tiyyagura; Andrea G Asnes; John M Leventhal; Eugene D Shapiro; Marc Auerbach; Wei Teng; Emily Powers; Amy Thomas; Daniel M Lindberg; Justin McClelland; Carol Kutryb; Thomas Polzin; Karen Daughtridge; Virginia Sevin; Allen L Hsiao Journal: Acad Pediatr Date: 2021-11-12 Impact factor: 2.993
Authors: Samuel J Stellpflug; William Weber; Ann Dietrich; Brian Springer; Robin Polansky; Carolyn Sachs; Antony Hsu; Sarayna McGuire; Casey Gwinn; Gael Strack; Ralph Riviello Journal: J Am Coll Emerg Physicians Open Date: 2022-04-16