Emergency medicine

Injury prevention

Surgery

Medical emergency

Pediatrics

Poison control

Psychology

Ecchymosis

Medicine

JAMA Network Open

<h3>Importance</h3> 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. <h3>Objective</h3> 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 &lt;4.99 months of age), for identifying children at risk of having been physically abused. <h3>Design, Setting, and Participants</h3> 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. <h3>Exposures</h3> 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. <h3>Main Outcomes and Measures</h3> Injury from abusive vs nonabusive trauma was determined by the consensus judgment of a multidisciplinary expert panel. <h3>Results</h3> 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). <h3>Conclusions and Relevance</h3> 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.

Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics