On behalf of the Fellows form the Division of Emergency Medicine at Cincinnati Children’s I am delighted to bring you a new series that will highlight what we are learning during our ongoing didactic conferences. The main goal of the Pediatric Emergency Digest series will be to provide concise teaching points to reinforce in-person learning and to further the conversation. As always, feedback is welcome.
Child Abuse Clinical Decision Rules Review
with James Gray
This is by no means an exhaustive review of child abuse decision rules, and you know how I feel about mnemonics, but it can be helpful to have a scaffold in place to help guide your exam of injuries children. Knowing when to be suspicious is incredibly important. As always, I recommend you read the index studies to fully understand the rules, and make sure you are familiar with local practice guidelines.
TEN-4
This is a case-control study of 95 0-48 month old children (42 cases who were abused and 53 controls who were not) who were all admitted to a PICU because of trauma. The authors used bruising characteristics and age to develop a clinical decision rule that ultimately was 97% sensitive and 84% specific for predicting abuse.
Bruising in the following regions:
- Torso
- Ears
- Neck
In a child that is:
- Under 4 months of age ANY bruise without a public accident (someone other than parents saw it happen)
- ≤4 year old child with bruising in the TEN region without a public accident
FACES-P
A decision rule that is not as validated as TEN-4, but does serve as a good reminder of location to examine in injuries children. You should be concerned for abuse if there is injury or bruising to:
- Frenulum
- Angle of the jaw
- Cheek
- Eyelid
- Subconjunctival
- Patterned bruising
PIBIS Score
The above study is the validation of the previously derived Pittsburgh Infant Brain Injury Score for abusive head trauma. The data is from a 1,040 patient multi-center, prospective case-control study of well-appearing infants. The 5-point PIBIS score is:
- Abnormality on dermatologic exam: 2 points
- Age >3 or equal months: 1 point
- Head circumference >85thpercentile: 1 point
- Hemoglobin <11.2: 1 point
Per the authors, “at a score of 2, the sensitivity and specificity for abnormal neuroimaging was 93.3% (95% confidence interval 89.0%-96.3%) and 53% (95% confidence interval 49.3%-57.1%), respectively.”
