There are a few presenting signs and symptoms in primary care pediatrics that ignite a healthy dose of trepidation in even the most experienced practitioner. Does that adolescent’s neck stiffness represent a simple muscle strain, or could it be bacterial meningitis? Are that child’s nosebleeds due to picking or leukemia? Similarly, when is a bruise just a bruise and not the harbinger of future potentially fatal child abuse?
Two submissions in July’s issue of Pediatrics in Review on bruising and identifying child abuse attempt to answer that last question (10.1542/pir.2022-001271, 10.1542/pir.2021-004978). Active children should be exploring and playing, and they frequently injure themselves accidentally, resulting in occasional bruises. But certain bruising features should give the pediatrician pause to carefully consider child abuse in the differential diagnosis. The authors appropriately identify the current medical literature to help guide the primary care pediatrician most notably by referencing the landmark paper by Naomi Sugar that those who don’t cruise shouldn’t bruise and more recently by Mary Clyde Pierce on the use of the TEN-4 FACESp rule.1,2 These easy-to-remember mnemonics emphasize that even a single bruise on a young infant, or an isolated ear bruise on a toddler, are significant findings despite being ostensibly minor, and it is incumbent upon the practitioner to act on these findings by pursuing a workup for occult trauma.
But what if that work up is negative for additional injuries and the pediatrician is left with a well appearing pre-cruising infant with a single bruise and no appropriate history? Ay, there’s the issue for the clinician on the front line. The medical literature has exposed that bruising is the most common sentinel finding in children in whom abuse is later discovered, including cases of fatal child abuse.3,4 Any bruise on an infant younger than 5 months without a compelling history should trigger a practitioner to not only pursue an occult injuries evaluation but also, importantly, to contact the appropriate state child protective registry. Certainty in a diagnosis of inflicted trauma is not necessary for reporting and could be a potentially life saving act for the child because abusive behavior is often both repetitive and escalating if not addressed.5
As a practitioner in the trenches, this is a difficult conversation to have with families especially given the history of bias in medicine. Children of color have been disproportionately reported to child protective services compared to their white peers for similar injuries.6 It is critical to remain non-judgmental and clear with parents when approaching these cases. By remaining empathetic and objective, and by consistently following a standard of practice that is evidenced based, the goal is for bias to be minimized or eliminated. The consequences of not acting out of a well-intended hesitancy of offending a parent can be a life-threatening act of omission.
- Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers: those that don’t cruise rarely bruise. Puget Sound Pediatric Research Network. Arch Pediatr Adolesc Med. 1999; 153 (4): 399–403
- Pierce MC, Kaczor K, Lorenz DJ, et al. Validation of a clinical decision rule to predict abuse in young children based on bruising characteristics. JAMA Netw Open. 2021; 4 (4): e215832
- Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA. 1999; 281 (7): 621–626
- Sheets LK, Leach ME, Koszewski IJ, et al. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics. 2013; 131 (4): 701–707
- Adamsbaum C, Graber S, Mejean N, et al. Abusive head trauma: judicial admissions highlight violent and repetitive shaking. Pediatrics. 2010; 126 (3): 546–55
- Lane WG, Rubin DM, Monteith R, Christian CW. Racial differences in the evaluation of pediatric fractures for physical abuse. JAMA. 2002; 288 (13): 1603–9