Year: 2025
Type: article
Abstract: The TEN-4 rule has been one of the most recognized and disseminated clinical decision support tools in child abuse pediatrics (CAP).1 This tool is used to guide medical providers in assessing bruising in children and whether there should be increased concern for abuse. TEN-4 has been refined and expanded with additional areas of concern and patterns of injury to become TEN-4-FACESp.2 This tool is available as a smartphone app and free downloadable infographic to provide readily accessible, evidence-based support for clinicians assessing bruising in young children. Underscoring the importance of the tool, in 2021, October 4 (10–4) was aptly proclaimed “TEN-4 Day” by Illinois Governor JB Pritzker to honor the importance of recognition and awareness of child abuse prevention.3–5In this issue of Pediatrics, Raut et al6 evaluated the performance of the TEN-4 FACESp bruising clinical decision rule (BCDR) in patients aged younger than 4 years with a single bruise in the TEN-4-FACESp distribution presenting to the emergency department. In this latest study, the authors report that the BCDR performs with 81.0% sensitivity and 87.6% specificity among such patients, noting that a single bruise is nearly as concerning as multiple bruises in the TEN-4-FACESp distribution and should prompt consideration of further workup for potential child physical abuse. Disregarding a single bruise in an atypical or concerning body region as an “inconsequential” injury could result in missed cases of abuse, with a risk of subsequent injury with escalation in severity and a missed opportunity for intervention.7,8Clinical decision support tools, such as TEN-4-FACESp, aim to bolster objectivity. They aid in distancing clinical decision-making from emotional responses often cloaked in cognitive and implicit biases.9,10 This becomes particularly relevant when interpreting physical findings concerning for child abuse. The internal pressure to identify child abuse is tempered by the awareness of the potential impact of the workup on patients and families.11,12 Making the wrong call can result in a child being removed from loving caregivers or being placed back into an unsafe environment. CAP providers must also face situations in which their diagnoses are acted on by outside agencies, such as law enforcement and child protective services, over which they have little control. It can be difficult for CAP providers who have spent years in training to have their medical findings challenged by those with less medical knowledge or experience in the field.The field of CAP has recently come under intense attack by the media and the legal system, although CAP providers, when making recommendations, understand the full differential of findings that could be associated with child abuse and consider the potential trauma that child welfare and law enforcement investigations may have on a child and a family.13,14 CAP consultation can be instrumental in identifying alternative explanations for injuries that initially raised concern for maltreatment.15,16TEN-4-FACESp is an effective risk-prediction tool that has revolutionized medical providers’ approach and understanding of seemingly minor injuries in childhood. It is not a diagnostic tool. Child abuse pediatricians are pivotal in providing input that clinical decision support tools are not built to provide, and we encourage providers to engage in conversation and establish relationships with child abuse pediatricians in their areas. This study carries great relevance for general pediatricians and all other pediatric subspecialties, making TEN-4FACESp an important tool for all providers working with children to be aware of and to use.
Source: PEDIATRICS
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W4407631784