Recognizing Inflicted Injury in Young Children

Child maltreatment, including abusive injury, is often recognized late. The child cannot tell you what happened. The explanation comes from the people who may be responsible. Your job here is narrow. Spot the injuries that do not fit the history, use the validated screening rules, protect the child and report as state law requires. Deciding who caused it is not your call. This page covers physical injury in young children: bruising, sentinel injuries, abusive head trauma and fractures. Burns, abdominal or thoracic injury, sexual abuse and neglect are not covered in detail.

Bruising is the central warning sign in young children. The authors of the study that refined the bruising decision rule describe bruising from physical abuse as the most common earlier injury to be missed or misdiagnosed before an abuse-related fatality or near-fatality in a young child.

Why Kids Are Different

• No reliable history: Preverbal infants and young children cannot give their own account. The caregiver's explanation has to be tested against the injury itself.
• Minor injuries can be the first sign: "Sentinel" injuries such as bruises and frenulum injuries can come before serious abuse. A small injury is a reason to look further.
• Injuries can be hidden: Bruises may sit under clothing or hair. A complete skin exam is part of the assessment.
• Development limits the mechanism: A non-mobile infant cannot produce some injuries by falling. Mobility has to be checked against the history.

Recent U.S. data show how big the screening problem is. Of 23,919 children aged 0 to 24 months who had an emergency department sentinel-injury visit (2014 to 2019), 1,156 (4.8%) were diagnosed with abuse at that index visit. The same authors warn that widespread screening can harm children and families. A structured tool matters for exactly that reason.

1. Treat life threats first: ABCDE. Recognition and documentation follow stabilisation.
2. Check the injury against the child: does the child's age and mobility fit the injury (can an infant that does not yet roll or sit have made this mark)?
3. Record the history word for word: who gave it, when it was given, how the injury happened, and when care was sought. Do not paraphrase or add conclusions.
4. Examine the whole skin: undress the child, look at the head, ears, neck, mouth, torso and buttocks, and document each bruise by site, size, colour and shape.
5. Apply the bruising rule: run every bruise through the TEN-4-FACESp elements in the table below. Any positive element is a positive screen.
6. Look for other injuries and signs: fractures, oral or frenulum injury and neurologic change. Ask for the child protection team and follow local protocol.
7. Protect and report: keep the child safe, do not confront the caregiver, and report under state law. See Prehospital & Transport Considerations.

TEN-4-FACESp is a bruising clinical decision rule. It was tested in children younger than 4 years with bruising, at five urban U.S. pediatric emergency departments. Only children with bruising get it applied. One positive element flags the child as at risk of abuse, for screening only. The validation cohort had 2,123 children with consensus classification. Sensitivity was 95.6% (95% CI 93.0% to 97.3%) and specificity 87.1% (95% CI 85.4% to 88.6%). At the cohort's abuse prevalence of 19%, positive predictive value was 63.9% and negative predictive value 98.8%. Prevalence moves those predictive values, so expect them to shift in other settings, such as prehospital care or triage.

• Population: The rule was validated in children younger than 4 years with bruising, in five urban U.S. emergency departments, between 2011 and 2016. Results may not carry over to other settings or ages. It was validated in emergency departments only, so prehospital use is an extrapolation.
• No true reference standard: A nine-member expert panel set abuse status by consensus. A second confirmatory exam of every screened child was not feasible.
• Visibility: Skin tone changes how easily a bruise shows. The authors report that accuracy did not vary substantially across skin tones. Examine the whole skin, including the areas that are easy to miss.
• Scope: The rule covers bruising in children younger than 4 years only. It does not reach older children. The sentinel-injury data and the AHT and fracture reports cover the other injury types.

Infants (4.99 Months or Younger)

• In this age group, any bruise at any site is a positive element of the TEN-4-FACESp rule.
• In a non-mobile infant, check the mobility history against the mechanism described.

Young Children (Under 4 Years)

• Bruises to the torso, ear, neck, frenulum, angle of jaw, cheek, eyelid or subconjunctiva are positive elements.
• Use a child-friendly approach. The child may not be able to say that it hurts, or where.

Adolescents and Possible Exploitation

• The AAP 2023 clinical report on exploitation, labor and sex trafficking sets out a trauma-informed, rights-based and culturally sensitive approach for health care providers.
• This page does not list trafficking indicators. Learn them from the full report or your local protocol, then follow your agency pathway.
• Victims may not see themselves as exploited. They may be reluctant to disclose. Ask about safety in private, where the child is willing, and follow local protocol.

EMS and transport clinicians are often the first to see the child, and often in the home, where the history is easiest to get. Your role: recognize, document, protect and hand off clearly. Scope and protocols vary by agency and state.

• Scene: Keep the child somewhere safe. Take a private history in another area only when it can be done calmly and without escalation. Scene safety and law enforcement come first. Avoid arguing about cause.
• Documentation: Record the history word for word, with who gave it and when. Describe each injury by site, size and colour, and mark a body diagram.
• Reporting: Report under state law to child protective services or law enforcement, as your protocol directs. Do not investigate or delay care to do so.
• Destination: A pediatric-capable emergency department. State the concern for abuse in the handoff, so the team can involve the child protection pathway.
• Handoff: Give the injuries, the history as told, the positive screen elements and any neurologic change, in that order.