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Pediatric physical abuse: 4 tips to recognize it during the physical exam

Suspect physical abuse of a child when there is a mismatch between the reported mechanism of injury, patient history and the physical exam findings

slap mark 300.jpg

Bruising consistent with abuse.

Photo courtesy of University of Louisville, Kosair Charities Division of Pediatric Forensic Medicine

By Ben Neal

Pediatric patients can be the most mentally stressful and complex patients we encounter on a daily basis. Emotions during these cases are at times hard to control, especially in the case of a death or traumatic injury. However, what about apparently benign calls for what seems to be a minor complaint? While the patient may not be able to articulate where they hurt or exactly what happened, our index of suspicion should always be high and a thorough physical assessment should follow — you never know what it may reveal.

The hard truth

In 2013 there were 678,932 reported victims of child abuse and neglect reported in the United States. This is 9.1 victims for every 1,000 children in the population and accounted for 1,484 child fatalities [1]. Emergency medical professionals are often the first medical contact for these patients and our findings can be the best opportunity to identify abuse or neglect and protect the child, as in most cases, child abuse does not stop on its own — it only escalates.

1. TEN-4, good buddy!

The TEN-4 rule of pediatric bruising, introduced by Pierce, Kaczor et al. has proved to be helpful in the identification of potential child abuse [2]. The TEN-4 rule, or TEN-4 BCDR (body region and age based bruising clinical decision rule).

TEN stands for torso, ears and neck — the body regions that, if bruised, were found to be predictive of abuse in patients less than 4 years old. These areas of the anatomy are not easily bruised in the everyday activities of a top-heavy toddler. Children this age are more apt to bruising on their heads, knees and arms from falls or playful injuries. Furthermore, any child who is not “cruising” (normally less than 4-months-old, dependent on developmental status) should never have bruising in any anatomic region [2]. Bruising on the torso, ears or neck in a child less than 4 years old or any bruising in an infant 4 months old or less, can be predictive of abuse.

2. Recognizing pattern injuries

Pattern injuries may be one of the easiest to spot while performing an assessment and are often accompanied by an inconsistent history from the caregiver or parent. However, detecting these injuries requires a complete physical assessment, as many times, the child’s clothing may hide clues. The simple act of removing a garment to fully inspect the skin may reveal previously concealed findings. Some examples of these injuries may be a handprint from a slap, a circular burn from a lit cigarette or cigar or even a small hole from a belt lash. Sadly, the mechanisms in which abuse occurs are quite endless, thus we must always be aware during our encounters and maintain a high index of suspicion.

3. Abusive head trauma

Abusive head trauma (AHT), or previously called “shaken baby syndrome” occurs when a child is forcefully shaken or experiences an impact to the head in a manner that is so violent that it ruptures blood vessels within the skull, causing intracranial hemorrhage. Patients who experience AHT often develop severe brain damage with accompanying neurological disorders, and approximately 25 percent do not survive [3].

Discoveries indicative of AHT may be subtle initially, such as mild lethargy, vomiting without diarrhea and subconjunctival hemorrhages. More ominous signs and symptoms can range from seizures, unconsciousness or cardiac arrest and can frequently have physical findings such as rib fractures from the violent circumferential grasp of the child, unequal pupils and Battle’s sign.

4. Burn patterns

While children, specifically toddlers that are beginning their “cruising” phase of development, are prone to accidents such as falls and scrapes, burns are a type of injury that should immediately raise suspicions for potential abuse. Obtain a thorough history of how the injury occurred and mentally put together the “could that mechanism cause this injury” puzzle. For example, could a 1-month-old roll over on to a hot curling iron that was lying near the baby on a bed? What is the likelihood that a 4-year-old would have multiple accidents that caused quarter inch diameter burns on their arms and legs?

As patient history and mechanism of injury information is obtained, dig into the injury itself and think, “Does this injury physically match this mechanism?” For example hot water immersion burns are often easy to spot, as they are not only severe, but look just as you would expect with a child being held by the shoulders and being placed into hot water. You will ordinarily observe burns on the buttocks, genitals, feet and posterior legs, as well as potentially the hands and arms, as the child attempts to fight away from the water.

Mandatory reporter

Encountering an abused child can be quite overwhelming and daunting in some cases, which calls for great composure and restraint in how to handle the situation. As medical professionals, we must always be aware for the potential of intentional physical injury when assessing our young patient population. In doing so, utilizing these tips in conjunction with a thorough physical exam — a complete skin inspection — and a comprehensive history of the injury and meticulously documenting those findings in our care reports, be the difference between life and death. Catching the subtle signs early can potentially prohibit the abuse from escalating to what could cause the tragic loss of young and innocent life.

Finally, remember your obligation as a mandatory reporter. Follow your local protocols and policy to document and report known or suspected abuse.

About the author

Ben Neal is a major and operations officer for Louisville Metro EMS in Louisville, Kentucky. He has served as a paramedic since joining the system in 2004. Neal’s passions include cardiac arrest management, data collection and analysis, education, emergency management and interdepartmental partnerships.


  1. Child Maltreatment 2013. U.S. Department of Health and Human Services
  2. Clyde Pierce, M., Kaczor, K., Aldridge, S., O’Flynn, J., & Lorenz, D. (2010). Bruising Characteristics Discriminating Physical Child Abuse From Accidental Trauma. PEDIATRICS, 125(1), 68-73. doi:10.1542/peds.2008-3632
  3. Faces of Child Abuse 2013. Child Abuse Statistics.
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