To be effective, rules like PIBIS and the one developed by Pierce et al 2 (TEN-4-FACESp bruising to the torso, ear, neck, frenulum, angle of jaw, cheeks, eyelids, or subconjunctivae, patterned bruising, or any bruising on an infant <4.99 months of age) need to be remembered by thousands of frontline clinicians with many demands on their attention. Clinicians in these settings may spend only a fraction of their time seeing children and encounter physical abuse once a year or less. While parents might move heaven and earth to find a subspecialist for their child with diabetes, severe asthma, or leukemia, caregivers of children who have been maltreated are more likely to present to general emergency departments, urgent care clinics, or their family physician. Gone are the days when we could simply remember to look for spiral fractures or differently colored bruises, as these findings have been shown to be unreliable.įor another thing, children who have been abused are not preferentially brought to abuse specialists. The Pittsburgh Infant Brain Injury Score (PIBIS)-another important advance-applies to infants who are vomiting, but only if they do not have fever or diarrhea and if they present without a history of trauma. In a 3-month old, even forehead bruising is concerning. In a 12-month old, forehead bruising is not unexpected, but bruising to the fleshy part of the cheek is alarming. For one thing, the new data, including that in the study by Pierce et al, 2 are necessarily nuanced. However, the benefits of these new data will only be realized if they are broadly implemented, and that will not happen from awareness-building campaigns alone. It leads to a world where Black children and children from lower-income families are disproportionately likely to be evaluated for abuse, while White children and children from relatively wealthy families are at increased risk for missed abuse. An intuition-based approach is both insensitive and susceptible to intrinsic bias. Just as importantly, they allow clinicians to use a more objective approach, rather than waiting for their own intuition to kick in. Recognizing and responding to these warning signs can have a lifesaving impact for children who have been abused. In addition to the work by Pierce et al, 2 teams 3 - 5 have described other so-called sentinel injuries, such as fractures, burns, oral injuries, and signs of occult brain injury, and have called attention to the children who live in homes with other forms of family violence. ![]() While bruising is easy to dismiss or overlook in older children, it can be a critical opportunity to identify abuse in infants and toddlers and to protect them from serious or permanent injury. 1Įlsewhere in JAMA Network Open, Pierce and colleagues 2 validated a short list of bruise characteristics that should raise the alarm for abuse. Since 1999, when we learned that nearly one-third of children with the most severe forms of abuse had been seen by medical professionals who had failed to make the diagnosis, the new pediatric subspecialty of child abuse pediatrics has produced an explosion of research to identify the earliest signs of physical abuse. ![]() Early recognition of child physical abuse is having its moment.
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