238 - Occult Injury Identification and Child Protective Services Referrals in Children with TEN-4-FACESp Bruising

Publication Number: 2229.238

Nathaly Perez Rojas, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; M Katherine Henry, Children's Hospital of Philadelphia/UPenn, Philadelphia, PA, United States; Jan Leonard, CHOP, Philadelphia, PA, United States; Daniel M. Lindberg, University of Colorado Anschutz Medical Campus, Denver, CO, United States; Candace LeFlame, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Kristine A. Campbell, University of Utah School of Medicine, Salt Lake City, UT, United States; Jennifer Wolford, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Farah W.. Brink, Brink, Dublin, OH, United States; Danielle Horton, Children's Mercy Hospitals and Clinics, Kansas City, MO, United States; Caroline L.S.. George, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States; Natalie Laub, University of California, San Diego School of Medicine, San Diego, CA, United States; Joanne Wood, Children's Hospital of Philadelphia, Philadelphia, PA, United States

Background: TEN-4-FACESp is a widely used clinical decision rule that guides child abuse evaluations, but rates of occult injury identification and child protective services (CPS) referrals in children presenting with TEN-4-FACESp bruising are unknown.

Objective: We leveraged a multicenter child physical abuse dataset to examine (1) the association between TEN-4-FACESp positivity and detection of new occult injuries, and (2) TEN-4-FACESp and CPS referral decisions.

Design/Methods: We conducted a retrospective study of well-appearing children < 2 years who had an evaluation by child abuse practitioners from 2/2021-1/2024 with bruising, subconjunctival hemorrhage, frenulum injury at 10 CAPNET sites. Children with signs of other injuries (e.g., fracture symptoms) on history or physical exams were excluded. Our primary independent variable was any TEN-4-FACESp bruising versus other bruising. Outcomes were occult injury testing and detection and referrals to CPS. Main analyses were limited to those ≥ 5 months to allow for age-based modelling, as infants < 5 months with any bruising are TEN-4-FACESp positive. We reported frequencies and proportions for imaging (skeletal survey [SS] or neuroimaging [MRI, fast MRI, or CT]) and yield for new fracture or intracranial injury (ICI, defined as extra-axial hemorrhage or parenchymal injury). Outcomes were evaluated using multivariable generalized linear mixed effects models, clustered by site, and adjusted for age and other clinical factors.

Results: Of 1,425 children < 2 years, 1,205 (85%) had a TEN-4-FACESp injury. Among 894 children 5–23.9 months old, 675 had TEN-4-FACESp bruising (76%). Of these, 608 (90%) underwent SS and 288 (43%) had neuroimaging; among 219 TEN-4-FACESp negatives, 171 (78%) had SS and 76 (35%) had neuroimaging. In unadjusted analysis, TEN-4-FACESp positivity was not associated with SS positivity (4.1% of positive vs 1.4% of negatives, p=0.051) but was associated with lower detection of ICI (1.8% of positive vs 4.6% of negative, p=0.021). After adjusting for age, SS positivity, and clustering by site, TEN-4-FACESp positivity remained associated with decreased odds of ICI (OR 0.3, 95% CI 0.1-0.7, p=0.007 and increased odds of CPS referral after adjusting for age, race/ethnicity, insurance, occult injury detection and clustering by site (OR 2.2, 95% CI 1.5-3.3, p< 0.001).

Conclusion(s): Occult injury rates are low in TEN-4-FACESp positive children, yet CPS referrals remain high. Conversely, TEN-4-FACESp negative bruising, which includes forehead and scalp bruising, were more likely to have ICI than TEN-4-FACESp positive children.