Key points
- Memory map: stabilize → examine → look for hidden injury → report → safe disposition.
- TEN-4-FACESp applies to children under 4 years with bruising.
- Skeletal survey for suspected abuse in children 2 years and younger; repeat it at about 10–14 days if concern remains.
- Infants under 6 months with suspected abuse need head imaging even without neurologic signs; consider it up to 12 months.
- Screen for occult abdominal injury with AST/ALT, lipase and urinalysis; AST or ALT above 80 U/L supports abdominal CT with IV contrast.
- Report on reasonable suspicion; normal imaging alone does not make discharge safe.
Recognize: history and examination
Abuse is suspected from the fit between the story, the injury and the child's development, not from the family's income, smoking or structure.
- History red flags: no explanation, a changing or inconsistent story, a mechanism the child could not manage developmentally, or an unexplained delay in care.
- Do a complete head-to-toe examination with the child undressed, including the scalp, ears, mouth and frenulum, and the diaper area.
- Bruising in a nonmobile infant does not fit the infant's ability and may be a sentinel injury before severe abuse.
- Document objective findings (size, site, pattern, photographs), the history and who gave it, exact statements, tests, consultations and the report details.
Bruising: the TEN-4-FACESp rule
The rule is for children younger than 4 years who have a bruise. Any positive part means the bruise needs an abuse evaluation; it does not prove abuse.
| Letters | Meaning |
|---|---|
| TEN | Bruising on the Torso, Ears or Neck |
| 4 | Any bruise anywhere in an infant 4.99 months or younger |
| FACES | Frenulum, Angle of the jaw, fleshy Cheeks, Eyelids, Subconjunctivae |
| p | Patterned bruising (loop, hand, bite, object) |
Fractures and burns that raise concern
- Classic metaphyseal lesions.
- Rib fractures, especially posterior.
- Any unexplained fracture in a child who is not yet walking.
- Fractures at different stages of healing.
- Burns: immersion pattern, stocking or glove distribution, sharp borders, uniform depth, or a contact burn shaped like an object.
Occult abdominal injury
- Screening labs: CBC, PT/INR, PTT, CMP (with AST and ALT), lipase and urinalysis.
- AST or ALT above 80 U/L is a commonly used trigger for abdominal CT with IV contrast.
- Get CT with IV contrast if there is abdominal or thoracoabdominal bruising, tenderness, distention, rigidity or blood in the urine.
- Abdominal injury in abuse may have no bruising at all.
Report and plan a safe disposition
- Report to child protective services on reasonable suspicion. Proof, positive imaging or a disclosure are not needed.
- Each clinician who suspects abuse is responsible for making sure the report is made.
- Involve the child abuse pediatrics team where available.
- Discharge needs both medical stability and a safe place to go, agreed with child protective services; normal imaging alone is not enough.
- Screen siblings and other young household contacts as advised by the child abuse team.
Common questions
Which children need a skeletal survey for suspected abuse?
Children 2 years and younger with suspected physical abuse. Older children get imaging of painful or abnormal areas, with a survey only case by case.
What does TEN-4-FACESp stand for?
Bruising on the Torso, Ears or Neck; any bruise at 4.99 months or younger; bruising of the Frenulum, Angle of the jaw, Cheeks, Eyelids or Subconjunctivae; and patterned bruising. It applies to children under 4 years.
Study this topic
Sources
- AAP 2015: The evaluation of suspected child physical abuse (Pediatrics)
- Pierce et al. 2021: TEN-4-FACESp bruising clinical decision rule (JAMA Netw Open)
- AAP 2014: Evaluating children with fractures for child physical abuse (Pediatrics)
- AAP 2020: Abusive head trauma in infants and children (Pediatrics)
Written for Pedemy in our own words from the sources above; checked November 2026. For education only, not medical advice; check doses and local protocols before treating a patient. Pedemy is independent and not affiliated with or endorsed by the organizations cited.