Applies to a child under 4 years with bruising evaluated in an ED or hospital setting. A positive result means refer for an abuse evaluation — it does not diagnose abuse.
The “4” is its own criterion: any bruising anywhere in an infant 4 months or younger is positive, whatever the region. Derivation and validation: Pierce et al., JAMA Network Open 2021 — sensitivity about 96%, specificity about 87%.
Five points. Built to find occult head injury in a well-appearing infant under 1 year with no history of trauma who has a symptom that could be something else. It is not for an infant who already looks sick or has known trauma — those get a CT regardless.
A score of 2 or more should prompt a head CT. Validation: Berger et al., JAMA Pediatrics 2016 — sensitivity about 93%, specificity about 53%. It rules in far better than it rules out; a score under 2 in a child you are worried about is not permission to skip imaging.
Any single threshold sends the patient to CT abdomen with IV contrast.
| Test | Threshold |
|---|---|
| AST or ALT | > 80 U/L |
| Lipase | > 100 U/L |
| Urinalysis red cells | 20 /hpf |
| Hemoglobin | < 11.5 g/dL |
AST or ALT > 80 U/L is the validated trigger for abdominal CT (Lindberg et al., Pediatrics 2009; ExSTRA, J Pediatr 2013). Lipase, hematuria and hemoglobin cut-offs are pragmatic additions — the 11.5 g/dL here screens for intra-abdominal bleeding and is not the PIBIS item (11.2). For younger children consider anemia specific to the age category.
Note. Children with developmental delay should be assessed per their developmental age category rather than biological age — for example an 8-year-old non-verbal child.
| Age | Head CT |
|---|---|
| ≤ 6 mo | Mandatory, even with no signs or symptoms |
| 6–12 mo | Consider even with no signs or symptoms; PIBIS may risk-stratify |
| > 12 mo | Consider based on clinical concern and subsequent evaluation |
| ≤ 2 y | Any signs or symptoms of head injury → CT |
| > 2 y | GCS < 15 → CT. GCS 15 → observation vs MRI, child abuse team |
Team huddle if there is suspicion of non-accidental trauma, to discuss the case. The duty to report is personal to each mandated reporter, the threshold is reasonable suspicion rather than certainty, and you do not need to know who caused the injury.
Exceptions — when not to notify yet
Depends on individual medical and social circumstances as well as CPS findings, and the child abuse team as needed.
Admit
Discharge
Educational decision support for trained clinicians. It does not replace clinical judgement, your local child abuse pediatrics team, or your institution’s pathway, and it does not diagnose abuse. Built from public sources: Christian CW and AAP Committee on Child Abuse and Neglect, The Evaluation of Suspected Child Physical Abuse, Pediatrics 2015; AAP clinical report, Evaluating Young Children With Fractures for Child Abuse, Pediatrics 2025; ACR Appropriateness Criteria, Suspected Physical Abuse — Child; Pierce et al., JAMA Network Open 2021 (TEN-4-FACESp); Berger et al., JAMA Pediatrics 2016 (PIBIS); Lindberg et al., Pediatrics 2009 and J Pediatr 2013 (transaminase screen); Lindberg et al., Pediatrics 2012 (contact screening); Sheets et al., Pediatrics 2013 (sentinel injuries). This page keeps no data. Nothing you type is saved or transmitted — keep patient identifiers out of it.