When I started as a pediatric resident, I was prepared to see children with runny noses, funny rashes and perhaps even the odd Lego piece in the ear. I quickly recognized I was far from prepared for one of the greatest pediatric health concerns I never expected: child abuse and neglect.

My Experience Recognizing Child Abuse

My third week of residency, a bright-eyed toddler arrived on the pediatric floor. It was obvious at first glance that she had colorful bruises over cheek and forehead. She had slipped and fallen on her toy, explained her parents. Upon closer inspection, one could see a chain of small bruises marching around the circumference of her neck. It was obvious that this little one had been harmed. Her bruises told the real story.

Bruises are often the only visible indicator of an injury. There is substantial research in recognizing the characteristics of bruising due to abuse. We can distinguish bruises concerning for abuse from common accidental bruises by looking at factors such as the pattern and location of bruising and the age of the child.

An infant who has not yet began rolling over or crawling is not capable of movements which could cause accidental bruising. Because of this, there is a common saying among pediatricians: “Those who don’t cruise, rarely bruise.”

Any bruise on a young infant should raise concern for potential abuse. Those who can “cruise” (or walk or run for that matter) are more likely to have accidental bruises over bony prominences of the body such as knees, shins, and forehead. For children ages four years and younger, we see a strong correlation for abuse in bruises found over the ears, neck, or torso (abdomen, chest and back).

The “TEN-4” Pneumonic

We identify the characteristics of bruises concerning for abuse using the pneumonic “TEN-4”:

  • T: Torso
  • E: Ears
  • N: Neck
  • 4: Any bruise over the torso, ears or neck of a child 4 years old or younger


A bruise anywhere on a child under four months of age (an infant who cannot roll over or “cruise”)

The TEN-4 Rule is for anyone who lays eyes on a child. Whether you’re a neighbor, a daycare provider, a friend, a babysitter, a teacher, a stranger on a bus or a concerned parent, anyone can apply the rules of “TEN-4” to assess bruising on a young child. Recognition of child abuse and maltreatment starts in the community. We all share the responsibility.

If you have concern for a bruise on a child, contact your local child protection agency, or call the Child Abuse Hotline at 1-800-649-5285.

Kelly Finnegan, MD, is a first year pediatric resident at the University of Vermont Children’s Hospital at the UVM Medical Center.

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