Helping clinicians better recognize signs of child abuse

Helping clinicians recognize when a childhood bruise may signal something more

By Jessica Zimmerman

From left: Chair of Pediatrics Joanne Wolfe, MD, MPH, pediatric emergency physician Wee-Jhong Chua, MD, and Executive Vice Chair of Emergency Medicine Margaret Samuels-Kalow, MD, MPhil, MSHP, display the state proclamation signed by Gov. Maura Healey recognizing TEN-4 Day on Oct. 4, 2026.

Content warning: This article discusses child abuse.

When does a childhood injury become a sign of something more concerning? How can clinicians tell a routine boo-boo from physical abuse in babies and toddlers?

Mass General Brigham for Children pediatric emergency physician Wee-Jhong Chua, MD, is among a national group of experts working to help healthcare professionals make those distinctions more easily, consistently and accurately. Since 2021, Chua has worked to increase statewide and nationwide awareness of the TEN-4-FACESp Bruising Rule, a validated clinical decision rule used to determine if bruising on a child under age 4 is more likely caused by abuse than accidental injury.

Developed at Ann & Robert H. Lurie Children's Hospital of Chicago, TEN-4-FACESp is an acronym that stands for bruising of the torso, ears and neck (TEN), as well as the frenulum, angle of jaw, cheeks, eyelids and subconjunctivae (FACES). The numeral 4 refers to infants 4 months and younger with any bruise, anywhere, and the "p" represents patterned bruising.

In addition to educating clinicians across Mass General Brigham about TEN-4-FACESp, Chua has led efforts in Massachusetts to have the governor proclaim Oct. 4 as TEN-4 Day Open external link in a new window for the past five years. The annual recognition day seeks to increase awareness of the TEN-4-FACESp rule and the importance of identifying, reporting and preventing child abuse.

In this Q&A, Chua shares more about this critical issue and his work to train more clinicians across Mass General Brigham.

How did you get interested in this initiative?

Chua: During my fellowship training in Pediatric Emergency Medicine in Seattle, I had the opportunity to meet Dr. Mary Clyde Pierce, the lead researcher and creator of the TEN-4-FACESp Bruising Clinical Decision Rule, at a conference. Two years later, she recruited me to join her at Lurie Children's to help lead the advocacy arm of her work.

As a pediatric emergency medicine physician who is passionate about advocacy, I take care of children who are ill and injured every day. I think that gives us a particular responsibility to serve as a voice for children, especially those who may not be able to speak for themselves.

Most parents and caregivers take wonderful care of their children. But for the children who are experiencing abuse or neglect, the interaction that physicians, nurses, teachers, social workers and other mandated reporters have with these children may be one of the few opportunities to recognize that something is wrong and intervene before a child experiences more serious harm.

That is what drew me to TEN-4-FACESp. It gives clinicians a practical, evidence-based tool to help recognize bruising patterns that should prompt us to stop, think and consider whether abuse could be contributing to a child's injury.

Aren't pediatric clinicians already trained to recognize signs of abuse?

Chua: Pediatric clinicians are certainly trained to recognize child abuse, but recognizing physical abuse can be difficult. The injuries can be subtle, and bruises are often dismissed as insignificant - particularly when there isn't an obvious history of trauma.

This is important because bruising is the most common injury associated with physical abuse and can sometimes be an early warning sign before a child experiences a more serious or even fatal injury.

Massachusetts has one of the highest reported rates of child maltreatment in the country, with more than 16 children per 1,000 experiencing substantiated or indicated maltreatment.

We also know that our youngest children are particularly vulnerable. According to the 2024 Child Maltreatment report, approximately 65% of child fatalities from abuse and neglect occurred in children under 3 years of age, and nearly half occurred in children under 1 year.

One of the important concepts behind TEN-4-FACESp is that developmental stage matters. Young children who are not yet independently mobile generally do not get bruises. So, a bruise in an infant 4 months or younger is particularly concerning and should prompt further evaluation. Similarly, bruising in the TEN-4-FACESp locations - such as the torso, ears, neck, frenulum, angle of the jaw, cheeks, eyelids or subconjunctival region - in a child under 4 years of age should prompt the clinician to consider the possibility of abuse.

The goal isn't to say that every bruise means abuse. It is to give clinicians a simple way to recognize bruising patterns that deserve a second look and potentially a more thorough evaluation.

How have you helped grow awareness across MGB?

Chua: First, we've expanded education across multiple departments. In 2025 and 2026, I taught TEN-4-FACESp to our pediatric and emergency medicine residents and the Department of Surgery, as well as at our Pediatric Emergency Medicine Academic Conference, which includes physicians and advanced practice providers (APPs) from across Mass General Brigham.

This work is definitely interprofessional and multidisciplinary. We've trained physicians, APPs, residents, medical students and social workers. That's important because recognition of child abuse really is a team effort. Anyone who interacts with young children could identify a concerning bruise.

The more people across the healthcare system who understand the significance of these bruising patterns, the greater the opportunity to identify children who may need additional evaluation and protection.

The initiative has also grown nationally. Since 2023, we've held six national TEN-4 Day webinars. Most recently, in September 2026, we hosted a session with colleagues from Inova health system in Virginia focused on their systemwide implementation of TEN-4-FACESp using implementation science principles. Inova incorporated TEN-4-FACESp into the nursing workflow and electronic medical record across its hospital system. They achieved approximately 95% compliance with screening children under 4 for bruising of concern and sustained more than 94% compliance after one year.

This example demonstrates that TEN-4-FACESp doesn't have to remain an educational initiative. The goal is to integrate recognition of concerning bruising into the systems where clinicians are already caring for children.