Innovative app can be a screening tool to help identify red flags for abuse in young children

Reviewed by Emily Henderson, B.Sc.Apr 4 2023

An innovative app from Ann & Robert H. Lurie Children's Hospital of Chicago aims to increase earlier recognition of abuse in babies and children under 4 years of age who have bruises, with the hope of decreasing the incidence of severe injury and death from child abuse in this age group. The hospital launched the app in April, which coincides with National Child Abuse Prevention month.

Bruising caused by physical abuse is the most common injury to be overlooked or misdiagnosed as accidental before an abuse-related fatality or near-fatality in a young child. In a study of children with fatal and near-fatal abuse, over half had prior bruises that were unrecognized or misinterpreted by a professional who was a mandated reporter.

The new app, called LCAST (Lurie Children's Child Injury Plausibility Assessment Support Tool), is the brainchild of Lurie Children's Emergency Medicine physician Mary Clyde Pierce, MD, and Sr. Research Scientist Kim Kaczor, who developed it in partnership with Slingshot and BioDigital. LCAST utilizes distinguishing characteristics of bruising to aid evidence-based decision making. It is in no way meant to supplant judgment. Importantly, LCAST cannot be used to diagnose abuse, but rather functions as a screening tool to help identify red flags for abuse that may call for further evaluation.

Bruising on a young child is often dismissed as a minor injury, but depending on where the bruise appears, it can be an early sign of child abuse. We need to look at bruising in terms of risk. Our new app, LCAST, helps clinicians identify high-risk cases that warrant evaluation for child abuse. This is critical, since abuse tends to escalate, and earlier recognition can save children's lives."

Dr. Mary Clyde Pierce, Professor of Pediatrics and Preventive Medicine at Northwestern University Feinberg School of Medicine

LCAST was built by Slingshot and features an interactive 3D rotating model of a child, powered by the BioDigital Human Platform, that allows users to click on the body parts where the child's bruises are located. The user is also required to answer a few questions about the presence of other signs and symptoms and the injury event. The user receives a result based on the summary of the child's information that indicates whether abuse or accident is more likely. The result algorithm is driven by published research evidence. The app has links to relevant published studies and helpful resources. LCAST is free and available for Apple and Android devices.

LCAST is based on evidence from research funded through the National Institutes of Health (NIH) and led by Dr. Pierce that derived, refined and validated a bruising clinical decision rule called TEN-4-FACESp, which specifies body regions on which bruising is likely due to abuse in infants and young children. According to the study findings, published in the journal JAMA Network Open, TEN-4-FACESp reliably signals high risk for abuse when bruising appears on any of the following regions. "TEN" stands for torso, ear, and neck. "FACES" specifies facial features – frenulum (skin between upper lip and the gum, lower lip and the gum, and under the tongue), angle of jaw, cheeks (fleshy), eyelids, and subconjunctivae (red bruise on white part of the eye). The "p" is for patterned bruising, when, for example, the shape of the hand is visible on the child's skin. The "4" represents any bruising anywhere to an infant 4.99 months of age or younger. Importantly, the rule only applies to children with bruising who are younger than 4 years of age. Dr. Pierce cautions that the rule is not relevant in children without bruising, nor in children aged 4 years or older. In those circumstances, other methods of identifying abuse would be needed.

In this study, Dr. Pierce, Ms. Kaczor and colleagues screened for bruising in over 21,000 children younger than 4 years of age at five pediatric emergency departments. They enrolled 2,161 patients with bruising. Researchers found that the TEN-4-FACESp screening tool had a sensitivity of 95 percent and specificity of 87 percent, which means that it distinguished potential abuse from non-abuse with a high level of accuracy.

"It was very important to us to make sure that the app screening tool captures potential abuse without over-capturing innocent cases of children with bruising caused by accidental or incidental injury," said Dr. Pierce. "We are excited that LCAST is based on highly reliable evidence, and it is practical enough to be used by clinicians in Emergency Departments, paramedics, social workers from the Department of Children and Family Services, and during any clinical encounter."

"We are honored to announce our collaboration with Lurie Children's and Slingshot, as we join forces to develop a groundbreaking mobile app that utilizes our state-of-the-art interactive 3D technology," says Aaron Oliker, BioDigital's Chief Innovation Officer. "The LCAST app represents a significant milestone in the field of child abuse prevention, offering a practical and user-friendly tool that equips healthcare professionals with the necessary resources to identify and prevent high-risk cases."

Slingshot is the software development company that developed the LCAST app. They've been working with Dr. Pierce and Kim Kazcor for over a decade and were the same team that built the software used to collect the data behind the TEN-4-FACESp rule.

When asked about the project, Slingshot's CEO David Galownia said: "It's been incredibly gratifying to be the tech company behind such an impactful vision. Dr. Mary Clyde Pierce and Kim Kazcor have been tireless in their dedication to the field and are leaders in driving tangible research that ultimately improves patient outcomes and saves lives. My favorite part of this app is the impact it can have. I love that this project was donor-funded and made possible entirely by people who want to make a difference."

The data driving LCAST results were generated from research supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and The Grainger Foundation. The infrastructure to build the app was supported by an anonymous donor.