Every time a child abuse death is reported in the Maine news the most important question to ask is not: “What agency failed this child?”

The question should be: “How could this death have been prevented and can that knowledge inform our prevention efforts in the future?”

The rates of child abuse in America, though improving, are still astonishingly high. One in three children will have been part of a child protective investigation by the time they reach 18 years of age. One in ten will be substantiated for abuse. This is not just a child welfare problem, it is a societal problem.

What is specifically a child welfare problem, though, is re-abuse, defined as further abuse of a child who has previously been substantiated for abuse. According to the latest 2022 National Child Abuse and Neglect Data Set (NCANDS), the national average is 10% within one year of the initial substantiation. No percentage is acceptable. How do we address this?

Knowing that such solutions work in the long run, could we have implemented more social and economic solutions for all at-risk families?

Could we have identified risk factors in a specific high-risk family and mitigated those risks?

Could we have identified subtle signs of physical abuse and intervened more aggressively to prevent re-abuse?

All these solutions work. It is the last one that has as its namesake Oct. 4.

In 2013, a study from the Medical College of Wisconsin described 200 severely abused infants less than 12 months of age. Of these, an astounding 27%, or 1 in 4, had previous injuries that medical providers should have recognized as indicative of abuse. The authors concluded that “Previous sentinel injuries are common in infants with severe physical abuse and rare in infants evaluated for abuse and found to not be abused. Detection of sentinel injuries with appropriate interventions could prevent many cases of abuse.”

Another study in the same year from the Children’s National Hospital in Washington, D.C., emphasized why such missed diagnoses are important. This study found that, of 53 children who experienced recurrent abuse, 24% died.

However, just knowing about sentinel injuries has not prevented such missed diagnoses from continuing to happen.

In 2021, a multicenter research study looked at over 2,000 children who underwent abuse evaluations for bruising. The authors developed a “bruising clinical decision rule” that correctly identified most abuse victims and, just as importantly, correctly identified those who had not been abused.

The rule is a simple acronym, TEN-4-FACESp: Bruises of the trunk, ears, neck, frenula of the lip, angle of the jaw, cheek (fleshy area), eyelid and subconjunctiva (the white of the eye) in children 4 years of age and under, bruises anywhere in children 4 months of age and under (that is less than 5 months), and bruises in a pattern such as from a hand or belt. These sometimes subtle signs may be the only indication that a child is at risk of further abuse or even death. The authors stated that such findings always warrant further evaluation, ideally by a child abuse pediatrician.

The authors subsequently suggested that Oct. 4 (TEN-4) be identified as TEN-4 FACES Awareness Day by asking for a proclamation from state governors (governors from Illinois, Kentucky and Massachusetts have signed such a proclamation, as has most recently Gov. Janet Mills from Maine). They also suggested implementing hospital-based child abuse awareness campaigns, pediatric abusive head trauma training and TEN-4 media days.

In Maine, the state chapter of the American Academy of Pediatrics, the Maine Children’s Trust, the Spurwink Center for Safe and Healthy Families and the Maine Child Death and Serious Injury Review Panel have joined to develop such initiatives.

No child should die from abuse. One way to prevent such deaths is to identify concerning injuries the first time they occur and then take appropriate steps to prevent further abuse. It takes all of us, particularly mandatory reporters, to identify these findings and report them to the appropriate agency such as Child Protective Services. I would add that such injuries should always be evaluated medically by the most highly trained, experienced medical provider available such as the board-certified child abuse pediatricians at the Spurwink Center for Safe and Healthy Families.