Bruising in Children

Abstract

The evaluation for children with bruising may be affected by the specialty to which they are referred. We conducted a 3-year retrospective review of subjects referred for bruising to Child Abuse Pediatrics (CAP) or Pediatric Hematology to identify characteristics associated with referral to each specialty and to compare the diagnostic evaluations and diagnoses based on specialty. Of 369 subjects, 275 were referred to CAP and 94 to Hematology. Clinical exam findings were similar in both groups. Hematology referrals were significantly more likely to have laboratory evaluations. Among those referred to CAP, 9.5% had head computed tomography scans and 27.3% had skeletal surveys. No children referred to Hematology had these imaging studies performed. Hematology never diagnosed child physical abuse, and CAP never diagnosed bleeding disorders. Pediatric hematologists and CAPs perform different evaluations and reach different diagnostic conclusions for similar patients with bruising. Further investigation of these practice patterns is warranted.

Skeletal surveys in young, injured children: A systematic review

“…Data on SS utilization represents 62,226 children aged 0-59 months (see Appendix 2). The inclusion and exclusion criteria varied across studies, with 4 including all children with suspected or diagnosed with abuse (Belfer, Klein, & Orr, 2001; Hansen & Campbell, 2009; Hicks & Stolfi, 2007; Lindberg, Berger, Reynolds, Alwan, & Harper, 2014), 6 including children evaluated for suspected abuse with specific injuries or presentations (Carrim, Arbabi, & Long, 2012; Deye, Berger, & Lindberg, 2013; Ghahreman, Bhasin, Chaseling, Andrews, & Lang, 2005; Harper, Feldman, Sugar, Anderst, & Lindberg, 2014; Jackson et al, 2015; Lindberg et al, 2012), 10 including all children with specific injuries or presentations regardless of whether abuse was suspected (Anderst, 2008; Higginbotham et al, 2014; Hymel et al, 2015; Lane et al, 2002; Laskey, Stump, Hicks, & Smith, 2013; Lindberg et al, 2015; Rangel et al, 2009; Shelmerdine, Das, Ingram, & Negus, 2014; Wood et al, 2009; Wood et al, 2010), and 2 including some combination of these populations (Wood et al, 2012; Wood, French, et al, 2015). All 22 studies included infants, but the upper age limit ranged from 5 to 59 months.…”

“…A much lower percentage of infants diagnosed with abuse (58%) were evaluated with SS in a study of primarily non-pediatric hospitals (Wood, French, et al, 2015). Study-specific SS utilization percentages were also high in studies of infants with specific injuries referred to a child protection team (CPT) for evaluation of suspected or diagnosed abuse, including infants with retinal hemorrhages (100%; Carrim et al, 2012), skull fracture (94%; Deye et al, 2013), bruising (91% to 94%; Harper et al, 2014; Jackson et al, 2015), and burns (89%; Hicks & Stolfi, 2007).…”

Patterns of bruising in preschool children with inherited bleeding disorders: a longitudinal study

“… 1–4 14 If a mild laboratory abnormality is assumed to be the cause of bruising then abuse may go unrecognised but, if a bleeding disorder is missed, a family may be inappropriately accused of abuse. Interpretation of clinical findings may differ between paediatricians and haematologists 15 and both conditions may coexist. 16 This study aims to characterise bruising in children with bleeding disorders at different developmental stages, in comparison to children without bleeding disorders.…”