Child abuse specialists note that there is high testing variability in children with bruising, with testing choices made based on physician gestalt and on social risk factors.

Additional Injuries in Young Children with Concern for Abuse and Apparently Isolated Bruises

This study draws data from index children whose sibs were examined for abuse as part of a prospective study within a research network of 20 child abuse teams in the US. The authors focused on young infants < 6 months with isolated bruising.

The purpose of the study was to determine the rates of testing and to determine whether testing could help in uncovering either evidence of abuse or of bleeding diatheses.

Results:

• 146 infants <6mo with isolated bruising: 2890 index patients, of whom 33.9% (980/2890) were < 6mos, of whom 25.9% (254/980) had bruising, of whom 57.5% (146/254) had isolated bruising.
• Bruising = exclude other exam findings unrelated to bruising (AMS, oral bleeding, disuse of an extremity) or a hx of assault. Bruising included falls as a cause of injury.
• Testing: overall over 90% had additional testing, with 50% having additional injuries identified by testing!
• Types of tests:
  • Skeletal survey: 94% (137/146) tested, with 23% (34/137) having new fractures identified.
  • Neuroimaging: 91% (133/146) had a head CT, with 27% (40/133) having important findings. Of note, 36 of these 40 also had face or head bruising.
  • Transaminases: 63% (92/146) had labs, and 14 had >80, with 12 proceeding to CT.
  • Abd CT: 10% (15/146) had a CT, of whom 12 had bumped LFTs and 4 had abdominal bruising. 4/15 had injuries, all of the liver.
  • Bleeding evaluation: 70% (103/146) had testing for bleeding disorders- plt count, PT/PTT checked >> thrombin time, F8, F9, vW antigen, PFA-100. Testing was done more often when there were multiple bruises. No bleeding disorders were identified.

What are major take-aways:

1. Babies < 6mo shouldn’t bruise: ‘those who don’t cruise rarely bruise,’ as the landmark article from 1999 said.
2. Abusive brain injuries are highly associated w face and head bruises. And, in this study, 54% of face and head bruises were associated with other injuries being identified.
3. Even a single bruise is worrisome, with 30/50 babies with a single bruise having other injuries identified by skeletal survey, neuro- or abdominal imaging.
4. Bleeding disorders are an unlikely explanation for bruising. Nevertheless, given that this is a relatively small cohort, there continues to be recommendations for testing as part of an abuse work-up: Anderst JD, et al. Evaluation for bleeding disorders in suspected child abuse. Pediatrics, 2013; 131:e1314-22.