Guidance for the Clinician in Rendering Pediatric Care CLINICAL REPORT Evaluation for Bleeding Disorders in Suspected Child Abuse James D. Anderst, MD, MS, Shannon L. Carpenter, MD, MS, abstract Thomas C. Abshire, MD and the SECTION ON HEMATOLOGY/ Bruising or bleeding in a child can raise the concern for child abuse. ONCOLOGY and COMMITTEE ON CHILD ABUSE AND NEGLECT Assessing whether the findings are the result of trauma and/or KEY WORDS intracranial hemorrhage, inherited coagulation disorders, whether the child has a bleeding disorder is critical. Many bleeding bruising, nonaccidental trauma disorders are rare, and not every child with bruising/bleeding concern- ABBREVIATIONS ing for abuse requires an evaluation for bleeding disorders. In some aPTT—activated partial thromboplastin time instances, however, bleeding disorders can present in a manner sim- DIC—disseminated intravascular coagulation — ilar to child abuse. The history and clinical evaluation can be used to ICH intracranial hemorrhage ITP—immune thrombocytopenia determine the necessity of an evaluation for a possible bleeding dis- PFA-100—platelet function analyzer order, and prevalence and known clinical presentations of individual PT—prothrombin time bleeding disorders can be used to guide the extent of the laboratory VKDB—vitamin K deficiency bleeding VWD—von Willebrand disease testing. This clinical report provides guidance to pediatricians and This document is copyrighted and is property of the American other clinicians regarding the evaluation for bleeding disorders when Academy of Pediatrics and its Board of Directors. All authors child abuse is suspected. Pediatrics 2013;131:e1314–e1322 have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any INTRODUCTION commercial involvement in the development of the content of this publication. Children often present for medical care with bleeding or bruising that The guidance in this report does not indicate an exclusive can raise a concern for child abuse. Most commonly, this occurs with course of treatment or serve as a standard of medical care. cutaneous bruises and intracranial hemorrhage (ICH), but other Variations, taking into account individual circumstances, may be presentations, such as hematemesis,1 hematochezia,2 and oronasal appropriate. bleeding can be caused by child abuse and/or bleeding disorders.3–7 When bleeding or bruising is suspicious for child abuse, careful consideration of medical and other causes is warranted. The in- appropriate diagnosis of child abuse could occur,8–10 potentially resulting in the removal of a child from a home and/or the potential prosecution of an innocent person. Conversely, attributing an abusive injury to medical causes or accidental injury puts a child at risk for future abuse and possible death.11 Laboratory evaluations should be conducted with the understanding that the presence of a bleeding disorder does not rule out abuse as the etiology for bruising or bleeding.9 Similarly, the presence of a history of trauma (accidental or Accepted for publication Jan 23, 2013 nonaccidental) does not exclude the presence of a bleeding disorder www.pediatrics.org/cgi/doi/10.1542/peds.2013-0195 or other medical condition. This clinical report provides guidance to doi:10.1542/peds.2013-0195 pediatricians and other clinicians regarding the evaluation for All clinical reports from the American Academy of Pediatrics bleeding disorders when child abuse is suspected (Fig 1). automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2013 by the American Academy of Pediatrics e1314 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 26, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS that their child “bruises easily.” These statements are difficult to assess dur- ing an evaluation for possible abuse, as they can be a sign of a bleeding disorder, a reflection of the child’s (fair) skin tone, or a fabrication to mask abuse. Children who are verbal and capable of providing a history should be interviewed away from po- tential offending caregivers, if possible. A thorough physical examination should include an evaluation of areas of bruising that have higher specificity for abuse,14 such as the buttocks, ears, and genitals. Any bleeding disorder can cause cu- taneous bruising, and sometimes this bruising can be mild, can appear in locations that are considered suspi- cious for abuse,19 and can appear at any age. Given the extreme rarity of some bleeding disorders, it is not reasonable to perform extensive lab- oratory testing for bleeding disorders in every child. In some cases, the constellation of findings, taken in conjunction with the clinical history and physical examination, can be so strongly consistent with an abusive injury that further laboratory in- FIGURE 1 vestigation for medical conditions is Recommended pathway for evaluation of possible bleeding disorders when child abuse is suspected. not warranted. For instance, a child VWF, von Willebrand factor. with a patterned slap mark who describes being hit with an open hand does not require a laboratory evalua- ASSESSING THE NEED FOR excessive bleeding after dental proce- A LABORATORY EVALUATION FOR dures, increases the possibility of tion for a bleeding disorder. BLEEDING DISORDERS a bleeding disorder. Family history of In addition to bleeding disorders, the aspecific bleeding disorder or ethnic- possibility of other medical causes of The age and developmental capa- ity of a population with higher rates easy bruising or bleeding, such as bilities of the child, history of trauma, of a certain bleeding disorder (eg, Ehlers-Danlos syndrome, scurvy, can- the location and pattern of bruising, Amish) might necessitate testing for cer and other infiltrative disorders, and, in the case of ICH, findings on that condition. The child’smedications glutaric aciduria, and arteriovenous neuroimaging should be considered should be documented, because cer- malformations, should be assessed, when assessing children with bruising/ tain drugs can affect the results of as should a history of use of any – bleeding for possible abuse.12 18 Addi- some tests that might be used to medications or alternative therapies tionally, a medical history of symptoms detect bleeding disorders, such as that may increase bleeding/bruising. suggestive of a bleeding disorder, such the platelet function analyzer (PFA- Comprehensive descriptions of medi- as significant bleeding after a circum- 100; Siemens Healthcare Diagnostics, cal conditions that could be confused cision or other surgery, epistaxis, Tarrytown, NY) and platelet aggrega- with child abuse and alternative bleeding from the umbilical stump, or tion testing. Caregivers might state therapies that may predispose to PEDIATRICS Volume 131, Number 4, April 2013 e1315 Downloaded from www.aappublications.org/news by guest on September 26, 2021 bleeding/bruising are beyond the scope In cases of bruising, the assessment of suffer ICH, such as a small subdural or of this report and can be found else- the need for an evaluation for bleeding an epidural hematoma underlying where.20,21 Results of the history, re- disorders should focus on the following: a site of impact, from a short fall; view of systems, physical examination, the specific history offered to ex- however, short falls rarely result in and, in the case of ICH, neuroimaging plain the bruising; significant brain injury.16 Birth trauma are generally adequate to exclude and some medical conditions can also the nature and location of bruis- these conditions. When there are con- result in ICH in infants. Consultation ing; and cerns that a medical condition might with a child abuse pediatrician should be the cause of bruising or bleeding, mobility and developmental status be considered in complex or con- the evaluation for the conditions in of the child. cerning cases. question should occur simultaneously The following factors generally exclude No studies have systematically com- with the evaluation for abuse. the need for an evaluation for pared the presentation, clinical find- a bleeding disorder: ings, patterns of ICH, or presence of Bruising the caregivers’ description of retinal hemorrhages found in children In the absence of independently wit- trauma sufficiently explains the with bleeding disorders with those nessed accidental trauma or a known bruising; found in children in whom abusive medical cause, any bruising in a non- the child or an independent wit- head trauma is diagnosed. However, mobile child is highly concerning for ness is able to provide a history bleeding disorders can cause ICH in abuse and necessitates an evalua- of abuse or nonabusive trauma any part of the cranial contents, and tion for child abuse.12–15 Additionally, that explains the bruising; or up to 12% of children and young adults bruising in a young infant could also abusive object or hand-patterned with bleeding disorders have had fi 22,23 be the rst presentation of a bleeding bruising is present. ICH at some time. Children with disorder.19 As such, a simultaneous ICH concerning for abuse require an The injury history offered by care- evaluation for bleeding disorders is evaluation for bleeding disorders. givers might be purposefully