, et al
The prevalence of bruising among infants in pediatric emergency departments
Ann Emerg Med
; doi:

Researchers from multiple institutions sought to determine the prevalence of bruising in infants who presented to pediatric emergency departments (PEDs). The study population included infants aged ≤12 months who presented to 1 of 3 large PEDs between 2011 and 2013. Infants were excluded if they were referred for a concern of abuse or had a known coagulation abnormality, severe neurological/neuromuscular impairment, or severe skin disorder. Data were collected prospectively using a structured sampling approach with predetermined “research shifts” to minimize bias in data collection. During each research shift, a trained study investigator prospectively identified all eligible patients (ie, infants <1 year old without an exclusion criterion) and confirmed this with the treating physician. Systematic skin examinations were performed by the treating clinician on eligible infants to determine whether there were any bruises present. Additional data collected on each participant included age, chief complaint, and occurrence of abuse evaluation. An encounter was considered to include an abuse evaluation if the treating physician requested an evaluation by the hospital’s Child Protection Team or from a hospital-based social worker for possible abuse, or if a patient was reported to a child protection agency for suspected abuse/neglect. The primary outcome was presence of bruising. Rates of bruising were compared in infants of different ages (0–5 months vs 6–12 months) and by chief complaint (categorized as “medical” or “trauma”).

A total of 2,488 infants, with a mean age of 5 months, were enrolled in the study; 90% presented with a “medical” chief complaint. Among the enrolled infants, 88 (3.5%; 95% CI, 2.9%–4.4%) had bruising. Infants aged >5 months had a significantly higher rate of bruising than infants aged ≤5 months (6.4% vs 1.3%). Only 0.2% of infants aged 0–5 months with a “medical” chief complaint had bruising. Abuse evaluations occurred for 38 infants (1.5%), including 20 (23%) of the 88 bruised infants. Of these 20 children, 14 (70%) had a trauma-related chief complaint. The highest frequency of abuse evaluation occurred among bruised infants 0–5 months of age (50%).

The authors conclude that bruising in previously healthy infants presenting to a PED is rare, is most commonly associated with a trauma-related chief complaint, and that abuse evaluations occurred in fewer than half of bruised infants.

Dr Anderst has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

This study has several important findings. First, bruising in infants, particularly young, immobile infants, is rare. Therefore finding a bruise in an immobile infant should be alarming to treating clinicians. Second, in the 3 large academic PEDs affiliated with free-standing children’s hospitals which enrolled patients, only 50% of infants 0–5 months of age with bruises had an abuse evaluation. Previous studies have shown that...

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