Your last appointment of the day is a 15-month-old in for a well-child check. You know the family well, and both parents seem attentive and engaged. While doing the physical exam, you note nonpatterned bruising to the abdomen, buttocks and right cheek. The parents state they had not noticed the bruises and are unsure how they happened. With bruises in these locations highly concerning for abuse, you determine that you need to file a report with child protective services.
You order liver function tests and a skeletal survey to screen for occult (clinically unapparent) injuries. You also realize that medical conditions can present in manners that can be confused with abuse. In a child with suspicious bruising, bleeding disorders can present in such a fashion. As there are many bleeding disorders, you want to order the correct tests, knowing that a complete blood count (CBC), prothrombin time (PT) and activated partial thromboplastin time (aPTT) likely are inadequate.
Evaluating a child for possible abuse is one of the most challenging roles for a pediatrician. Given that errors in such an evaluation can have catastrophic consequences, it is critical to be accurate and thorough. Two updated AAP reports provide guidance to pediatricians in such situations.
The clinical report Evaluation for Bleeding Disorders in Suspected Child Abuse is available at https://doi.org/10.1542/peds.2022-059276. The technical report Evaluating for Suspected Child Abuse: Conditions that Predispose to Bleeding is at https://doi.org/10.1542/peds.2022-059277. The reports, from the Section on Hematology/Oncology, American Society of Pediatric Hematology/Oncology and Council on Child Abuse and Neglect, will be published in the October issue of Pediatrics.
Presentations of bleeding disorders and abuse
Bleeding disorders and abuse both can present with cutaneous bruising and intracranial hemorrhage (ICH). Any bleeding disorder can present with bruising; however, different bleeding disorders have variable potentials to cause ICH.
When considering the possibility of a bleeding disorder causing ICH, it is useful to consider the prevalence of the condition and its potential to result in ICH. The AAP reports incorporate the latest data to assist pediatricians in conducting appropriate evaluations.
When to obtain tests for bleeding disorders
Not all situations concerning for abuse that involve bruising require testing for a bleeding disorder. For example, if there is a clear history of nonabusive trauma, a bleeding disorder evaluation likely is not necessary. Additionally, some findings are highly consistent with abuse and highly unlikely from a bleeding disorder. Examples of such presentations include ear, neck or genital bruising or clear object or hand-patterned bruising.
Bruising occurring in the context of other clearly abusive injuries (e.g., fractures or burns) also does not require testing for bleeding disorders. However, bruising in an immobile child or bruising in concerning locations in a mobile child generally necessitates an evaluation for bleeding disorders, including CBC, PT, PTT, von Willebrand factor (VWF) antigen, VWF activity (e.g., VWF:GP1bM), factor VIII activity level and factor IX activity level.
Children with other findings consistent with abuse or independently witnessed trauma and ICH do not require an evaluation for bleeding disorders. In most other scenarios, testing for bleeding disorders is recommended in children with ICH. Recommendations were formulated using newer data allowing for tailored testing based on the situation.
Testing recommended for children with concerning ICH includes CBC, PT and aPTT. If there is a history of trauma or potential trauma, measuring factor VIII activity level and factor IX activity level is recommended.
Additionally, if there is neurologic compromise, fibrinogen and D-dimer tests are recommended.
These testing recommendations were constructed using condition prevalence, prevalence of ICH in the context of trauma and known presentations of conditions. Further or different testing may be necessary in specific clinical situations and is best guided by specialists in pediatric hematology.
Children with bleeding or bruising that is concerning for abuse require careful evaluation for bleeding disorders. The guidance in the updated AAP reports is intended to reduce excessive testing while minimizing the chances of missing a bleeding disorder and increasing confidence in the diagnosis of abuse if appropriate.
Drs. Anderst and Carpenter are lead authors of the reports. Dr. Anderst is a member of the Council on Child Abuse and Neglect, and Dr. Carpenter is a member of the Section on Hematology/Oncology.