This prospective observational study bolsters our notion of what is "normal" bruising in preschool children, lending some insight into when evaluation for bleeding diathesis or child abuse should be considered.
Source:Collins PW, Hamilton M, Dunstan FD, et al. Patterns of bruising in preschool children with inherited bleeding disorders: a longitudinal study. Arch Dis Child. 2017;102:1110–1117; doi:10.1136/archdischild-2015-310196. See AAP Grand Rounds Commentary by Dr. Mary-Jane Staba Hogan (subscription required).
All children have bruises from time to time, and one of many challenges in front-line pediatric practice is deciding when bruises should raise a flag for further investigation. This prospective observational study helps though still doesn't provide a definitive set of "rules" for triggering evaluation.
The researchers, from the UK and Canada, looked at children below 6 years of age enrolled at 6 hemophilia centers and compared them to healthy controls recruited from various sites in South Wales. Children were analyzed over 3 age groups related to mobility (premobile, early mobile, and walking) as well as by degree of bleeding disorder (none versus mild/moderate versus severe). They also looked at whether or not the children with bleeding disorders were receiving replacement therapy. Parents were trained to record numbers and sizes of bruises, and a validity subset showed that they were pretty accurate in their measurements compared to researcher measurements.
The main analysis consisted of 328 healthy control children, 57 with severe bleeding disorders, and 47 with mild/moderate bleeding diathesis. The take-home messages from the study aren't new but do reinforce findings from other studies:
- Children with bleeding problems have more bruises than healthy children, especially in the premobile stage (crawling and cruising).
- Children in the severe bleeding disorders category had larger bruises than the other 2 groups.
- Walking children with severe bleeding disorders didn't seem to differ that much based on whether or not they were receiving prophylaxis; this counterintuitive finding likely reflects confounding variables associated with the decision to prophylax specific children.
- Bruising on the ears, neck, cheeks, eyes, and genitalia was rare in all groups. (Other studies have suggested that bruising in those sites should prompt consideration of non-accidental trauma.)
- In premobile children, bruising is so uncommon that non-accidental trauma should be considered. Also, blood tests compatible with a mild or moderate bleeding disorder should not rule out non-accidental trauma.
The authors refer us to the Royal College of Paediatrics and Child Health Companion child protection publications, but most of them require membership (which I don't have). Fortunately, the AAP guideline for evaluating child physical abuse is available to all-comers. It contains a valuable section on evaluating bruising in children. I hope someone will take a detailed look at all the bruising studies in children and come up with a clinical prediction rule soon, similar to what is in place for pediatric abusive head trauma.