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When a Bruise Isn’t Just a Bruise

September 19, 2022

Any parent of a toddler will let you know that bruises can be a common occurrence for many children. But there are 2 times when bruises really do matter and should be addressed – in the instances of bleeding disorders and child abuse. And while there are times when it is easy to distinguish between normal bruising, physical abuse, and a bleeding disorder, there are situations where clinicians can be challenged to figure out what is going on. Fortunately, in this month’s Pediatrics, the American Academy of Pediatrics (AAP) has a new policy statement out on the “Evaluation for Bleeding Disorders in Suspected Child Abuse” (10.1542/peds.2022-059276). When coupling this report with the recent publication of the Bruising Clinical Decision Rule (BCDR) for children under 4-years-old,1 pediatricians now have much clearer guidance on how to handle bruising in children.

Let’s start with unintentional injuries. For the most part, as Dr. Naomi Sugar from Seattle Children’s Hospital reported decades ago, most children over 18th months will show up with at least 1 bruise in the office for check ups. Unintentional bruises show up on bony surfaces – foreheads, elbows, knees, and shins commonly. And while parents may be concerned about their toddlers with scattered bruises in these areas, the vast majority of children with multiple bruises are fine. Concern for an underlying bleeding disorder most often comes about from a family history of bleeding disorders or excessive bleeding after a procedure (circumcision or dental care most commonly). As noted in the policy statement, a history alone cannot rule out a bleeding disorder and specific coagulation tests should be performed. The typical workup includes prothrombin time, activated partial thromboplastin time, von Willebrand factor (VWF) antigen, VWF activity (Ristocetin cofactor), Factor VIII activity level, Factor IX activity level, and complete blood count with platelet count. Consultation with a hematologist is recommended.

Bruises from child abuse are typically found in non-mobile infants and in atypical locations. The BCDR is extremely useful and should be used by all pediatricians. Using the easy pneumonic TEN-4-FACESp for children under the age of 4, the following bruises are 96% sensitive and 87% specific for distinguishing abusive from non-abusive trauma1:

  • Torso, ear, neck (TEN)
  • Frenulum, Angle of jaw, Cheeks (fleshy), Eyelids, Subconjunctivae (FACES)
  • Patterned (p)
  • The 4 represents any bruising anywhere to an infant 4.99 months or younger

If bruising in a child is suspected to be a result of child abuse, the pediatrician has a few obligations. First, express concern to the parents that their child may have been abused and make sure they understand you are a mandated reporter. Then, make the report to your state or local department of child protective services and file any required paperwork. Third, consider further evaluation or consultation by a child abuse pediatrician and/or hematologist, especially in infants. Any infant with a suspicion for child physical abuse should have a full skeletal survey and consider head imaging by CT scan or MRI.

We all are obligated to protect children and make sure they are in safe environments. As such, we need to protect ourselves from bias – both of over-reporting based on race and/or ethnicity, and under-reporting based on our feeling of knowing “this nice family.” It is important to distinguish between unintentional bruising, child abuse and bleeding disorders, and recognize that even children with bleeding disorders can be abused too. Fortunately, we can read and refer to the latest AAP policy which provides great guidance for all of us.


  1. Pierce MC, Kaczor K, Lorenz DJ, et al. Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics. JAMA Netw Open. 2021;4(4):e215832. doi:10.1001/jamanetworkopen.2021.5832
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