Bruising or bleeding in a child can raise the concern for child abuse. Assessing whether the findings are the result of trauma and/or whether the child has a bleeding disorder is critical. Many bleeding disorders are rare, and not every child with bruising/bleeding that may raise a concern for abuse requires an evaluation for bleeding disorders. However, in some instances, bleeding disorders can present in a manner similar to child abuse. Bleeding disorders cannot be ruled out solely on the basis of patient and family history, no matter how extensive. The history and clinical evaluation can be used to determine the necessity of an evaluation for a possible bleeding disorder, and prevalence and known clinical presentations of individual bleeding disorders can be used to guide the extent of laboratory testing. This clinical report provides guidance to pediatricians and other clinicians regarding the evaluation for bleeding disorders when child abuse is suspected.

Significant variability exists in the evaluation of suspected child abuse, including the evaluation for bleeding disorders.1,4 The purpose of this clinical report is to reduce variability by providing guidance to pediatricians and other clinicians regarding the evaluation for bleeding disorders when suspicious bruising or intracranial hemorrhage (ICH) is present (Fig 1).

FIGURE 1

Recommended pathway for evaluation of possible bleeding disorders when child abuse is suspected. *Child with age or developmentally related immobility.

FIGURE 1

Recommended pathway for evaluation of possible bleeding disorders when child abuse is suspected. *Child with age or developmentally related immobility.

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On the basis of recent data, this clinical report provides updated recommendations for:

  1. Evaluating bleeding disorders in suspected child abuse (Fig 1);

  2. Identifying bruising that is suspicious for child abuse;

  3. Identifying bruising that may commonly be seen in children with congenital bleeding disorders;

  4. Testing for factor XIII deficiency in children with ICH;

  5. Testing for deficiencies of factor VIII and factor IX in children with subdural hemorrhage (SDH) on the basis of history of trauma;

  6. Testing for deficiencies of factor VIII and factor IX in females; and

  7. The utility of whole blood-clotting assays for testing for bleeding disorders.

Children often present for medical care with bleeding or bruising that can raise a concern for child abuse. Most commonly, this occurs with cutaneous bruises and ICH, particularly SDH, but other presentations, such as hematemesis,5 hematochezia,6 and oronasal bleeding can be caused by child abuse and/or bleeding disorders.7,9 When bleeding or bruising is suspicious for child abuse, careful consideration of medical and nonmedical causes is important. Mistaken diagnosis, whether an inappropriate finding of abuse, a missed case of abuse, or overlooking of a medical cause, can cause harm to the child and his or her family.10,13 Infants, in particular, are at high risk of abusive bruising/bleeding; however, bleeding disorders may also present in infancy in a similar manner to abusive bruising or bleeding.1318 

The patient’s medical and family history of bleeding/bruising, no matter how thorough, cannot completely eliminate a bleeding disorder as the cause of a patient’s findings.19,20 For instance, male infants who have had a circumcision with no significant bleeding issues may still have a bleeding disorder.21 As such, laboratory evaluations are often necessary to detect bleeding disorders. However, the presence of a bleeding disorder does not rule out abuse as the etiology for bruising or bleeding. Similarly, the presence of a history of trauma (accidental or nonaccidental) does not exclude the presence of a bleeding disorder or other medical condition.

Recommendations in this report are based on data summarized in the accompanying technical report.22 To determine the need for testing for bleeding disorders in children with suspicious bruising, recommendations are based on evidence that distinguishes accidental bruising from abusive bruising in children without bleeding disorders and evidence that characterizes bruising in children with congenital bleeding disorders. For suspicious bruising, the testing strategy was determined by the prevalence of the bleeding disorder. For suspicious ICH, the recommended testing strategy was based on the prevalence of specific bleeding disorders and evidence detailing the probability of ICH and, if possible, SDH, in certain clinical situations.

Recommendation 1: If a child has bruising/bleeding concerning for abuse, a thorough medical history of the child and family history should be obtained. However, the lack of a history of bruising/bleeding symptoms does not rule out the possibility of a bleeding disorder.1921 

Although a medical history of signs suggestive of a bleeding disorder, such as significant bleeding after a circumcision or other surgery, epistaxis, bleeding from the umbilical stump, or excessive bleeding after dental procedures, increases the possibility of a bleeding disorder, the absence of such a history does not rule out the presence of a bleeding disorder. If there is a family history of a specific bleeding disorder, testing for that specific disorder should be completed. Additionally, certain bleeding disorders have higher prevalence within specific populations, which may guide testing. Caregivers might state that their child “bruises easily.” These statements are difficult to assess during an evaluation for possible abuse because they can be a sign of a bleeding disorder, a reflection of the child’s (fair) skin tone, or a falsification to mask abuse. If children can provide a history, such a history should be obtained from them away from potential offending caregivers, if possible.

The child’s medications should be documented, because certain drugs, such as nonsteroidal antiinflammatory drugs, some antibiotics, antiepileptics, and herbal medications, can affect the results of some tests that might be used to detect bleeding disorders, such as the platelet function analyzer (PFA-100 [Siemens Healthcare Diagnostics, Tarrytown, NY]) and platelet aggregation testing. In addition to bleeding disorders, the possibility of other medical causes of easy bruising or bleeding, such as Ehlers-Danlos syndrome, scurvy, cancer and other bone marrow infiltrative disorders, glutaric aciduria, and arteriovenous malformations, should be considered, as should a history of use of any restrictive or unusual diets, ingestions, or alternative therapies that may increase the likelihood of bleeding/bruising. Comprehensive descriptions of medical conditions that could be confused with child abuse and alternative therapies that may predispose to bleeding/bruising are beyond the scope of this report and can be found elsewhere.23,26 

Recommendation 2: If a child has bruising that is concerning for abuse, the assessment of the need for laboratory testing for bleeding disorders should focus on:

  • the specific history offered to explain the bruising;

  • the location and pattern of bruising; and

  • mobility and developmental status of the child.13,17,2730 

Any bleeding disorder can cause cutaneous bruising, and sometimes this bruising can be mild, can appear in locations that are considered suspicious for abuse,18 and can appear at any age. Children with inherited bleeding disorders have more and larger bruises than children without bleeding disorders.16 

Recommendation 2a: If a child has any of the following factors, then an evaluation for a bleeding disorder is generally not needed:

  • the caregivers’ description of trauma sufficiently explains the bruising;

  • the child or an independent witness can provide a history of abuse or nonabusive trauma that explains the bruising;

  • object or hand-patterned bruising is present (highly consistent with abuse); or

  • bruising to the ears, neck, or genitals (highly consistent with abuse).16,17,27,29,30 

Clinicians should consider that the injury history offered by caregivers might be purposefully misleading if the caregivers have caused the bruising by abusive means. 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 investigation for medical conditions is not warranted. For instance, a child with a patterned slap mark who describes being hit with an open hand does not require a laboratory evaluation for a bleeding disorder.

Recommendation 2b: If a nonmobile child has bruising, and there is no history of an independently witnessed accidental cause or a known medical cause, an evaluation for bleeding disorders should be conducted simultaneous to a child abuse evaluation.13,14,17,18,27,29 

Any bruising in a nonmobile child is highly concerning for abuse. Additionally, bruising in a young infant could also be the first presentation of a bleeding disorder. As such, in young infants or children with developmental delays with minimal or no mobility, who present with bruising, it is recommended that an evaluation for bleeding disorders occur simultaneous to an abuse evaluation. In nonmobile children, bleeding disorders can present with bruising or petechiae in sites of normal handling or pressure. Examples of this include:

  • petechiae at clothing line pressure sites;

  • bruising at sites of object pressure, such as in the pattern and location of infant seat fasteners; and

  • excessive diffuse bruising/bleeding if the child has a severe bleeding disorder.

Absence of these examples does not rule out a bleeding disorder; however, their presence might increase the probability of a bleeding disorder.

Recommendation 2c: If a mobile child has bruising, then the possibility of abuse should be assessed using the locations and patterns of the bruising (Table 1).

TABLE 1

Suspicion of Child Abuse in Ambulatory Children on the Basis of Characteristics of Bruises16,17,2730,43 

Less Suspicious for Child AbuseMore Suspicious for Child Abuse
Forehead/nose/chin (facial T) Location 
Elbows  Cheeks 
Lower arms  Angle of the jaw 
Hips  Ears 
Shins  Neck 
Ankles  Upper arms 
  Torso 
  Hands 
  Genitalia 
  Buttocks 
 Pattern 
  Slap or hand marks 
  Object marks 
  Bite marks 
  Bruises in clusters 
  Multiple bruises of uniform shape 
  Large cumulative size of bruising 
  Petechial bruisinga 
Less Suspicious for Child AbuseMore Suspicious for Child Abuse
Forehead/nose/chin (facial T) Location 
Elbows  Cheeks 
Lower arms  Angle of the jaw 
Hips  Ears 
Shins  Neck 
Ankles  Upper arms 
  Torso 
  Hands 
  Genitalia 
  Buttocks 
 Pattern 
  Slap or hand marks 
  Object marks 
  Bite marks 
  Bruises in clusters 
  Multiple bruises of uniform shape 
  Large cumulative size of bruising 
  Petechial bruisinga 
a

Petechial bruising may also be suggestive of a bleeding disorder, particularly platelet function disorders.

In mobile children, bleeding disorders can cause bruising in areas generally considered suspicious for abuse, such as the buttocks or torso. Bruising to the ears, neck, or genitals is rarely seen in either accidental injuries or in children with bleeding disorders and is highly concerning for abuse.16,17,27,29,30 

Recommendation 3: If a child has ICH concerning for abuse, then an evaluation for bleeding disorders should be conducted (see Recommendation 9). Exceptions to required evaluation can include:

  • independently witnessed or verifiable trauma (abusive or nonabusive); or

  • other findings consistent with abuse, such as fractures, burns, or internal abdominal trauma.

The decision to conduct an evaluation for bleeding disorders can be made on a case-by-case basis depending on case specific factors. Excepting obvious known trauma, ICH, particularly SDH, in a nonmobile child is highly concerning for child abuse.

Children can suffer ICH, such as a small SDH or an epidural hematoma underlying a site of impact, from a short fall. However, short falls rarely result in significant brain injury.31 Birth trauma and some medical conditions can also result in ICH, including SDH, in infants. No studies have systematically compared the presentation, clinical findings, patterns or locations of ICH, or presence of retinal hemorrhages found in children with bleeding disorders to those found in children in whom abusive head trauma (AHT) is diagnosed. However, bleeding disorders can cause ICH in any part of the cranial contents and can cause spontaneous ICH, including SDH.15 Up to 12% of children and young adults with bleeding disorders have had ICH (traumatic, spontaneous, or otherwise) at some time.32,33 

Recommendation 4: Children with conditions such as hematemesis, hematochezia, or oronasal bleeding as presenting signs should be evaluated on a case-by-case basis for possible abuse.

Caregiver-fabricated illness in a child, inflicted trauma, and/or medical conditions can cause any of these findings. A hematologist may be consulted to determine the necessity of an evaluation for bleeding disorders in a specific circumstance.

Recommendation 5: If performing tests for bleeding disorders in a child who has findings concerning for abuse, tests should be chosen on the basis of their ability to detect specific bleeding disorders that may cause the findings. Whole blood clotting assays, such as the thromboelastograph or rotational thromboelastography, should not be used as part of a testing strategy for bleeding disorders in the setting of possible abuse. Bleeding time is not a helpful test for diagnosing specific bleeding disorders.22 

Bleeding disorders that can produce patterns of bruising or bleeding that may mimic abuse include coagulation factor deficiencies/abnormalities, fibrinolytic defects, defects of fibrinogen, and platelet disorders. Table 2 contains a listing of the most common bleeding disorders in children and characteristics of potential testing strategies for each disorder. Most factor deficiencies can be detected by the prothrombin time (PT) and activated partial thromboplastin time (aPTT). However, von Willebrand disease (VWD) and factor XIII deficiency are not reliably detected by these tests. Additionally, mild deficiencies in factor VIII or factor IX (mild hemophilia) might not cause abnormalities in the aPTT, and, if testing for these conditions is desired, a specific factor level is necessary. Fibrinolytic defects can cause significant bleeding/bruising but are extremely rare and require specific testing. Defects of fibrinogen are also rare and can be detected by the fibrinogen concentration and thrombin time.

TABLE 2

Common Testing Strategies for Bleeding Disorders

ConditionFrequencyInheritanceInitial TestsSn and Sp (%)PPV, NPV (%)Confirmatory Test
Factor abnormalities/efficiencies 
 VWD type 1 1 per 1000 AD PFA-100a Sn = 79–96,b Sp = 88–96b PPV = 93.3, NPV = 98.2 VWantigen,c VWF activity, vW multimer analysis, factor VIII activity 
 VWD type 2A Uncommon AD or AR PFA-100a Sn = 94–100,b Sp = 88–96b PPV = 93.3, NPV = 98.2 VWantigen,c VWF activity, vW multimer analysis, factor VIII activity 
 VWD type 2B Uncommon AD PFA-100a Sn = 93–96,b Sp = 88–96b PPV = 93.3, NPV = 98.2 VWantigen,c VWF activity, vW multimer analysis, factor VIII activity 
 VWD type 2M Uncommon AD or AR PFA-100a Sn = 94–97,b Sp = 88–96b PPV = 93.3, NPV = 98.2 VWantigen,c VWF activity, vW multimer analysis, factor VIII activity 
 VWD type 2N Uncommon AR, or compound heterozygote aPTT NA NA VWF-factor VIII binding assay 
 VWD type 3 1 per 300 000–1 000 000 AR, or compound heterozygote PFA-100a Sn = 94–100,b Sp = 88–96b PPV = 93.3, NPV = 98.2 VWantigen,c ristocetin cofactor, vWF multimer analysis, factor VIII activity 
 Factor II deficiency (prothrombin) Estimated 1 per 1–2 million  aPTT, PT (may be normal) Sn = variable NA Factor II activity ± antigen levels 
 Factor V deficiency 1 per 1 million AR aPTT, PT Sn = variable NA Factor V activity 
 Combined Factor V/factor VIII deficiency 1 per 1 million AR aPTT > PT Sn = variable NA Factor V and factor VIII activities 
 Factor VII deficiency 1 per 300 000–500 000 AR PT Sn = variable NA Factor VII activity 
 Factor VIII deficiency 1 per 5000 male births X-linked aPTT Sn = variable NA Factor VIII activity 
 Factor IX deficiency 1 per 20 000 male births X-linked aPTT Sn = variable NA Factor IX activity 
 Factor X deficiency 1 per 1 million AR aPTT, PT, RVV Sn = variable NA Factor X activity 
 Factor XI deficiency 1 per 100 000 AR aPTT Sn = variable NA Factor XI activity 
 Factor XIII deficiency 1 per 2–5 million AR NA NA NA Factor XIII activity 
Fibrinolytic defects 
 α-2 antiplasmin deficiency ∼40 reported cases AR TEG/ROTEM Sn = variable NA α-2 antiplasmin activity 
 (PAI-1) Very rare AR NA NA NA PAI -1 antigen and activity 
Defects of fibrinogen 
 Afibrinogenemia 1 per 500 000 AR PT, aPTT Sn = high NA Fibrinogen level 
 Hypofibrinogenemia Less than afibrinogenemia AD PT, aPTT Sn = variable NA Thrombin time, fibrinogen activity 
 Dysfibrinogenemia 1 per million AD; occasionally AR Thrombin time, fibrinogen level Sn = variable NA Thrombin time, fibrinogen antigen and activity level comparison, reptilase time 
Platelet disorders 
 ITP Age-related NA CBC Sn = high NA Antiplatelet Ab (rarely needed) 
 Glanzmann thrombasthenia Very rare AR PFA-100a Sn = 97–100 NA Platelet aggregation testing flow cytometry 
 Bernard Soulier syndrome Rare AR PFA-100a Sn = 100 NA Platelet aggregation testing flow cytometry 
 Platelet release/storage disorders Unknown, more common than other platelet function disorders Variable PFA-100a Sn = 27–50 NA Platelet aggregation and secretion, electron microscopy, molecular and cytogenetic testing 
ConditionFrequencyInheritanceInitial TestsSn and Sp (%)PPV, NPV (%)Confirmatory Test
Factor abnormalities/efficiencies 
 VWD type 1 1 per 1000 AD PFA-100a Sn = 79–96,b Sp = 88–96b PPV = 93.3, NPV = 98.2 VWantigen,c VWF activity, vW multimer analysis, factor VIII activity 
 VWD type 2A Uncommon AD or AR PFA-100a Sn = 94–100,b Sp = 88–96b PPV = 93.3, NPV = 98.2 VWantigen,c VWF activity, vW multimer analysis, factor VIII activity 
 VWD type 2B Uncommon AD PFA-100a Sn = 93–96,b Sp = 88–96b PPV = 93.3, NPV = 98.2 VWantigen,c VWF activity, vW multimer analysis, factor VIII activity 
 VWD type 2M Uncommon AD or AR PFA-100a Sn = 94–97,b Sp = 88–96b PPV = 93.3, NPV = 98.2 VWantigen,c VWF activity, vW multimer analysis, factor VIII activity 
 VWD type 2N Uncommon AR, or compound heterozygote aPTT NA NA VWF-factor VIII binding assay 
 VWD type 3 1 per 300 000–1 000 000 AR, or compound heterozygote PFA-100a Sn = 94–100,b Sp = 88–96b PPV = 93.3, NPV = 98.2 VWantigen,c ristocetin cofactor, vWF multimer analysis, factor VIII activity 
 Factor II deficiency (prothrombin) Estimated 1 per 1–2 million  aPTT, PT (may be normal) Sn = variable NA Factor II activity ± antigen levels 
 Factor V deficiency 1 per 1 million AR aPTT, PT Sn = variable NA Factor V activity 
 Combined Factor V/factor VIII deficiency 1 per 1 million AR aPTT > PT Sn = variable NA Factor V and factor VIII activities 
 Factor VII deficiency 1 per 300 000–500 000 AR PT Sn = variable NA Factor VII activity 
 Factor VIII deficiency 1 per 5000 male births X-linked aPTT Sn = variable NA Factor VIII activity 
 Factor IX deficiency 1 per 20 000 male births X-linked aPTT Sn = variable NA Factor IX activity 
 Factor X deficiency 1 per 1 million AR aPTT, PT, RVV Sn = variable NA Factor X activity 
 Factor XI deficiency 1 per 100 000 AR aPTT Sn = variable NA Factor XI activity 
 Factor XIII deficiency 1 per 2–5 million AR NA NA NA Factor XIII activity 
Fibrinolytic defects 
 α-2 antiplasmin deficiency ∼40 reported cases AR TEG/ROTEM Sn = variable NA α-2 antiplasmin activity 
 (PAI-1) Very rare AR NA NA NA PAI -1 antigen and activity 
Defects of fibrinogen 
 Afibrinogenemia 1 per 500 000 AR PT, aPTT Sn = high NA Fibrinogen level 
 Hypofibrinogenemia Less than afibrinogenemia AD PT, aPTT Sn = variable NA Thrombin time, fibrinogen activity 
 Dysfibrinogenemia 1 per million AD; occasionally AR Thrombin time, fibrinogen level Sn = variable NA Thrombin time, fibrinogen antigen and activity level comparison, reptilase time 
Platelet disorders 
 ITP Age-related NA CBC Sn = high NA Antiplatelet Ab (rarely needed) 
 Glanzmann thrombasthenia Very rare AR PFA-100a Sn = 97–100 NA Platelet aggregation testing flow cytometry 
 Bernard Soulier syndrome Rare AR PFA-100a Sn = 100 NA Platelet aggregation testing flow cytometry 
 Platelet release/storage disorders Unknown, more common than other platelet function disorders Variable PFA-100a Sn = 27–50 NA Platelet aggregation and secretion, electron microscopy, molecular and cytogenetic testing 

AD, autosomal dominant; AR, autosomal recessive; CBC, complete blood count; ITP, immune thrombocytopenia; NA, not available or not applicable; NPV, negative predictive value; PAI-1, plasminogen activator inhibitor-1; PPV, positive predictive value; ROTEM, rotational thromboelastometry; RVV, Russell viper venom (test); Sn, sensitivity; Sp, specificity; TEG, thromboelastography; vW, von Willebrand; VWantigen, von Willebrand antigen; VWF, von Willebrand factor.

a

PFA-100 sensitivity and specificity provided for informational purposes. Testing may miss some forms of VWD and mild platelet abnormalities.

b

Values derived from data before 2008 National Institutes of Health consensus guidelines. Sensitivity and specificity using current diagnostic cutoffs unknown but would be expected to have higher specificity with lower sensitivity.

c

May be reasonable to proceed directly to diagnostic testing depending on availability. See accompanying technical report for detailed discussion.22 

Mild platelet disorders are those that typically result in mild mucocutaneous bleeding/bruising, menorrhagia, and/or postsurgical bleeding.22 The prevalence of mild platelet disorders is unknown, and testing for mild platelet disorders is challenging. The most common clinical presentations include bruising and mucocutaneous bleeding. The prevalence of ICH in mild platelet disorders is unknown but is likely to be low. Platelet aggregation testing, best performed by a specialized laboratory and interpreted by a pediatric hematologist, requires a relatively large volume of blood.34 A PFA-100 can evaluate for many platelet function disorders, including more severe types, such as Bernard Soulier syndrome and Glanzmann thrombasthenia, as well as many types of VWD. However, the PFA-100 is not an effective test for some types of VWD and milder platelet abnormalities. Individual patient characteristics, such as hematocrit, platelet count, pregnancy, age, multisystem trauma, sepsis, and medications, can affect the results of the PFA-100. Accurate diagnosis often requires additional testing, such as specific VWD testing or platelet aggregation testing.34,35 Assessment of the results of a PFA-100 and the need for further testing are best accomplished in consultation with a pediatric hematologist.

Recommendation 6: If an infant, typically younger than 6 months, has bleeding/bruising findings concerning for abuse and a prolonged PT, provision of vitamin K at birth should be confirmed and/or testing for vitamin K deficiency should be performed.

Vitamin K deficiency in younger infants can result in bleeding in the skin or from mucosal surfaces from circumcision, generalized ecchymoses, large intramuscular hemorrhages, or ICH. Because of the widespread provision of vitamin K at birth, vitamin K deficiency bleeding (VKDB) is rare; however, not all states require vitamin K to be administered at birth, refusal of vitamin K by parents has increased, and some medical conditions predispose to VKDB.22 In VKDB, there is a prolonged PT and possibly aPTT for age. In patients who have already received vitamin K, fresh-frozen plasma, or specific factor replacement as treatment, measurement of proteins induced by vitamin K absence can confirm the diagnosis.36,37 

Recommendation 7: Physicians who do not have the necessary resources available or who are not comfortable with evaluating for bleeding disorders in the context of possible child abuse should refer to a child abuse pediatrician, pediatric hematologist, or other physician who is capable of completing the evaluation.

The extent of laboratory evaluations performed by a physician may be affected by the availability of such tests to the physician and the physician’s comfort or skill in interpreting the test(s) in the context of the child’s findings. Additionally, because coagulation testing results can be altered by delay of processing after drawing the sample or by relative inexperience in running the assay, it may be better to have testing performed at a reference laboratory. For cases in which the recommended tests are not readily available, the authors recommend referral.

Recommendation 8: If a child has bruising concerning for abuse that necessitates an evaluation for bleeding disorders, the following tests should be obtained:

  • PT;

  • aPTT;

  • VWF antigen;

  • VWF activity (Ristocetin cofactor);

  • Factor VIII activity level;

  • Factor IX activity level; and

  • complete blood count with platelet count.

The initial testing panel in a patient who presents with bruising evaluates for idiopathic thrombocytopenic purpura, all factor deficiencies (except factor XIII deficiency), and VWD (Fig 1). It does not evaluate for extremely rare conditions, including factor XIII deficiency, defects of fibrinogen, and fibrinolytic defects. This strategy also does not test for extremely rare platelet disorders and more common, but relatively more difficult to diagnose, platelet function disorders.

Recommendation 8a: If a child who has bruising suspicious for abuse is removed from a potentially dangerous setting where the abuse likely occurred, a thorough physical examination should be performed in the weeks after removal. If that examination reveals minimal bruising and/or bruising only in locations of common accidental bruises, abuse is supported as the cause of the original suspicious bruising.

Each case should be evaluated individually, considering the totality of findings, and with the understanding of the need to balance safety with the emotional trauma of removing a child from his or her home. Bleeding disorders are generally permanent conditions that do not result in abatement after a change in caregivers. One exception to this is immune thrombocytopenia which is a transient, often self-resolving bleeding disorder. Testing for immune thrombocytopenia with a platelet count is necessary at the time of presentation with bruises.

Specific data regarding the prevalence of bleeding disorders in the population of children with ICH are not available. However, there are data regarding the probability of specific bleeding disorders to cause ICH, and in some cases, specifically SDH. If the prevalence of a condition and the frequency of a presentation of that condition are known, the probability of that specific condition (bleeding disorder) resulting in the specific presentation (ICH or, more specifically, SDH) can be determined (Table 3). Some probabilities are so low as to preclude calculation. Data summarizing the prevalence and probability of SDH in children younger than 2 years with mild, moderate, and severe deficiencies of factors VIII and IX on the basis of history of trauma are in Table 4.

TABLE 3

Probabilities for Congenital Coagulopathies to Cause ICH

ConditionPrevalence of ConditionPrevalence of ICHProbabilitya
VWD 1 per 1000 Extremely rare Lowb 
Factor II deficiency 1 per 1 million 11% 1 per 10 million 
Factor V deficiency 1 per 1 million 8% of homozygotes 1 per 10 million homozygotes 
Combined factors V and VIII deficiencies 1 per 1 million 2% 1 per 50 million 
Factor VII deficiency 1 per 300 000 4%–6.5% 1 per 5 million 
Factor VIIl deficiency (all)c 1 per 9500 males 7.0% 1 per 140 000 
 Severe 1 per 20 000 males 9.1% 1 per 220 000 
 Moderate 1 per 40 000 males 4% 1 per 1 million 
 Mild 1 per 30 000 males 2.8% 1 per 1.1 million 
Factor IX deficiency (all)c 1 per 34 000 males 7.6% 1 per 450 000 
 Severe 1 per 95 000 males 10.7% 1 per 885 000 
 Moderate 1 per 110 000 males 3.4% 1 per 3.1 million 
 Mild 1 per 120 000 males 8% 1 per 1.5 million 
Factor X deficiency 1 per 1 million 21% 1 per 5 million 
Factor XI deficiency 1 per 1 million Extremely rare Lowb 
Factor XIII deficiency 1 per 2 million 33% 1 per 6 million 
α-2 antiplasmin deficiency Extremely rare Not reported Lowb 
Plasminogen activator inhibitor-1 deficiency (PAI-1) Extremely rare Common Lowb 
Afibrinogenemia 1 per 500 000 10% 1 per 5 million 
Dysfibrinogenemia 1 per 1 million Single case report Lowb 
ConditionPrevalence of ConditionPrevalence of ICHProbabilitya
VWD 1 per 1000 Extremely rare Lowb 
Factor II deficiency 1 per 1 million 11% 1 per 10 million 
Factor V deficiency 1 per 1 million 8% of homozygotes 1 per 10 million homozygotes 
Combined factors V and VIII deficiencies 1 per 1 million 2% 1 per 50 million 
Factor VII deficiency 1 per 300 000 4%–6.5% 1 per 5 million 
Factor VIIl deficiency (all)c 1 per 9500 males 7.0% 1 per 140 000 
 Severe 1 per 20 000 males 9.1% 1 per 220 000 
 Moderate 1 per 40 000 males 4% 1 per 1 million 
 Mild 1 per 30 000 males 2.8% 1 per 1.1 million 
Factor IX deficiency (all)c 1 per 34 000 males 7.6% 1 per 450 000 
 Severe 1 per 95 000 males 10.7% 1 per 885 000 
 Moderate 1 per 110 000 males 3.4% 1 per 3.1 million 
 Mild 1 per 120 000 males 8% 1 per 1.5 million 
Factor X deficiency 1 per 1 million 21% 1 per 5 million 
Factor XI deficiency 1 per 1 million Extremely rare Lowb 
Factor XIII deficiency 1 per 2 million 33% 1 per 6 million 
α-2 antiplasmin deficiency Extremely rare Not reported Lowb 
Plasminogen activator inhibitor-1 deficiency (PAI-1) Extremely rare Common Lowb 
Afibrinogenemia 1 per 500 000 10% 1 per 5 million 
Dysfibrinogenemia 1 per 1 million Single case report Lowb 

The probability of having a specific bleeding disorder increases in the setting of a family history of that specific-named bleeding disorder or if the patient is from an ethnicity in which a specific bleeding disorder is more common (eg, Ashkenazi Jewish people and factor XI deficiency). PAI-1, plasminogen activator inhibitor-1.

a

“Probability” indicates the probability that an individual in the general population would have the following specific coagulopathy causing an ICH.

b

It is not possible to calculate a probability on the basis of the rarity of the occurrence.

c

Age-adjusted prevalence of all, severe, moderate, and mild deficiencies of factor VIII and IX were used. Probability is calculated for children younger than 4 years.

TABLE 4

Probabilities for Hemophilia A (Factor VIII deficiency) and B (Factor IX deficiency) to Cause SDH in Children Younger Than 2 Years

ConditionPrevalence of ConditionaPrevalence of Traumatic SDHProbabilityb of Traumatic SDHPrevalence of Spontaneous SDHProbabilityb of Spontaneous SDH
Factor VIII deficiency (all) 1 per 9500 males 1% 1 per 1.2 million 1.1% 1 per 860 000 
 Severe 1 per 20 000 males 1% 1 per 2.2 million 1.8% 1 per 1.1 million 
 Moderate 1 per 40 000 males 1% 1 per 5.7 million 0% Lowc 
 Mild 1 per 30 000 males 1% 1 per 3 million 0% Lowc 
Factor IX deficiency (all) 1 per 34 000 males 0.9% 1 per 3.8 million 0.9% 1 per 3.8 million 
 Severe 1 per 95 000 males 0% Low 2% 1 per 4.8 million 
 Moderate 1 per 110 000 males 3% 1 per 4.4 million Lowc 
 Mild 1 per 120 000 males 0% Low Lowc 
ConditionPrevalence of ConditionaPrevalence of Traumatic SDHProbabilityb of Traumatic SDHPrevalence of Spontaneous SDHProbabilityb of Spontaneous SDH
Factor VIII deficiency (all) 1 per 9500 males 1% 1 per 1.2 million 1.1% 1 per 860 000 
 Severe 1 per 20 000 males 1% 1 per 2.2 million 1.8% 1 per 1.1 million 
 Moderate 1 per 40 000 males 1% 1 per 5.7 million 0% Lowc 
 Mild 1 per 30 000 males 1% 1 per 3 million 0% Lowc 
Factor IX deficiency (all) 1 per 34 000 males 0.9% 1 per 3.8 million 0.9% 1 per 3.8 million 
 Severe 1 per 95 000 males 0% Low 2% 1 per 4.8 million 
 Moderate 1 per 110 000 males 3% 1 per 4.4 million Lowc 
 Mild 1 per 120 000 males 0% Low Lowc 
a

Age-adjusted prevalence of all, severe, moderate, and mild deficiencies of factor VIII and factor IX were used.

b

“Probability” indicates the probability that an individual in the general population would have the following specific coagulopathy causing an ICH.

c

It is not possible to calculate a probability on the basis of the rarity of the occurrence.

Recommendation 9: If a child has ICH concerning for abuse and testing for bleeding disorders is conducted, then the following initial testing panel is recommended (Fig 1):

  • PT;

  • aPTT; and

  • complete blood count with platelet count.

The initial testing panel for ICH evaluates for most factor deficiencies. Although the prevalence of severe hemophilia in females is significantly lower than that in males, it does occur, and will be detected by aPTT. This panel does not include testing for mild and moderate deficiencies of factors VIII and IX. This panel also does not test for factor XIII deficiency. Consideration should be given to prevalence in certain populations because it is estimated that one-third of the human population with severe congenital deficiency of factor XIII deficiency is in Iran.22 The most frequent type of ICH in factor XIII deficiency is intraparenchymal hemorrhage.22 Other conditions for which testing is not included in the suggested initial panel include VWD, fibrinolytic defects, and disorders of fibrinogen. These conditions either have not been associated with ICH or they are so rarely the cause of ICH that testing for the conditions is generally not helpful.

Recommendation 9a: In ICH concerning for abuse, testing for mild and moderate hemophilia, d-dimer, fibrinogen, and VWD may be necessary on the basis of specific clinical scenarios. If there is a history of trauma, testing for mild hemophilia (levels of factor VIII and factor IX) should be performed. If there is neurologic compromise, testing for d-dimer and fibrinogen should be performed (Fig 1).

Mild or moderate hemophilia may result in SDH after trauma but is not a reasonable explanation for spontaneous SDH. Mild hemophilia, which might be missed if only a PTT test is ordered, can be detected by measuring specific activity levels of factor VIII and factor IX. If there is concern that a history of trauma may be offered at a time subsequent to the medical evaluation, consideration should be given to evaluating for deficiencies of factors VIII and IX at the time of the medical evaluation. The prevalence of mild and moderate hemophilia in females is unknown, and therefore, the recommendations for testing in the case of ICH do not differ on the basis of gender.22 If the child is acutely neurologically compromised, a d-dimer and fibrinogen are recommended because of the potential of disseminated intravascular coagulation (DIC). Because DIC can cause any type of bruising/bleeding, including ICH, the finding of DIC in the context of suspected child abuse could significantly change the clinical approach to a patient. In children with DIC and bleeding symptoms as the only finding concerning for abuse, consideration should be given to the multitude of primary causes of DIC, including trauma, and sepsis, among many others. Although not specifically included in the recommended testing panel, VWD has been associated with SDH after minor trauma in children who return to neurologic baseline.38 VWD has not been demonstrated to cause spontaneous SDH and/or accompanying persistent neurologic compromise that may be confused with AHT.15 In some select cases, particularly those involving young children with SDH and no neurologic compromise in the setting of possible trauma, testing for VWD may be considered.

Recommendation 9b: If blood products have been given to the patient, the definitive evaluation for bleeding disorders should be postponed until the transfused blood components are no longer in the patient’s system (Table 5).

TABLE 5

Half-Lives of Coagulation Factors

FactorHalf-Life Postinfusion (h)
Fibrinogen 96–150 
II 60 
24 
VII 4–6 
VIII 11–12 
IX 22 
35 
XI 60 
XIII 144–300 
VWF 8–12 
FactorHalf-Life Postinfusion (h)
Fibrinogen 96–150 
II 60 
24 
VII 4–6 
VIII 11–12 
IX 22 
35 
XI 60 
XIII 144–300 
VWF 8–12 

Republished with permission of McGraw Hill LLC, from Goodnight S, Hathaway W. Disorders of Hemostasis and Thrombosis: A Clinical Guide, second ed. New York, NY: McGraw-Hill Professional; 2001:497; permission conveyed through Copyright Clearance Center, Inc. VWF, von Willebrand factor.

In general, waiting 7 half-lives until testing for a specific factor deficiency should be sufficient for depletion of transfused product. However, the clinical status of the patient should also be considered. In some cases, testing may be able to be performed sooner, if clinical suspicion is exceptionally high and need for treatment is paramount. Assistance from a pediatric hematologist should be considered in addressing the possibility of factor deficiencies after a transfusion has occurred.

Abnormal laboratory test results require further evaluation for the possibility of false-positive results and/or the necessity for further testing. The aPTT can be falsely prolonged in certain circumstances, such as in the presence of a lupus anticoagulant, or can be prolonged and might not indicate a true bleeding disorder, such as in factor XII deficiency or other contact factor deficiencies. In addition, patients who experience a traumatic brain injury often have a transient coagulopathy that does not reflect an underlying congenital disorder.39 Coagulation tests are very sensitive to specimen handling and should be performed in laboratories experienced with these assays. Inappropriate collection and handling commonly lead to false-positive results, and one should consider careful repeat testing. It may be reasonable to obtain a sample in a sodium citrate tube before transfusion. Clinical scenarios that may affect the results of testing should also be noted.

Additionally, consideration should be given to the likelihood of a preexisting bleeding disorder as the primary cause of a child’s bleeding/bruising. For example, given the relatively high prevalence of VWD, it is inevitable that some children with VWD will be abused and present with bleeding/bruising symptoms. Determining the causative factor in these situations is challenging. Bruising is a common finding in VWD. If a child has test results consistent with VWD and bruising concerning for abuse, an absence of new concerning bruising in a different care setting over time is supportive of abuse as the cause of the previous concerning bruises. Most reported ICH in children with VWD would not be confused with typical abusive ICH.15,39,42 Given the rarity of ICH in VWD, particularly spontaneous ICH, testing consistent with VWD does not mean that ICH is definitively attributable to VWD.

The prevalence of a bleeding disorder (greater than 1 per 500 000) used for testing in cases of suspicious bruising is based on expert opinion of the authors of this report. This level was chosen to detect reasonably common bleeding disorders. Similarly, the level of probability (greater than 1 per 5 million) for the initial testing for ICH was based on expert opinion to detect bleeding disorders that were extremely unlikely to cause an ICH. Using this level of probability minimizes the chances of misdiagnosing a bleeding disorder as AHT. Expert opinion was used for the testing recommendations for DIC and VWD on the basis of case-specific information. If more extensive testing is desired, a pediatric hematologist may be consulted. Although testing for some bleeding disorders may be costly, testing is necessary because bleeding disorders may manifest in ways that are difficult to otherwise distinguish from abuse.

Children who present with bleeding and bruising concerning for abuse require careful evaluation for the potential of bleeding disorders as a cause. No single panel of tests rules out every possible bleeding disorder. Given the rarity of most bleeding disorders and the possible presence of specific clinical factors that decrease the likelihood of a bleeding disorder causing a child’s findings, extensive laboratory evaluation is usually not necessary. If a laboratory evaluation is conducted, tests should be chosen on the basis of the prevalence of the condition, patient and family history, blood volume required for testing, and in the case of ICH, probability of a bleeding disorder causing ICH. Testing can be further tailored on the basis of specific patient factors. Further consultation with a pediatric hematologist is recommended if expanded testing is necessary, if preliminary testing suggests the presence of a bleeding disorder, if testing is needed to rule out a specific bleeding disorder, or if testing for very rare conditions is preferred.

Data used for recommendations in this report are summarized in the accompanying technical report.22 Specifically, evidence was used that distinguishes abusive from accidental bruising and that characterizes bruising in children with congenital bleeding disorders. Additionally, for ICH and, when possible, SDH, evidence was used that characterized the probability of ICH and/or SDH in certain clinical scenarios. Specific recommendations were included in this report to increase clarity. Below is guidance for pediatricians, each followed by its corresponding recommendations(s) within the report.

In children who have bruising or bleeding that is suspicious for abuse:

  1. Complete medical, trauma, and family histories, screening for unusual or restrictive diets, and a thorough physical examination are critical tools in evaluating for the possibility of abuse or medical conditions that predispose to bleeding/bruising. However, family and patient medical history alone have not been shown to effectively predict the presence of a bleeding disorder. (Recommendation 1)

  2. In each case, careful consideration of the possibility of a medical condition causing the bleeding/bruising is essential. Specific elements of the history, developmental status of the child, and characteristics of the bleeding/bruising can be used to determine the need for a laboratory evaluation for bleeding disorders. (Recommendations 2, 2a, 2b, 2c, 3, 4)

  3. If the evaluation indicates a need for laboratory testing for bleeding disorders, initial testing is focused on the prevalence of the condition and potential of each specific condition to cause the specific findings in a given child (Fig 1). Tests should be chosen on the basis of their ability to detect specific bleeding disorders that may cause the findings. In some cases, testing may be tailored on the basis of the history, findings, and patient characteristics. (Recommendations 5, 6, 8, 9, and 9a)

  4. Consultation with child abuse pediatricians and/or pediatric hematologists should be strongly considered in children with bruising/bleeding concerning for abuse, including ICH and particularly in cases of SDH. (Recommendation 7)

  5. Laboratory testing suggesting or indicating the presence of a bleeding disorder does not eliminate abuse from consideration. In children with bruising and laboratory testing suggestive of a bleeding disorder, a follow-up evaluation after a change in home setting can provide valuable information regarding the likelihood of a bleeding disorder causing the concerning findings. (Recommendation 8a)

  6. Children with ICH often receive blood product transfusions. It is suggested that testing for bleeding disorders in these patients be delayed until elimination of the transfused blood clotting elements. (Recommendation 9b)

  7. The discovery of new information regarding condition prevalence, laboratory testing, and clinical presentations of bleeding disorders is to be expected. Close collaboration with a pediatric hematologist may be necessary. (Recommendation 7)

James D. Anderst, MD, MS, FAAP

Shannon L. Carpenter, MD, MS, FAAP

Emily Killough, MD, FAAP

Thomas Abshire, MD

Eneida A. Mendonca, MD, PhD, FAAP, FACMI

Stephen M. Downs, MD, MS, FAAP, FACMI

Cynthia Wetmore, MD, PhD, FAAP, chairperson

Carl Allen, MD, PhD, FAAP

David Dickens, MD, FAAP

James Harper, MD, FAAP

Zora R. Rogers, MD, FAAP

Juhi Jain, MD, FAAP

Anne Warwick, MD, MPH, FAAP

Amber Yates, MD, FAAP

Jeffrey Hord, MD, FAAP

Jeffrey Lipton, MD, PhD, FAAP

Hope Wilson, MD, FAAP

Suzanne Kirkwood, MS

Suzanne B. Haney, MD, MS, FAAP, chairperson

Andrea Gottsegen Asnes, MD, FAAP

Amy R. Gavril, MD, MSCI, FAAP

Rebecca Greenlee Girardet, MD, FAAP

Nancy Heavilin, MD, FAAP

Amanda Bird Hoffert Gilmartin, MD, FAAP

Antoinette Laskey, MD, MPH, MBA, FAAP

Stephen A. Messner, MD, FAAP

Bethany Anne Mohr, MD, FAAP

Shalon Marie Nienow, MD, FAAP

Norell Rosado, MD, FAAP

Sheila M. Idzerda, MD, FAAP

Lori A. Legano, MD, FAAP

Anish Raj, MD

Andrew P. Sirotnak, MD, FAAP

Heather C. Forkey MD, FAAP, Council on Foster Care, Adoption and Kinship Care

Brooks Keeshin, MD, FAAP, American Academy of Child and Adolescent Psychiatry

Jennifer Matjasko, PhD, Centers for Disease Control and Prevention

Heather Edward, MD, Section on Pediatric Trainees

Müge Chavdar, MPH

Jorge Di Paola, MD (president)

Patrick Leavey, MD, FAAP

Doug Graham, MD, PhD

Caroline Hastings, MD

Nobuko Hijiya, MD

Jeffrey Hord, MD, FAAP

Dana Matthews, MD

Betty Pace, MD

Maria C. Velez, MD, FAAP

Dan Wechsler, MD, PhD

Amy Billett, MD, FAAP

Linda Stork, MD

Ryan Hooker, MPT

Drs Anderst and Killough created the initial and subsequent drafts of the document; Drs Carpenter and Abshire provided editing to the initial and subsequent drafts; and all authors conceptualized and outlined the manuscript.

Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/1542/peds.2022-059277.

    Abbreviations
     
  • AHT

    abusive head trauma

  •  
  • aPTT

    activated partial thromboplastin time

  •  
  • DIC

    disseminated intravascular coagulation

  •  
  • ICH

    intracranial hemorrhage

  •  
  • PFA-100

    platelet function analyzer

  •  
  • PT

    prothrombin time

  •  
  • SDH

    subdural hemorrhage

  •  
  • VKDB

    vitamin K deficiency bleeding

  •  
  • VWD

    von Willebrand disease

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Competing Interests

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors 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 commercial involvement in the development of the content of this publication.

FINANCIAL/CONFLICT OF INTEREST DISCLOSURES:None.