Although bruising or bleeding in a child can raise suspicions of abuse, treating physicians must be careful in assessing whether the injuries might result from accidental trauma or bleeding disorders, according to guidelines published March 25 in a clinical report in Pediatrics.
The American Academy of Pediatrics Section on Hematology/Oncology and Committee on Child Abuse and Neglect compiled the report. Committee members James D. Anderst, MD, and Shannon L. Carpenter, MD, both from the University of Missouri-Kansas City School of Medicine, and Thomas C. Abshire, MD, from the Medical College of Wisconsin, Milwaukee, were lead writers.
Physicians may suspect abuse when children present with bruising or bleeding, which often includes cutaneous bruises and intracranial hemorrhage (ICH). However, other conditions also could cause bruising or bleeding, the committee writes.
"When bleeding or bruising is suspicious for child abuse, careful consideration of medical and other causes is warranted," they write. Inappropriate diagnosis of abuse could result in removal of a child from the home or prosecution of an innocent person, while attributing an abusive injury to a medical condition or accidental injury could place a child at future risk for abuse or death.
Extensive laboratory testing may be warranted, combined with comprehensive medical history-taking and physical examination. However, if findings during an examination reveal likely abuse, the lab testing is unnecessary.
"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," the committee writes.
In bruising cases, an evaluation should focus on the reason given for the bruising, the nature and location of the bruising, and the mobility and developmental status of the child. Unless an obvious trauma event explains a case, "ICH in a nonmobile child is highly concerning for child abuse," they write.
The clinical report contains 6 guidelines for assessing children who have bruising or bleeding suspicious for abuse:
1Take a complete medical and family history and perform a thorough physical examination.
2Consider the possibility of a medical condition as the cause.
3Tailor any laboratory test to the individual child.
4Note that laboratory testing suggesting a bleeding disorder does not eliminate abuse as a potential cause.
5Delay screening for children with ICH until transfused blood clotting elements are eliminated.
6Closely collaborate with a pediatric hematologist to ensure effectiveness of evaluation and testing methods.
The committee also compiled a technical report that provides details on medical conditions that predispose children to bruising and bleeding, including ICH, hemophilia, heritable disorders, and congenital platelet abnormalities, for which evaluation for coagulopathies might be required.
Ironically, the committee writes, "Because of the chronic nature of their disease, children with bleeding disorders may be at higher risk of abuse." Modification of large databases to include such factors as bruising location or location and character of ICH would help in distinguishing cases, they write. "In the absence of such data, physicians must use existing data, including epidemiologic and clinical factors, in their decision-making process."
Pediatrics. Published online March 25, 2013. Clinical Report Abstract • Technical Report Abstract
Larry Hand • Medscape Medical News © 2013 WebMD, LLC