Bleeding Disorder or Child Abuse?

When a child is taken for medical care with bleeding or bruising, often it can raise red flags for child abuse. However, it is critical to assess whether or not there is an underlying bleeding disorder.

This is because bleeding disorders are rare, but can present themselves in almost “textbook” child abuse patterns.

In this article, we give a brief review of the following: James Anderst, Shannon Carpenter, Thomas Abshire. Evaluation for Bleeding Disorders in Suspected Child Abuse. Pediatrics Vol. 131, No. 4, April 2013.

Bruises or blood clots under the skin and intracranial hemorrhages are the most likely bleeding disorders to be mistaken for child abuse.

In these instances, it is important to consider all other possibilities. A failure to do this can result in a child being separated from their loving parents, as well as potentially life-ruining accusations of child abuse.

How Does Bruising in Children Present?

While it can be difficult to assess the difference between “normal” bruises, there are still some established norms around bruising that apply.

Studies find that small bruises frequently occur in preschool and school age children happen particularly on the front of the body. Bruises on the forehead and shins can also be expected.

“Uncommon” bruises appear on the back, arm, and abdomen, and any significant bruising in non-mobile children is considered to be outside the realms of “normal.”

However, it’s important to understand that bruising can also occur in larger families, as well as being more likely to occur in the summer.

There have been attempts made to score bruises by severity and age, but so far research suggests that there is no universally accepted measure by which to gage “normal.”

When is a Laboratory Evaluation Needed?

There are many factors to consider when it comes to deciding whether or not a child should undergo laboratory evaluation.

The age of the child, the location and patterns of bruising, results from neuroimaging, a complete history of traumas, and total medical history. A total family medical history can indicate the presence of a genetic bleeding disorder and can also warrant a laboratory evaluation.

Sometimes a child with an underlying bleeding disorder will have experienced pronounced bleeding after circumcision or dental surgery.

It’s also relevant to take account of any medication that the child might be taking. Certain test results, such as a platelet function analyzer or a platelet aggregation test, can be affected by a number of different medications.

Certain ethnicities may also be more likely to suffer from certain genetic disorders, including blood disorders.

What Might Cause Bleeding Other Than Blood Disorders?

There are certain other medical explanations that can be responsible for easy bruising or bleeding in children. It’s vital in any cases of suspected abuse that these also be definitively ruled out.

Ehlers-Danos syndrome, scurvy, and cancer can lead to an increase in bruising or bleeding. It’s also possible that a child exposed to alternative therapies may experience an increased case of bleeding or bruising.

What Should a Physician Test for?

It is important that as much care and attention is spent in establishing whether or not a child is being subjected to abuse, or whether or not they have an underlying condition.

One study (cited above) has laid out the six practical steps that a healthcare professional should take in order to establish the cause of a child’s bleeding or bruising.

A complete medical, trauma, and family history, as well as a thorough physical examination, is the first step.

In every case or presented bruising or bleeding, it’s important to cross-reference with the possibility of a medical condition. This will further outline whether or not a laboratory evaluation is necessary.

A laboratory test will be able to provide more conclusive evidence of a bleeding disorder, however this should also be cross-referenced with the placement and kind of bruising or bleeding that the child is experiencing. While a laboratory test will indicate the likelihood of a bleeding disorder, it may not conclusively rule out a case of abuse.

In a case where the bruising or bleeding isn’t significantly explained by the blood disorder, it may be recommended that the child have a change in home setting. A follow-up evaluation is essential here to see if the bruising or bleeding still occurs.

If a child has a case of intracranial hemorrhage, they will often receive a blood transfusion. If this has happened, any screening for bleeding disorders should wait until the transfused blood-clotting elements have been eliminated.

Finally, a physician should work with a pediatric hematologist in cases of bleeding disorders. This ensures that the most current testing methods are being employed, and the most appropriate treatment is being given.