Bruising in children poses a diagnostic challenge to health care providers. Bruising can be caused by an underlying medical condition, accidental injury, or physical abuse. It is estimated that over 50% of children older than 1 year will have bruising from minor accidental injury.[1-4] However, bruising is also the most common injury in children who have been physically abused.
Distinguishing accidental bruising from inflicted injury can be difficult for clinicians. Recent literature offers guidelines to assist medical professionals in distinguishing between abusive bruising and accidental bruising.[5] The literature also suggests that bruising may be the first sign of physical abuse and that there is a link between early abusive injury and later severe
injury.[6-8] In almost 40% of fatal or near-fatal cases, physically abused children will have a history of a minor injury such as bruising, and recent research suggests health care providers are often aware of the minor injury.[6] Medical practitioners have a unique opportunity to
identify abuse before it escalates, but in order to intervene effectively they must possess a good understanding of when a bruise may be “more than just a bruise.” They must be able to: Case report The child was born at term following an uneventful pregnancy and received vitamin K. When examined in the family doctor’s office, the child looked well and was alert and active. The only finding of note was a right-sided cephalohematoma (Figure 1). No investigations were conducted and the doctor reassured the mother that the child appeared well. Two weeks later, the infant presented to the local hospital emergency department. He was unresponsive and seizing. The parents stated that over the previous few days the baby had seemed sleepier and was feeding less. The father also noted that a similar scalp swelling had appeared on the left side of the baby’s head the day before presentation, although once again no history of trauma was provided by the parents. A CT scan of the head revealed acute subdural hemorrhage, cerebral edema, and biparietal skull fractures (Figure 2). A skeletal survey revealed further healing fractures of the ribs. Given the signs of abuse, child protection officials were contacted and an investigation was initiated. Distinguishing accidental from inflicted bruising Development—mobile vs nonmobile Further, almost 20% of infants, regardless of age, who begin to crawl and cruise (walk with support) develop bruising, and over 50% of independently walking children have bruises. There have been numerous case reports of infants who ultimately suffered a fatal injury after being found to have minor bruising, in some cases a single bruise, that was not investigated.[6-9] Sheets and colleagues conducted a case-control retrospective study to determine how often abused infants have a previous history of injury.[6] They defined such a “sentinel” injury as “a previous injury reported in the medical history that was suspicious for abuse because the infant could not cruise or the explanation was implausible.” Bruising was the most common sentinel injury and was found in almost 25% of infants with abusive head trauma. In this study, health care providers were aware of the sentinel injury in 42% of the abuse cases. As illustrated by our case report, the bruising on the infant was historical and appeared insignificant, yet it was eventually revealed to be a sentinel injury. Any bruising in a nonmobile infant, no matter how minor, should prompt further investigation. Location—hard vs soft This model was found to have a sensitivity of 97% and a specificity of 84% for predicting abuse. As illustrated by our case report, an investigation of the first instance of bruising, which was likely inflicted, might have prevented further abusive injuries. Number of bruises Patterned or clustered bruises Mechanism of injury Medical evaluation History Physical examination Investigation and
consultation All bruising in babies and bruising in mobile children that does not appear to be accidental require urgent consultation with a pediatrician or a clinician who specializes in child maltreatment. In British Columbia, Suspected Child Abuse and Neglect (SCAN) teams are located in Prince George, Kamloops, Surrey, Vancouver, and Nanaimo. Each team consists of physicians, nurses, social workers, and psychologists with expertise in child maltreatment. The SCAN teams operate collaboratively with local law enforcement and child protection social workers. The child abuse physicians can support health care providers who are concerned about a child and can offer advice regarding specific laboratory testing and medical imaging. Reporting to child protection services Summary Competing interests This article has been peer reviewed. References1. Maguire S, Mann MK, Sibert J, et al. Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review. Arch Dis Child 2005;90:182-185. Dr Chapple is the director of pediatrics at Royal Inland Hospital in Kamloops and a clinical instructor in the University of British Columbia Southern Medical Program at UBC’s Okanagan campus. |