BudWiederman, MD, MA, Evidence eMended Editor, Grand Rounds
This prospective observational study bolsters our notion of what is "normal" bruising
in preschool children, lending some insight into when evaluation for bleeding diathesis
or child abuse should be considered.
All children have bruises from time to time, and one of many challenges in front-line
pediatric practice is deciding when bruises should raise a flag for further investigation.
This prospective observational study helps though still doesn't provide a definitive
set of "rules" for triggering evaluation.
The researchers, from the UK and Canada, looked at children below 6 years of age enrolled
at 6 hemophilia centers and compared them to healthy controls recruited from various
sites in South Wales. Children were analyzed over 3 age groups related to mobility
(premobile, early mobile, and walking) as well as by degree of bleeding disorder (none
versus mild/moderate versus severe). They also looked at whether or not the children
with bleeding disorders were receiving replacement therapy. Parents were trained to
record numbers and sizes of bruises, and a validity subset showed that they were pretty
accurate in their measurements compared to researcher measurements.
The main analysis consisted of 328 healthy control children, 57 with severe bleeding
disorders, and 47 with mild/moderate bleeding diathesis. The take-home messages from
the study aren't new but do reinforce findings from other studies:
Children with bleeding problems have more bruises than healthy children, especially
in the premobile stage (crawling and cruising).
Children in the severe bleeding disorders category had larger bruises than the other
Walking children with severe bleeding disorders didn't seem to differ that much based
on whether or not they were receiving prophylaxis; this counterintuitive finding likely
reflects confounding variables associated with the decision to prophylax specific
Bruising on the ears, neck, cheeks, eyes, and genitalia was rare in all groups. (Other
studies have suggested that bruising in those sites should prompt consideration of
In premobile children, bruising is so uncommon that non-accidental trauma should be
considered. Also, blood tests compatible with a mild or moderate bleeding disorder
should not rule out non-accidental trauma.