CliniCian’s Corner
Case 2: An 11-week-old female
infant with multiple bruises
A
n 11-week-old female infant was brought to the emergency
department by both of her parents, who were concerned
about abdominal marks that resembled bruising. The parents did
not have any explanation for the marks, stating they “just came up
like that”. No history of falls or injuries was reported. The infant
was born following an uncomplicated pregnancy and vaginal
delivery, and had received vitamin K prophylaxis at birth. No
bleeding after umbilical stump detachment was reported.
On examination, the child measured within the normal ranges
for height, weight and head circumference. Notable findings
included four round bruises 1 cm to 1.5 cm in diameter (separated
by 1 cm to 3 cm) on the upper left abdomen; normal frenulae; no
adenopathy or joint issues; nondistended, nontender abdomen;
and no hepatosplenomegaly or masses. The anus and genitalia
appeared normal. Three additional bruises (right and left forearm,
mid-upper back) were discovered by the examining physician and
had not been reported by the parents. Investigations were
initiated.
Correspondence (Case 1): Dr Michael Bishara, Pediatrics, London Health Sciences Centre, Victoria Hospital, 800 Commissioners Road East, Department
of Pediatrics, London, Ontario N6A 5W9. Telephone 519-685-8500, e-mail [email protected]
Correspondence (Case 2): Mr Dustin Jacobson, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4L8.
Telephone 905-518-0240, fax 905-764-3322, e-mail [email protected]
Case 1 accepted for publication January 21, 2013. Case 2 accepted December 20, 2012
Paediatr Child Health Vol 18 No 5 May 2013
©2013 Pulsus Group Inc. All rights reserved
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Clinician’s Corner
Case 2 diagnosis: Child PhysiCal abuse
Skeletal survey revealed a healing fracture of the right clavicle. A
repeat survey two weeks later revealed callus formation on the
posterior 10th and 11th ribs. A computed tomography scan of the
head and abdominal ultrasound were normal. The infant’s platelet
levels, international normalized ratio, partial thromboplastin time,
fibrinogen, factor XIII and von Willebrand factor levels were
normal.
A differential diagnosis of bruising in a young child should
consider inflicted trauma, accidental causes and underlying medical conditions.
box 1: susPeCted Child PhysiCal abuse
• DSMIVCodeV61.21
• International Classification of Disease, Ninth Revision,
Clinical Modification Code 995.50 (www.icd9data.com)
• International Classification of Disease, Tenth Revision,
Clinical Modification Code T76.12XA, T76.12XD,
T76.12XS (www.icd10data.com)
• Othercommontermsusedbyhealthprofessionalsinclude
child maltreatment, child ill-treatment or nonaccidental
injury
Age is critical: the preambulatory child cannot self-bruise. A
diagnosis of child physical abuse (CPA) (Box 1) is strengthened by
multiple areas of bruising, absence of a causative history, atypical
location of bruises (ie, abdomen, back, ears, torso and neck) and
clustered/patterned bruises, which may point toward a mechanism
of injury (1).
Bleeding disorders may present with ‘easy’ bleeding, particularly after umbilical stump detachment or postcircumcision (2).
Previous bruising could suggest either noninflicted or inflicted
causation. For example, a bleeding disorder can be associated with
bleeding from the mucosa of the mouth, particularly with brushing
teeth, or recurrent spontaneous nosebleeds (3). A positive family
history (because many bleeding disorders are heritable) would support an organic cause for the child’s bleeding (3). Normal clotting
tests decrease the likelihood of a bleeding disorder. Importantly,
abused children can also have bleeding disorders.
Physical examination (‘top-to-toe’) is critical for the evaluation, and diagrams of bruises or photography may be helpful.
Bruises cannot be reliably dated. All maltreatment types (ie, neglect, sexual abuse) need to be considered (3). Findings such as
lymphadenopathy or hepatosplenomegaly are indicative of an
organic cause. Hypermobility may indicate a connective tissue
disease, which may thin skin and result in easy bruising (3).
A full work-up is necessary for children two years of age and
younger (3). Skeletal surveys are critical for evaluating the extent
of CPA. Fractures, such as clavicle injury, are not uncommon with
the birthing process, especially during vaginal delivery. However,
by this age, healing should have occurred. Callous formation can
help to determine the timing of the trauma; bone mineralization
can also be assessed. Evidence of a disorder of bone fragility (ie,
blue sclera or positive family history) leads to consideration of a
disorder such as osteogenesis imperfecta; however, normal findings
Paediatr Child Health Vol 18 No 5 May 2013
on skeletal survey makes this very unlikely. Posterior rib fractures
are highly specific for CPA (4). In our case, the two-week
follow-up skeletal survey revealed new fractures, supporting a CPA
etiology.
CPA is consistent with the clinical picture, given bruising in a
nonambulatory infant; lack of explanation offered by parents; history of unusual injury; multiple bruises in atypical locations; posterior rib fractures; normal blood clotting abilities in an otherwise
healthy infant; and normal bone structure.
Infants and toddlers, as opposed to older children, are more
likely to suffer CPA, severe CPA and recurrent CPA (5). A computed tomography scan of the head should be considered, even if
the neurological examination is normal (6). It is important to add
measurement of alanine aminotransferase, aspartate aminotransferase and amylase levels, and abdominal imaging to the investigation in cases involving abdominal bruising.
Suspicion of maltreatment must lead to contact being made
with the local child protection agency. Although there was no
previous child welfare involvement, a physician visit at eight
weeks of age for a bruised tongue and an emergency department
visit at four weeks of age for bleeding from the mouth were opportunities for intervention.
CliniCal Pearls
• Bruisesinthepreambulatoryinfantshouldraisearedflagfor
CPA.
• Bruisingcanbethemanifestationofanorganiccause.
Knowledge of common conditions associated with bruising in
an infant is important. If suspicion exists for CPA, a report
should be made to the local child protection agency. While
delay in seeking medical attention can be a maltreatment
correlate, delay among health professional can lead to more
severe injuries.
reFerenCes
1. Jenny C. Child Abuse and Neglect: Diagnosis, Treatment and
Evidence. Philadelphia: Saunders/Elsevier, 2010.
2. Mokhtar GM, Tantawy AAG, Adly AAM, Telbany MAS, Arab SEE,
Ismail M. A longitudinal prospective study of bleeding diathesis in
Egyptian pediatric patients. Blood Coagul Fibrinolysis 2012;23:411-8.
3. Minford AM, Richards EM. Excluding medical and haematological
conditions as a cause of bruising in suspected non-accidental injury.
Arch Dis Child Educ Pract Ed 2010;95:2-8.
4. Kleinman PK. Diagnostic Imaging of Infant Abuse, 2nd edn.
St Louis: Mosby, 1998.
5. Thompson S. Accidental or inflicted? Pediatr Ann 2005;34:372-81.
6. Meyer JS, Gunderman R, Coley BD, et al; Expert Panel on Pediatric
Imaging. ACR Appropriateness Criteria® suspected physical abuse –
child. Reston: American College of Radiology, 1995 (updated 2009).
<http://guidelines.gov/content.aspx?id=23828> (Accessed September
20, 2012).
Dustin Jacobson BMSc
Anne Niec MD
Christine Wekerle PhD
Child Advocacy and Assessment Program
McMaster University
Hamilton, Ontario
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