Nigerian Journal of Paediatrics

1Bruising in children Evaluation in cases of suspected non accidental injuries in children physical child abuse

Niger J Paediatr 2017; 44 (1): 1 – 6

ORIGINAL

Igwe WC

Bruising in children: Evaluation

Igwebuike VO

in cases of suspected non-

accidental injuries in children

(physical child abuse)

DOI:http://dx.doi.org/10.4314/njp.v44i1.1

Accepted: 6th December 2016

Abstract : Background: Bruises

view of relevant papers sourced

commonly occur in children and

from Pubmed using the search

Igwe WC

(

)

are often due to minor accidental

terms

“bruising, non -accidental

Department of Pediatrics,

injuries. However, they can also

injuries in children, evaluation.

Igwebuike VO

occur in bleeding disorders or

Conclusion: It is instructive to

Department of Histopathology

inflicted injuries (physical abuse)

carefully and thoroughly evaluate

College of Health sciences,

and is often the most common

bruise in children utilizing peer

Nnamdi Azikiwe University,

visible manifestation of child

review and the necessary ancillary

PMB 5001, Nnewi Campus,

physical abuse.

tests. It is also advisable to always

Anambra State, Nigeria

Objective: This paper aims at

consider other possible causes of

Email: wc.igwe@unizik.edu.ng

highlighting

the

factors

that

bruise and bruise-like lesions in

should raise concern about non-

forming opinion about suspected

accidental injury (physical abuse)

bruise as implications of false di-

in children presenting with bruis-

agnosis are grave.

ing and the approach to their

evaluation.

Keywords:

Bruise, bruise-like

Method: This paper is based ona

lesions, physical child abuse,

manual literature search and re-

evaluation.

Introduction

because it is not usually a significant injury, yet in cases

of abuse it may be the only visible sign of internal inju-

ries. Bruising may be due to physical abuse,accidental

A bruise is an escape of blood into the skin or subcuta-

neous tissue, or both, following the rupture of blood

trauma or traditional scarifications and each of these

vessels, usually capillaries, by the application of blunt

have characteristics which distinguish them.

force. There may be associated swelling. Bruises do not

Bruises in childhood need careful evaluation, particu-

blanch on pressure but may vary in color, depending on

larly in the borders of child protection and forensics.

their age. Bruising may be confused with paint or pen

Therefore care must be taken to forestall faulty evalua-

marks, dye from clothes, capillary hemangioma and

tion and flawed forensic opinion(s) about bruise particu-

periorbital swelling resulting from allergy or infection.

larly in children which presents peculiar challenges.

In dark-skinned children, bruises may be confused with

Very young children cannot communicate verbally;

café-au-lait spots.

when the child is a little older, he may not be able to

give coherent history of events, and those who have rea-

Petechiae are tiny blood spots in the skin, each about the

sonable cognitive attainment may present factitious ac-

size of a pinhead, of fairly regular size and circular in

counts: all these pose problems to the clinical assess-

ment of bruising in children.

shape and are usually red at initial presentation. These

are seen in conditions associated with reduced/

Sugar et al noted that non cruising infants rarely bruise

dysfunctional platelets or clothing disorders such as

Idiopathic thrombocytopenic purpura, meningococcal

and any bruise seen in such age groups must be investi-

infection and leukemia. Petechiae may also arise in chil-

gated thoroughly to exclude non accidental injury. They

dren with normal clothing and platelet count as a result

observed also thatbruising due to accidental injuries in

of trauma. Examples of petechial bruising are, bruising

mobile childrenis seen only on the bony prominences of

affecting the pinna when it is squeezed or slapped, bruis-

the body.Certain sites such as the torso, ear and neck,

ing on the cheek or around the orbit as a result of a slap

rarely bruise in the non-abused child but are common

sites of bruising in the physically abused child.

mark to the face.

Bruising is one of the most common and most readily

Based on the available studies and published recommen-

visible injuries resulting from non-accidental injury

dations, this paper will help clinicians to know what

(physical child abuse). Although it may be overlooked

factors should raise concern about inflicted injury

(physical abuse) when clinicians observe bruising and

mental status is an important index to determining

how to investigate them. It will also discuss the assess-

whether the injury is accidental or otherwise.. Sugar et

al noted that bruise is a rarity in infants under 6 months

ment to be performed to distinguish other causes of

bruising in children. The implications for pediatric prac-

of age. In their study only 0.6% of infants below 6

tice will also be highlighted.

months had bruise, while a total of 1.7% under 9 months

presented with bruise. Expectedly the occurrence of

Bruising in children

bruise in childhood increased as the child becomes more

ambulant and independent The incidence of bruising

The non-accidental bruise may be self-inflicted or as a

increased to about 17.8% in cruising children and 51.9%

result of abuse or traditional practices. There are other

in children who were walking.

bruise-like lesions caused by congenital and acquired

In the court, lawyers often demand that the expert wit-

conditions. The segregation of these different causes and

ness quantify, usually with some level of precision, the

mechanisms of bruise including proper diagnoses of

amount of force involved in wound causation. This may

lesions that have similar features is pertinent to the ho-

probably be used by the court to adduce possible intent

listic management of the child-patient. Error in evalua-

of the offender among other issues. It suffices to say that

tion and interpretation of bruise can be immeasurably

calibration of the force should not be attempted, rather a

hurtful to the child-patient, the family and the commu-

broad categorization should be used (for instance, insig-

nity. Causes of bruise may be broadly categorized as

nificant, moderate and significant force) where it is pos-

shown below.

sible. In simple terms, the degree of traumatic skin

bruise is a function of the force applied.

Classification of bruising

In practice however, the determinant of the extent and

Accidental

pattern of bruise is exceedingly multi-factorial. At least

the area impacted is important. The larger the area the



Self-inflicted

lesser the bruise expected and vice versa.



Non self-inflicted

The pattern and extent of bruise also depends on age of

Non-accidental

the bruise, skin color and thickness, site of trauma and

the depth at which bleeding occurred. Some disease



Abuse



Non-abuse

conditions (for instance bleeding disorders) can exagger-

ate bruise, so also can anti-thrombotic medications such

Non-abuse: (a) cultural practices, resuscitation proce-

as aspirin and heparin, Vitamin K deficiency and or any

of the clotting factors.

dures,

disorders

clotting/bleeding

disorders

(deficiency of clotting factors, thrombocytopenia, Vita-

Bruises spread more easily if the underlying connective

min K deficiency, hemophilia, drugs e.g. aspirin, hepa-

tissue is loose as is seen in eyebrow injuries. Infants and

rin), chronic diseases e.g. chronic renal failure, liver

the elderly tend to show more bruising because their

failure.

skin is looser, more delicate and have more subcutane-

Non-accidental injury in child is an injury in a child

ous fat.

which is neither non-self-inflicted nor accidental. The

likelihood of bruise occurring and its extent depends on

A bruise should not be examined in isolation if reason-

several factors including the force applied, the area

able inference is to be reached. The distribution and col-

struck, site and nature of tissue, age of patient, presence

lective assessment of all bruises and other associated

or absence of certain disease conditions, drugs and so

injuries on the patient is pertinent to the investigation of

on. These multi-factorial determinants of the outcome of

the child abuse and particularly when reconstructing

bruise make the exactness of predicting cause and

events leading to the injuries. Table 1 below summarizes

mechanism difficult.

observations that will suggest accidental or non-

accidental injuries. However, it is important to note that

Some features of bruise may aid prediction of theetiol-

these signs are not pathognomonic.

ogy and the reconstruction of the events leading to it.

For instance a tram-line bruise crossing multiple planes

from the position of the clavicle to the back will make

attack with a linear wrap-round object highly probable.

Also a slap on a child’s cheek may leave characteristic

parallel finger imprint-bruises with sparing or pallor in

between. Perineal redness in early childhood is not

enough to diagnose abuse, however sexual abuse is

highly probable when it is associated with infection by

pathogens atypical with the child’s age, for instance

Neisseria gonorrhoea and Chlamydia trachomatis .

Bruises caused by bites often show two symmetrical (or

one) arched-bruises with inter-canine diameter usually

more than 3 cm if bite is by an adult human.

When evaluating bruise in children, the child's develop-

Table 1: Features associated with accidental and non-accidental bruise in childhood

Accidental injury

Non-Accidental injury/abuse

Age

Ambulatory children may sustain bruise

Non-ambulatory children (particularly below 6

months old).

Site

Over bony prominences, anterior part of the body,

Upper arms, upper anterior thighs, trunk, genitalia,

shins, lower arms, under chin, forehead, hips, elbows, buttocks, face, ears, neck

ankles

Body plane

Often on one body plane

May involve more than one plane

Number

More often single isolated injuries but may be few

often multiple but may be single

Stage of healing

Often have similar stage of healing

Bruises at different stages of healing

Grouping and bilateralism Rarely grouped and bilateralism is uncommon

Grouped and bilateral injuries are suspicious of

abuse in young children who have not attained

cognitive function for factitious attitude

Consistency

Often consistent with history

Often inconsistent with history

Presence of other injuries Usually isolated injuries

There may be other injuries including fractures.

Good and detailed history is the key to evaluating bruise

tural differences in the tendency for child abuse; for

in children including bruise resulting from abuse. Unfor-

instance, corporal punishment is used to discipline

tunately such reliable history is not always available;

"erring" children in Africa. Other risk factors for child

and most times the history is mired by poor communica-

abuse include delayed development, children with spe-

tion or deliberate lies. When it is possible, it is advisable

cial needs, crying persistently, unwanted children, and

children less than 4 years of age. When the child for

to interview the child and care-giver separately.

The setting of child abuse is often complex and its un-

any reason is not wanted, the risk of abuse is high. Chil-

derstanding is pertinent to identifying pointers from his-

dren with intellectual disability, such as autism and hy-

tory taking The background for child abuse ranges from

peractivity disorders are prone to accidents, yet they are

often victims of abuse.

sudden isolated loss of temper by the adult care-giver(s)

to persistent premeditated acts of abuse.

Conditions that may exaggerate or cause easy bleeding

When abuse is the case, often there is a delay on the side

include bleeding disorders due to hemophilia, deficiency

of the ‘guilty’ care -giver in accessing health care for the

of clothing factors, thrombocytopenia, and Vitamin K

affected child. The history volunteered by the care-giver

deficiency, use of anti-thrombotic drugs like heparin or

is often inconsistent with the injuries and the history

aspirin, chronic illnesses like hepatic or chronic renal

may change with time .Sometimes the index child or

failure. These conditions must be excluded in children

sibling or others may be blamed for the injuries. History

presenting with bruise through appropriate history,

of previous accidents and prior attendance by child pro-

physical examination and laboratory tests.

tective service for the child or sibling should increase

suspicion and scrutiny.

Some conditions which may resemble bruise in children

include allergic dermatitis, amoniacal napkin dermatitis,

Other signals for suspicion of child abuse are family

drug reactions, and skin staining by dyes or chemicals.

disharmony, intra-family violence, and drug and/or alco-

Sometimes pseudo-bruise may be encountered in the

hol abuse by one or both parents or care-giver. Further-

setting of post-mortem. Tissue disruption after death

more, previous criminal conviction of the care-giver(s)

either by hitting the corpse, inadvertent fall of the corpse

is a risk factor for child abuse. Research has shown that

or by autopsy procedure can cause seepage of blood into

adults who suffered abuse in childhood tend to be abus-

the tissues and may mimic bruise thereby confounding

ers later in life, the so called "victim-to-victimizer cycle"

interpretation. Post-mortem pseudo-bruise emphatically

and that women have more tendencies to abuse children

is not bruise since they occurred after death by which

particularly in the setting where they were also victims

period active circulation would have ceased; the blood

of family violence.

seepage is rather passive. However, interpreting peri-

mortem “bruise” is a difficult issue in forensics.

There is controversy on the influence of socio-economic

Livor-mortis is the gravitational settling of blood in de-

status and poor educational attainment of child’s care -

pendent areas after death. If unfixed, livor-mortis can

giver on child abuse. Review by Cacain et al

showed

shift with the change in the position of the corpse, unlike

significant positive correlation. However, earlier review

ante-mortem bruise.

by Katz et al did not find significant association with

low socio-economic status and education attainment. It

The onset of the body decomposition and putrefaction

is pertinent to add that the potential for child abuse is

process can further confound the picture by effacing

not limited to dysfunctional families but also exists in

important clues for discrimination between inflicted

injuries and pathological lesions.

families living in apparent harmony. There are also cul-

The choice of laboratory and radiological investigations

missed because pediatricians fail to recognize the early

signs of child abuse.

21,22

is determined by the information drawn from history and

This leads to lost opportunities

physical examination findings.

to intervene and prevent repeat abuse.

Pediatricians managing children must be able to distin-

The basic laboratory investigations to exclude bleed-

guish bruising due to accidental injury, physical child

ing disorders include:

abuse or bleeding disorders. They must understand the

patterns of bruising in children based on child’s devel-



Complete blood count (CBC)

opmental stage, social and environmental factors includ-



Platelet aggregation test

ing the explanation given by the care giver. Any bruise



PT/PTT (Prothrombin time/Partial thromboplastin

in non mobile children raises the suspicion of physical

time)

abuse more so if the explanation given is not compatible

with the extent of the bruise sustained.



Thrombin clotting time and fibrinogen level

Cases where



Screening for Von Willebrand disease- estimation

the pattern of bruising is not in keeping with the expla-

of Factor VIII, Von Willebrand factor antigen, and

nation given must be investigated further. Child physical

abuse cuts across cultures and socio-economic classes.

22-

ristocetin co-factor levels

The clinical approach to evaluation of suspected abuse

In blood clothing disorders the above laboratory tests

includes detailed medical history, thorough physical

will be abnormal while they are normal in inflicted inju-

examination, ordering of the appropriate ancillary labo-

ries.

ratory tests to identify occult trauma and exclude other

Depending on the results, other tests may be recom-

causes of bruising, and treatment. Adequate measures

mended. In death, post-mortem histological and histo-

must be put in place to prevent further abuses.

chemical investigations of the suspected “bruised” tissue

are helpful in distinguishing ante-mortem and post-

The medical history should include details about the

mortem bruise.

onset and progression of the bruising, associated symp-

Significant bruise on the lower trunk particularly the

toms and any known events leading to the bruising. Past

abdomen may warrant abdominal radiologic examina-

history of previous bleeding or easy bruising such as

tion, urinalysis and estimation of the pancreatic amy-

after injections, circumcision, venipuncture or ear pierc-

lases, aspartate aminotransferase, and alanine ami-

ing will assist in confirming bleeding disorders. Family

notransferase to exclude rupture of the intra-abdominal

history of bleeding or easy bruising should also be ex-

viscera. There is high index of suspicion if positive

cluded.A drug history is also important to exclude drug-

physical examination is supported by microscopic hema-

induced bleeding disorders. The behavior of the child

turia and elevation of these pancreatic and hepatic en-

and relationship with the caregiver must be observed

zymes.

17,18

In cases of recurrent physical abuse, skeletal

during the interview.

survey or bone scan is advisable which may show multi-

The careful pediatrician will however note in the history

ple fractures in different stages of healing.

whether:



The explanation given is appropriate for the injury,

Accurate and prompt diagnosis of bruise no matter how

child’s physical development or timing of seeking

subtle is important to forestall untoward morbidity and

for treatment.

adversity on the child-victim. However, opinion in sup-



The details of the history are consistent or changes

port of abuse must be given after thorough assessment

with time.

and peer review, when it is available. False diagnosis of



The information provided by different informants is

abuse dislocates the affected child from family environ-

markedly in agreement with explanations for the

ment and causes immeasurable psychological pains to

injuries.

the child and family. Wheeler and Hobbs reported a

A complete physical examination should be conducted

case of a 3-year-old Asian child who was referred for

with particular attention to general appearance, hydra-

excessive bruising and child abuse was suspected. After

tion, vital signs, nutrition, growth and development. If

appropriate evaluation he was subsequently diagnosed

child abuse is suspected, the general examination may

as a case of hemophiliac A. Similarly Schwer et al re-

reveal evidence of neglect, oral injuries like torn frenu-

ported a case of a 10-month infant with severe bruising

lae in infants and injuries in different stages of healing.

involving multiple parts of the body with a healing

The entire skin must be examined with special attention

clavicle fractures. Child abuse was suspected until the

to site, number, pattern of the bruises and associated

partial thrombin time (PTT) was found to be abnormal.

injuries. Careful documentation of visible injuries with

The suspicion of child abuse was dropped when hemo-

clinical photographs will be helpful in adducing evi-

philia was confirmed.

dence in law courts.

The general physical examination may suggest abuse in

Evaluating the child with Bruising and suspected

the following settings:

physical abuse



Any significant unexplained injury in non-mobile

child.

Pediatricians are often consulted in the clinic or during



Patterned injuries.

legal proceedings for an opinion when child abuse is



Multiple injuries in different stages of healing.

suspected in the setting of bruising.



Injuries located away from bony prominences, or

About 75% of cases of child physical abuse may be

other unusual sites.



Co-existence of injuries in different body planes.

abused child for appropriate care, report suspected abuse

to child welfare services for further investigation, sup-

When child abuse is confirmed, other siblings should

port the families of the abused child, and coordinate

also be assessed for possible abuse.

other healthcare services to provide both immediate and

Laboratory tests are often invaluable in not only identi-

long term treatment and prevention of abuse and to pro-

fying other injuries but also to exclude other causes of

vide court testimony when needed.

bruising in suspected child abuse. Useful tests to ex-

clude bleeding disorders in non-accidental injuries in-

clude : Full blood count & blood film, Platelet count,

size & shape, Prothrombin time (PT), Partial throm-

Conclusion

boplastin time (PTT), thrombin time, fibrinogen levels,

Bleeding time, levels of Factors II, VIII, & IX.

Evidently bruise is a common sign of child physical

In cases of suspected associated abdominal injuries it is

abuse. However, bruise in children can originate from

needful to assay pancreatic amylases, and liver enzymes.

diverse causes and some non-traumatic lesions can

Radiologic studies such asskeletal survey, ultrasonogra-

mimic bruise. No feature is pathognomonic of bruising

phy, and computerized tomography scan (CT) will prove

due to physical abuse. The occurrence, pattern and ex-

invaluable in confirming associated occult injuries in-

tent of bruise are dependent on several interacting fac-

volving the bone and abdominal organs.

tors. A careful and detailed history supported by thor-

It is the responsibility of the pediatrician to recommend

ough physical examination is imperative if informed

appropriate treatment based on examination findings or

opinion about bruise is to be achieved. Relevant investi-

refer the child for further care if required. Efforts must

gations and peer review is helpful for optimum evalua-

be made to remove the child from the abusing environ-

tion.

ment with assistance of Child welfare services.

Continuing medical education on child abuse for first-

line emergency physicians and pediatricians is important

Implications for pediatric practice

to boost human capacity and quality service delivery in

this area.

It is the responsibility of the pediatrician to identify the

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