Guidance for Evaluating for Bleeding Disorders in Suspected Child Abuse

A clinical report published in Pediatrics, the journal of the American Academy of Pediatrics, provides guidance on evaluating children for bleeding disorders in situations where abuse is suspected.¹ The recommendations aim to make this type of evaluation more consistent in cases when children have suspicious bruising or intracranial hemorrhage (ICH).

“When bleeding or bruising is suspicious for child abuse, careful consideration of medical and nonmedical causes is important,” the authors wrote. “Mistaken diagnosis, whether an inappropriate finding of abuse, a missed case of abuse, or overlooking of a medical cause, can cause harm to the child and his or her family.”

Infants are at an increased risk of abusive bruising or bleeding, but their presentation of bleeding disorders can be similar to abusive bruising or injury. Contextual information about the patient’s medical and family history of bleeding or bruising is also not sufficient to rule out a bleeding disorder. Laboratory evaluation is often needed to confirm bleeding disorders, but even when a disorder is present, it is still possible for abuse to be the cause.

The clinical recommendations in the report are informed by a technical report published in tandem with the recommendations,² with data that include evidence differentiating accidental bruising vs abusive bruising in healthy children and the types of bruising seen in children with bleeding disorders.

The first recommendation is to conduct thorough medical, trauma, and family history assessments on children with bruising or bleeding that is suspicious for abuse. Notably, medical history cannot rule out bleeding disorders. If there is a specific bleeding disorder within a child’s family history, testing for that disorder should be completed. If possible, information on a child’s history should be obtained directly from the child and away from caregivers.

Recommendations 2 through 4 address the characteristics of bruising and specific medical history information that would indicate the need for a laboratory test to identify or rule out bleeding disorders. The need for laboratory testing should be based on the location and pattern of the bruising, the reasoning provided for the bruising, and the child’s developmental status and mobility level. For example, certain bruising patterns, such as hand-patterned bruising or bruising to the ears, neck, or genitals, are highly consistent with abuse and generally indicate that testing for a bleeding disorder is unnecessary.

Testing for bleeding disorders is addressed in recommendations 5, 6, 8, 9, 9a, and 9b. The type of testing should be informed by the prevalence of various conditions and the findings on the child that led to suspicion of a disorder. This can be based on patient medical history and characteristics, as well as physical findings. Whole blood clotting assays, such as thromboelastograph or rotational thromboelastography, should not be used in testing when abuse is possible. The report authors note that children with ICH often receive transfusions, so testing for bleeding disorders should be delayed until any transfused blood clotting elements have been eliminated.

Recommendation 7 suggests that when a physician does not have the necessary resources or comfort level to evaluate children for bleeding disorders in cases of possible abuse, they consult with a child abuse pediatrician or pediatric hematologist. This especially concerns cases of subdural hemorrhage and any instances where ICH is present. Testing for prothrombin time, activated partial thromboplastin time, von Willebrand factor antigen, von Willebrand factor activity, clotting factor VIII activity level, clotting factor IX activity level, and a complete blood count with platelet count are recommended in cases of suspicious bruising.

Even if laboratory testing indicates a bleeding disorder, Recommendation 8a emphasizes that abuse should not be eliminated as a possibility. Following up in a home setting is suggested to gather information that may help determine the likelihood that a bleeding disorder alone led to the suspicious findings.

Overall, the recommendations emphasize a need for thorough assessment of children with bleeding or bruising that could be caused by a bleeding disorder. Due to the rarity of bleeding disorders overall, identifying significant characteristics of these disorders prior to testing is recommended.

“Children who present with bleeding and bruising concerning for abuse require careful evaluation for the potential of bleeding disorders as a cause. No single panel of tests rules out every possible bleeding disorder,” the authors wrote. “Given the rarity of most bleeding disorders and the possible presence of specific clinical factors that decrease the likelihood of a bleeding disorder causing a child’s findings, extensive laboratory evaluation is usually not necessary.”

References

1. Anderst JD, Carpenter SL, Killough E, Abshire TC. Evaluation for bleeding disorders in suspected child abuse. Pediatrics. Published online September 19, 2022. doi:10.1542/peds.2022-059276

2. Carpenter SL, Abshire TC, Killough E, Anderst JD. Evaluating for suspected child abuse: Conditions that predispose to bleeding. Pediatrics. Published online September 19, 2022. doi:10.1542/peds.2022-059277