Evaluation for Bleeding Disorders in Suspected Child Abuse

Publication Date: September 19, 2022
Last Updated: October 5, 2022

Summary of Recommendations

Recommendation 1

If a child has bruising/bleeding concerning for abuse, a thorough medical history of the child and family history should be obtained. However, the lack of a history of bruising/bleeding symptoms does not rule out the possibility of a bleeding disorder.

Recommendation 2

If a child has bruising that is concerning for abuse, the assessment of the need for laboratory testing for bleeding disorders should focus on:
  • the specific history offered to explain the bruising;
  • the location and pattern of bruising; and
  • mobility and developmental status of the child.
Any bleeding disorder can cause cutaneous bruising, and sometimes this bruising can be mild, can appear in locations that are considered suspicious for abuse,18 and can appear at any age. Children with inherited bleeding disorders have more and larger bruises than children without bleeding disorders

Recommendation 2a

If a child has any of the following factors, then an evaluation for a bleeding disorder is generally not needed:
  • the caregivers’ description of trauma sufficiently explains the bruising;
  • the child or an independent witness can provide a history of abuse or nonabusive trauma that explains the bruising;
  • object or hand-patterned bruising is present (highly consistent with abuse); or
  • bruising to the ears, neck, or genitals (highly consistent with abuse).
Clinicians should consider that the injury history offered by caregivers might be purposefully misleading if the caregivers have caused the bruising by abusive means. In some cases, the constellation of findings, taken in conjunction with the clinical history and physical examination, can be so strongly consistent with an abusive injury that further laboratory investigation for medical conditions is not warranted. For instance, a child with a patterned slap mark who describes being hit with an open hand does not require a laboratory evaluation for a bleeding disorder.

Recommendation 2b

If a nonmobile child has bruising, and there is no history of an independently witnessed accidental cause or a known medical cause, an evaluation for bleeding disorders should be conducted simultaneous to a child abuse evaluation.

Any bruising in a nonmobile child is highly concerning for abuse. Additionally, bruising in a young infant could also be the first presentation of a bleeding disorder. As such, in young infants or children with developmental delays with minimal or no mobility, who present with bruising, it is recommended that an evaluation for bleeding disorders occur simultaneous to an abuse evaluation. In nonmobile children, bleeding disorders can present with bruising or petechiae in sites of normal handling or pressure. Examples of this include:
  • petechiae at clothing line pressure sites;
  • bruising at sites of object pressure, such as in the pattern and location of infant seat fasteners; and
  • excessive diffuse bruising/bleeding if the child has a severe bleeding disorder.
Absence of these examples does not rule out a bleeding disorder; however, their presence might increase the probability of a bleeding disorder.

Recommendation 2c

If a mobile child has bruising, then the possibility of abuse should be assessed using the locations and patterns of the bruising

Recommendation 3

If a child has ICH concerning for abuse, then an evaluation for bleeding disorders should be conducted (see Recommendation 9). Exceptions to required evaluation can include:
  • independently witnessed or verifiable trauma (abusive or nonabusive); or
  • other findings consistent with abuse, such as fractures, burns, or internal abdominal trauma.

The decision to conduct an evaluation for bleeding disorders can be made on a case-by-case basis depending on case specific factors. Excepting obvious known trauma, ICH, particularly SDH, in a nonmobile child is highly concerning for child abuse.

Recommendation 4

Children with conditions such as hematemesis, hematochezia, or oronasal bleeding as presenting signs should be evaluated on a case-by-case basis for possible abuse.

Recommendation 5

If performing tests for bleeding disorders in a child who has findings concerning for abuse, tests should be chosen on the basis of their ability to detect specific bleeding disorders that may cause the findings. Whole blood clotting assays, such as the thromboelastograph or rotational thromboelastography, should not be used as part of a testing strategy for bleeding disorders in the setting of possible abuse. Bleeding time is not a helpful test for diagnosing specific bleeding disorders.

Recommendation 6

If an infant, typically younger than 6 months, has bleeding/bruising findings concerning for abuse and a prolonged PT, provision of vitamin K at birth should be confirmed and/or testing for vitamin K deficiency should be performed.

Recommendation 7

Physicians who do not have the necessary resources available or who are not comfortable with evaluating for bleeding disorders in the context of possible child abuse should refer to a child abuse pediatrician, pediatric hematologist, or other physician who is capable of completing the evaluation.

Recommendation 8

If a child has bruising concerning for abuse that necessitates an evaluation for bleeding disorders, the following tests should be obtained:
  • PT;
  • aPTT;
  • VWF antigen;
  • VWF activity (Ristocetin cofactor);
  • Factor VIII activity level;
  • Factor IX activity level; and
  • complete blood count with platelet count.

Recommendation 8a

If a child who has bruising suspicious for abuse is removed from a potentially dangerous setting where the abuse likely occurred, a thorough physical examination should be performed in the weeks after removal. If that examination reveals minimal bruising and/or bruising only in locations of common accidental bruises, abuse is supported as the cause of the original suspicious bruising.

Recommendation 9

If a child has ICH concerning for abuse and testing for bleeding disorders is conducted, then the following initial testing panel is recommended:
  • PT;
  • aPTT; and
  • complete blood count with platelet count.

Recommendation 9a

In ICH concerning for abuse, testing for mild and moderate hemophilia, d-dimer, fibrinogen, and VWD may be necessary on the basis of specific clinical scenarios. If there is a history of trauma, testing for mild hemophilia (levels of factor VIII and factor IX) should be performed. If there is neurologic compromise, testing for d-dimer and fibrinogen should be performed.

Recommendation 9b

If blood products have been given to the patient, the definitive evaluation for bleeding disorders should be postponed until the transfused blood components are no longer in the patient’s system.

Guidance for Pediatricians

Below is guidance for pediatricians, each followed by its corresponding recommendations(s) within the report.
  • In children who have bruising or bleeding that is suspicious for abuse:
  • Complete medical, trauma, and family histories, screening for unusual or restrictive diets, and a thorough physical examination are critical tools in evaluating for the possibility of abuse or medical conditions that predispose to bleeding/bruising. However, family and patient medical history alone have not been shown to effectively predict the presence of a bleeding disorder. (Recommendation 1)
  • In each case, careful consideration of the possibility of a medical condition causing the bleeding/bruising is essential. Specific elements of the history, developmental status of the child, and characteristics of the bleeding/bruising can be used to determine the need for a laboratory evaluation for bleeding disorders. (Recommendations 2, 2a, 2b, 2c, 3, 4)
  • If the evaluation indicates a need for laboratory testing for bleeding disorders, initial testing is focused on the prevalence of the condition and potential of each specific condition to cause the specific findings in a given child (Fig 1). Tests should be chosen on the basis of their ability to detect specific bleeding disorders that may cause the findings. In some cases, testing may be tailored on the basis of the history, findings, and patient characteristics. (Recommendations 5, 6, 8, 9, and 9a)
  • Consultation with child abuse pediatricians and/or pediatric hematologists should be strongly considered in children with bruising/bleeding concerning for abuse, including ICH and particularly in cases of SDH. (Recommendation 7)
  • Laboratory testing suggesting or indicating the presence of a bleeding disorder does not eliminate abuse from consideration. In children with bruising and laboratory testing suggestive of a bleeding disorder, a follow-up evaluation after a change in home setting can provide valuable information regarding the likelihood of a bleeding disorder causing the concerning findings. (Recommendation 8a)
  • Children with ICH often receive blood product transfusions. It is suggested that testing for bleeding disorders in these patients be delayed until elimination of the transfused blood clotting elements. (Recommendation 9b)
  • The discovery of new information regarding condition prevalence, laboratory testing, and clinical presentations of bleeding disorders is to be expected. Close collaboration with a pediatric hematologist may be necessary. (Recommendation 7)

Recommendation Grading



Evaluation for Bleeding Disorders in Suspected Child Abuse

Authoring Organization

Publication Month/Year

September 19, 2022

Last Updated Month/Year

February 13, 2024

Supplemental Implementation Tools

Document Type


Country of Publication


Document Objectives

Bruising or bleeding in a child can raise the concern for child abuse. Assessing whether the findings are the result of trauma and/or whether the child has a bleeding disorder is critical. Many bleeding disorders are rare, and not every child with bruising/bleeding that may raise a concern for abuse requires an evaluation for bleeding disorders. However, in some instances, bleeding disorders can present in a manner similar to child abuse. Bleeding disorders cannot be ruled out solely on the basis of patient and family history, no matter how extensive. The history and clinical evaluation can be used to determine the necessity of an evaluation for a possible bleeding disorder, and prevalence and known clinical presentations of individual bleeding disorders can be used to guide the extent of laboratory testing. This clinical report provides guidance to pediatricians and other clinicians regarding the evaluation for bleeding disorders when child abuse is suspected.

Inclusion Criteria

Male, Female, Adolescent, Child, Infant

Health Care Settings

Ambulatory, Childcare center, School

Intended Users

Nurse, nurse practitioner, physician, physician assistant, social worker


Counseling, Diagnosis, Assessment and screening

Diseases/Conditions (MeSH)

D001778 - Blood Coagulation Disorders, D002649 - Child Abuse

Source Citation

Anderst J, Carpenter SL, Abshire TC, Killough E; AAP SECTION ON HEMATOLOGY/ONCOLOGY, THE AMERICAN SOCIETY OF PEDIATRIC HEMATOLOGY/ONCOLOGY, THE AAP COUNCIL ON CHILD ABUSE AND NEGLECT; Consultants, Mendonca EA, Downs SM; Section on Hematology/Oncology executive committee, 2020–2021, Wetmore C, Allen C, Dickens D, Harper J, Rogers ZR, Jain J, Warwick A, Yates A; past executive committee members, Hord J, Lipton J, Wilson H; staff, Kirkwood S; Council on Child Abuse and Neglect, 2020–2021, Haney SB, Asnes AG, Gavril AR, Girardet RG, Heavilin N, Gilmartin ABH, Laskey A, Messner SA, Mohr BA, Nienow SM, Rosado N; cast Council on Child Abuse and Neglect executive committee members, Idzerda SM, Legano LA, Raj A, Sirotnak AP; Liaisons, Forkey HC; Council on Foster Care, Adoption and Kinship Care, Keeshin B; American Academy of Child and Adolescent Psychiatry, Matjasko J; Centers for Disease Control and Prevention, Edward H; Section on Pediatric Trainees; staff, Chavdar M; American Society of Pediatric Hematology/Oncology Board of Trustees, 2020–2021, Di Paola J, Leavey P, Graham D, Hastings C, Hijiya N, Hord J, Matthews D, Pace B, Velez MC, Wechsler D; past board members, Billett A, Stork L; staff, Hooker R. Evaluation for Bleeding Disorders in Suspected Child Abuse. Pediatrics. 2022 Oct 1;150(4):e2022059276. doi: 10.1542/peds.2022-059276. PMID: 36180615.