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.

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)



Evaluation for Bleeding Disorders in Suspected Child Abuse

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