RCH logo

Victorian Forensic Paediatric Medical Service

Bruising

  • 2025 VFPMS Guideline: Forensic investigation of bruising

    Bruises are injuries caused by bleeding under intact skin, usually resulting from blunt force trauma.

    Bruises are common childhood injuries. In children, most bruises are caused by accidental falls and collisions. Bruising is also the most common injury sustained by children who have been abused.

    Key points:

    • Bleeding disorders and child abuse can co-exist.
    • Bruises on pre-mobile infants are uncommon and rarely caused by accidents.  
    • Top-to-toe examination of skin and orifices should always occur.
    • Bruising mimics such as dermal melanocytoses, pigmented naevi, post-inflammatory pigmentation, vascular malformations, venous stasis and dyes or stains on the skin must be ruled out.
    • The age of a bruise cannot be determined on the basis of its colour.
    • Testing for inherited and acquired disorders of coagulation should be undertaken wisely, as clinically indicated.
    • Consider consulting a paediatric haematologist for expert interpretation of abnormal coagulation test results or to seek advice about testing for uncommon disorders.

    Clinical Advice:


    Information should be obtained about the number, locations, pattern and features of all bruises as well as changes to the child’s skin observed over time.

    The following information should be obtained regarding medical history. Ask about

    • Evolution of bleeding symptoms and signs over time. Ask about dates of prior bruises and bleeding and enquire about photographs of bruises taken by family members.
    • Bleeding during the neonatal period (cephalhaematoma, bleeding from the umbilical stump, heel prick or immunisation sites, excessive bleeding from sites of minor trauma)
    • Excessive bleeding from previous haemostatic challenges (eg tonsillectomy, surgery)
    • Mucocutaneous bleeding (epistaxis, gum bleeding, prolonged bleeding from minor wounds, menorrhagia, GIT bleeding)
    • Medications (eg infants < 9 months – ask if vitamin K was administered IM at birth and about unusual or restrictive diets (including exclusive breast feeding and restricted solids that might contribute to Vitamin K deficiency bleeding (VKDB))
    • Developmental skills (increasing mobility correlates with increasing risk of accidental injury)

    The following information should be obtained about family history. Ask about

    • Consanguinity
    • Family members with significant bleeding symptoms and/or diagnosed bleeding disorders
    • Family members with symptoms and signs of collagen disorders (eg osteogenesis imperfecta) and connective tissue disease (eg Ehlers Danlos syndrome) 

    The following findings generate concern about a non-accidental cause:

    • An injury mechanism that is not concordant with the child’s developmental skills
    • Bruising that is not easily attributed to the mechanism described.
    • Even a single bruise on an infant who is not cruising or independently mobile (eg < 4 mo).
    • Bruising on the torso (including chest, abdomen, back, buttocks and genitalia), ears, neck and some regions of the face (TEN 4 FACES P Clinical Decision Rule). Under certain circumstances, bruising on upper arms or anterior thighs might also raise suspicion about inflicted trauma.
    • Bruising that is not on the front of the body or over a bony prominence.
    • Individual bruises that are abnormally large and/or involve an extensive area of skin
    • A large total number of bruises
    • Bruising that is clustered or patterned (eg a tram track pattern or shape of an implement).
    • Bruising containing petechiae.

    Blood tests are unlikely to be required when

    • The clinical findings are entirely compatible with accidental causes and no concerns exist about possible non-accidental causes.
    • The clinical findings are entirely compatible with inflicted trauma (child abuse) and an accidental cause seems improbable (eg child has a slap mark, spanked buttocks, imprint of an implement)
    • There is a single bruise in the TEN-4-FACES-P distribution in a mobile child and there is no clinical suspicion of a haematological disorder
    • The child has a history of a major haemostatic challenge (eg tonsillectomy) with no excessive bleeding and there is no clinical suspicion of an acquired haemostatic disorder (such as petechiae, bruising and /or mucosal bleeding)

    Consider laboratory testing when

    • An infant or immobile child has bruising
    • New onset bruising is extensive and not easily explained by accidental or inflicted trauma (consider ITP, leukemia).
    • The bruising pattern and/or bleeding is out of proportion to the purported mechanism
    • Bleeding has occurred at a critical site (intracranial, retinal, gastrointestinal, intraspinal, joint) without adequate explanation
    • Family history, past medical history or examination findings suggest possible coagulopathy.

    Laboratory investigations for underlying causes of bruising and haemorrhage

    Note that care must be taken during collection to ensure that sample is not mishandled in a manner that might activate coagulation. When possible, avoid sampling from lines flushed with heparin. 

    First line investigations                                    

    (Test urgently when infant is less than 9 months old)

    FBE

    APTT

    Prothrombin Time/INR

    Fibrinogen

    Consider additional investigations when intracranial / spinal / retinal bleeding is present and in selected situations when disorders of coagulation are suspected for other reasons (for example, large haematomas or haemarthroses, extensive bruising observed on multiple dates, past medical history/ family history suggests coagulopathy). Seek advice from a haematologist when necessary. 


    Second line investigations                                                                          

    von Willebrand Disease screen (vWF antigen and ristocetin cofactor) and blood group.

    • Note that normal VWD screening results can be obtained in infants who actually have VWD so retesting after 12 months may be required.
    • A diagnosis of VWD is made only after test results compatible with VWD have been obtained on multiple (at least 2-3) occasions.

    Factor VIII (1-stage and chromogenic) and Factor IX levels when clinical history compatible with haemophilia. Consider Factor VIII and Factor IX in all infants (particularly boys) with intracranial haemorrhage.

    Factor XIII in newborns with intracranial haemorrhage  (consider testing infants in the first few months of life in the presence of intracranial haemorrhage) and in infants and young children with a history of umbilical stump bleeding.
    Note that platelet function screening test (PFA 100) results are frequently abnormal in infants. PFA 100 screening test may be considered in selected cases. Consult with a haematologist when necessary.

    Third line tests                                                                    If vasculitis is suspected consider inflammatory markets of maternal lupus is suspected and infant is < 3 months old, consider lupus anticoagulant.
    Consult a Haematologist when                                                                        Coagulation test results require interpretation by an expert
    Consideration is being given to rare coagulation factor deficiencies and other uncommon conditions associated with coagulation disturbances.and other uncommon conditions associated with coagulation disturbances.
    Child is > 12 months old and consideration is being given to platelet function disorders. These are rare conditions
    • Note Glanzmann’s thrombasthenia and Bernard-Soulier syndrome can result in bruising and intracranial haemorrhage
    • Note even small doses of NSAID such as ibuprofen can result in abnormal platelet function test results so should be avoided for at least 10 days prior to testing.

    Investigations for associated (possibly occult) injuries

    In children <2years-old (and rarely in older children) consideration should be given to radiological investigations for occult fractures.

    In the presence of abdominal bruising, consideration should be given to screening for abdominal injury.

    In selected cases (particularly young infants with bruising) consideration should be given to searching for clinical and radiological signs of head injury.

    Resources

    Lurie Children's Child Injury Plausibility Assessment Support Tool (LCAST) App (free download)

    Child Protector (Children’s Mercy Kansas City) App (free download)

    References

    Pierce MC, Kaczor K, Lorenz DJ, Bertocci G, Fingarson AK, Makoroff K, Berger RP, Bennett B, Magana J, Staley S, Ramaiah V, Fortin K, Currie M, Herman BE, Herr S, Hymel KP, Jenny C, Sheehan K, Zuckerbraun N, Hickey S, Meyers G, Leventhal JM. Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics. JAMA Netw Open. 2021 Apr 1;4(4):e215832. doi: 10.1001/jamanetworkopen.2021.5832. Erratum in: JAMA Netw Open. 2021 Sep 1;4(9):e2130136. doi: 10.1001/jamanetworkopen.2021.30136. PMID: 33852003; PMCID: PMC8047759.

    Biss T, Sibson K, Baker P, Macartney C, Grayson C, Grainger J, et al Haematological evaluation of bruising and bleeding in children undergoing child protection investigation for possible physical maltreatment: A British Society for Haematology Good Practice Paper. Br J Haematol. 2022; 199(1): 45–53. https://doi.org/10.1111/bjh.18361

    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.

    Carpenter SL, Abshire TC, Killough E, Anderst JD; AAP SECTION ON HEMATOLOGY/ONCOLOGY, THE AMERICAN SOCIETY OF PEDIATRIC HEMATOLOGY AND ONCOLOGY, and the AAP COUNCIL ON CHILD ABUSE AND NEGLECT. Evaluating for Suspected Child Abuse: Conditions That Predispose to Bleeding. Pediatrics. 2022 Oct 1;150(4):e2022059277. doi: 10.1542/peds.2022-059277. PMID: 36120799.

    The Royal College of Paediatrics and Child Health Child Protection Evidence on Bruising. https://childprotection.rcpch.ac.uk/child-protection-evidence/bruising-systematic-review/