Bruises in Children |
| Bruising
is one of the most common physical injuries observed in children,
occurring frequently due to everyday activities. However, it is also a
hallmark of child abuse, especially in younger children who are unable
to communicate their experiences. Differentiating between accidental
and abusive bruising is critical for clinicians and child welfare
professionals. Although bruises from physical abuse often go unnoticed
or are misinterpreted, accurate identification is essential for
preventing further harm. This essay reviews the current understanding
of bruising patterns in children, focusing on how to distinguish
between accidental injuries and abuse, with an emphasis on recent
developments in clinical guidelines and decision-making tools. Bruising in children is a common result of physical activity, particularly in those who are mobile. A longitudinal study by Kemp et al. (2015) revealed that bruising increases with a child?s mobility, with a marked difference between non-mobile infants and those who can crawl or walk. The study found that 45.6% of early mobile children had at least one bruise, while 78.8% of walking children presented with bruises. Bruises typically appear over bony prominences such as the shins, knees, and forehead. The study also noted that bruising was rare on soft tissues like the neck, buttocks, genitalia, and hands, areas where bruising is more concerning for abuse. This research highlighted that bruising in pre-mobile infants is rare, and when present, warrants further investigation. Infants who are not yet rolling over rarely have bruises, and any bruising in these children should be considered suspicious. The study also emphasized that bruises tend to occur on the front of the body due to the natural tendencies of children to fall forward when they lose balance. Bruising is the most common injury resulting from child abuse and is often the first visible sign of maltreatment. However, differentiating between accidental bruising and bruising caused by abuse can be challenging due to the general prevalence of bruising in children. Several studies have shown that abusive bruising tends to occur in non-bony areas, such as the torso, neck, and ears. These are fewer common sites for accidental bruises, especially in young, non-mobile children. Additionally, patterned bruises those with distinct shapes or outlines that suggest the use of an object are highly indicative of abuse and should raise immediate concern. The presence of petechiae (small red or purple spots caused by bleeding into the skin) can also suggest a high-force impact, which is more consistent with abusive trauma. Another red flag for abuse is the presence of multiple bruises in various stages of healing, indicating repeated trauma. However, it is important to note that dating bruises based on their color is unreliable. A systematic review concluded that the color of a bruise cannot accurately determine its age. Clinicians should therefore refrain from using bruise color as a method for determining when an injury occurred, particularly in child protection cases. Recent advances in clinical guidelines have aimed to assist healthcare providers in identifying bruises that may indicate child abuse. One of the most significant developments in this area is the TEN-4 FACESp clinical decision rule, developed by Pierce et al. (2021). This tool is designed to help clinicians assess whether bruising is more likely to be accidental or abusive, particularly in children under four years old. The TEN-4 FACESp rule focuses on specific areas of the body: bruises on the torso, ears, neck, frenulum, angle of the jaw, cheeks, eyelids, and subconjunctiva are considered highly suspicious for abuse. Additionally, any bruising in an infant younger than five months, or any patterned bruising, raises concern. The rule has been validated with a sensitivity of 95.6% and a specificity of 87.1%, making it a reliable tool for clinicians. Wood et al. (2015) also developed guidelines for performing skeletal surveys (SS) in young children with bruising. Skeletal surveys involve a series of radiographs used to detect occult fractures that may accompany bruises, particularly in cases of suspected abuse. These guidelines recommend performing an SS for children under six months of age with bruising, regardless of the location of the bruise. For older children, SS is recommended if bruising occurs on the cheek, ears, neck, upper arms, torso, or other less commonly bruised areas. The necessity of performing an SS decreases with age unless the bruises are in non-bony areas, which are more consistent with abuse. Differentiating between accidental and abusive bruising involves a comprehensive evaluation of the child's developmental stage, bruise location, and the history provided by caregivers. Accidental bruises typically occur on bony areas of the body, such as the shins and knees, and are most commonly associated with everyday activities like falling or bumping into objects. In contrast, abusive bruising is more likely to occur on soft tissues or areas that are not prone to accidental contact, such as the back, buttocks, and neck. Studies have shown that bruises from accidental injuries are typically singular or few in number. A study by Pierce (2017) indicated that most accidental bruises result from a single incident, with more than one bruise being relatively rare in typical accidents. Conversely, multiple bruises from a single event, especially if they are in various stages of healing, are more consistent with repeated trauma or abuse. Linear or patterned bruises, such as those caused by belts or hands, should also raise immediate suspicion. Bruising is a common occurrence in children, particularly those who are mobile. However, it is also a sentinel injury in cases of child abuse. Differentiating between accidental and abusive bruising is a challenge that requires careful evaluation of bruise location, child development, and the history of the injury. Tools like the TEN-4 FACESp clinical decision rule provide valuable guidance to clinicians, helping to identify when bruising is more likely due to abuse rather than an accident. As research in this area continues, it is hoped that these tools and guidelines will become even more refined, allowing for earlier intervention and the prevention of further abuse in vulnerable children. References: 1- Maguire S, Mann MK, Sibert J, Kemp A: Can you age bruises accurately in children? A systematic review. Arch Dis Child. 90(2):187-9, 2005 2- Wood JN, Fakeye O, Mondestin V, Rubin DM, Localio R, Feudtner C: Development of hospital-based guidelines for skeletal survey in young children with bruises. Pediatrics. 135(2), 2015 3- Kemp AM, Dunstan F, Nuttall D, Hamilton M, Collins P, Maguire S: Patterns of bruising in preschool children--a longitudinal study. Arch Dis Child. 100(5):426-31, 2015 4- Pierce MC: Bruising characteristics from unintentional injuries in children: the 'green flag' study. Arch Dis Child. 102(12):1097-1098, 2017 5- Pierce MC, Kaczor K, Lorenz DJ, Bertocci G, Fingarson AK, Makoroff K, Berger RP, et al: Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics. JAMA Netw Open. 4(4), 2021 |
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