Evaluation of Unexplained Bruising

Introduction to Bruising Evaluation

The American Academy of Pediatrics recommends that when bruising appears without reported trauma, the primary considerations are bleeding disorders, underlying medical conditions, medications/supplements, and in children—particularly those under 24 months or non-ambulatory—child abuse must be systematically evaluated 1, 2, 3

Any bruising in infants under 6 months requires immediate evaluation regardless of location or reported trauma history, as bruising in pre-mobile infants is highly suspicious for abuse 4, 3
Bruising in non-ambulatory children warrants heightened concern 5
The American Academy of Pediatrics states that bruising on ears, neck, trunk, buttocks, or genitals has higher specificity for abuse than bruising on bony prominences 5, 4
Patterned bruising is pathognomonic for inflicted injury 1, 2

The American Academy of Pediatrics notes that Von Willebrand disease and Factor XIII deficiency are not detected by standard PT/aPTT screening, making them critical considerations in unexplained bruising 6, 3
Hemophilia, platelet disorders, and fibrinogen defects are other bleeding disorders that may cause bruising 1, 6, 3
Ehlers-Danlos syndrome, scurvy, and malignancy are systemic medical conditions that may contribute to bruising 2, 5, 3

The American Academy of Pediatrics recommends that NSAIDs, anticoagulants, antiplatelet agents, and corticosteroids be considered as potential causes of easy bruising 3
Alternative therapies and supplements may affect coagulation 1, 2

A complete medication review, including over-the-counter drugs and supplements, is essential in evaluating bruising 1, 2, 3
The American Academy of Pediatrics recommends that location and pattern of bruising be carefully evaluated, as unusual locations suggest abuse or bleeding disorder 5, 4, 3

A skeletal survey is required for children under 24 months with bruising when there is witnessed or confessed abuse history, domestic violence history, additional injuries on examination, patterned bruising, or when the child is under 6 months 4, 3, 2, 5, 6

The American Academy of Pediatrics advises against performing extensive bleeding disorder testing without clinical indication, as extreme rarity makes universal screening unreasonable 3
Normal PT/aPTT does not exclude bleeding disorders, as von Willebrand disease and Factor XIII deficiency require specific testing 6, 3
Medication effects on both bleeding tendency and test interpretation should not be overlooked 3
In children, implausible trauma explanations should not be accepted, and abuse evaluation should not be delayed while pursuing medical workup 5, 1, 2

The American Academy of Pediatrics recommends referral to a specialist when there are abnormal initial laboratory results, high clinical suspicion with normal laboratory workup, need for specialized testing, or complex cases requiring expert interpretation 3
Any suspected child abuse case should involve child abuse pediatrician consultation 1

In infants with unexplained bruising, the presence of multiple or changing versions of the caregiver’s history is a strong indicator of potential abuse and should trigger immediate child protection evaluation. 7