Evaluation of Excessive Bruising

Clinical Assessment

• The American Academy of Pediatrics recommends that the history should specifically evaluate for bleeding symptoms suggestive of a disorder, such as significant bleeding after surgery, epistaxis, or joint hemorrhages, to determine if laboratory testing is warranted 1, 2, 3
• A family history of specific bleeding disorders or ethnicity associated with higher rates of certain bleeding disorders should be assessed 1, 2, 3
• A medication review should document all medications and alternative therapies that may increase bleeding/bruising, as certain drugs can affect coagulation test results 1, 2, 3
• The trauma history should determine if the bruising pattern is explained by reported trauma 4, 2
• The age and developmental capabilities of the patient, particularly in children, should be assessed to determine if bruising location is consistent with normal activity 1, 2

Physical Examination Findings

• The location and pattern of bruising, such as bruising on buttocks, ears, genitals, or patterned bruising, has higher specificity for abuse in children and warrants different evaluation 1, 2
• Signs of systemic illness, such as Ehlers-Danlos syndrome, scurvy, cancer, infiltrative disorders, or arteriovenous malformations, should be evaluated 1, 2, 3

Laboratory Testing

• The initial screening panel should include a complete blood count (CBC) with platelet count, peripheral blood smear, prothrombin time (PT), activated partial thromboplastin time (aPTT), and fibrinogen level if PT or aPTT are abnormal 4, 5
• Most factor deficiencies can be detected by PT and aPTT; however, von Willebrand disease (VWD) and factor XIII deficiency are NOT reliably detected by these screening tests 4, 5

Special Considerations

• Children with intracranial hemorrhage (ICH) concerning for abuse require evaluation for bleeding disorders, with exceptions including independently witnessed or verifiable trauma, or other findings consistent with abuse 4, 2
• Vitamin K deficiency testing should be considered in infants with prolonged PT, particularly if vitamin K was not administered at birth or if there are predisposing medical conditions 5
• Platelet function testing, such as the platelet function analyzer (PFA-100), can screen for platelet disorders but has limitations, and consultation with a pediatric hematologist is recommended for interpretation 4, 5
• Disseminated intravascular coagulation (DIC) evaluation should consider the multitude of primary causes, including trauma, sepsis, and primary bleeding disorders 5

Referral Indications

• Referral to hematology is indicated when initial laboratory evaluation indicates a bleeding disorder, high clinical suspicion remains despite normal laboratory workup, specialized testing is needed, or complex cases require expert interpretation 1, 2

Initial Investigation for Easy Bruising

History and Clinical Assessment

• The American Academy of Pediatrics recommends asking about bleeding symptoms, such as significant bleeding after surgery, dental procedures, or menorrhagia, to determine if testing is warranted in a 17-year-old female with easy bruising 6
• A medication review is necessary to document all medications, including NSAIDs, anticoagulants, antiplatelets, steroids, and alternative therapies, as these can affect both bleeding tendency and coagulation test results in patients with easy bruising 6

Initial Laboratory Testing

• The addition of fibrinogen level to the screening panel is recommended if PT or aPTT are abnormal to detect fibrinogen defects in patients with easy bruising 7

Common Pitfalls to Avoid

• The American Academy of Pediatrics advises against performing extensive testing without clinical indication, as the extreme rarity of some bleeding disorders makes universal screening unreasonable 6
• It is important not to overlook medication effects, as certain drugs affect both bleeding tendency and test interpretation, particularly platelet function testing in patients with easy bruising 6

Evaluation of Easy Bruising in Adolescents

Clinical History Assessment

• Systematically inquire about bleeding symptoms, medication exposures, family history, and connective‑tissue manifestations to differentiate benign bruising from inherited bleeding disorders or systemic disease. 8
• Significant bleeding after surgical or dental procedures (e.g., wisdom‑tooth extraction, tonsillectomy) is a red‑flag for an underlying hemostatic disorder. 8
• Prolonged or recurrent epistaxis that requires medical intervention or cauterization suggests a bleeding disorder. 8
• Heavy menstrual bleeding defined by pad/tampon changes more frequently than every 2 hours, lasting > 7 days, or causing anemia is indicative of a possible coagulopathy. 8
• History of bleeding from the umbilical stump in infancy may point to a congenital bleeding disorder. 8
• Gastrointestinal bleeding (hematemesis or hematochezia) should raise suspicion for a systemic or inherited bleeding condition. 9

Medication and Supplement Review

• Non‑steroidal anti‑inflammatory drugs (e.g., ibuprofen, naproxen) impair platelet function and can alter coagulation test results, potentially masking underlying disorders. 8
• Herbal and alternative supplements such as ginkgo biloba, fish oil, and garlic may increase bleeding tendency and should be documented. 8

Family History

• A diagnosed family member with von Willebrand disease— the most common inherited bleeding disorder, affecting roughly 1 in 1,000 individuals— strongly supports a hereditary etiology. 8
• Certain ethnic groups (e.g., Amish populations) have higher prevalence of specific bleeding disorders and should be queried. 8

Connective‑Tissue and Systemic Evaluation

• Skin hyperextensibility or fragility may indicate Ehlers‑Danlos syndrome, which can coexist with abnormal bleeding despite normal coagulation studies. 8
• Nutritional deficiencies, particularly of vitamin C (scurvy) or vitamin K, can produce easy bruising and should be considered. 8
• Constitutional symptoms such as fever, unexplained weight loss, or night sweats may signal malignancy or infiltrative disorders that can present with bruising. 8

Bruising Pattern Analysis

• Bruises located on soft‑tissue areas (thighs, upper arms, trunk) are more suggestive of a bleeding disorder than bruises over bony prominences, which often result from normal activity. 8
• The absence of a clear trauma history that adequately explains the bruising distribution warrants further hemostatic evaluation. 8
• Patterned bruising (e.g., linear or shape‑specific marks) is more consistent with external trauma rather than a primary bleeding disorder. 8

Laboratory and Diagnostic Pitfalls

• Routine PT and aPTT tests do not reliably detect von Willebrand disease, Factor XIII deficiency, or platelet function disorders; normal results do not exclude these conditions. 9
• Mild hemophilia (Factor VIII or IX deficiency) can present with significant bleeding despite a normal aPTT, so specific factor assays may be required. 9

Evaluation of Bruising in Children Under 24 Months

Assessment of Bruising Patterns

• In children younger than 24 months, clinicians should consider the child’s age and developmental abilities to determine whether the location of bruises is consistent with normal activity for that developmental stage. 10
• Bruises located on the buttocks, ears, genital area, or those with a patterned shape are more specific indicators of possible non‑accidental trauma (abuse) in this age group. 10

Indications for Bone Marrow Examination

• Bone‑marrow evaluation is recommended when any of the following are present: abnormal hemoglobin or white‑blood‑cell counts or morphology, fever, bone or joint pain, a family history of thrombocytopenia, skeletal abnormalities, a non‑petechial rash, lymphadenopathy, or hepatosplenomegaly. 10