Clinical Context

Assessment of suspected child abuse varies significantly, including coagulopathy workup. An American Academy of Pediatrics (AAP) clinical report offers guidance to pediatricians and other members of the healthcare team, regarding evaluation for bleeding disorders when there is suspicious bruising or intracranial hemorrhage (ICH).

Before laboratory testing for suspected coagulopathy, it is useful to understand its biochemical basis and clinical presentation, condition prevalence, and test characteristics. An AAP technical report reviews major medical conditions predisposing to bruising or bleeding to help inform healthcare professionals (HCPs) who are evaluating children for abusive injury.

Study Synopsis and Perspective

In some cases, bruising or bleeding from bleeding disorders may look like signs of child abuse, but new guidance may help HCPs distinguish one from the other.

On September 19, the AAP published 2 reports -- a clinical report^[1] and a technical report^[2] -- in the October issue of Pediatrics on evaluating for bleeding disorders when child abuse is suspected.

The reports were written by the AAP Section on Hematology/Oncology and the AAP Council on Child Abuse and Neglect.

One Does Not Rule Out the Other

The reports emphasize that laboratory testing of bleeding cannot always rule out abuse, just as a history of trauma (accidental or nonaccidental) may not rule out a bleeding disorder or other medical condition.

In the clinical report, led by James Anderst, MD, MSCI, with the division of child adversity and resilience, Children's Mercy Hospital, University of Missouri-Kansas City, Missouri, the researchers noted that infants are at especially high risk of abusive bruising/bleeding, but bleeding disorders may also present in infancy.

The authors gave an example of a situation when taking a thorough history will not necessarily rule out a bleeding disorder: Male infants who have been circumcised with no significant bleeding issues may still have a bleeding disorder. Therefore, laboratory evaluations are often needed to detect disordered bleeding.

Children's medications should be documented, the authors noted, because certain drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs), some antibiotics, antiepileptics, and herbal supplements, can affect tests that might be used to detect bleeding disorders.

Likewise, asking about restrictive or unusual diets or alternative therapies is important, as some could increase the likelihood of bleeding/bruising.

Signs That Bleeding Disorder Is Not Likely

The authors advised that, if a child has any of the following, an evaluation for a bleeding disorder is generally not needed:

• Caregivers' description of trauma sufficiently explains the bruising
• The child or an independent witness can provide a history of abuse or nonabusive trauma that explains the bruising
• The outline of the bruising follows an object or hand pattern
• The location of the bruising is on the ears, neck, or genitals

"Bruising to the ears, neck, or genitals is rarely seen in either accidental injuries or in children with bleeding disorders," the authors wrote.

Specification of which locations for injuries are more indicative of abuse in both mobile and immobile children was among the most important information from the paper, Seattle pediatrician Timothy Joos, MD, said in an interview.

Also very helpful, he said, was the listing of which tests should be done if bruising looks like potential abuse.

The authors wrote that if bruising is concerning for abuse that necessitates evaluation for bleeding disorders, the following tests should be done: prothrombin time (PT); activated partial thromboplastin time (aPTT); von Willebrand Factor (VWF) activity (Ristocetin cofactor); factor VIII activity level; factor IX activity level; and a complete blood count (CBC), including platelets.

"I think that's what a lot of us suspected, but there's not a lot of summary evidence regarding that until now," Joos said.

Case-by-Case Decisions on When to Test

The decision on whether to evaluate for a bleeding disorder may be made case by case.

If there is no obvious known trauma or intracranial hemorrhage (ICH), particularly subdural hematoma (SDH) in a nonmobile child, abuse should be suspected, the authors wrote.

They acknowledged that children could have ICH, such as a small SDH or an epidural hematoma, under the point of impact from a short fall; "[h]owever," the authors wrote, "short falls rarely result in significant brain injury."

Conditions May Affect Screening Tests

Screening tests for bleeding disorders can be falsely positive or falsely negative, the authors cautioned in the technical report, led by Shannon Carpenter, MD, MS, with the department of pediatrics, University of Missouri-Kansas City, Missouri.

• If coagulation laboratory test specimens sit in a hot metal box all day, for instance, factor levels may be falsely low, the authors explained
• Conversely, factors such as VWF and factor VIII are acute-phase reactants, and factor levels will be deceptively high if blood specimens are taken in a stressful time
• Patients who have a traumatic brain injury often show temporary coagulopathy that does not signal a congenital disorder

Vitamin K Deficiency

The technical report explained that if an infant, typically younger than 6 months, presents with bleeding/bruising that raises flags for abuse and has a long PT, physicians should confirm vitamin K was provided at birth and/or testing for vitamin K deficiency should be performed.

Not all states require vitamin K to be administered at birth, and some parents refuse it. Deficiency can lead to bleeding in the skin or from mucosal surfaces from circumcision, generalized ecchymoses, and large intramuscular hemorrhages or ICH.

When infants don't get vitamin K at birth, vitamin K deficiency bleeding (VKDB) is seen most often in the first days of life, the technical report stated. It can also occur 1 to 3 months after birth.

"Late VKDB occurs from the first month to 3 months after birth," the authors wrote. "This deficiency is more prevalent in breast-fed babies, because human milk contains less vitamin K than does cow milk."

Overall, the authors wrote, extensive lab tests are usually not necessary, given the rarity of most bleeding disorders and specific clinical factors that decrease the odds that a bleeding disorder caused the child's findings.

Joos said the decisions described in this paper are the kind that can keep pediatricians up at night.

"Any kind of guidance is helpful in these difficult cases," he said. "These are scenarios that can often happen in the middle of the night, and you're often struggling with evidence or past experience that can help you make some of these decisions."

Authors of the reports and Dr Joos declared no relevant financial relationships.

Clinical Implications

• Bleeding disorders may present similarly to child abuse and cannot be excluded solely from thorough patient and family history.
• Laboratory evidence of coagulopathy does not exclude child abuse.
• Implications for the Healthcare Team: Specific clinical factors help reduce the likelihood of bleeding disorder and need for laboratory testing.

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