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CME / ABIM MOC / CE

Can New Guidance Help Distinguish Child Abuse from Bleeding Disorders?

  • Authors: MDEdge News Author: Marcia Frellick; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 11/18/2022
  • Valid for credit through: 11/18/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for pediatricians, critical care physicians, family medicine/primary care physicians, internists, hematologists/oncologists, nurses/nurse practitioners, pharmacists, physician assistants, adolescent medicine physicians, and other members of the healthcare team for patients with bruising, bleeding, and possible child abuse.

The goal of this activity is for learners, as members of the healthcare team, to be better able to describe current evidence and recommendations for distinguishing bruising and bleeding in children with coagulopathies from similar findings in child victims of abuse, according to a clinical report by the American Academy of Pediatrics (AAP) Council on Child Abuse and Neglect and a technical report by the AAP Section on Hematology/Oncology.

Upon completion of this activity, participants will:

  • Describe current recommendations for distinguishing bruising and bleeding in children with coagulopathies from similar findings in child victims of abuse, according to a clinical report by the AAP Council on Child Abuse and Neglect
  • Determine current evidence comparing bruising and bleeding in children with coagulopathies with similar findings in child victims of abuse, according to a technical report by the AAP Section on Hematology/Oncology
  • Outline implications for the healthcare team


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


MDEdge News Author

  • Marcia Frellick

    Disclosures

    Marcia Frellick has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has the following relevant financial relationships:
    Formerly owned stocks in: AbbVie Inc.

Editor/Compliance Reviewer

  • Lisa Simani, APRN, MS, ACNP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Lisa Simani, APRN, MS, ACNP, has no relevant financial relationships.

Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

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  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

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    Medscape, LLC has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.25 AAPA Category 1 CME credits. Approval is valid until 11/18/2023. PAs should only claim credit commensurate with the extent of their participation.

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CME / ABIM MOC / CE

Can New Guidance Help Distinguish Child Abuse from Bleeding Disorders?

Authors: MDEdge News Author: Marcia Frellick; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 11/18/2022

Valid for credit through: 11/18/2023

processing....

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.

Study Highlights

  • Bruising or bleeding in a child can raise concerns of child abuse.
  • It is essential to determine whether these findings result from trauma and/or bleeding disorder.
  • As many coagulopathies are rare, not every such child must be evaluated for bleeding disorders.
  • Complete medical, trauma, and family histories; screening for unusual/restrictive diets; and thorough examination are essential in evaluating for possible abuse or medical conditions predisposing to bleeding/bruising.
  • Specific clinical factors help reduce the likelihood of bleeding disorder and need for laboratory testing: caregivers' description of trauma sufficiently explains the bruising; the child or an independent witness provides a history of abuse or nonabusive trauma explaining the bruising; outline of the bruising follows an object or hand pattern; and bruising on the ears, neck, or genitals, rarely seen in accidental injuries or bleeding disorders.
  • Without obvious known trauma, or with ICH, particularly SDH in a nonmobile child, abuse should be suspected. Children can have a small SDH or epidural hematoma, from a short fall, but these rarely cause significant brain injury.
  • Bleeding disorders can sometimes present similarly to child abuse and cannot be excluded solely from thorough patient and family history, as these alone cannot effectively predict bleeding disorder.
  • Specific elements of the history, developmental status, and bleeding/bruising characteristics help determine the need for laboratory evaluation for bleeding disorders.
  • No single panel of tests rules out every possible coagulopathy.
  • If laboratory workup is conducted, tests should be chosen according to prevalence of the suspected coagulopathy, patient and family history, blood volume needed for testing, and if there is ICH or probability of a bleeding disorder causing ICH.
  • Indicated tests may include PT, aPTT, VWF activity; factor VIII activity; factor IX activity; and CBC, including platelets.
  • Specific patient factors, history, and findings can further tailor testing.
  • Indications for consultation with a pediatric hematologist include bleeding disorder suggested by preliminary testing and the need for expanded testing, testing for very rare conditions, or testing to exclude a specific bleeding disorder.
  • Consultation with child abuse pediatricians and/or pediatric hematologists should be strongly considered in children with bruising/bleeding concerning for abuse, including ICH and particularly SDH.
  • Laboratory testing suggesting a bleeding disorder does not exclude abuse; follow-up evaluation after a change in home setting may help determine whether bleeding disorder caused the concerning findings.
  • For children with ICH given blood product transfusions; coagulopathy testing should be delayed until elimination of transfused blood clotting elements.
  • The technical report noted that screening tests for bleeding disorders can be falsely positive or negative.
  • If coagulation test specimens are subjected to excessive or prolonged heat, factor levels may be falsely low.
  • As VWF and factor VIII are acute-phase reactants, levels may be falsely high if blood is sampled during times of physiological stress.
  • Patients with traumatic brain injury often have temporary coagulopathy that does not reflect a congenital disorder.
  • NSAIDs, some antibiotics, antiepileptics, and herbal supplements may affect tests for coagulopathy.
  • If an infant, typically aged < 6 months, presents with bleeding/bruising suspicious for abuse and has a long PT, physicians should confirm receipt of vitamin K at birth and/or perform testing for VKDB.
  • Deficiency can cause bleeding in the skin or mucosal surfaces from circumcision, generalized ecchymoses, large intramuscular hemorrhages, or ICH.
  • VKDB usually occurs in neonates but also 1 to 3 months after birth.
  • Late VKDB is more prevalent in breastfed babies, as human milk contains less vitamin K than cow's milk.
  • Laboratory evidence of coagulopathy does not exclude child abuse.
  • Because of the chronic nature of their disease, children with bleeding disorders may be at higher risk for abuse.

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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