Bruise in a child where child maltreatment should be suspected or considered

Bruising is the commonest abusive injury seen in a suspected case of physical abuse (1).

They are common in a normal active child. However, they tend to occur in specific places - shins, elbows, foreheads. Bruising in other places is more suggestive of physical abuse.

• be aware that a patient of any age may face an abusive situation leading to bruising (2)
• it is important not to misdiagnose mongolian blue spots as bruises
• bruises on the inner thighs or genitalia are suggestive of sexual abuse.

NICE have suggested guidance concerning bruises in a child where child maltreatment should be suspected or considered (3):

• child maltreatment should be suspected if a child or young person has bruising in the shape of a hand, ligature, stick, teeth mark, grip or implement
• child maltreatment be suspected if there is bruising or petechiae that are not caused by a medical condition (for example, a causative coagulation disorder) and if the explanation for the bruising is unsuitable . Examples where a clinician would suspect child maltreatment include:
  • bruising in a child who is not independently mobile
  • multiple bruises or bruises in clusters
  • bruises of a similar shape and size
  • bruises on any non-bony part of the body or face including the eyes, ears and buttocks
  • bruises on the neck that look like attempted strangulation
  • bruises on the ankles and wrists that look like ligature marks

Notes:

• suspect
  • for the purposes of this guidance, to suspect child maltreatment means a serious level of concern about the possibility of child maltreatment but is not proof of it (3)
• It is important to differentiate accidental from abusive bruises
  • accidental bruising in young children
    • depends on their level of independent mobility. The prevalence of experiencing accidental bruises is,
      • <1% in non-mobile infants
      • 17% in crawling, cruising infants
      • >50% in walking infants (1)
    • is seen in specific locations
      • occurs on the front of the body and over bony prominences
        • <6% of accidental bruises to the face are found on the cheeks or periorbital area.
          
          
  • abusive bruises
    • although any part of the body may be involved, abusive bruises should be suspected if seen predominantly on the cheeks, neck, genitals, buttocks, and back (1,4)
    • involvement of the forearms, upper limb and adjoining area of trunk, or outside thigh may indicate 'defensive bruising' (when the child has tried to protect themselves from the blows) (1)
    • if associated with petechiae is a strong predictor of abusive injury (but the absence of petechiae is of no diagnostic value)
    • occasionally the imprint of the weapon (e.g. - studded dog collar, belt buckle) might be visible (1)

Reference:

• (1) Maguire S. Which injuries may indicate child abuse? Arch Dis Child Educ Pract Ed. 2010;95(6):170-7.
• (2) Valente MJ, Abramson N.Easy bruisability. South Med J. 2006;99(4):366-70.
• (3) NICE (July 2009). When to suspect child maltreatment.
• (4). Harris TS. Bruises in children: normal or child abuse? J Pediatr Health Care. 2010;24(4):216-21.