When EDs Should Screen for Abuse in Children with Bruising

October 9th, 2016

PHILADELPHIA – Accidental bruising is common among mobile older infants and rambunctious toddlers. The challenge for emergency physicians is differentiating those innocuous bumps and bruises from injuries caused by abuse.

“Bruising is the most common injury experienced by young victims of physical abuse,” according to a recent article in the journal Pediatrics. “Although abusive bruising usually does not require medical intervention, bruising may be the only visible sign of serious injuries, such as fractures or traumatic brain injury. Abusive bruising also is a frequent precursor to more severe forms of physical abuse, including fatal head trauma.”

Now, a new guideline offers advice to emergency physicians on when to perform an initial skeletal survey (SS) for children younger than 24 months presenting with bruising at the emergency department and elsewhere in the hospital.

A multispecialty panel of 10 experts, led by researchers from The Children’s Hospital of Philadelphia, Philadelphia and the University of Pennsylvania, used evidence from the literature and their own clinical expertise to rate the appropriateness of performing SS for 198 clinical scenarios involving young children with bruising.

“Accurate recognition and evaluation of abusive bruising can lead to identi?cation of additional injuries requiring treatment and allow for intervention and prevention of further injury,” the guideline states. “Performing an evaluation for suspected physical abuse is, however, not without risks and should not be performed if abuse is unlikely.”

The guideline suggests that a skeletal survey is necessary in children under 2 with bruising if any of the following are present:

• History of confessed abuse
• History of bruising occurring during domestic violence
• Additional injuries on physician exam, such as burns or whip marks
• Patterned bruising
• More than four bruises not limited to bony prominences, and
• Bruises on ears, neck, torso, buttocks, genital region, hands and feet if there is no history of trauma

For children young than a year, skeletal survey is necessary, according to the guideline, with the following:

• Bruising on cheeks, eye area, ear or neck
• Bruising on upper arms or legs not over bony prominences
• Bruising on hands or feet
• Bruising on torso, buttocks or genital region
• More than one bruise not limited to bony prominences

When the child is less than 9 months old, a skeletal survey is necessary with a bruise in any one location, the panel advises, adding that, for younger children, those less than 6-months old, skeletal survey should be done if there is bruising on bony prominences – such as head T-shaped area, frontal scalp, extremity, bony prominences – unless it is single bruise and the parent presents with a history of a fall.

“The appropriateness and necessity of SS in children presenting for care to the hospital setting with bruising, as determined by a diverse panel of experts, depends on age of the child and location of bruising,” the authors conclude.