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How and When to Work Up Bleeding Disorder in Suspected Abuse

November 30, 2022

Written by Clay Smith

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Not all pediatric bruising needs workup for a bleeding disorder. This report details not only how but when to do it.

Why does this matter?
We’ve covered high risk bruising before (TEN-4), which is bruising on the Torso, Ears, or Neck if <4 years or any bruising in infants <4-6 months. Another mnemonic is TEN 4 FACES P (i.e. injury to the Frenulum, Auricle, Cheek, Eyes, Sclera, or Patterned bruising).

Know when to test
When should we do a lab workup for a bleeding disorder in pediatric patients with bruising?

A child presents with bruising. Is there a clear non-abusive traumatic explanation, or is there obvious abusive trauma?
This does not need a lab workup.

What if there is some suspicion, not obvious abusive trauma, but may meet some TEN 4 FACES P criteria?
This is the time to either transfer the patient or do the lab workup: PT, aPTT, VWF antigen, VWF activity (Ristocetin cofactor), Factor VIII activity level, Factor IX activity level, and CBC/platelet and differential. If labs are abnormal, consult pediatric hematology.

What if a child is mobile and does not have suspicious bruising (i.e. on forehead/nose/chin (facial T), elbow, lower arms, hips, shins, and ankles)?
Lab workup is not needed.

What if a child has an ICH, specifically SDH?
Obtain CBC/platelet and differential, PT, aPTT. Congenital coagulopathies causing ICH are extremely rare: 1 in 10,000 to 1 in 1,000,000.

Other key points
Family history of bleeding disorder doesn’t preclude abuse. Suspicious-appearing, non-abusive bruising can be seen in bleeding disorders, but these disorders are very rare. Infants < 6 months with bleeding or bruising should have perinatal vitamin K administration confirmed; vitamin K deficiency will cause prolonged PT.

From cited article. There is also an algorithm for ICH that’s too complex. For ICH, get labs mentioned and consult heme.

Evaluation for Bleeding Disorders in Suspected Child Abuse. Pediatrics. 2022 Oct 1;150(4):e2022059276. doi: 10.1542/peds.2022-059276.