CASE

A 2-month-old presents to the emergency department with chief complaint of “bruising”.

discussion

As emergency medicine physicians, we are often in the position of screening for and diagnosing abuse and neglect in childhood. While we all hope to see this rarely, it is unfortunately a common occurrence. About 1 in 7 children in the United States have experienced abuse or neglect over the past year (CDC, 2022).  Children living in poverty are particularly vulnerable, with a 5x increase in rates of abuse and neglect for children in families with low socioeconomic status. Therefore, it is critically important that emergency medicine physicians understand how to diagnose and document childhood injuries, and how to talk with parents and caregivers about them.

Before even examining the patient, there are several questions that providers need to understand—What is a bruise? How can we tell a traumatic injury apart from a rash, a café-au-lait spot, a hemangioma, or any of the other vascular or pigmented birthmarks?

What is a bruise? When should I be concerned?

Bruising is defined as extravasation of blood in the soft tissues. Because it is outside of the blood vessels, a bruise does not blanch when touched. A bruise will also heal over time, with colors ranging from blue/brown/purple to green or yellow, although it is worth noting that color is not a reliable way of dating a bruise. Even with clear identification of a “bruise”, it is rarely possible to determine exactly what caused an injury. Still, there is a common phrase in pediatrics: “Those who don’t cruise don’t bruise”. A baby as young as two months can’t sit up on its own, let alone crawl around, bump into things, or fall. Any traumatic injury in a child that cannot walk raises red flags for possible abuse.  

In a hallmark study in 1999, researchers showed that bruise frequency in “pre-cruisers” (children younger than 9 months who are not independently mobile) was much lower compared to their walking counterparts. In mobile children, the knees and shins are the most common injury sites, although forehead and thigh bruising were also seen frequently (Sugar, 1999). Other sites of bruising are much less common, including the ears, jaw, and inside the mouth, which can be hallmarks of abuse.

More recently, researchers developed a clinical decision rule to help predict abuse in young children based on characteristics of their injuries. The clinical decision rule is called TEN-4-FACESp and the graphic is shown below:

This clinical decision rule was found to have 96% sensitivity and 87% specificity for distinguishing abuse from non-abusive trauma in young children (Pierce, 2021). The most concerning regions, and the regions that should be examined on all children in whom abuse is suspected, are the TEN FACES areas: the torso, ears, and neck, as well as the frenulum, angle of the jaw, cheeks, eyelids, and subconjunctiva. Any bruise in a child younger than 4 months is cause for concern, and any bruise with a pattern, which includes things like finger marks, loops, or belt marks.

 A thorough work-up of organic causes of bruising includes a complete blood count, a basic metabolic panel, liver function tests, a PT/PTT/INR, and specific tests of Factor VII and VIII levels for hemophilia. Keep in mind that any malabsorptive process that affects vitamin K absorption can also cause bleeding and bruising, particularly in infants who have very low reserves of vitamin K. Things like celiac disease, cystic fibrosis, hepatitis, α1-antitrypsin deficiency, abetalipoproteinemia, warfarin exposure, and biliary atresia can all present as abnormal clotting in an infant.

While the work-up for organic causes is ongoing, it is important to be thorough and methodical in your investigation of child abuse, as well. Typically, this includes a full skeletal survey, a head CT, and pediatric ophthalmology consultation to evaluate for retinal hemorrhage.

Often the most difficult part of these cases is not the work-up or diagnosis but rather, communication with caregivers. As providers, we want to build trust and rapport with our patients, and these conversations can feel as though we are casting blame or suspicion rather than support.

 Starting the Conversation (Early!)

The earlier a parent or caregiver can safely be made aware of the plan, the better. Caregivers can often sense the medical team withholding information from them, which can make an already very stressful moment feel more high-stakes and potentially even adversarial. In a case where we suspect we may need to involve child protective services or when abuse is on the differential, the conversation might go something like this:

“I can tell that you are worried about your child, and I am too. We want to do everything we can to help take care of your baby. At this age, it is rare to see an injury like this, and we need to figure out how this happened. This means we will do a lot of things for them in a short period of time. We think about things like bleeding and clotting problems, which means we check lots of different blood work. We also look at how these injuries heal, which means we take pictures to put in your baby’s chart to keep track of them over time. The other thing we always must consider is the possibility that someone may have hurt your baby. While we test for all the medical things, we will also discuss with our child injury specialists to help us do everything we can to keep your family safe.”

Staying Aware and Prepared

Most of the time, even in cases of confirmed abuse, caregivers want what is best for their child. Many families are forthcoming, cooperative, and eager to do everything they can to find out what is going on with their child and how to help them. Providers also need to be aware that these conversations can be emotionally fraught and sometimes dangerous for healthcare workers, caregivers, and patients themselves. Preparing for the worst-case scenario is a good idea in most cases in emergency medicine, and this is no exception. Identifying a plan for crisis, including involving hospital security officers and police, if necessary, is an important step towards ensuring patient and provider safety. 

A United Front and Avoiding Judgment

It can be easy to feel anger towards parents or caregivers, especially if the healthcare team suspects injuries may be the result of abuse. It is also easy to think that there is no way a caregiver or parent could have hurt their child. Either way, it is important to maintain a neutral and supportive environment. Emphasizing safety and avoiding blame and judgment may both be helpful:

“We may never know exactly what happened or how. The important thing is that you are in the right place for us to keep your baby safe.”

“I’m very glad you came in because I am worried about your baby. We are not sure exactly what’s going on, but your baby has an injury, and they need to stay in the hospital until we have a safe plan.”

Bruising is the most common injury from physical child abuse and the most common injury to be overlooked or misdiagnosed. Several studies have identified bruises as the preceding injury to fatal or near-fatal abusive head trauma. As screening and emergency care providers, being familiar with early signs of child abuse and comfortable discussing the diagnosis with families is an important skill.  

Author: Dr. Allison Barshay is a current second-year emergency medicine resident at Brown Emergency Medicine Residency.

Faculty Reviewer: Kristina McAteer, MD, is an attending physician and Rhode Island Hospital and Newport Hospital

References

Cumbria Safeguarding Children Partnership. (2018). Bruising in Babies and Children who are Not Independently Mobile. CSCP Procedures Manual. https://cumbrialscb.proceduresonline.com/chapters/p_bruising_babies.html.

Lifespan: Delivering health with care. (2022). Centers and Services: Lawrence A. Aubin, Sr. Child Protection Center. https://www.lifespan.org/centers-services/lawrence-aubin-sr-child-protection-center.

Pierce, M.C., Kaczor K., Lorenz D.J., et al. (2021). Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics. JAMA Network Open; 4(4):e215832. Doi: 10.1001/jamanetworkopen.2021.5832.

Sugar, N. F., Taylor, J. A., & Feldman, K. W. (1999). Bruises in infants and toddlers: those who don't cruise rarely bruise. Puget Sound Pediatric Research Network. Archives of pediatrics & adolescent medicine, 153(4), 399–403. https://doi.org/10.1001/archpedi.153.4.399.