Paediatric Clinical Guidelines

RESUS/A&E 1.14

January 2002

Protocol for Bruising in Infants (<1 year)

Bruising in young infants is uncommon. Patterns and sites of bruising in children that are suggestive of abuse have been well documented1-3. Several more recent studies4-6 have increased our knowledge about the age, frequency, site and association with developmental stage in relation to accidental infant bruising. This guideline is based on these studies and looks at different factors useful in the assessment of non-accidental injury in infants found to have bruising presenting to the paediatric emergency department (QMC) or to the non-accidental injury clinic (CHN).

Age.

There is good evidence that babies less than 9 months of age rarely have bruises related to accidental injury. In two large studies4,5 only 1.2% and 1.5% of babies under nine months had bruising. Those over nine months had bruising much more commonly (12-40%). One study showed that this increase in bruising with age was independent of mobility5.

Based on this evidence there should be a high index of suspicion of non-accidental injury in babies less than nine months of age who are found to have bruising. This is particularly true of those less than 6 months of age.

Developmental stage.

Several studies have shown that the numbers of bruises is directly related to mobility. Accidental injuries occur rarely in those babies who are ‘pre-cruisers’5. One study5 showed that babies who were not yet cruising had bruises in only 2.2 % of cases. However, 18% of cruisers and 52% of walkers had at least one bruise. Another study6 showed that in babies from 6 to 12 months only 4% of ‘sitters’ had bruises compared to 17% of ‘crawlers’ and 38% of ‘walkers’.

It is therefore essential to obtain information about gross motor development.

Site.

There is good evidence that site of bruising can be useful in helping to determine the risk of non-accidental injury in infants. The most common sites of accidental injury in infants4-6 are the anterior tibia, knee and upper leg (especially in ‘walkers’) and the forehead.

‘Soft’ sites such as the face (not forehead) and trunk are very rare in accidental injury and suggest non-accidental injury in all age groups4,7, especially infants.

Number of bruises.

The number of bruises found in accidental injury is related to age and mobility. One study5 showed that the mean number of bruises for a ‘pre-cruiser’ who had bruising was 1.3 (1-4) as compared to 2.4 (1-11) per ‘walker’ with bruising. Other studies4,8 have shown that in mobile children of all ages about 20% will have >5 injuries, 4% have 10 or more and <1% will have over 15. This is independent of age. Therefore suspicion should be raised if an infant is found to have numerous bruises even if they are mobile.

History

It has long been recognised that delay in consulting, physical findings incompatible with the history or developmental age, association with other injuries and a suspicious attitude of the parents increases the likelihood of non-accidental injury. One study8 summarised studies which stated that injuries sustained after falling from a bed or sofa tend to be minor. Similarly children falling down a flight of stairs will frequently injure themselves but not seriously9.

It is important to document developmental stage clearly

Infant with bruising

Age

<6 months old 6-9 months old >9 months old

Mobility

C

‘Pre-cruiser’Cruiser/Walker

Site

C

‘Soft’‘Common’

(see text)(see text)

Face/TrunkLegs/Forehead

Number

C

>10<10

Other

(inc history etc see text)

Suspected medical cause

Concerns

MedicalNo concerns

Minor concerns

Skeletal surveyFollow-upNo action

CT scan head+/- FBC, Clotting

FBC, Clotting(if medical concerns)

Photos

N.B. C = Consider

References

  1. Hobbs C.J. Hanks H.G.I. Wynne J.M. (1994) Child abuse and neglect- a clinicians handbook. Edinburgh: Churchill Livingstone.
  1. Roberton D.M.Barbor P. Hull D. (1982) Unusual injury? Recent injury in normal children and children with suspected non-accidental injury. BMJ; 285: 1399-401.
  1. Stephenson T. (1995) Bruising in children. Current Paediatrics; 5: 225-9.
  1. Labbe J.M.D. Caouette G. (2001) Recent skin injuries in normal children. Paediatrics; 108(2): 271-6.
  1. 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 Pediatric and Adolescent Medicine; 153(4): 399-403.
  1. Carpenter R.F. (1999) the prevalence and distribution of bruising in babies. Archives of Disease in Childhood; 80(4): 363-6.
  1. Pascoe J.M. Hildebrandt M.D. Tarrier A. et al. (1979) Patterns of skin injury in non-accidental and accidental injury. Paediatrics; 82: 457-61.
  1. Hobbs C. (1994) Could it have happened when he fell doctor? Child Abuse Review; 3: 148-150.
  1. Joffe M. Ludwig S. (1988) Stairway injuries in children. Paediatrics; 82:457-61.

PAEDIATRIC CLINICAL GUIDELINES

ISSUE:VERSION: FINAL

Title: Bruising in Infants

Author: Dr Louise Wells

Job Title:Paediatric Specialist Registrar

First Issued:January 2002Date Revised: Review Date: January 2005

Document Derivation:Consultation Process:

i.e. References:

Included in document

Ratified By: Paediatric Clinical Guidelines Committee

Chaired By:

Consultant with Responsibility: Dr Stephanie Smith

Distribution:All wards QMC and CHN

Training issues: Included in Induction Programme

Audit:

This guideline has been registered with Nottingham City Hospital NHS Trust and QMC Clinical Guidelines Committee. However, clinical guidelines are ’guidelines’ only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

MANUAL AMENDMENTS RECORD
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