Bruising Patterns in Young Children With Bleeding Disorders

Source: Collins PW, Hamilton M, Dunstan FD, et al. Patterns of bruising in preschool children with inherited bleeding disorders: a longitudinal study. Arch Dis Child. 2017; 102: 1110– 1117; doi: 10.1136/archdischild-2015-310196Investigators from multiple institutions in the United Kingdom and Canada conducted a prospective observational study to characterize bruising in young children with bleeding disorders. Study participants were patients <6 years old recruited from 6 hemophilia centers. These children were characterized as having either a severe bleeding disorder (levels of factors VIII/IX or XI <1 IU/dL or type 3 von Willebrand disease [vWD]) or a mild/moderate disorder (levels >1 IU/dL or type 1 or 2 vWD). A comparison group of control children without bleeding disorders was also enrolled. The developmental status of participants was categorized as premobile, early mobile (crawling and/or cruising), or walking. On a weekly basis for 12 weeks, parents recorded the number, location, and measured size of all bruises noted on their child. Main study outcomes included the mean number of bruises per data collection, percentage of data collections with at least one bruise noted, number of collections with a bruise >1 cm, and location of bruises. Longitudinal analysis was performed using multilevel modeling to compare outcomes among children with bleeding disorders and controls.Data were analyzed on 103 study participants with bleeding disorders, including 57 with a severe disorder, and 328 controls. Among premobile children, at least one bruise was noted at 52% of data collections in those with a severe bleeding disorder, compared to 7% of collections in controls. Overall, the number of bruises per collection was significantly higher in those with a severe or mild/moderate bleeding disorder than control children (mean number of bruises per data collection 1.06, 0.19, and 0.09, respectively). The rate of bruising increased in early mobile and walking children without a bleeding disorder (>1 bruise noted at 46% and 79% of data collections, respectively); however, the mean number of bruises for participants with severe or mild/moderate bleeding disorders per collection was significantly higher at each of these developmental stages than in controls. At least one bruise >1 cm was noted during 1.0% of data collections for premobile controls, compared to 3.4% of those with mild/moderate bleeding disorders and 24.6% of those with severe bleeding disorders. In premobile children, bruises on the cheeks, neck, buttocks, eyes, and genitalia were rare among those with bleeding disorders (noted on <0.5% of data collections) and absent in controls.The authors conclude that young children with bleeding disorders have more, and larger, bruises than those without a bleeding disorder at all developmental stages.Dr Hogan has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Although significant bruising in young, healthy children may indicate a hemostatic disorder, non-accidental injury, or both, the determination of severity is often subjective.1 The location, number, and size of bruises vary with motor development, trauma, and acquired or inherited bleeding disorders.2 Excessive bruising in ambulatory children on bony prominences of the limbs is often due to bleeding disorders, while bruising over the head, neck, back, palms/soles, and long bones, or on any location in infants <4 months of age, may signal abuse.3 However, bruising locations may overlap.4 Infants and toddlers are less likely to need surgery or are too young for menorrhagia, which are frequent prompts for mild to moderate bleeding disorder testing in older children.5 Laboratory results, especially for mild bleeding disorders, are sometimes difficult to interpret.5 For these reasons, the current study of bruising characteristics in premobile and mobile children with mild to severe bleeding disorders may be a useful screening tool for pediatricians and hematologists.Study limitations included combining mild and moderate bleeding disorders, as well as reporter bias. Acquired bruising issues due to medications (eg, aspirin, nonsteroidal anti-inflammatory drugs), vitamin K deficiency, and vasculitis were not investigated.1,5 Children with more rare bleeding disorders, such as deficiency or dysfunction of factor I, II, V, VII, X, or XIII, were not included in this analysis.2,5Although bruising severity is subjective, larger and more numerous bruises appear on preschool children with severe hemophilia A, hemophilia B, or type 3 vWD, compared to unaffected children.The results of this study confirm those of prior investigations. Bruising in premobile infants and in mobile young children in specific locations (eg, ears, genitalia) raises the specter of abuse. (See related article AAP Grand Rounds, April 2015;33[4]:42.6)

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