Journal Club Dr Karen Arnold July 2015

Case Scenario 18 month old boy Multiple bruises Knees, shins, right elbow, right hand, forehead Boisterous boy with older siblings “bruise easily”

Patterns of bruising in preschool children- a longitudinal study Alison M Kemp et al Arch Dis Child :

Aims Identify the prevalence and pattern of bruises in preschool children over time and to explore influential variables

Methods Prospective longitudinal study Children aged 0-6 years South Wales Recruited from well-baby clinics, hospital outpatient clinics and mother & baby groups Excluded motor disability, confirmed bleeding disorder or suspected child abuse

2 phases in study Phase 1 (Apr 2005 – Dec 2007) Phase 2 (Apr 2008 – Aug 2011) Both phases collected gender, age, developmental stage and PMH Phase 2 included ethnicity, family order and socioeconomic status, parental report on cause of bruise

Parents trained to recognise a bruise Record number and location of bruises Trained not to record cuts, abrasions, birthmarks Bruises recorded on body map weekly for up to 12 weeks Walking children had four weekly collections

At each collection parents recorded the most advanced developmental milestone reached Classified as premobile (not rolling or rolling), early mobile (crawling or cruising) and walking

Validation Parents recorded number, location and size of bruise Random sample of 40 data collections from 40 different children selected Single research nurse verified lesions recorded by independently repeating process Parents not warned about visit

Analysis Longitudinal analysis performed using multilevel modelling with Poisson distribution and a log link function

Categorisation of sites where the locations of bruises were recorded at each data collection. Alison M Kemp et al. Arch Dis Child 2015;100: Copyright © BMJ Publishing Group Ltd & Royal College of Paediatrics and Child Health. All rights reserved.

Results 1002 parents approached 380 gave informed consent 328 children had at least one collection (mean age 19 months, 54% female) 2570 data collections Average of 7.8 collections per child

Ethnicity recorded in 280 children 269 White British 11 other ethnic groups Socioeconomic status 46% from least deprived area 15% two most deprived areas

Validation process showed complete agreement between parents and research nurse for number and site of bruising For bruise size (within 5mm) agreement was 55% - size not included in analysis

Number and percentage with 95% CI of collections with at least one bruise Mean (SD) number of bruises per collection Mean (SD) number of sites affected per collection Range, median and 90th centile of number of bruises per collection Premobile Age range 0– 11 months 68/ % (95% CI 5.3 to 8.4) 0.09 (0.35)0.08 (0.30) 0–3 0 0 Early mobile Age range 4– 18 months 218/ % (95% CI 41.2 to 50.1) 0.80 (1.19)0.59 (0.79) 0–7 0 2 Walking Age range 10– 70 months 852/ % (95% CI 76.2 to 81.1) 2.82 (2.77)1.50 (1.23)0–16 10–36 months 422/ % (95% CI 67.3 to 74.5) 2.31 (2.59)1.28 (1.17) 0– –70 months 387/ % (95% CI 86.8 to 92.4) 0– Overall Age range 0– 70 months 1138/ % (95% CI 42.4 to 46.2) 1.37 (2.27)0.77 (1.10) 0–16 0 4

Prevalence Prevalence of bruising in first collection for each child was: –5.3% premobile children –55.8% early mobile children –87.5% walking children

12 bruises recorded in 9/405 collections in children not rolling 2.2% ( 95% CI 1.2% - 4.2%) 75 bruises recorded in 59/605 collections in children rolling but not yet crawling 9.8% ( 95% CI 7.6% %)

Premobile 1010 collections Early mobile 478 collections Walking 1082 collections Number of collections Per cent Number of collections Per cent Number of collections Per cent Left cheek Right cheek Left ear Right ear Head Facial T Eyes Front trunk Rear trunk Neck Buttocks Genitalia Upper arms Hands Lower arms Front thighs Back thighs Feet Below knees All bruises

Distribution of percentage of 2570 collections from 328 children with at least one bruise by location and development stage. Alison M Kemp et al. Arch Dis Child 2015;100: Copyright © BMJ Publishing Group Ltd & Royal College of Paediatrics and Child Health. All rights reserved.

Some sites numerous bruises Mean number bruises below knee 2.8 Mean number bruises to front of thigh 1.4 Ears, neck, genitalia and hands were rarely bruised (<1% of collections) Majority premobile children had no bruise 73% (97/133) never had a bruise in 1010 collections

Independently mobile children Wide variation between children Considerable variation between collections Walking children Majority of variation was between children Suggests different children tend to sustain different amounts of bruising

FactorRatio of means95% CIs Development stage Premobile to 0.09 Early mobile (reference) 1 Walking to 2.99 Gender (female) to 1.09 Any sibling to 1.99 Season January–March (reference) 1 April–June to 1.20 July–September to 1.18 October–December to 1.06 Ethnicity White 1 Ethnicity (not White) to 1.79 Not recorded to 1.23 Deprivation Quintile 1 1 Quintile to 1.32 Quintile to 1.65 Quintile to 1.48 Quintile to 2.66

Conclusions Strong relationship between presence, number and location of bruises and motor development stage Bruising in babies who were not yet rolling was uncommon Percentage of collections with at least one bruise and the number of bruises at each collection increased with increased development stage

Comparisons and Contrasts Greater prevalence of bruising in this study for all developmental groups Comparative study with some children who have more than expected number of bruises

Safeguarding Considerations Probability of abuse in this population low Explanations, where available, compatible with bruise If bruise pattern deemed unusual they were independently reviewed by child protection team and child abuse was excluded Parents informed that referral to social services would be made if maltreatment suspected

Limitiations Recruitment challenging as it required prolonged participation Over representation of less socially deprived population Parents knowledge of cause of bruising

Analysis Clearly focused issue? Cohort recruitment? Potential bias excluded? Confounding factors? Follow-up long/complete enough? Results? Can results be applied locally? Implications?

Clearly focused issue? Bruising in preschool children (0-70months) Prevalence of bruising Patterns of bruising

Cohort recruitment? Wide cross section – well baby clinics, hospital OPDs, mum & baby groups 1002 approached, 328 in study Under representation of lower socioeconomic groups How was suspected child abuse identified and excluded? Cohort of motivated parents agreeing to intensive participation

Potential bias excluded? Selection bias – motivated parents BUT prospective study Study compliance – some participants involved for 24 weeks Subjective recording by parents Inter – observer variability – reduced by training parents

Confounding factors? Non-accidental injury Suspected child abuse excluded Unusual pattern of injury reviewed by child protection team and abuse excluded

Was follow-up complete? Over weeks Could potentially follow-up until 16 years looking for SC involvement and look back at their history of bruising

Results Bruising in non-rolling babies uncommon Number of bruises increases with developmental stage Ears, neck, genitalia, hands are rare sites for bruising in any preschool child 9% children have twice as many bruises as would be expected

Case Scenario 18 month old boy Multiple bruises Knees, shins, right elbow, right hand, forehead Boisterous boy with older siblings “bruise easily”