Susan Lamb, MD Division of Child Abuse Pediatrics November 2015 When is a bruise NOT just a bruise: evaluating young children with bruising concerning for abuse Susan Lamb, MD Division of Child Abuse Pediatrics November 2015

Dating of bruises depends on which of the following? Color of the bruises History of when bruises were observed by a caretaker Size of the bruises 1 & 2 All of the above

Which of the following bruises are concerning for abuse? Chest bruise in a 3 year old active boy Anterior shin bruise in a 3 month old boy Ear bruise in a 2 year old girl 2 & 3 All of the above

What is the indicated medical work-up for a 4 month old previously healthy infant boy with a bruise on his abdomen? Skeletal Survey Head CT LFTs, amylase and lipase 1 & 2 All of the above

What is the indicated medical work-up for the 4 month old twin sister of the previous child with an abdominal bruise? Skeletal Survey Head CT LFTs, amylase and lipase 1 & 2 All of the above

What percentage of children with serious physical abuse have a history of a prior suspicious injury? 5% 15% 30% 40% 55%

I have no financial disclosures.

Participant will be able to identify the characteristics of abusive bruising and differentiate abusive from accidental bruising. Participant will know the appropriate medical work-up for children with abusive bruises. Objectives

Outline What is a bruise? Which bruises should concern me? Why? What do I do next if I identify an abusive bruise? What is the importance of the work-up? An abusive bruise is missed; what is the potential harm? Outline

Outline What is a bruise? Which bruises should concern me? Why? What do I do next if I identify an abusive bruise? What is the importance of the work-up? An abusive bruise is missed; what is the potential harm? Outline

Definitions Bruise/Contusion: Hematoma: Bleeding beneath the intact skin at the site of blunt impact trauma Hematoma: Blood that has extravasated from the vascular system into the body Hematomas may develop in the presence of natural disease process in the absence of trauma Definitions

Definitions Ecchymosis: Petechiae: Blood that has dissected through tissue planes to become visible externally May be visible in an area never subjected to trauma Petechiae: Small (1-2mm) red or purple spot caused by a minor hemorrhage of capillary blood vessels Definitions

Anatomy of the Skin Epidermis- compact firm outer layer; not easily damaged Dermis- capillaries and fibrous tissue; resistant to damage Subcutaneous tissue- rich in capillaries and fat, easily deformed; majority of hemorrhage occurs here

Bruises are Injuries Blunt force impact to skin External force exceeds vessel integrity  vessels are crushed and leak Bruising is vascular damage, not skin damage Site of discoloration is site of blunt impact Presence of blood and its breakdown causes various colors associated with bruising Bruises are Injuries

Dating Bruises Common knowledge: Older bruises are green/yellow Newer bruises are purple/red Truth: Bruises cannot be dated by appearance Dating Bruises

Can you age bruises accurately in children? S. Maguire et al, Archives of Disease in Children 2005 Systematic review: 167 studies reviewed, 3 included Conclusion: “A bruise cannot accurately be aged from clinical assessment in vivo or on a photograph.” Can you age bruises accurately in children?

Bruising Appearance of bruise is influenced by Site of impact Object used for impact Amount + rate of force behind the impact When a bruise appears depends on depth of injury Superficial bruises appear early Deep bruises may take days to appear Healing time varies with location on body Bruising

Dating Tools Biopsy History of a reliable caretaker Presence of swelling Dating Tools

Outline What is a bruise? Which bruises should concern me? Why? What do I do next if I identify an abusive bruise? What is the importance of the work-up? An abusive bruise is missed; what is the potential harm? Outline

“Those who don’t cruise rarely bruise”

Bruising and Mobility Bruises are uncommon in infants <6 months of age < 6 months: 2% had bruises 6-8 months: 5.6% 9-12 months- 17.8% 12-15 months- 51% Study of 366 infants Bruising and Mobility Sugar NF et al. Bruises in infants and toddlers. Arch Pediatr Adolesc Med. 1999;153:399-403 22 22

MC Pierce et al. Pediatrics 2010 Case control study of children 0 to 48 months of age admitted to PICU for trauma 42 case subjects, 53 control subjects (total 95) Bruising characteristics (total number and body region) compared Excluded children with bleeding disorders or indeterminate cases Bruising Characteristics Discriminating Physical Child Abuse from Accidental Trauma

Cause of Injury n MVC 29 Non–MVC 24     Fall (ground based)a 1     Fall from bed/couch/tablea 5     Fall in car/bouncy seat from table/countera 4     Fall out of bed of pick-up truck     Fall with caregiver 2     Fall from father's shoulders     Fall from moving golf cart     Pedestrian vs truck     Jumped out of car     All-terrain vehicle accident     Dropped by caregiver     Bouncy seat collapsed     Stair fall (in walker)     Stair fall (with caregiver)     Caregiver fell on child Total 53

Mary Clyde Pierce “Bruising Characteristics Discriminating Physical Child Abuse from Accidental Trauma” Pediatrics 2010

TEN 4 Bruising Model Torso: Ears: Neck: 4: A lot of cushion to absorb injury forces Direct abdominal blows can cause internal injury with minimal external bruising Ears: Difficult to bruise Not very vascular Neck: Protected by the shoulders with short falls Usually neck bruising is in the form of petechiae 4: Bruising to T-E-N regions for children under 4 yrs of age > 4 bruises Any bruising on an infant < 4 months of age

Torso

Ears

Neck

Abuse Accident MVC Non–MVC All Total no. of bruises (no. of patients) 226 (33) 49 (24) 19 (14) 68 (38) No. of bruises in TEN aggregate region (no. of patients) 103 (25) 3 (3) 6 (6) No. of bruises (all regions) on patients <4.0 mo of age (no. of patients) 74 (14) 9 (4) 4 (3) 13 (7) No. of patients with >4 bruises 18

Stairway Injuries Significant injury is rare Predominately reported in infants being carried down the stairs Multiple injuries are rare Most common injuries: Minor soft tissue injury Minor head or facial injury Limb fractures Stairway Injuries

M. Joffe and S. Ludwig “Stairway Injuries in Children” Pediatrics 1988

Patterned Injuries

•Relatively round marks that correspond with fingertips and/or thumb

Handprint (slap)

Buttock Bruising Gluteal crease Transverse blows to buttocks vertical bruising along the gluteal cleft Vascular rupture at the junction between compressed vessels on the buttock and the protected vessels within the gluteal crease

Outline What is a bruise? Which bruises should concern me? Why? What do I do next if I identify an abusive bruise? What is the importance of the work-up? An abusive bruise is missed; what is the potential harm? Outline

Report to DSS Work up is for ADDITIONAL injury

Work-Up Index Child Complete skin examination < 1 year: Head CT < 2 years: Skeletal Survey Follow up skeletal survey in 2 weeks > 2 years: Targeted x-rays as indicated Potential skeletal survey up to 4 years Abdominal Injury suspected: LFTs, amylase, lipase Work-Up Index Child

Bleeding Disorders Family history Bleeding disorder clinically suspected Isolated bruising without other injury Screening with CBC, PT, PTT; consider adding Factor 8, Factor 9, testing for von Willebrand disease Bleeding Disorders

N Harper et al Journal of Pediatrics 2014 Observational multicenter study 146 infants < 6 months had isolated bruising at presentation No other injury clinically suspected Additional Injuries in Young Infants with Concern for Abuse and Apparently Isolated Bruises

Total 73 children of 146 had an additional serious injury identified (50%) Skeletal survey identified new injury in 34 (23%) Neuroimaging identified new injury in 40 (27%) Abdominal injury identified in 4 (3 %) 103 had coagulation studies performed and no bleeding disorders were identified Results

Siblings All siblings should have a complete skin examination Twins Don’t forget household contacts Twins Skeletal surveys < 2 years EVEN IF there are no visible injuries Strongly consider Head CT < 1 year Siblings

Outline What is a bruise? Which bruises should concern me? Why? What do I do next if I identify an abusive bruise? What is the importance of the work-up? An abusive bruise is missed; what is the potential harm? Outline

Sentinel Injuries in Infants Evaluated for Child Physical Abuse L. Sheets et al. Pediatrics 2013 Retrospective case-control study 401 infants <12 months of age evaluated for abuse by the hospital based child abuse team Sentinel injury defined as previous injury suspicious for abuse Child was non-mobile Explanation implausible Sentinel Injuries in Infants Evaluated for Child Physical Abuse

Results Of 200 definitely abused infants, 27.5% had sentinel injuries 30 in AHT cohort 25 in the non-AHT cohort Of 100 infants with intermediate concern for abuse, 8% had sentinel injuries Of 101 nonabused infants, none had sentinel injuries Odds Ratio: 4.4 (CI 2-9.6) p<.001 Results

Sentinel Injuries: 80% bruises, 11% intraoral injury, 7% fracture In 23 of 55 (42%) abuse cases parents reported a medical provider was aware of the sentinel injury 10/23 cases provider suspected abuse Some reported abuse and child was not protected by authorities Some providers concluded there was no abuse due to no additional injuries 13/53 cases provider did NOT suspect abuse Diagnosed as accident, self-inflicted or medical condition

In 27% of cases of definite physical abuse there may be escalating and repeated violence Finding of a sentinel injury or the history of a sentinel injury is an opportunity to intervene and prevent further abuse Conclusion

Practice Recommendations Do a thorough skin examination Always consider injuries in light of child’s mobility Utilize the TEN-4 rule when evaluating young children and infants with bruising Complete the medical work-up indicated by a suspicious bruise Report all suspicious bruising to DSS EVEN IF no additional injuries are found during the work-up Practice Recommendations

Dating of bruises depends on which of the following? Color of the bruises History of when bruises were observed by a caretaker Size of the bruises 1 & 2 All of the above

Which of the following bruises are concerning for abuse? Chest bruise in a 3 year old active boy Anterior shin bruise in a 3 month old boy Ear bruise in a 2 year old girl 2 & 3 All of the above

What is the indicated medical work-up for a 4 month old previously healthy infant boy with a bruise on his abdomen? Skeletal Survey Head CT LFTs, amylase and lipase 1 & 2 All of the above

What is the indicated medical work-up for the 4 month old twin sister of the previous child with an abdominal bruise? Skeletal Survey Head CT LFTs, amylase and lipase 1 & 2 All of the above

What percentage of children with serious physical abuse have a history of a prior suspicious injury? 5% 15% 30% 40% 55%

S. Maguire et al. “Can you age bruises accurately in children S. Maguire et al. “Can you age bruises accurately in children? A systemic review.” Archives of Diseases in Children 2005;90:187-189. MC. Pierce et al. “Bruising Characteristics Discriminating Physical Child Abuse from Accidental Trauma.” Pediatrics 2010;125:67-74. American Academy of Pediatrics. “The Evaluation of Suspected Child Physical Abuse” Pediatrics 2015. M. Joffe and S. Ludwig “Stairway Injuries in Children” Pediatrics 1988.82;2:4457-461. N. Harper et al. “Additional Injuries in Young Infants with Concern for Abuse and Apparently Isolated Bruises.” Journal of Pediatrics 2014;165:383-388. L. Sheets et al. “Sentinel Injuries in Infants Evaluated for Child Physical Abuse.” Pediatrics 2013;131:701-707. References

Thank you