1. Clinical presentation of a child with abnormal bleeding Dr Barnabas R Atwiine

2. Is this a bleeding disorder? Not all bleeding episodes mean bleeding disorder Epistaxis may be caused by rhinitis, trauma, dry air, etc Non-accidental injury (NAI) suspected? NAI and abnormal bleeding may occur in the setting of a bleeding disorder

3. History Age at onset of bleeding – Inherited bleeding most likely presents in neonatal period and infancy Did circumcision wound bleed? Did umbilical stump bleed or/and heal well? Did child have a cephalohematoma? Did tooth extractions bleed a lot

4. History… Age of child and duration of symptoms – How old is child now and for how long has he/she been bleeding? Sex – Males more likely to suffer inherited sex-linked disorders like hemophilia – Von Willebrand disease more common in girls History of trauma – Was bleeding spontaneous or after trauma – Was bleeding out of proportion with severity of trauma?

5. History… Family history of bleeding – To support possibility of inherited conditions like hemophilia (may occur even in absence of family history) – Autosomal dominant disorders may occur sporadically – Family history of autoimmune disorders may support chronic ITP – Consanguinity?

6. History… Medication history – Use of ibuprofen and aspirin may impair platelet function and exacerbate an underlying coagulation disorder

7. Physical exam Pattern of bleeding – Mucosal bleeding (eg epistaxis, menorrhagia, oral, GUT and rectal) may herald a platelet disorder or vWD (platelet-blood vessel interaction problems) – Deep tissue bleeding into muscles and joints or unexpected post-surgical bleed most likely due to coagulation factor disorders

8. Physical exam… Location of bleeds – Hemostatic problems usually cause bleeds over bony prominences and are superficial – NAI may occur over non-dependent areas and may take the shape of an object

9. Types of bleeds Petechiae and purpura: – usually platelet disorders or vWD – Where there’s h/o trauma, bleeding out of proportion of the trauma

10. Types of bleeds Ecchymoses and hematomas: – Most commonly due to coagulation factor problems

11. Types of bleeds… Epistaxis: – One that requires emergency visit – Occurs in both nostrils – Other bleeding areas

12. Types of bleeds… Hemarthrosis – Joint effusion – Warmth, pain on movement – Failure to use limb or refusal to walk in the infant

13. Types of bleeds… Menorrhagia – Frequent pad change (>2 times per day) – >7 days of flow – >1 flow per month – May respond to oestrogen – May have occurred in the family and treated with oestrogen Intra-cranial bleeds – Present with CNS symptoms like seizures, hemiplegia and coma

14. Types of bleeds… Post-surgical bleeds – Extends beyond surgical sites (drains, vascular access) – Poor wound healing or infection – Need for transfusion – Bleed from adenotonsilectomy usually occurs up to after 7 days post-surgical

15. General status of the child Is bleeding due to primary bleeding disorder or secondary to a systemic disease? – Well appearing child ITP or hemophilia? – Acutely sick-looking DIC? Acute leukemias? – Chronically sick-looking child Chronic liver disease? Disseminated cancers or chronic leukemias, etc?