Bruises in Children: Normal or Child Abuse?

Tomika S. Harris, DNP, MSN, CPNP


J Pediatr Health Care. 2010;24(4):216-221. 

In This Article

Evaluation of the Child with Bruising

The evaluation of a child with bruises should begin with a detailed history. The history should include the current problem and the medical history of the child and family, specifically addressing bleeding disorders, psychosocial history, and review of systems (Mayer & Burns, 2000). The parent or guardian accompanying the child should be asked to provide a detailed history of the current problem. The history should begin with the last time the child appeared to be bruise free and should include information about who was present when the child was injured (Hornor, 2005). Next, depending on age and developmental level, the child should be questioned directly about the injury. Direct, open-ended questions should be used (Herendeen, 2002). If possible, this questioning should occur outside of the presence of the parent or caregiver. Red flags that should alert the provider to possible abuse include a history that is inconsistent with the injury, no explanation offered for the injury, history that is inconsistent with the child's developmental level, and/or injury blamed on another child or sibling.

A child presenting with bruising should have a complete head-to-toe examination. The examination should begin with an assessment of the child's general appearance, including behavior, physical appearance, and hygiene. During the examination, the child should be unclothed to inspect the skin thoroughly. In conjunction with the physical examination, any child with suspicious or unexplained bruising should have a coagulation screen, including a platelet count, complete blood cell count and film, prothrombin time, and activated partial thromboplastin time to assess for a bleeding disorder (Herendeen, 2002; Thomas, 2004). In addition, any child younger than 2 years with suspected physical abuse should have a radiological skeletal survey (AAP, 2000).

Accurate documentation is always crucial but is of particular importance in cases of suspected child abuse because of the potential legal implications. Documentation should be objective and complete. The location, size, color, and description of all bruises should be noted on a body diagram and photographed, if possible. In addition, the developmental history of the child, procedures performed, the diagnosis, and final disposition of the child should be included in the record (Limbos & Berkowitz, 1998). When completing the medical report, it is important to remember that most readers of reports in cases of suspected child abuse are not medical personnel. Medical terminology or jargon should be avoided or explained (David, 2004).


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