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

Conditions Mistaken for Abuse

Mongolian spots are congenital lesions that often are mistaken for bruises and reported as abuse (Bays, 2001). They appear as blue-gray areas of pigmentation and commonly are found on the sacral area and the buttocks (Figure 5). However, mongolian spots also have been seen on the back, legs, shoulders, upper arms, and scalp. Mongolian spots are predominately found in African American, Asian, Latino, and American Indian infants and tend to fade during childhood (Bays). Mongolian spots can be distinguished from bruises in that they do not fade or change color as bruises do. In uncertain cases, re-evaluating the child in 1 week can assist in distinguishing a mongolian spot from a bruise.

Figure 5.

Mongolian spot. This figure is available in color at

Another skin lesion that may be mistaken for bruising is a capillary hemangioma. Hemangiomas are benign vascular malformations that occur in about 10% of infants (Tanner, Dechert, & Frieden, 1998). They usually develop during the first few weeks of life, with dramatic growth during the first few months followed by slower growth and involution. Hemangiomas typically have an erythematous or bruised appearance and commonly occur on the face, but also may be seen elsewhere on the body (Figure 6). These lesions can be distinguished from bruises in that they blanch with pressure and exhibit a classic pattern of growth and involution.

Figure 6.

Capillary hemangioma. This figure is available in color at

Erythema multiforme minor is an acute reactive erythema thought to be caused by a reaction to drugs or infections (Mudd & Findlay, 2004). The sudden appearance of ecchymotic lesions can be mistaken for bruises. A complete medical history including recent medications and illnesses can aid the provider in distinguishing this disorder from abuse. Henoch-Schönlein purpura (HSP) can also be mistaken for non-accidental bruising, especially early in the disease. HSP is a fairly common pediatric disease that typically presents as symmetrical bruises on the buttocks and extensor surfaces of the arms and legs (Daly & Siegel, 1998; Mudd & Findlay). HSP should be suspected in a child with a history of a recent upper respiratory infection.

Children with conditions such as idiopathic thrombocytopenic purpura and leukemia may present with unexplained bruises in different stages of healing that can be mistaken for abuse (Bays, 2001). The parents may give a history that the child bruises easily. A complete blood cell count with differential, prothrombin time, activated partial prothrombin time, and bleeding time should be done to distinguish these disorders from abusive bruising. It is important to remember that the diagnosis of a bleeding disorder does not exclude non-accidental injury, and children with bleeding disorders are at increased risk for bleeding and bruises due to trauma (Thomas, 2004).


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