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Patterns of bruising in preschool children with inherited bleeding disorders: a longitudinal study
Peter W Collins1, Melinda Hamilton2, Frank D Dunstan3
1Department of Haematology, Institute of Infection and Immunity, School of Medicine Cardiff University, Cardiff, UK.
Insights
Children with inherited bleeding disorders experience more and larger bruises, particularly when they are not yet mobile. Early coagulation studies are crucial for diagnosing bleeding disorders and preventing misdiagnosis of abuse in young children.
Area of Science:
- Pediatrics
- Hematology
- Genetics
Background:
- Bruising is common in young children, but excessive bruising may indicate an underlying medical condition.
- Inherited bleeding disorders are a significant cause of abnormal bruising in children.
Purpose of the Study:
- To determine the impact of inherited bleeding disorders on the number, size, and location of bruises in children under six years old.
- To differentiate bruising patterns between children with and without bleeding disorders across different mobility stages.
Main Methods:
- A prospective, longitudinal, observational study involving 105 children with bleeding disorders and 328 controls.
- Bruise assessment (number, size, location) was conducted weekly for up to 12 weeks.
- Multilevel modeling was used to analyze data, comparing disease severity and mobility levels.
Main Results:
- Children with bleeding disorders had significantly more and larger bruises compared to controls, especially in the premobile stage.
- Severe bleeding disorders showed a more pronounced increase in bruise number and size.
- Bruises were rarely observed on the head, neck, or genitalia in children with bleeding disorders.
Conclusions:
- Inherited bleeding disorders are associated with increased bruising in children across all developmental stages, with the most significant differences observed in premobile infants.
- Early diagnostic evaluation, including coagulation studies, is essential for children presenting with unexplained bruising to rule out bleeding disorders and avoid misdiagnosis of non-accidental trauma.
- A mild or moderate bleeding disorder diagnosis should not be automatically assumed as the cause of bruising without further investigation.
Objective:
The extent that inherited bleeding disorders affect; number, size and location of bruises in young children <6 years.
Design:
Prospective, longitudinal, observational study.
Setting:
Community.
Patients:
105 children with bleeding disorders, were compared with 328 without a bleeding disorder and classified by mobility: premobile (non-rolling/rolling over/sitting), early mobile (crawling/cruising) and walking and by disease severity: severe bleeding disorder factor VIII/IX/XI <1 IU/dL or type 3 von Willebrand disease.
Interventions:
Number, size and location of bruises recorded in each child weekly for up to 12 weeks.
Outcomes:
The interventions were compared between children with severe and mild/moderate bleeding disorders and those without bleeding disorders. Multiple collections for individual children were analysed by multilevel modelling.
Results:
Children with bleeding disorders had more and larger bruises, especially when premobile. Compared with premobile children without a bleeding disorder; the modelled ratio of means (95% CI) for number of bruises/collection was 31.82 (8.39 to 65.42) for severe bleeding disorders and 5.15 (1.23 to 11.17) for mild/moderate, and was 1.81 (1.13 to 2.23) for size of bruises. Children with bleeding disorders rarely had bruises on the ears, neck, cheeks, eyes or genitalia.
Conclusions:
Children with bleeding disorder have more and larger bruises at all developmental stages. The differences were greatest in premobile children. In this age group for children with unexplained bruising, it is essential that coagulation studies are done early to avoid the erroneous diagnosis of physical abuse when the child actually has a serious bleeding disorder, however a blood test compatible with a mild/moderate bleeding disorder cannot be assumed to be the cause of bruising.
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