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Testing for bleeding disorders in child abuse: AAP recommendation adherence and testing results
Lyndsey Hultman1, Angela Doswell2, Henry T Puls3
1Division of Child Adversity and Resilience, Children's Mercy Hospital, University of Missouri Kansas City School of Medicine, Kansas City, MO, United States of America.
Insights
Bleeding disorder testing adherence to American Academy of Pediatrics (AAP) guidelines was low and varied across centers. Rare bleeding disorders were identified in children with bruising or intracranial hemorrhage (ICH) concerning for abuse.
Area of Science:
- Pediatric Medicine
- Child Abuse Pediatrics
- Hematology
Background:
- Child abuse evaluations often involve assessing for underlying medical conditions.
- The American Academy of Pediatrics (AAP) provides guidelines for bleeding disorder testing in suspected abuse cases.
- Variability in adherence to these guidelines may impact diagnosis and care.
Purpose of the Study:
- To evaluate adherence to AAP bleeding disorder testing recommendations in children with suspected abuse.
- To determine the frequency of bleeding disorder identification in this population.
- To analyze variations in testing practices across different centers.
Main Methods:
- A descriptive study was conducted using data from the Child Abuse Pediatrics Network (CAPNET).
- Children under 10 years with bruising and/or intracranial hemorrhage (ICH) concerning for abuse were included.
- Adherence to AAP testing recommendations and the rate of bleeding disorder identification were primary outcomes.
Main Results:
- 2491 children were analyzed; 25.1% met AAP criteria for testing.
- Testing completion rates were low: 10.5% for bruising and 33.1% for ICH.
- Bleeding disorders were identified in 0.7% of cases, with higher rates at centers with increased testing.
Conclusions:
- Adherence to AAP bleeding disorder testing guidelines in suspected child abuse cases is inconsistent and varies significantly by center.
- While rare, bleeding disorders are present in this patient population.
- Standardized implementation of AAP guidelines may improve diagnostic yield.
Objectives:
Using a multicenter child abuse pediatrics research network (CAPNET), the study objectives were to characterize the adherence to American Academy of Pediatrics (AAP) recommendations for bleeding disorder testing and the frequency of bleeding disorder identification.
Methods:
We performed a descriptive study of bleeding disorder evaluations among children younger than 10 years of age who presented with bruising and/or intracranial hemorrhage (ICH) concerning for abuse from February 2021-May 2022 utilizing CAPNET. Cases were classified as bruising without ICH or ICH with or without bruising. Based on AAP guidance, testing was not recommended in cases with concomitant suspicious injuries, inflicted injury history, patterned injury, and low clinical concern for abuse. The primary outcome was adherence to AAP recommendations for testing by study group. We also calculated the frequency of bleeding disorder identification.
Results:
A total of 2491 children presented with bruising and/or ICH concerning for abuse during the study period. 25.1 % of subjects (468 with bruising and 157 with ICH) were recommended to have testing by AAP criteria. Of these, 10.5 % cases of bruising and 33.1 % cases of ICH completed all AAP recommended testing. Among CAPNET centers, AAP recommended testing completion ranged from 0 to 34.1 % of bruising cases and 4.8-100 % of ICH cases. In total, 0.7 % (18/2491) cases had a newly identified bleeding disorder, with more identified at one center with higher testing rates.
Conclusions:
Testing for bleeding disorders based on AAP recommendations frequently did not occur and varied by CAPNET center. Although rare, bleeding disorders were present among cases with testing.
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