Investigation for Bleeding Disorders in Suspected Non-Accidental Intracranial Haemorrhage

Abusive head trauma is the most common cause of death in children suffering non-accidental injury (NAI). Intracranial haemorrhage can (rarely) be caused by inherited bleeding disorders. Evaluation of children with suspected NAI and intracranial bleeding involves diagnosis or exclusion of a bleeding disorder; however, there is a paucity of evidence to guide haematological evaluation in these patients.

To determine the prevalence of inherited bleeding disorders in children with intracranial haemorrhage suspected of NAI and determine which tests have the highest diagnostic yield.

We conducted a retrospective cohort study of children referred to the Child Protection Unit at Sydney Children's Hospital, Australia, between 2011 and 2020 with intracranial haemorrhage. Descriptive analyses of the data were completed.

A total of 120 children were included in the cohort. Eighty-seven (73%) had a baseline coagulation screen (FBC, PT and APTT) performed with initial pathology testing within 72 h of presentation. Three children (2.5%) were identified to have an underlying inherited bleeding disorder, all of whom (100%) had a prolonged APTT on initial testing.

An extensive array of haematological investigations was performed, but with a lack of consistency. Three patients were identified to have an inherited bleeding disorder, including haemophilia A, haemophilia B and von Willebrand disease, two of whom were confirmed NAI regardless. All three had abnormal APTT on the initial coagulation screen. We propose initial haematological screening with FBC, PT/APTT/fibrinogen only, unless bleeding risk factors are identified. If an abnormality is detected, subsequent factor levels and further haematological investigations are recommended.