A Prospective Study of the Causes of Bruises in Premobile Infants

Abstract

Objective This study had 2 objectives. First, to determine the behavior of physicians evaluating premobile infants with bruises. Second, and most importantly, to learn whether infants with unexplained bruising who had been initially evaluated by primary care and emergency department (ED) physicians are as likely to have their bruises attributed to child abuse as those children evaluated by child abuse physicians. Methods Primary care, ED, and child abuse pediatricians (CAPs) in King County, Washington, San Mateo, Calif, Albuquerque, NM, La Crosse, Wis, and Torrance, Calif prospectively identified and studied infants younger than 6 months with less than 6 bruises, which were judged by the evaluating clinician to be explained or unexplained after their initial clinical examination. Results Between March 1, 2010, and March 1, 2017, 63 infants with initially explained and 46 infants with initially unexplained bruises were identified. Infants with unexplained bruises had complete coagulation and abuse evaluations less frequently if they were initially identified by primary care pediatricians or ED providers than by CAPs. After imaging, laboratory, and follow-up, 54.2% (26) of the infants with initially unexplained bruises, including 2 who had been initially diagnosed with accidental injuries, were diagnosed as abused. Three (6.2%) infants had accidental bruising, 6 (12.4%) abuse mimics, 1 (2.5%) self-injury, 1 (2.5%) medical injury, and 11 (22.9%) remained of unknown causation. None had causal coagulation disorders. A total of 65.4% of the 26 abused infants had occult injuries detected by their imaging and laboratory evaluations. Six (23.1%) abused infants were not diagnosed until after they sustained subsequent injuries. Three (11.5%) were recognized abused by police investigation alone. Thirty-eight percent of the abused, bruised infants had a single bruise. Clinicians' estimates of abuse likelihood based on their initial clinical evaluation were inaccurate. Primary care, ED, and child abuse physicians identified abused infants at similar rates. Conclusions More than half of premobile infants with initially unexplained bruises were found to be abused. Abuse was as likely for infants identified by primary care and ED providers as for those identified by CAPs. Currently, physicians often do not obtain full abuse evaluations in premobile infants with unexplained bruising. Their initial clinical judgment about abuse likelihood was inadequate. Bruised infants often have clinically occult abusive injuries or will sustain subsequent serious abuse. Bruised infants should have full abuse evaluations and referral for Protective Services and police assessments.

Advances and Future Directions of Diagnosis and Management of Pediatric Abusive Head Trauma: A Review of the Literature

“…It is important for clinicians to be educated in recognizing the sometimes subtle signs of non-accidental injuries such as bruising or fractures in non-cruising infants, vomiting without diarrhea, lethargy, poor oral intake, or injuries without adequate trauma history (114,115). Studies have demonstrated frequently missed opportunities to diagnose sentinel abusive injuries in children who were later diagnosed with AHT (116)(117)(118). Unfortunately, as shown in a recent study by Letson et al there has not been a significant improvement in the rate of missed sentinel abuse events over the last two decades (117).…”

Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics

“…[7][8][9][10] Published evidence confirms that measurable differences exist between bruising from nonabusive and abusive injury in infants and young children. [10][11][12][13][14][15][16][17][18][19][20][21][22][23] An evidence-based screening tool may prevent these high-stakes failures.…”

Child Protection Team Consultation for Injuries Potentially Due to Child Abuse in Community Emergency Departments

“…32,46,47 This reluctance to consider abuse when a young child presents with injury is especially relevant in the field of child abuse, where a seemingly minor and self-resolving injury, such as a single bruise in a premobile infant, should trigger concern for abuse. [48][49][50] While linking CED providers to a regional CPT when infants present with high-risk injuries, such as bruising, has the potential to help overcome some of these barriers, we similarly found that CED providers wished for their own discretion about when to seek a consultation from the CPT and often felt that they were able to discern independently between abusive and nonabusive injury although available research does not support this view. 3,23,51,52 In contrast, when ED providers consulted the CPT, they appreciated the screening questions asked by the CPT to help determine the need for further evaluation, especially in settings with limited social work availability.…”

“…These include difficulty distinguishing abusive from nonabusive injury, socioeconomic and racial biases that falsely allow providers to feel capable of discerning which caregivers would and would not abuse their children, concerns about the effectiveness of CPS, and fear of falsely “accusing” caregivers of abusing their children 32,46,47 . This reluctance to consider abuse when a young child presents with injury is especially relevant in the field of child abuse, where a seemingly minor and self‐resolving injury, such as a single bruise in a premobile infant, should trigger concern for abuse 48–50 . While linking CED providers to a regional CPT when infants present with high‐risk injuries, such as bruising, has the potential to help overcome some of these barriers, we similarly found that CED providers wished for their own discretion about when to seek a consultation from the CPT and often felt that they were able to discern independently between abusive and nonabusive injury although available research does not support this view 3,23,51,52 .…”