Certain physical injuries tend to occur more often as a result of child abuse than accidents. Injuries of high significance for child abuse are often seen in the central nervous system (CNS), within the abdomen, and as bone fractures. Highly suspicious CNS injuries include subdural hematomas, retinal bleeding, retinoschisis, and vitreous body bleeding. Within the abdomen, intramural duodenal hematoma and hollow organ perforations may be indicative of physical abuse. Lastly, fracture locations that are often concomitant with physical abuse include metaphyses (in children 2 years old or younger), ribs, scapulae, spinal processes, and the sternum. Fractures in premobile infants, typically younger than 6 months, should also be met with suspicion.

The age and activity level of a child undergoing evaluation must be considered when critically checking parent or caregiver explanations for bleeding. Children develop motor skills progressively and experience more injuries on prominent areas of the body, such as the forehead, elbows, knees, and pretibial areas. Bite marks and patterned hematomas, such as marks from fingers, belts, loops, or sticks, are highly specific to child abuse. Atypical hematomas may be located on the chest, forearms, neck, back, dorsal sides of legs, and genitals. Petechial bleedings are also more commonly associated with child abuse than with accidents.

Of particular significance in children between 2 and 5 months old is intracranial hemorrhage, which is the most common nonaccidental cause of death in infants and toddlers. Intracranial bleeding may be caused by direct force, such as hits or kicks to the skull, or by indirect force, referred to as “shaken baby syndrome.”

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If childhood bleeding symptoms are present, especially if child abuse is suspected, coagulation diagnostics should be conducted. Level 1, preliminary onsite coagulation testing includes prothrombin time, activated partial thromboplastin time, fibrinogen activity, and full blood count with differential. Level 2 testing may be onsite or offsite and should be able to detect common coagulation disorders such as von Willebrand syndrome and hemophilia as well as rare inherited disorders. Level 3 testing consists primarily of platelet function diagnostics. Since many platelet tests must use fresh blood collections, patients should be referred to a specialty clinic with expertise in bleeding disorders.

It may be difficult to distinguish child abuse from coagulation disorders or other diseases. When suspicious bleeding is being assessed, an interdisciplinary child protection group consisting of pediatricians, surgeons, radiologists, forensic doctors, and social workers should discuss the clinical findings to arrive at a diagnosis. Many hospitals are partnered with local child protective service groups to help inform authorities of child abuse cases.

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  1. Knöfler R, Streif W, Watzer-Herberth I, Hahn G, Schmidt U. Child abuse or bleeding disorder — an interdisciplinary approach [published online January 25, 2019]. Haemostaseologie. doi: 10.1055/s-0039-1677714