The presenting symptoms of suspected child abuse or non-accidental trauma can mimic the sequelae of an underlying bleeding disorder. Consequently, a careful approach to bleeding evaluation in children with suspicious symptoms is essential to avoid unnecessary testing and limit the false attribution of symptoms to medical causes.1,2

According to findings presented in a poster at the 2023 ASPHO Annual Meeting by Meghan McCormick, MD, of UPMC Children’s Hospital of Pittsburgh, in Pittsburgh, PA and colleagues, a low incidence of bleeding disorders were diagnosed in children with suspected child abuse or non-accidental trauma despite use of expanded hematologic testing, raising questions about the utility of testing for these patients.1

In this study, the researchers analyzed data from the Pediatric Health Information System, an administrative database of US children’s hospitals, and included pediatric patients diagnosed with child physical abuse, shaken infant syndrome, unspecified child maltreatment or child neglect or abandonment from 2007 through 2017.

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Of the 15,530 patients analyzed, 61% of patients were non-White race and 14% were Hispanic ethnicity. With respect to symptoms upon presentation, fracture, bruising, intracranial hemorrhage, and retinal hemorrhages were observed in 50%, 14%, 1.8% and 19% of patients with child physical abuse, shaken infant syndrome, unspecified child maltreatment or child neglect or abandonment, respectively.

The researchers noted that almost all patients (91%) were sent for hematologic testing and expanded testing was ordered in 31.4% of encounters. Moreover, hematology consultation was obtained in 1.98% of cases, and consultation was associated with increased odds of expanded testing (odds ratio, 15.51; P <.001).

In the multivariate analysis, expanded hematologic testing was significantly associated with hematology consultation, presenting symptom, younger age, Hispanic ethnicity, geographic region, private insurance, as well as greater severity of injury and mortality risk scores (P <.001 for all).

Importantly, a bleeding disorder was only identified in 0.5% of patients, of whom 9.21% presented with fracture, 38.16% with retinal hemorrhage and 26.32% with multiple injuries suspicious for child abuse. In addition, expanded testing was associated with a significant increase in laboratory-related costs (median $6495 vs $1826; P <.001).

Results in context

These findings have “important implications” for potential future screening programs that utilize expanded hematologic testing, according to the researchers. Based on these data, they proposed that health inequities may contribute to the selection of patient groups for expanded testing, leading to significant expense and potential financial toxicity.

Furthermore, they stated that additional studies are needed to address the health inequities and develop recommendations for more judicious use of testing.

“If clinicians are interested in learning more about this topic, the American Academy of Pediatrics (AAP) published updated guidelines last year,” commented Dr McCormick in an interview with Hematology Advisor.