From the Guidelines
The evaluation of abnormal bruising should begin with a thorough history and physical examination to distinguish between normal bruising and pathological causes, as recommended by the American Academy of Pediatrics 1.
Key Components of Evaluation
- A thorough physical examination should include an evaluation of areas of bruising that have higher specificity for abuse, such as the buttocks, ears, and genitals 1.
- Laboratory evaluation typically includes complete blood count, peripheral blood smear, coagulation studies (PT, PTT), and specific factor assays when indicated 1.
- The pattern, distribution, and timing of bruises should be documented while assessing for associated symptoms like bleeding from other sites.
Considerations for Bleeding Disorders
- Any bleeding disorder can cause cutaneous bruising, and sometimes this bruising can be mild, can appear in locations that are considered suspicious for abuse, and can appear at any age 1.
- Given the extreme rarity of some bleeding disorders, it is not reasonable to perform extensive laboratory testing for bleeding disorders in every child 1.
- Screening for immune thrombocytopenia (ITP) with a platelet count is necessary at the time of presentation with bruises, as it is a transient and often self-resolving bleeding disorder 1.
Treatment Approach
- Treatment depends on the underlying cause, and may include vitamin K for deficiency, platelet transfusions for thrombocytopenia, fresh frozen plasma for coagulation factor deficiencies, and specific factor concentrates for hemophilia 1.
- For medication-induced bruising, adjusting or discontinuing the causative agent (like anticoagulants or antiplatelet drugs) may be necessary.
- Local measures such as applying pressure, ice, and elevation can help manage acute bruising.
- Severe cases with significant bleeding may require hospitalization for intensive monitoring and treatment.
- Patients should be educated about avoiding trauma, using protective equipment during activities, and recognizing warning signs that require immediate medical attention.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Evaluation Approach
The evaluation of abnormal bruising involves a comprehensive history, physical examination, and laboratory testing to determine the underlying cause.
- A detailed history can help identify potential causes of bruising, including medication use, family history of bleeding disorders, and previous bleeding episodes 2, 3, 4.
- Physical examination findings, such as mucocutaneous bleeding or hemarthroses, can suggest specific underlying conditions, such as platelet dysfunction or coagulopathy 2.
- Laboratory testing, including complete blood count, peripheral blood smear, prothrombin time (PT), and partial thromboplastin time (PTT), can help identify abnormalities in blood clotting and platelet function 2, 4.
Laboratory Testing
Initial laboratory testing for abnormal bruising may include:
- Complete blood count (CBC) to evaluate for anemia or thrombocytopenia
- Peripheral blood smear to evaluate for platelet abnormalities
- Prothrombin time (PT) and partial thromboplastin time (PTT) to evaluate for coagulopathy
- A normal PT and PTT may indicate a platelet disorder, such as von Willebrand disease 2, 4.
- A normal PT and prolonged PTT may indicate a disorder of the intrinsic coagulation pathway, and a mixing study should be performed 2.
Referral to Specialist
If initial evaluation does not reveal an etiology in a patient with a high suspicion for a bleeding disorder, referral to a hematologist for additional evaluation is recommended 2, 3, 4.
- A hematologist can perform further testing and provide guidance on management and treatment of underlying bleeding disorders.
- In certain circumstances, referral to other specialists, such as a gastroenterologist, nephrologist, rheumatologist, or endocrinologist, may be necessary 3.