What is the recommended treatment for bruises in children?

Management of Bruises in Children

The primary treatment for bruises in children is not about treating the bruise itself, but rather conducting a systematic evaluation to identify potential child abuse, underlying bleeding disorders, or serious occult injuries—with the specific approach determined by the child's age, bruise location, and clinical context. 1

Immediate Clinical Priorities

The management algorithm depends critically on three factors that determine whether skeletal survey or further workup is necessary:

Age-Based Risk Stratification

For infants <6 months old:

• Skeletal survey is necessary for ANY bruising regardless of location or reported trauma history 1
• This age group should essentially never have bruises, making any bruising highly suspicious 1

For infants 6-12 months old:

• Skeletal survey is necessary if bruising occurs on the cheek, eye area, ear, neck, upper arm, upper leg, hand, foot, torso, buttock, or genital area 1
• Bruising on bony prominences may not require skeletal survey if there is a consistent accidental history 1

For toddlers 12-24 months old:

• Skeletal survey is inappropriate for single bruises on the forehead, upper lip, chin, scalp, or extremity bony prominences 1
• Skeletal survey remains necessary for bruising on the ear, neck, torso, hand, or foot when there is no trauma history or only rough play reported 1

High-Risk Scenarios Requiring Immediate Skeletal Survey

Regardless of age, skeletal survey is necessary when: 1

• Witnessed or confessed abuse
• History of domestic violence
• Patterned bruising (showing imprint of an object)
• Additional injuries present (burns, whip marks, frenulum tears)

Evaluation for Bleeding Disorders

Obtain complete blood count, PT, aPTT, and peripheral blood smear if: 2

• Bruising is disproportionate to reported trauma
• Multiple bruises in unusual locations
• Personal or family history of bleeding symptoms
• Spontaneous bruising without clear mechanism 3

Special Consideration for Chemotherapy Patients

For children receiving chemotherapy, bruising requires immediate platelet count assessment: 4

• Hold anticoagulation including prophylactic LMWH 4
• Transfuse platelets to maintain >20 × 10⁹/L prophylactically or >50 × 10⁹/L if active bleeding 4
• Monitor fibrinogen levels in patients receiving asparaginase 4
• Avoid intramuscular injections and invasive procedures 4

Symptomatic Treatment of the Bruise Itself

For uncomplicated accidental bruises after abuse and bleeding disorders are excluded: 5

• Apply local cold therapy immediately
• Use compression to the injured area
• Elevate the affected body part
• These measures prevent muscle shortening and reduce hematoma expansion 5

Critical Pitfalls to Avoid

Never dismiss bruising in pre-mobile infants (<6 months) as accidental - skeletal survey is mandatory regardless of caregiver explanation 1

Do not wait for "more serious" bleeding before acting - in chemotherapy patients, failure to recognize severe thrombocytopenia can lead to life-threatening intracranial hemorrhage 4

Document bruising patterns photographically when there is any concern for non-accidental trauma, as bruise appearance changes rapidly 2

Consider transient acquired inhibitors of coagulation in children with spontaneous bruising after common diagnoses are excluded 3

Assess for deeper injuries - bruising may indicate underlying fractures, organ damage, or traumatic brain injury requiring urgent imaging 2, 6

Wound Care for Associated Injuries

For abrasions and lacerations accompanying bruises: 6

• Clean with good quality water
• Remove all foreign material meticulously
• Use topical anesthetics for pain control
• Apply tissue adhesives for superficial wounds
• Reserve antibiotics for extensively contaminated or deep tissue damage 6
• Verify tetanus prophylaxis status 6