What is the appropriate evaluation and management for a 6-year-old female presenting with easy bruising?

Evaluation and Management of Easy Bruising in a 6-Year-Old Female

Begin with a focused clinical assessment to distinguish between benign causes, bleeding disorders, and non-accidental trauma, followed by targeted laboratory screening if clinically indicated. 1

Initial Clinical Assessment

Critical History Elements

Obtain a detailed bleeding history specifically asking about:

• Significant bleeding after surgery, dental procedures, or minor trauma 1, 2
• Epistaxis requiring medical intervention or cauterization 1
• Joint hemorrhages or hemarthroses 1
• Prolonged bleeding from minor cuts 2

Document medication exposure thoroughly:

• All prescription medications, NSAIDs, anticoagulants, antiplatelets, and corticosteroids 1, 2
• Alternative therapies and supplements, as these affect both bleeding tendency and coagulation test results 1, 2

Assess family history:

• Specific bleeding disorders in relatives 1, 2
• Ethnicity associated with higher rates of certain bleeding disorders 1

Evaluate trauma history and developmental context:

• Determine if bruising pattern is explained by reported trauma 1, 2
• Assess whether bruising location is consistent with the child's age and developmental capabilities 1
• At 6 years old, bruising on shins, knees, and bony prominences is typical for normal activity 1

Physical Examination Red Flags

Examine bruising pattern and location carefully:

• Bruising on buttocks, ears, genitals, or patterned bruising has higher specificity for abuse and warrants different evaluation 1, 3
• Multiple bruises in different stages of healing may suggest non-accidental trauma 3

Look for signs of systemic illness:

• Ehlers-Danlos syndrome features (hyperelastic skin, joint hypermobility) 1
• Petechiae or mucosal bleeding suggesting platelet disorders 4
• Hepatosplenomegaly or lymphadenopathy suggesting malignancy or infiltrative disorders 1, 2

Laboratory Testing Algorithm

Initial Screening Panel

Order the following tests if clinical history or examination raises concern: 1, 2

• Complete blood count (CBC) with platelet count 1, 2
• Peripheral blood smear to assess platelet morphology 1, 2
• Prothrombin time (PT) 1, 2
• Activated partial thromboplastin time (aPTT) 1, 2
• Fibrinogen level if PT or aPTT are abnormal 1, 2

Critical Limitations of Screening Tests

Recognize that PT and aPTT do NOT reliably detect:

• Von Willebrand disease (the most common inherited bleeding disorder, affecting 1 in 1000 people) 1, 4
• Factor XIII deficiency 1, 4
• Platelet function disorders 4, 2

If PT and aPTT are normal but clinical suspicion remains high, proceed with:

• Von Willebrand disease-specific testing: VWF antigen, VWF ristocetin cofactor activity, and Factor VIII coagulant activity 4
• Consider platelet function testing (PFA-100) with hematology consultation for interpretation 1, 4

Special Considerations for This Age Group

When to Consider Non-Accidental Trauma

Skeletal survey is NOT routinely indicated for a 6-year-old with bruising alone, as guidelines focus on children under 24 months. 5 However, if bruising pattern is concerning (buttocks, ears, genitals, patterned), or if there are additional injuries suggestive of abuse, child protective services evaluation is warranted 5, 1

When Laboratory Testing May NOT Be Necessary

Avoid extensive testing without clinical indication:

• The extreme rarity of some bleeding disorders makes universal screening unreasonable 1
• If bruising is limited to typical locations (shins, knees) in an active 6-year-old with no bleeding symptoms and no concerning history, observation may be appropriate 1

Referral Indications

Refer to pediatric hematology when: 1, 2

• Initial laboratory evaluation indicates a bleeding disorder
• High clinical suspicion remains despite normal laboratory workup
• Specialized testing is needed (platelet function studies, VWD multimer analysis, Factor XIII assay)
• Complex cases require expert interpretation

Common Pitfalls to Avoid

Do not assume normal platelet count excludes all platelet disorders - qualitative platelet defects require specialized testing 4, 2

Do not overlook medication effects - certain drugs affect both bleeding tendency and test interpretation 1, 2

Do not miss vitamin K deficiency - particularly important if vitamin K was not administered at birth or if there are predisposing medical conditions 1

An abnormal coagulation test does not exclude child abuse - the two conditions may coexist, or the abnormality may be a consequence of maltreatment 6