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Study Findings
Overall, 50% of the children were judged as having either "definite" inflicted injury or "substantial evidence of" inflicted injury. One third of the children had a single bruise, 52% had two to five bruises, and almost 14% had six or more bruises. The location of bruising was the face or head in 75% of the children; one third had a bruise on the trunk, and approximately one fourth had bruises on extremities.
At least one additional injury was uncovered by diagnostic testing in 73 children (50%). Head imaging by CT or MRI was completed for 91% of the children, and 27.4% had some type of new injury identified. Most common among these were skull fractures, subdural hematomas, and subarachnoid hemorrhages. Skeletal surveys were performed in 137 children (93.8%), and 23% showed a fracture. Among the 62 children with fractures, 58% had multiple fractures.
Hepatic aminotransferases were tested in 92 children (63%), but only 15% of these children proved to have elevated levels. The treating teams completed evaluations for bleeding disorders in 71% of the children, but no child had a bleeding disorder.
There was no relationship between the number of bruises and the frequency of any additional injuries uncovered by evaluation. Nor was the location of the bruise related to the frequency of additional injuries. The frequency of additional injuries was the same in infants with bruises on the head as those with bruising on an extremity.
The investigators concluded that infants younger than 6 months with bruising who also underwent subspecialty evaluation for abuse had a high chance of having an additional serious injury. They reiterate that bruising in infants younger than 6 months who are not mobile should serve as a "red flag" prompting further evaluation.
Viewpoint
Data published in the past year have emphasized the need to consider expanded testing for children aged ≤ 18 months with isolated skull fractures and the need to complete follow-up skeletal surveys after initial evaluations for abuse. These epidemiologic studies are very helpful in determining guideline recommendations for which patients should receive specific evaluations.
This was a referral population, and that affects the findings of the study in two ways. First, each child was evaluated by a child-abuse team, and I suspect that means that the children were much more likely to undergo comprehensive testing than the average infant seen in a nonpediatric emergency department or a pediatric emergency department without access to a child abuse specialist.
The other bias is that the study may not be representative of the findings that might be expected in all children younger than 6 months with isolated bruises. All of these children presented because of some concern about abuse, so we don't know how similar or dissimilar they are to the wider population of children aged less than 6 months with bruising. Nevertheless, these data should be applicable to most emergency department settings and should certainly get the attention of anyone evaluating a young infant with bruising.
Abstract
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