Practice Rational Testing

Investigating easy bruising in a child

BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c4565 (Published 11 October 2010) Cite this as: BMJ 2010;341:c4565
  1. Julia A M Anderson, consultant haematologist12,
  2. Angela E Thomas, consultant paediatric haematologist23
  1. 1Department of Clinical and Laboratory Haematology, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK
  2. 2South East Scotland Comprehensive Care Haemophilia and Thrombosis Centre, Royal Infirmary of Edinburgh
  3. 3Department of Haematology, Royal Hospital for Sick Children, Edinburgh
  1. Correspondence to: J A M Anderson julia.anderson{at}luht.scot.nhs.uk

Differentiating “normal” from “abnormal” bruising in a child depends on careful history taking and appropriate investigations

Learning points

  • In a child, unusual bruising or bleeding out of proportion to the injury sustained should be investigated after careful history taking and examination, and an open view kept

  • Early discussion with a paediatric haematologist, or adult haematologist with expertise in haemostasis, is essential to ensure optimal investigation with as few venepunctures as possible

  • All children under investigation for easy bruising or a bleeding tendency should have a full blood count, blood film, and coagulation screen including a thrombin time, in addition to a Von Willebrand factor assay and assays of factors VIII and IX; this is to ensure that mild forms of haemophilia are excluded even if the activated partial thromboplastin time is normal

  • In 30% of cases of haemophilia, there is no family history: it arises secondary to new genetic mutations

An eight month old white boy is seen by his general practitioner with a sore throat and a temperature. The GP notes several easily visible bruises on the lateral aspect of his left temple, and on examining his chest notes bruises on his left upper arm and left lumbar region. On questioning, both parents independently state that there is no history of trauma or injury and that the bruises occurred spontaneously over the past two weeks. Both parents are anxious and upset. The GP is concerned about a child with a high fever and bruising, and after discussion with the on-call paediatric registrar the child is referred to the paediatric accident and emergency department.

What is the next investigation?

The investigations to be performed in a child with easy bruising depend on a carefully taken personal and family history to attempt to differentiate “normal” from “abnormal” bruising.1 2 3 A negative history of bleeding in a …

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