Child abuse is a common cause of pediatric morbidity and mortality. In 2015, over 650,000 children were found to be victims of maltreatment and over 1,500 child deaths occurred due to child abuse or neglect in the United States.¹ Children under 1 year of age are at the highest risk of abuse with potential for lifelong sequelae. Emergency department providers are in a unique position to recognize child abuse and take appropriate steps to reduce further injury to children. An understanding of the motor development of young children can aid physicians in the identification of clinical red flags in the history.

Case

Laura is a 6 month old who presents to the ED for “fussiness”. On exam, she is difficult to console and you notice symmetrical bruises on her thighs. When you ask her parents, they state that she was “cruising” with the support of a table and hit her legs on the table legs.

Bruising is often the only external sign of abuse. Accidental bruising is very uncommon in infants who are not mobile. “Cruising” is when children can walk holding onto an parent’s hand or a piece of furniture. This typically begins around 10 months of age. Bruises are very rare in children who are not yet cruising.

For children who do walk or cruise, bruising typically occurs over the shins, knees, upper legs, and forehead.² Bruising on the face, buttocks, or abdomen is uncommon and should raise suspicion for abuse. Additionally, symmetric or patterned bruising is rare and should prompt further questions. In addition to abuse, providers should consider the possibility of dermatologic, hematologic, and oncologic conditions.

Red Flags for Bruising

• Children who are not mobile should not have ANY unexplained bruises.
• Symmetrical bruising
• Torso, ear, or neck bruising in any child
• Patterned bruising, especially hand prints
• Soft tissue bruising: buttocks, abdomen
• Bruises in different stages of healing
  1.

  Christian C, Committee on. The evaluation of suspected child physical abuse. Pediatrics. 2015;135(5):e1337-54. [PubMed]

  2.

  Feldman K. The bruised premobile infant: should you evaluate further? Pediatr Emerg Care. 2009;25(1):37-39. [PubMed]

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