Bruises that occur in nonmobile infants, those over soft tissue areas, and those that carry the imprint of the implement used or multiple bruises of uniform shape could be signs of physical abuse.
That is the key conclusion from the first-ever systematic attempt to answer the question “what patterns of bruising in childhood are diagnostic or suggestive of abuse?”
For the study, Sabine Maguire, M.B., and associates at Cardiff (Wales) University examined 23 studies on the topic that were published in the medical literature from 1951 to 2004 (Arch. Dis. Child. 2005;90:182-6).
They ranked the study by design and definition of abuse used and excluded review articles, expert opinion, single-case reports, and studies that failed to define abuse and addressed medical conditions that predispose children to bruising.
The investigators found that bruises in nonabused children tend to be 10-15 mm in size, sustained over bony prominences, and located on the front of the body, typically the result of a fall. The prevalence of bruising in babies who are not independently mobile is less than 1%. “Around 17% of infants who are crawling or cruising have bruises, whereas the majority of preschool and school-age children have accidental bruises,” they wrote.
They listed the following patterns of bruising that suggest physical abuse: bruising in children who are not independently mobile; bruising in babies; bruises that are seen away from bony prominences; bruises to the face, back, abdomen, arms, buttocks, ears, and hands; multiple bruises in clusters; multiple bruises of uniform shape; and bruises that carry the imprint of the implement used or a ligature.
“When interpreting the significance of any bruising, it is essential to evaluate the full clinical and social picture and note the developmental level of the child,” they said. “All bruising must be interpreted in the context of the explanation given.”
In a related study, the same investigators searched the medical literature to determine if it is possible to tell the age of a bruise in a child (Arch. Dis. Child. 2005;90:187-9). Dr. Maguire and associates identified 167 studies but only used three in their assessment. It was concluded that it is not currently possible to “accurately age a bruise from clinical assessment. Any clinician who offers a definitive estimate of the age of a bruise with the naked eye is doing so without adequate published evidence.”