Normal bruising pattern

Normal bruising or bleeding due to accidental injury is commonly seen around the age of 1 when most children become mobile or 'cruising' (1)

• it is usually restricted to certain areas of the body
  • in crawling children bruises may be seen on the knees, shins and the forehead
  • in preschool and school age children, small bruises on bony prominences on the front of the body (2)
  • in young children (<6 years)
    • if the head is involved - occurs predominantly in a 'T' shape across the forehead, nose, upper lip and chin (3)
      
      
• is not associated with mucosal bleeding, petechiae, or purpura
  
  
• the family history is negative (1)

In non mobile infants usually before the age of 9 months, occurrence of significant bruising is abnormal and is beyond the spectrum of 'normal' bruising (2)

A child with bruises in the typical distribution but seems to be "over bruised" may have a mild coagulation defect (4).

Abnormal bruising

Patients who present with an "abnormal" pattern of bruising may have a haemostatic disorder or may have been subjected to non-accidental injury (NAI).

• physicians should remember that NAI and bleeding disorders are not mutually exclusive and any person with a haemostatic disorder may have experienced a non-accidental injury
• if the bruising or bleeding is abnormal in site and severity relative to the history, suspect NAI (2)

Reference:

• 1. Anderson JA, Thomas AE. Investigating easy bruising in a child. BMJ. 2010;341:c4565.
• 2. Khair K, Liesner R. Bruising and bleeding in infants and children-a practical approach. Br J Haematol. 2006;133(3):221-31.
• 3. Maguire S. Which injuries may indicate child abuse? Arch Dis Child Educ Pract Ed. 2010;95(6):170-7.
• 4. Valente MJ, Abramson N.Easy bruisability. South Med J. 2006;99(4):366-70.