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Case 130

Veena Ramaiah


A 6-month-old presents to the emergency department for coughing and congestion. The child is happy, smiling, playful, and in no distress, with mild URI symptoms but otherwise appears well. On full skin exam, red marks are found as shown. There is mild tenderness over the red marks but no pain or marks anywhere else on the body. When asked, the mom reports “blowing kisses” on the child’s back. The resident is very concerned as these bruises do not blanch and are not fading.

What factors trigger the most concern in this child with bruising?


The age and developmental level of this child is the key to the concern. Unexplained bruising in a non-ambulatory infant is very concerning and should precipitate further workup.

Trauma labs, skeletal survey, and head CT are done. Upon return from radiology, her labs reveal elevated liver enzymes. Abdominal CT is performed and the child is found to have a moderate-sized liver laceration. Mom has no explanation for this.

In light of unexplained bruising and unexplained liver laceration—two significant indicators of trauma—child welfare and police are called and the child is placed in a safe environment.

Bruising in infants is rare, especially in non- mobile infants. In 1999, Sugar et al. published a study looking at bruising in healthy children from 0 to 36 months presenting for well-child visits. Of 973 children, 203 (20.9%) had bruises. They divided the children into three groups: pre-cruisers, cruisers, and walkers. Age was associated with bruising as 2.2% of pre-cruisers, 17.8% of cruisers, and 51.9% of walkers had bruises. The pre-cruisers group had the largest number of patients. Based on this data, the authors created the phrase “Those who don’t cruise rarely bruise.”

Building on this, in 2010, Pierce et al. published a study proposing a clinical decision rule for predicting abusive trauma called the TEN-4 BCDR. This was a body region–based and age-based bruising clinical decision rule. This study compared children 0–48 months who were victims of abuse with controls who sustained known accidental trauma. TEN-4 represents bruising found on the thorax, ears, and neck in a child <4 years old or bruising found anywhere on the body of a child <4 months old. Their data showed that bruising in the TEN region or bruising in a young infant in the absence of a verified or corroborated accidental injury was highly sensitive (97%) and specific (84%).

Bruising in infants, especially pre-mobile ones, is extremely concerning. Infants are at highest risk of death by inflicted injury as they cannot escape from the perpetrator. Even a single bruise in an infant that is unexplained or inadequately explained should raise suspicion for abuse and trigger further workup or reporting.

Keywords: child abuse, dermatology


Pierce MC, Kaczor K, Aldridge S, O’Flynn J, Lorenz DJ. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics January 2010;125(1):67–74.

Sugar NF, Taylor JA, Feldman KW, Puget Sound Pediatric Research Network. Bruises in infants and toddlers: Those who don’t cruise rarely bruise. Arch Pediatr Adolesc Med 1999;153(4):399–403.

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