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Bruising

Symptoms of Common Childhood Illnesses

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Updated June 05, 2014

Mother checking daughters injured elbow
J.A. Bracchi/Stone/Gett Images

Kids seem to bruise easily, whether it is a toddler taking his first steps to a preschooler who is rough housing all of the time.

Fortunately, although parents often worry that this bruising is a sign of a serious illness, it is often normal.

Signs of Normal Bruising

Of course, it is important to separate the kids who have a serious bleeding disorder, like hemophilia, from those who have normal easy bruising when they begin to cruise and walk around.

Normal bruising is usually found on a child's shins, because this they often bump their lower legs against things as they walk or run; these bruises are usually flat and smaller than the size of a quarter. Younger children often get bruises on their foreheads from bumping their heads and falling, too.

Frequent nosebleeds are the other thing that often prompts parents to think that their child has a bleeding disorder, but without some of the signs listed below, like normal bruising, nosebleeds are often normal in young children.

Signs of abnormal bleeding and bruising can include:

  • Large bruises that are raised and seem out of proportion for the injury that caused it, for example a very large bruise for a small bump against a table.

  • Unexplained bruises that occur without any history of a fall or injury.

  • Bruises that seem to last too long (more than a few weeks).

  • A family history of bleeding or easy bruising in the family. Many bleeding disorders, like von Willebrand disease and hemophilia are genetic, so a family history of bleeding and easy bruising would raise suspicions that a child could have the same bleeding problem.

  • A bloody nose (epistaxis) that lasts longer than 15 minutes, after proper treatment with direct pressure.

  • Excessive bleeding after dental procedures or surgery.

  • Any bruises in infants who have not started to crawl, cruise, or walk yet.

  • Bruises in unusual places, like a child's chest, back, hands, ear, face, or buttocks.

  • In teens, menstrual periods that last longer than seven days or that are heavy for more than three days.

Tests for Bruising

Most kids with normal bruising won't need any testing. When bruises are large, or are associated with other signs that might suggest a bleeding disorder, then testing might be needed.

Common tests for kids with bruising can include:

  • complete blood count (CBC) - in addition to the number or red blood cells and white blood cells, a complete blood count will show the amount of platelets a child has, which are important in helping blood to clot.
  • peripheral blood smear - a test in which a lab work manually looks at a child's blood under a microscope to check the quantity and quality of a child's blood cells
  • PT and PTT, or prothrombin time and partial thromboplastin time, are used to test how well blood is clotting and if a child could have a bleeding disorder, such as hemophilia.
  • factor VIII, factor IX, and factor XI - these are specific factors that are missing or deficient in different types of hemophilia.
  • fibrinogen - a protein that helps blood to clot.
  • bleeding time - a test to see how long it takes a child to stop bleeding.
  • PFA-100 platelet function screen - a newer test to see how well platelets are working and which is replacing the less reliable bleeding time test in many labs.
  • ristocetin cofactor activity - a test for von Willebrand disease.
  • von Willebrand antigen - another test for von Willebrand disease which measures how much von Willebrand factor a child has.

Bruising

As your toddler learns to walk, he will likely fall and bump into things a lot, getting quite a few bruises along the way.

Other causes of bruising can include:

  • falls and injury - not surprisingly, severe injuries can often lead to extensive bruising. Instead of simply looking at the size of a bruise, it is more important to think about whether or not the bruise is proportionate to the injury. So you would expect a much larger bruise if your child falls out of a tree than if he simply trips and falls on the grass.
  • child abuse - bruising on infants, unexplained bruises, bruises in unusual places (upper arms, hands, ears, neck, buttocks, etc.), and bruises in specific shapes, like a large bite mark, cigarette burn, or belt mark, can be signs of child abuse.
  • von Willebrand disease - a common, although often mild, genetic bleeding disorder that can cause easy bruising, frequent nosebleeds, heavy menstrual bleeding, and bleeding after surgery.
  • thrombocytopenia - a low platelet count, which can be caused when platelets aren't being produced, they are being destroyed, or when they are being sequestered in an enlarged spleen.
  • Idiopathic thrombocytopenic purpura (ITP) - an autoimmune disorder that leads to the break down of platelets in the blood by antibodies and a low platelet count. It is usually thought to be triggered by a recent viral infection, after which young children develop large bruises and petechiae (small purple dots under the skin).
  • Henoch-Schonlein purpura (HSP) - an immune disorder that can cause abdominal pain, bloody stools, joint pain, and a distinctive rash on a child's arms, legs, and buttocks that looks like bruises (purpura)
  • hemophilia A (factor VIII deficiency) or hemophilia B (factor IX deficiency) - hemophilia is usually diagnosed before a child is two to five years old, when kids may have easy bruising, bleeding in joints, or excessive bleeding after a cut or dental procedure.
  • leukemia - in addition to easy bruising, bleeding, and a low platelet count, children with leukemia will usually have other signs and symptoms, such as a low red cell count, fever, weight loss, etc.
  • vitamin K deficiency
  • a side effect of certain medications, including aspirin, seizure medicines, and some antibiotics.

Although bruising is often normal in active children, if your child has excessive bruising or easy bruising and other signs of a bleeding disorder, then be sure to see your pediatrician right away.

Sources:

Kliegman: Nelson Textbook of Pediatrics, 18th ed.

Approach to the bleeding child. Allen GA - Pediatr Clin North Am - 01-DEC-2002; 49(6): 1239-56

Bruising and Physical Child Abuse. Kaczor K - CPEM - September 2006; 7(3); 153-160

Hoffman: Hematology: Basic Principles and Practice, 4th ed.

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