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When to Worry About Bruises
By Courtney D. Thornburg, MD and Dennis Clements, MD, PhD, MPH.

What is a bruise?

A bruise is a black-and-blue mark caused by bleeding into the skin from damaged blood vessels. Many children older than one year of age develop bruises associated with accidental injury and physical activity.

Most bruises are not a cause for concern and will go away on their own. However, bruising can be a sign of an inherited bleeding disorder, illness, or non-accidental trauma (child abuse).

Bruises may be abnormal if they occur spontaneously without explanation, if they are in other places than the lower legs (“unexplained” bruises on the shins are usually normal because children often bump this area and then forget that they bumped it), if they are larger than a quarter in size, and if they are lumpy rather than flat.

Bruises may also be abnormal if they are larger than expected for the degree of injury.

How can I take care of my child with normal bruising?

Apply ice (or a bag of frozen vegetables), wrapped in a thin towel, to the bruised area for 20 to 30 minutes. No other treatment should be necessary.

Give acetaminophen for pain. Don't use aspirin or ibuprofen because it may prolong the bleeding. After 48 hours apply a warm washcloth three times a day for 10 minutes each time to help the skin reabsorb the blood.

Bruises clear in about two weeks. They change colors during this time from black-and blue to green-and-yellow.

What causes abnormal bruising?

Abnormal bruising occurs if there is:

A low level of platelets. Platelets are tiny, sticky cells that join together to plug the hole in wounds. Platelets may be low if they are not made or if they are broken down too quickly.
A low level of clotting factor. Clotting factors are blood proteins that interact with the platelets to form a strong clot to cover the wound as it heals. Clotting factors may be low from birth or may be low due to infection, medication (blood thinner or long use of antibiotic), not enough vitamin K or liver problems.
Very weak skin
A major trauma

When is bruising a sign of a bleeding disorder?

Bleeding disorders may be caused by abnormalities in blood clotting factors or in platelets.

Bruising may be a sign of an inherited bleeding disorder especially if it is associated with a family history of easy bruising or bleeding, or with the following symptoms:

Pinpoint red spots called petechiae on the skin (often at areas of pressure such as the underwear line)
Frequent or prolonged nosebleeds
Excessive bleeding after surgery (such as circumcision)
Excessive bleeding after dental work
Excessive bleeding after injury
Heavy or prolonged menstrual periods. Menstrual periods may be abnormal if they last more than seven days, include passage of blood clots larger than one inch, or require changing saturated pads or tampons more than every two hours.

The evaluation for a bleeding tendency includes:

Family and personal history about bleeding symptoms
Physical examination
Laboratory evaluation

Types of bleeding disorders include:

Von Willebrand’s disease
Clotting factor deficiency (such as hemophilia)
Inherited disorders of low platelets
Acquired disorders of low platelets (immune thrombocytopenic purpura)
Inherited platelet dysfunction (“lazy platelets”)

When is bruising a sign of an underlying illness?

Bruising may be a sign of an underlying illness especially if it occurs suddenly and with other symptoms such as:
Unintended weight loss
Petechiae (pinpoint red spots on the skin)
Bone pain
Enlarged abdomen (due to swelling of spleen or liver)
Bone or facial abnormalities
Large red birthmarks (hemangiomas)

Illnesses associated with bruising include:

Severe infection
Bone marrow problems
Liver problems

When is bruising a sign of child abuse?

Bruising may be a sign of child abuse if there are unusually shaped bruises, bruises in unusual places, bruises in the shape of an object, or if there are other unexplained injuries.

What to do if you are worried about bruising?

Call your child’s primary care physician to talk about how your child is doing and decide how soon your child needs to be evaluated.

Depending on your child’s symptoms your child may be seen in the clinic or may need to go directly to the emergency room.

Your child’s physician will also decide if your child needs to see a doctor who specializes in blood disorders or blood clotting.

Call immediately if:

Your child develops new bruises and you don't know what caused them.
Your child has bruises around the eyes after a head injury.

On Other Web Sites

Visit these sites for more information:

-- Courtney D. Thornburg, MD , is a pediatric hematologist at Duke. Dennis Clements, MD, PhD, MPH, is the chief medical officer of Duke Children's Hospital. For more information, visit: www.DukeHealth.org

The information presented on this site is intended solely as a general educational aid, and is neither medical nor healthcare advice for any individual problem, nor a substitute for medical or other professional advice and services from a qualified healthcare provider familiar with your unique circumstances. Always seek the advice of your physician or other qualified healthcare professional regarding any medical condition and before starting any new treatment.

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