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The authors are to be congratulated for the systematic review “Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse?”.1 It is an extremely valuable piece of work, providing data for paediatricians working in the field of child protection.
Results show that non-abusive bruises are generally small, sustained over bony prominences, and found on the front of the body. Abusive bruises are away from bony prominences, and the commonest site is the head and neck (particularly face), followed by buttocks, trunk, and arms.
The paper highlights that children with significant motor delay would not be expected to have the same bruising pattern as their peers, but points out that most studies in the literature exclude children with neurodisability or diseases that predispose to bruising, to a varying degree.
Locally a small pilot study examining the bruising pattern in 14 children with a variety of disabilities aged 15 months to 4 years who attend two preschool special needs opportunity groups has shown interesting results. Thirteen of the 14 children (where there were no concerns about abuse) had bruises, the child with no bruises being the only child in the study who was unable to crawl. The other children were all cruising or walking, although one wore piedro boots, another had splints, and some had an unsteady gait. The average number of bruises was 5.7 (range 0–20) and size varied between 0.5 cm and 2.0 cm in diameter. Five children (35.7%) had bruising on their buttocks/bottom, four (28.6%) had bruising on their arms, and two (14.3%) had bruises on their face or neck—all areas usually associated with abusive bruising.
Bruising patterns in children with disabilities or special needs may be very different to bruising patterns in their peer group. Further research is needed.
Dr Finlay and Barton have undertaken a small case series, that amounts to the biggest series of observations in disabled children that we are aware of in the current published literature. Their findings further strengthen the hypothesis that bruising patterns in disabled children are very different to those in their age matched peer group. This reinforces the need for a large case-control study to confirm and delineate this hypothesis. Such a study should obey strict inclusion criteria and exclude any children where child abuse is suspected. It should take into consideration the proposed mechanisms of causality of the bruising and the characteristics of the participants’ disability and developmental parameters.
The observations emphasise that in clinical practice we should evaluate bruising pattern according to the developmental level of the child rather than their age.
Competing interests: none declared