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We thank Drs Chakraborty and Morris for their interest in our study.
We acknowledge that the children without bleeding disorders were only
recruited in south Wales whilst those with bleeding disorders were
recruited in centres around the UK. Given the data available we are not
able to comment on whether children are likely to bruise differently
dependent on where they live.
We agree that...
We agree that it would have been useful to validate training of
carers of children with bleeding disorders, although the 100% concordance
between carer and trainer in the children without bleeding disorders is a
result that suggests that the data are valid.
Children with bleeding disorders are inevitably more likely to be
male than female. Previous work by ourselves and others has shown that
there is no detectable difference between bruising pattern in male and
females in this age group (1-4). Importantly, this is the case for the
control children in this study (5).
Peter W Collins, Melinda Hamilton, Frank D Dunstan, Sabine Maguire,
Diane E Nuttall, Ri Liesner, Angela E Thomas, John Hanley, Elizabeth
Chalmers, Victor Blanchette and Alison M Kemp
1. R F Carpenter. The prevalence and distribution of bruising in
babies Arch Dis Child 1999;80:363-366
2. Labb? J, Caouette G.Recent skin injuries in normal children.
Pediatrics. 2001 108:271-6.
3. Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers:
those who don't cruise rarely bruise. Puget Sound Pediatric Research
Network. Arch Pediatr Adolesc Med. 1999 153:399-403.
4. S Maguire, M K Mann, J Sibert, A Kemp, Are there patterns of
bruising in childhood which are diagnostic or suggestive of abuse? A
Arch Dis Child 2005;90:182-186
5. Kemp AH, Dunstan F, Nuttall D, Hamilton M, Collins P, Maguire S.
Patterns of bruising in pre-school children - a longitudinal study.
Archives of Disease in Childhood 2015;100:426-431.
We would like to congratulate the authors of this excellent
observational study. For paediatricians, and for medico-legal
professionals, data from this study would be invaluable in their practice.
While the authors have discussed most of the limitations of their
study, we would like to point out a few more which have come to our
1) Controls were recruited only from South Wal...
1) Controls were recruited only from South Wales, while cases were
multi-centre. This could give rise to inter-centre variability, which
needs to be looked at and accounted for.
2) Validation of training of carers was done on children with non-
bleeding disorders only. This should have been attempted on children with
bleeding disorders as well, as their reporting form the basis of this
3) While sexes were balanced in children with non-bleeding disorders,
children with bleeding disorders were dominated by males. Differences in
type or duration of activity could be a confounding factor in comparing
these groups. While this is difficult to correct without introducing
further bias, this needs to be considered as a factor for adjustment in
models, if possible.
Ian Paul Morris