While it’s not uncommon for older tykes to take a tumble and experience an occasional bruise, babies are an entirely different story. “When children aren’t old enough to be mobile, seeing bruising becomes a serious issue,” explains Dr. Shannon Thompson, pediatrician at Riley Hospital for Children at Indiana University Health. “We like to say if they don’t cruise, they don’t bruise.”
For older kids, bruises are accessories often earned from adventures or accidents. “Bruises result when there is trauma to blood vessels underneath the skin, which can occur from direct trauma like hitting your shin against a hard surface, or from indirect trauma, like strangulation,” explains Dr. Thompson. At the injury site, black and blue blotches inevitably bubble up to the surface on soft tissue spots where bone can be found underneath, like a mobile child’s forehead, elbows, knees, palms of hands, or shins. “These are the typical areas where bruises occur from accidents in mobile active children,” she says.
Bruises are more suspicious in locations in which there are no bony prominences underneath. “That means marks around their ears, neck, around eyes, abdomen, buttocks, and soft area of the cheeks. Especially in pre-mobile children, injuries to the frenulum are also suspicious. These are thin pieces of tissue that connect the lips to the gums. We have three of them-- one under the tongue and under the upper and lower lip.”
Any bruises that have a pattern to them are also concerning, she says, as well as subconjunctival hemorrhages, otherwise known as bleeding in the white of the eye. “When babies are first born, it’s common to see a rim of blood in the white of their eyes, which is not unusual because being born can be physically traumatic, but this usually disappears after a week,” says Dr. Thompson. “But encountering subconjunctival hemorrhages in children in other situations can be very concerning—it, like bruising and intraoral injury, is another example of a sentinel injury, or warning sign for potential abuse.”
Abusive head trauma (AHT), or previously called "shaken baby syndrome" can be common in babies—it occurs when a child is forcefully shaken and/or experiences an impact to the head in a manner that is so violent that it ruptures blood vessels within the skull, causing intracranial hemorrhage. Patients who experience AHT often develop severe brain damage with accompanying neurological disorders. Discoveries indicative of AHT may be subtle initially, such as mild lethargy, vomiting without diarrhea, periods of unresponsiveness, poor feeding, as well as any of those warning signs, she says.
When we talk about bruising in young kids, you should also remember the TEN-4 rule, suggests Dr. Thompson. The acronym highlights hallmark areas of potential abuse. “TEN stands for torso, ears and neck, the body regions that, if bruised, are found to be predictive of abuse in children less than 4 years old,” she says. “These areas of the anatomy are not easily bruised in the everyday activities of an active toddler. The 4 additionally refers to babies less than 4 months who are not yet mobile—any bruising anywhere in this age group is concerning.”
Sadly, research reveals that children under the age of 4 years old are the most at risk for maltreatment, with nearly 700,000 children abused in the United States each year.
So, what should a parent do if they have suspicions? “If a parent has any concerns (especially if the bruises don’t match up with the story that’s been shared or your baby is pre-mobile), confront the issue head on, take the child to the hospital or their regular physician for an exam and report it to the proper authorities immediately,” says Dr. Thompson.
Not a parent but witness inappropriate actions or suspect foul play? “If you see something, always say something,” she says. “In these cases, adults need to be strong advocates for little children.”
-- By Sarah Burns