• Petechiae: flat, red or reddish purple, 1 to 3 mm, non-blanching
• Ecchymoses: larger than petechiae, due to local extravasation, non-pulsatile, sometimes palpable, color depends on age of lesion

• Coagulation factor abnormality: Hemophilia, von Willebrand disease
• Platelet defect: Bernard-Soulier syndrome, Glanzmann thrombosthenia, and storage pool defects
• Congenital alloimmune or isoimmune thrombocytopenia
• Neonatal extramedullary hematopoiesis
• Hereditary hemorrhagic telangiectasia

• Meningococcemia
• Viral infections (coxsackieviruses, echoviruses)
• Rocky Mountain spotted fever (RMSF)
• Syphilis
• Pertussis—secondary to severe cough
• Septic or fat emboli
• DIC—acquired factor deficiency

• Warfarin—acquired factor deficiency
• Corticosteroids—striae caused by increased capillary fragility
• Aspirin and ibuprofen—cause a qualitative platelet abnormality
• Sulfonamides
• Bismuth
• Chloramphenicol

• Normal activity
• Child abuse
• Valsalva, crying, forceful coughing
• Cupping or coin rubbing
• Tight garments

• Bone marrow replacement—leukemia, myelofibrosis

• Uremia
• Vitamin C deficiency
• Vitamin K deficiency—due to antibiotics, biliary atresia, malabsorption (acquired factor deficiency)

• Henoch-Schönlein purpura (HSP)
• Bone marrow failure—aplastic anemia (including Fanconi, PNH)
• Increased destruction—idiopathic thrombocytopenic purpura, Evan syndrome, lupus
• Nephrotic syndrome
• Collagen vascular disease
• Ehlers-Danlos syndrome
• Snake bite (copperhead)

• Ataxia telangiectasia
• Cherry angiomata
• Kaposi sarcoma

• The acute onset of diffuse subcutaneous bleeding with bruises of different ages may indicate severe thrombocytopenia. Generally, children will not bruise or develop petechiae spontaneously until the platelet count is under 20,000/mm². ITP, leukemia, aplastic anemia, etc., can cause this bleeding. A hematologist should be consulted, because of the risk of potentially life-threatening bleeding.
• Chronic history of recurrent bleeding, such as mucosal, deep muscle or joint bleeds, may indicate an inherited coagulation defect such as von Willebrand disease or hemophilia. The familial history may be positive, although von Willebrand disease often goes undiagnosed into adulthood if there has been no challenge such as surgery.

• Platelet count to assess level of thrombocytopenia
• PT/PTT: Prolongation of either one or both of these may aid in the diagnosis of von Willebrand disease, coagulation factor deficiencies, liver disease, and vitamin K deficiency.
• Bleeding time: Prolongation may indicate the presence of a platelet aggregation disorder or von Willebrand disease.

Question: At what age was the bruising first noticed?
Significance: Significant bruising in the neonatal period may indicate neonatal thrombocytopenia, congenital infections, and sepsis with DIC. Hemophilia more typically presents with bleeding in the neonatal period, such as with circumcision. Other inherited disorders coagulation, such as von Willebrand disease, may not be diagnosed until a child is older, as these tend to be mild in nature and may be uncovered with preoperative testing or post-operative bleeding complications. ITP may occur at any age.

Question: What is the pattern or distribution of the bruises?
Significance: The pattern of bruising, especially in a younger child, may indicate normal toddler activity, child abuse, or religious practices such as coining (common among Southeast Asians) in which warm or hot coins are rubbed on the skin to help in the healing process.

Question: What medications is the child taking?
Significance: Use of aspirin, ibuprofen, cough syrups with guaifenesin, and some antihistamines cause platelet dysfunction by inhibiting cyclooxygenase and, therefore, interfering with the release of platelet granules. Use of these drugs may also unmask an otherwise mild inherited bleeding disorder.

Question: Are there any signs or symptoms of systemic illness or infection?
Significance: Infections such as meningococcemia or viruses and collagen vascular diseases may present with ecchymosis or petechiae.

Question: Is there any familial history of a bleeding diathesis, easy bruisability, or heavy menstrual bleeding?
Significance: A positive familial history of inherited disorders of coagulation factors or platelet aggregation may aid in directing the work-up. A negative familial history does not rule out any of these disorders, however.

Question: Does the child appear well or systemically ill?
Significance: A well appearance is often found in those with ITP, though there is often a history of an antecedent viral illness. An ill appearance should raise concerns about malignancy, infection (especially meningococcemia), or other acquired coagulation factor deficiencies such as those seen with liver failure.

Question: What is the distribution of the bruises?
Significance: Bruising in unusual locations such as the back, genitalia, or thorax should raise suspicions of child abuse, especially if the lesions are in different stages of healing (see table How to Estimate the Age of Bruises) or suggest the pattern of a hand, belt, etc. Purpura confined mostly to the legs are typical of HSP. Most toddlers will have multiple ecchymoses in the pretibial regions that occur with normal activity. Petechiae entirely above the nipple line is consistent with valsalva maneuver, severe cough, and viral infections.

Question: Is the bleeding confined to the skin surface or are deeper tissues such as muscles and joints involved?
Significance: Hemophilia generally causes deeper bleeding, although bruising is common in the infant and younger child.

Question: Are the mucous membranes involved?
Significance: Severe thrombocytopenia, streptococcal pharyngitis, varicella, measles, and other viral infections can cause this finding. Von Willebrand disease can also present with gingival bleeding.

Question: Is there hepatosplenomegaly or lymphadenopathy?
Significance: Involvement of the reticuloendothelial system can be found with malignancies such as leukemia or with viral or bacterial infections.

Question: Are there other congenital abnormalities?
Significance: Syndromes such as Fanconi anemia and thrombocytopenia absent radii (TAR) may present with upper extremity limb malformations and bruising.

Test: CBC
Significance: Platelet count is the most important, however, abnormalities of WBC or Hgb may aid in the diagnosis bone marrow infiltration or failure.

Test: PT
Significance: Elevation may indicate warfarin ingestion or factor VII deficiency.

Test: aPTT
Significance: Prolongation is seen with hemophilia and may be seen in von Willebrand disease.

Test: Both PT and PTT
Significance: Both are prolonged in DIC, liver failure, and vitamin K deficiency.

Test: Bleeding time
Significance: Lengthened in platelet aggregation disorders and with drug effects.

Test: Fibrinogen
Significance: Decreased in liver failure, DIC

Test: Urinalysis
Significance: Hematuria and/or proteinuria may indicate HSP, nephrotic syndrome, or other vasculitis.

• Severe thrombocytopenia below 10–20,000/mm³ carries a higher risk of spontaneous internal bleeding including intracranial bleeding.
• Bleeding or bruising accompanied by evidence of leukemia or other malignancy.
• Evidence of sepsis (DIC) or meningococcemia.

Q: Is hemophilia always diagnosed in the newborn period?
A: No. A familial history may provide clues, but a significant number of patients represent a spontaneous mutation. Additionally, not all boys with hemophilia will bleed with circumcision and the diagnosis may not be made until the infants become more active.

Q: What is a common cause of bruising among girls?
A: Girls may first come to attention at menarche and be diagnosed at that time with von Willebrand disease. Rarely, girls whose fathers have hemophilia may be unfavorably “lyonized” and, therefore, have decreased factor levels consistent with mild hemophilia.

• ITP should be referred to a hematologist especially if the child is older, because there is a higher risk of chronic ITP or an underlying disorder such as lupus.
• Prolonged PT/PTT/BT often require referral to work-up an inherited or acquired coagulation defect.
• Any concern about a malignancy, liver failure or child abuse.

• The amount of bruising may or may not correlate with the amount of internal bleeding that has occurred. Hemophiliacs can significantly drop their hemoglobin during a thigh or psoas bleed without having much in the way of ecchymosis.
• A child presenting with ITP may have bruises and petechiae from head to toe without changing the hemoglobin much at all.

Manno CS. Difficult pediatric diagnoses: bleeding and bruising. Pediatr Clin North Am 1991;38(3):637–655.