Because bruising is a common manifestation of maltreatment,179 careful consideration of the presence of a coagulopathy is warranted as a component of a comprehensive evaluation in children with bruising. The presence of a coagulopathy does not always exclude abuse as the cause of bruises or bleeding, nor does the presence of either accidental or abusive trauma exclude the likelihood of a coagulopathy.180 There are clinical situations in which the evaluation of a bleeding diathesis may not be necessary, such as when the abusive event that led to the bruising is independently witnessed or the child provides a clear history of the event, or when the bruises are in the configuration of an object, such as a belt. (See Figure 3.) If there is a clinical suspicion of bleeding diathesis, such as petechiae along pressure sites (eg, clothing line or from a tourniquet), then the initial screening panel should evaluate for the more common coagulation disorders, such as idiopathic thrombocytopenic purpura, factor deficiencies (except factor XIII deficiency), and Von Willebrand disease, and should include a complete blood cell count, prothrombin time, partial thromboplastin time, and Von Willebrand factor antigen testing.180 Even in children with bleeding diatheses, bruises on the ears, neck, cheeks, and genitalia are rare, and an evaluation for child abuse should be performed in these situations.181
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