Bleeding child: diagnostic approach

Overview & Definition

A child bleeds abnormally when the bleeding is out of proportion to injury, recurs without obvious trauma, sits at an unusual site, or follows a recognisable inherited pattern. The diagnostic task is not to list every cause at once, but to move through three ordered questions. Is the bleeding actually abnormal, or is it normal childhood bruising? Does the pattern point to a platelet problem or a clotting-factor problem? And which specific disorder is responsible? Answering these in sequence turns a scattergun panel of tests into a focused, safe workup. [1]

The first question is the hardest and the most often skipped. Normal children bruise their shins, have occasional nosebleeds, and cut themselves. Abnormal bleeding is defined by its site, severity, duration, and disproportion to injury, and it is best quantified with a validated bleeding assessment tool rather than a clinician's impression. The second question is settled by the pattern of bleeding and a small set of first-line tests. A child with petechiae, nosebleeds, and heavy periods has a primary-hemostasis (platelet-type) problem; a boy with a swollen knee and a deep muscle haematoma has a secondary-hemostasis (coagulation-type) problem. [1]

The third question is resolved by targeted confirmatory assays guided by the screening tests. A prolonged activated partial thromboplastin time with deep bleeding demands factor VIII and IX assays, while a normal screen with convincing mucocutaneous bleeding demands Von Willebrand disease testing and a platelet function workup. Holding these three questions in order is what separates a confident diagnostician from one who orders everything and waits. [2]

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1. [1]van Ommen CH, Peters M The bleeding child. Part I: primary hemostatic disorders. Eur J Pediatr, 2012.PMID 21800040
2. [2]van Herrewegen F, Meijers JC, Peters M, et al Clinical practice: the bleeding child. Part II: disorders of secondary hemostasis and fibrinolysis. Eur J Pediatr, 2012.PMID 21922352
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9. [9]Andrew M, Vegh P, Johnston M, et al Maturation of the hemostatic system during childhood. Blood, 1992.PMID 1391957
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