Children with signs of abuse: when is it not child abuse?

Child abuse is a problem that is frequently underdiagnosed. Recognition that underdiagnosis of abuse exists has produced a high zeal for identifying cases of child abuse, which has inevitably produced cases of overdiagnosis. Overdiagnosis of child abuse is as catastrophic as underdiagnosis. In this case, a family member is often accused of injuring or killing a child at a time when the loss is felt most deeply. This review focuses on 1 specific presentation of child abuse--the child with bruises and bleeding. Many children and adults have coagulation or vascular disorders that predispose them to bruise or bleed excessively with minor trauma. It is very easy for a health care worker to presume that bruising and bleeding is associated with trauma, because the coagulopathies that may explain the findings are often poorly understood. The clinical cases reviewed in this article show the need for an extremely thorough analysis for an underlying bleeding disorder in the bruised or bleeding child being evaluated as a possible victim of child abuse.