Evaluation for non-accidental trauma (NAT) and bleeding disorders in infants referred to pediatric hematology

Abstract Introduction: The most common presentation for both pediatric non-accidental trauma (NAT) and bleeding disorders is bruising. In non-mobile infants with bruising, NAT evaluation is recommended. We aimed to assess complete evaluation for NAT in patients 9 months of age presenting with bruising and/or bleeding to our pediatric hematology clinic, and frequency of diagnosis of NAT. Methods: A single center retrospective chart review was performed on children 9 months at time of evaluation referred to pediatric hematology from 1/1/2016 to 12/31/2025. Patients were eligible if their visit included ICD-10 diagnosis codes for bleeding and/or bruising, ICD-10 codes for bleeding disorders, ICD-10 codes for non-accidental trauma, or visit reason listed as bleeding and/or bruising. Patients were excluded if asymptomatic but seen due to family history, for follow-up from the neonatal intensive care unit (NICU) or newborn nursery, or if they were presenting for another clinical reason (thrombosis, GI bleeding only). Demographics, symptoms, family history of bleeding disorders, bleeding disorder and/or NAT evaluation performed, and diagnoses of bleeding disorders and/or NAT were collected. NAT evaluation was deemed complete if the following were obtained: head imaging (computed tomography and/or magnetic resonance imaging), skeletal survey, aspartate aminotransferase level (AST), and alanine aminotransferase level (ALT). Results: 100 patients were identified, with 26 included. Most were excluded due to being asymptomatic with a known family history or presenting for follow-up from a newborn nursery or NICU stay. 11 patients (42.3%) were diagnosed with NAT, and 7 patients (26.9%) were diagnosed with a bleeding disorder. Of those, only one patient was diagnosed with both a bleeding disorder and NAT. 16 patients (61.5%) received a complete evaluation for NAT and 5 patients (19.2%) underwent partial evaluation (e.g. imaging only). 5 patients (19.2%) received no NAT evaluation. Of those with no evaluation, 3 presented with petechiae only, 1 presented with a family history of hemophilia B and bruising after a witnessed fall, and 1 presented as a referral from an outside institution without complete records of prior evaluation. 10 (38.5%) patients had no NAT evaluation prior to their hematology clinic appointment, with the other 16 (61.5%) having previously received imaging and/or laboratory evaluation in the emergency department (ED), inpatient admission, or our institution's child abuse pediatrics clinic. Of the 11 patients diagnosed with NAT, 2 received no evaluation before their hematology appointment. One was a 2-month-old presenting with bruising starting at 4 weeks of age. On examination, the infant had right cheek and lower leg bruising. Family provided photographs demonstrating past bruising and petechiae along bilateral legs, forearms, and chin including horizontal linear bruising. The patient was redirected to the ED where complete workup was done; diagnosis of NAT was made based on patterned bruising in a non-mobile infant. A bleeding disorder was not diagnosed. The second patient presented to hematology clinic at 7 months of age for excessive bruising; primary workup consisted of normal PT/INR and von Willebrand disorder testing. PTT was prolonged (53.4 sec), corrected with a mixing study, but factors 8, 9, and 11 were normal. No bruising was documented on physical exam. The infant returned the following month without change in reported symptoms. A right lower extremity bruise was documented on physical exam. Testing was diagnostic for a mild platelet function disorder. Skeletal survey was obtained after this visit, which demonstrated healing left posterior sixth, seventh, and eighth rib fractures consistent with NAT. Remainder of evaluation with CT head and laboratory evaluation was normal. In all other cases of NAT, diagnosis was made by the ED, inpatient general pediatrics team, or in child abuse pediatrics clinic outside of hematology evaluation. Conclusions: Infants with symptomatic bruising and/or bleeding symptoms are infrequently seen in the hematology clinic. However, bleeding disorders and NAT are present in this population. Evaluation for these conditions is of critical importance as missed diagnosis of either could be catastrophic. Further evaluation in other settings, such as the primary care office or ED, is warranted.