Approach to the child with bleeding symptoms
- Donald L Yee, MD
Donald L Yee, MD
- Associate Professor of Pediatrics
- Baylor College of Medicine
Pediatricians will be confronted with an infant, child, or adolescent either with overt bruising or bleeding or with a history of increased bleeding sometime during their busy clinical practice. This topic review will discuss the approach to such patients, including selection of the most appropriate laboratory tests to arrive at a working diagnosis. An approach to the adult with bleeding symptoms and neonatal thrombocytopenia are discussed separately. (See "Approach to the adult patient with a bleeding diathesis" and "Causes of neonatal thrombocytopenia".)
Clinical evaluation of a patient with bleeding symptoms begins with taking a careful history, taking into account the child's age, sex, clinical presentation, past history, and family history.
Bleeding history — In assessing the patient's bleeding history, it is important to ask about prior bleeding episodes and to characterize the type of bleeding (table 1):
●Bleeding into the skin and mucous membranes is characteristic of disorders of platelets and blood vessels (purpuric disorders) and may be manifested as petechiae and/or ecchymoses.
●Bleeding into soft tissue, muscle, and joints suggests the presence of hemophilia or other disorders of coagulation proteins.
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- Bleeding history
- Clinical features
- Family history
- LABORATORY EVALUATION
- Initial testing
- - Platelet count and the peripheral smear
- - Prothrombin time (PT)
- - Activated partial thromboplastin time (aPTT)
- - Fibrinogen
- Second tier testing
- - Thrombin time and reptilase time
- - Tests for specific factor deficiencies and inhibitors
- - Antiphospholipid antibodies
- - Clot solubility in urea and factor XIII activity testing
- - Tests for fibrinolysis
- - Bleeding time and PFA-100
- DIAGNOSTIC APPROACH
- Abnormal initial testing
- - Pancytopenia
- - Thrombocytopenia
- - Normal PT and prolonged aPTT
- - Prolonged PT and normal aPTT
- - Prolonged PT and aPTT
- Well child
- Sick child
- Normal initial testing
- - Von Willebrand disease
- - Some cases of hemophilia
- - Factor XIII deficiency and other fibrinolytic disorders
- - Platelet function disorders
- - Vascular purpuras
- - Undetermined etiologies
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS