Bruising or bleeding

Disclaimer

These guidelines have been produced to guide clinical decision making for general practitioners (GPs). They are not strict protocols. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

If acute or major bleeding, give first aid as appropriate and refer to Emergency Department

 

Introduction

Causes of bleeding and bruising in children are numerous and include:

  • disorders of coagulation
  • disorders of platelets
  • malignancies
  • connective tissue disorders
  • some nutritional deficiencies
  • non accidental injury.

Initial clinical history and physical examination should be comprehensive and include detailed assessment of bleeding symptoms, family history and medications. If after this a bleeding disorder is suspected, the investigations listed below under Pre-Referral Investigations should be performed as first line.

A number of different bleeding disorders are known to occur in childhood (examples listed in the table below). Detailed discussion of each is beyond the scope of this guideline but they may loosely be considered in two symptom cluster groups.

*Please note there may be crossover between symptom groups.

Disorders associated with mucosal bleeding (eg epistaxis, gingival bleeding, menorrhagia)   Disorders associated with deep tissue bleeding (eg haemarthrosis, haematomas)
 ITP

Clotting factor deficiencies
Most common:

  • Factor VIII (haemophilia A)
  • Factor IX (haemophilia B)
  • Factor XI (haemophilia C)

Less common:

  • Factor VII
  • Factor XIII
  • Factor II
  • Factor V
 Types 1 and 2 von Willebrand disease  Type 3 von Willebrand disease
 Platelet function defects  
 Congenital macrothrombocytopenias  
 Afibrinogenaemia  

Pre-referral investigations

Please note the following MUST be included with all referrals for investigation of bleeding/bruising:

  • Full Blood Picture and film
  • LFT and UEC
  • Coagulation profile (INR, APTT, fibrinogen)
    • If coagulation profile is abnormal, further specific factor assays may be indicated and discussion with on-call Clinical Haematologist is recommended
  • Two separate sets of von Willebrand screening bloods (VWF Antigen, Ristocetin Cofactor, Collagen Binding and Factor VIII-C)

Platelet function analysis (PFA-100) or platelet aggregometry should not be requested without prior consultation with the on-call Clinical Haematologist.

Pre-referral management

  • If chronic bleeding history, collate above pre-referral information and refer to Haematology Outpatient Clinic
  • Haematologist on call available to discuss any cases with complex features or unusual concerns 

When to refer

Patients with bleeding symptoms should have the above investigations performed. If there are any abnormalities, they should then be referred to Haematology Clinic.

If there are no diagnostic abnormalities but a strong bleeding phenotype, the case should be discussed with the Haematologist on call to consider whether further investigations and/or clinic review are appropriate.

How to refer

  • Routine non-urgent referrals from a GP or a Consultant are made via the Central Referral Service
  • Routine non-urgent referrals from from a nurse practitioner, non-medical referrers or private hospitals are made via the PCH Referral Office.
  • Urgent referrals (less than seven days) are made via the PCH Referral Office. Please call Perth Children’s Hospital Switch on 6456 2222 to discuss referral with the relevant speciality registrar. 

Essential information to include in your referral

  • Bleeding history: onset, anatomical location, frequency, typical duration of a bleeding episode
  • All relevant investigation results (see above under pre-referral investigations)
  • Relevant family history. 

Useful resources


Reviewer/Team: Department of Oncology and Haematology Last reviewed: Nov 2021


Review date: Nov 2022
Endorsed by:

Dr Tina Carter, Head of Oncology and Haematology Date:  Nov 2021


This document can be made available in alternative formats on request for a person with a disability.