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Bleeding in a child can be a diagnostic dilemma, because the causes range from benign to serious. Children with mild bleeding disorders may not experience an episode of bleeding until faced with a hemostatic challenge, such as an interventional procedure or trauma. On the other hand, children without an underlying bleeding disorder commonly present with complaints of bruising and bleeding such as epistaxis or menorrhagia. Red flags for a potential bleeding disorder include bleeding or bruising out of proportion to the injury, prolonged and/or recurrent bleeding (particularly with unknown cause or after a small injury or procedure), spontaneous bruising or bleeding, uncommon sites of bleeding (joints, GI) or bruising (proximal extremities, trunk), and a family history of a bleeding disorder. Consider nonaccidental trauma in the child with unusual bruising patterns (see Chapter 150, “Child Abuse and Neglect”). Figure 144-1 provides a basic approach for the initial ED assessment of a child with bleeding. The most common bleeding disorders presenting in childhood are discussed below.

FIGURE 144-1.

Algorithm for the approach to a child with undiagnosed bleeding. aPTT = activated partial thromboplastin time; PT = prothrombin time; vWD = von Willebrand’s disease.


A detailed discussion of hemophilia is provided in Chapter 235, “Hemophilias and von Willebrand’s Disease.” Table 144-1 provides a summary of those bleeding disorders, which are also reviewed below.

TABLE 144-1Coagulation Disorders

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