FAQs derived from enquiries to the Systematic Review Group
Does the likelihood of non-abusive bruising increase with the age of the child?
Yes. Non-abusive bruising is very rare in children less than 6 months of age and increases with the increasing age of the child. 60% of children between two and four years have some bruising, as many as 80% of children aged between five and nine years, and 53% of older children.
Is age the only factor that affects the likelihood of non-abusive bruising?
No. It is far more important to know whether the child is cruising or walking, since this has a direct bearing on the amount of non-abusive bruising the child may have. Levels of non-abusive bruising increase dramatically once a child becomes mobile. This is vitally important when assessing children with developmental delay: clearly a non-mobile two year old should not have the same level of bruising as a child of the same age who is walking.
How much do levels of non-abusive bruising rise once a child is mobile?
When a child is walking with support, 9.2% have some bruising with no child having more than five bruises. When a child under two years old is walking independently more than half of children have bruises, with no child having more than 11 bruises.
What other factors should be taken into account?
Non-abusive bruising tends to increase in summer for all ages, and non-abusive bruising may increase with increasing family size.
Do children who are not independently mobile have non-abusive bruises at all?
Yes, but this is very rare. Bruising in infants aged less than six months old is very uncommon; in very young infants it can be due to birth trauma. Bruising in pre-cruisers (young children not independently mobile) is also rare: only 2.9% having bruising, with no child having more than three bruises.
Are there parts of the body that rarely bruise non-abusively at any age?
Yes. It is extremely rare to see bruises on the hands of children less than two years old, the buttocks of children less than nine years old, and the face and neck at any age.
How rare is ‘extremely rare’?
Less than 1.5% of children under four years of age had bruising to the hand. Less than 1% of children under five years of age had bruising to the buttocks. Less than 1% of children aged less than nine years had bruising to the neck or ear.
Which areas most commonly bruise non-abusively?
Almost all non-abusive bruises occur over bony prominences, the front of the body, and the lower leg, particularly over shins.
Is there a difference in levels of non-abusive bruising depending on the social or ethnic background of the child?
We have found no significant differences in the published literature. Two studies did find bruising to be relatively more common in white children.
Do boys get more bruises than girls in everyday activities?
No. There were no significant differences in levels of non-abusive bruising in boys and girls.
Bruising in abused children
Do all abused children have bruising?
Bruising is the commonest manifestation of child abuse. It is evident in up to 98% of abused infants under nine months of age. However, even in fatally abused infants, bruising may not always be present. The absence of bruising cannot exclude serious injury.
Which areas are most commonly bruised in abuse?
Of the fatally abused children under five years of age, the commonest site of bruising was the face. 78% of abused children aged less than four years had facial bruising, in comparison to non-abused children of this age group where 2% had facial bruising. In abused children, bruising is also much more common on the ear, head and neck, chest, abdomen, back and buttocks. Bruising to the hand occurs in up to one third of abused children.
Are there patterns of bruising that indicate abuse?
A recognised feature in abused children is clustering of bruises. These clusters of bruises are often defensive injuries: on the upper arm, outside of thigh.
Are there patterns that indicate particular causes of physical abuse?
Yes. Linear or tramline bruising can be caused due to being struck with a rod like instrument. Weapons such as an electrical cord, a studded belt or a dog collar can leave an imprint or negative image. Areas of bruising interspersed with small abrasions is consistent with being hit with a rope. There may be bands of bruises around wrists or ankles due to being tied up. Vertical bruising to the buttocks may occur, even if the child has been hit horizontally. All bruising showing an imprint of an object should have a clear explanation.
Are boys more likely than girls to display bruising due to abuse?
No. The only significant difference between the genders was that girls were more likely to be struck by the open hand than boys.