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Downloaded from adc.bmj.com on June 3, 2010 - Published by group.bmj.com The significance of bruising in infants−−a forensic postmortem study A I Ingham, N E Langlois and R W Byard Arch Dis Child published online June 3, 2010 doi: 10.1136/adc.2009.177469 Updated information and services can be found at: http://adc.bmj.com/content/early/2010/06/02/adc.2009.177469.full.html These include: References This article cites 17 articles, 9 of which can be accessed free at: http://adc.bmj.com/content/early/2010/06/02/adc.2009.177469.full.html#ref-list-1 P<P Published online June 3, 2010 in advance of the print journal. Email alerting Receive free email alerts when new articles cite this article. Sign up in the service box at the top right corner of the online article. NotesAdvance online articles have been peer reviewed and accepted for publication but have notyet appeared in the paper journal (edited, typeset versions may be posted when availableprior to final publication). Advance online articles are citable and establish publicationpriority; they are indexed by PubMed from initial publication. Citations to Advance onlinearticles must include the digital object identifier (DOIs) and date of initial publication.To order reprints of this article go to:http://adc.bmj.com/cgi/reprintformTo subscribe to Archives of Disease in Childhood go to:http://adc.bmj.com/subscriptions
Downloaded from adc.bmj.com on June 3, 2010 - Published by group.bmj.com ADC Online First, published on June 3, 2010 as 10.1136/adc.2009.177469 Original article The signiﬁcance of bruising in infants—a forensic postmortem study A I Ingham,1 N E Langlois,1,2 R W Byard1,2 1Discipline of Pathology, ABSTRACT The University of Adelaide, Objective To determine the signiﬁcance of bruises in What is already known on this topic Adelaide, South Australia, Australia cases of infant death to ascertain if their presence was 2Forensic Science South associated with other injuries or homicide. Australia, Adelaide, South Design Retrospective cohort study. ▶ The likelihood of having a non-inﬂicted bruise Australia, Australia Setting Forensic Science South Australia, Adelaide, in a child who is not independently mobile has South Australia, Australia. been estimated to be <1%. Correspondence to Professor Roger W Byard, Patients 135 infants aged between 7 and 364 days ▶ Infants rarely mobilise before the age of 6 Discipline of Pathology, Level 3 autopsied over a 9-year period from June 1999 to May months, with crawling and cruising generally Medical School North Building, 2008. developing from 8 months onwards. The University of Adelaide, Outcome measures Coronial forensic autopsy Frome Road, Adelaide, SA 5005, Australia; reports. email@example.com Methods Examination of autopsy reports to determine how many infants had bruising and whether bruising What this study adds Accepted 6 January 2010 was associated with other injuries or lesions of concern. Cause and manner of death were also recorded. Results There were 83 boys and 52 girls. Twenty-one ▶ The presence of bruising in infants at autopsy infants (15.6%) had one or more bruises, and 114 had is signiﬁcantly associated with the presence no bruises. In the group of 21 infants with bruises, of other injuries. 17/21 had other injuries/lesions (81%), with 5/21 ▶ Homicide is signiﬁcantly more common in homicides (24%). Of the 114 non-bruised infants, only infants with bruising. 9 (8%) had other injuries/lesions with only 4 homicides (3.5%). The incidence of other injuries/lesions was signiﬁcantly higher in bruised infants compared with the non-bruised group (p<0.001), as was the MATERIALS AND METHODS occurrence of homicide (p=0.003). Bruises were found Forensic Science South Australia provides in 15.6% of infants presenting to coronial autopsy, autopsy services to the state coroner for the with a sensitivity of 65% and a speciﬁcity of 96% as state of South Australia, Australia, which cur- markers for other injuries (positive predictive value rently has a population of approximately 1.5 0.81; negative predictive value 0.92). At <6 months million people. Cases referred to the state coro- of age, this increased to a sensitivity of 71%, with a ner include all unusual or violent deaths or cases similar speciﬁcity of 95%. where a cause of death cannot be established. Conclusions Bruising is a signiﬁcant marker for During the period of the study, this included all other injuries in infants presenting to coronial autopsy. infant deaths where the cause of death could Homicide occurs more commonly in this group. not be established, where there was evidence of injury or where there were unusual or suspicious circumstances. Cases not included were infants Although inﬂ icted trauma in children often who were expected to die from established med- involves the skin and subcutaneous tissues, it is ical conditions. not uncommon to ﬁ nd bruises on the limbs asso- All cases of infants aged between 7 and 364 days ciated with normal non-inﬂ icted “wear and tear” who were autopsied at Forensic Science South activities. For example, toddlers who are learn- Australia were reviewed over a 9-year period from ing to mobilize often fall and bump into objects June 1999 to May 2008. The cases had all under- or the ﬂoor and have minor injuries. However, gone full investigations by the police and the cor- infants, especially those <6 months of age, are oner with performance of a full autopsy including somewhat different, as their inability to crawl formal neuropathology. Neonates in the ﬁ rst week or walk severely limits their independent mobil- of life were excluded from the study to remove ity1 and thus reduces their chances of bruising the possible confounding factor of bruising due from unintentional trauma. Given that the ﬁ nd- to birth trauma. The cases were divided into two ing of bruises in infants raises the possibility of groups: 7–182 days (1–26 weeks) of age at death inﬂ icted trauma, 2 3 the following retrospective and 183–364 days (26–52 weeks) of age at death. autopsy study was undertaken to determine (1) Case ﬁ les including autopsy reports, photographs, the incidence of bruising in infants who present to and coronial and police records were reviewed. autopsy and (2) how sensitive and speciﬁc bruises All autopsy reports were initially divided into in these infants are as a marker for other forms of those infants with external bruising on examina- injury and homicide. tion and those without external bruising.Copyright ArticleNE, Byard RW. Arch Dis Child (2010). doi:10.1136/adc.2009.177469 by BMJ Publishing Group Ltd (& RCPCH) under licence. Ingham AI, Langlois author (or their employer) 2010. Produced 1 of 3
Downloaded from adc.bmj.com on June 3, 2010 - Published by group.bmj.com Original article For those infants with external bruising, the details of the as was the incidence of homicide (p=0.003). The male-to-fe-bruises were recorded. If a bruise was attributed to medical male ratio of injured infants in the bruised group was 13:4,intervention, it was not included in the study. Marks and with other injuries found in 10 (71.4%) of 14 bruised infantsparchmented lesions (due to postmortem dessication) were <182 days of age and in all 7 (100%) of the bruised infantsnot recorded as bruises. A bruise was noted as single if there >182 days of age.was an area of discoloration with a deﬁ ned margin. An area of Thus, bruises were found in 21 (15.6%) of 135 infants atstippled, irregular bruising was recorded as multiple bruising. autopsy, with a predominance in males <6 months of age.When more than one bruise was found in a particular location, Of the 26 infants with other injuries/lesions, 17 had bruisesthe number of bruises was recorded as multiple. Given that and 9 did not, and of the 109 infants without other injuries/bruises cannot be accurately assessed by their colour,4–7 the lesions, only 4 had bruising and 105 did not. In this study,colour was not recorded. therefore, bruises had a sensitivity of 65% and a speciﬁcity All other injuries found on external and internal exami- of 96% as markers for other injuries with a positive predic-nations were summarized from the autopsy reports. These tive value (PPV) of 0.81 (likelihood ratio 17.8, 95% CI 6.5 toincluded skin and organ lacerations, bone fractures (on exami- 48.5) and a negative predictive value (NPV) of 0.92 (likelihoodnation or x-ray) or intracranial haemorrhage. A full external ratio 0.36, 95% CI 0.21 to 0.61). At <6 months of age, thisexamination in infants involves an examination of all skin increased to a sensitivity of 71% (PPV 71%; likelihood ratiosurfaces, with recording of all traumatic lesions including 15.7, 95% CI 5.7 to 43.2), with a similar speciﬁcity of 95%bruises by written description, drawing and photography. (NPV 0.95%; likelihood ratio 0.3, 95% CI 0.13 to 0.69). InPetechial haemorrhages of the face and conjunctivae were males, the sensitivity of bruises as markers of other injuries/also recorded as signiﬁcant lesions. Minor excoriations, abra- lesions was 68% (PPV 87%; likelihood ratio 21.9; 95% CI 5.4sions, scratches and areas of parchmenting were not included. to 88.6), with a speciﬁcity of 97% (NPV 91%; likelihood ratioDetailed antemortem information on bruising or involve- 0.33; 95% CI 0.17 to 0.63). In the subgroup of nine infantsment with the Child Protection Services was not available. who were known to have been the victims of homicide, ﬁveStatistical analyses were undertaken using the χ2 test. were bruised (55.6%).RESULTS DISCUSSIONA total of 135 infants were included in the study consisting of Bruises typically arise when blunt force is applied to the skin83 boys and 52 girls (age range 7–364 days). There were 102 causing rupture of cutaneous and subcutaneous blood ves-cases <182 days of age (male-to-female ratio (M:F)=62:40) and sels. While the skin remains intact, extravasation of blood33 cases aged between 182 and 364 days (M:F=21:12). Twenty- into interstitial spaces leads to discolouration in the area ofone infants had one or more bruises, and 114 had no bruises. impact.8 The subsequent breakdown of erythrocytes and hae-Thus, bruises were found in 15.6% of infants presenting for moglobin in the interstitial spaces accompanies the healing ofcoronial autopsy, with a M:F ratio of 15:6. Of the 21 infants the bruised area and is responsible for the succession of colourswith bruises, 14 cases (66.6%; M:F=9:5) were aged <182 days, exhibited in a healing bruise (including red, violet, blue, yel-and 7 cases (33.3%; M:F = 6:1) were aged between 182 and 364 low, green and/or brown). Dating of bruises is, however, noto-days. riously inaccurate, as no predictable order or chronology of colour progression has been identiﬁed.9 Similarly, histological dating of bruises has been shown to be inaccurate.10Non-bruised infants Bruises may arise from inﬂ icted and non-inﬂ icted injury. InOnly 9 (7.9%) of 114 non-bruised infants had other injuries/ infancy, the presence of bruises may indicate the presence oflesions that consisted of subcutaneous bruising of the face, an underlying bleeding diathesis, for example, due to leukae-neck and scalp; facial petechial haemorrhages; recent rib frac- mia or thrombocytopaenia. However, in the absence of a med-tures and intraventricular, subdural and subarachnoid haem- ical cause for bruising, or an explained episode of trauma, theorrhage. The male-to-female ratio of injured infants was 6:3. possibility of inﬂ icted injury must be considered, as the mostOther injuries were found in 4 (4.6%) of 88 infants aged <182 common manifestation of physical abuse in children is cutane-days and in 5 (19.2%) of 26 infants aged >182 days. There were ous injury, particularly bruising.11–14only 4 homicides (3.5%) in this group of 114 infants, in which Bruising in infants is uncommon because of their lackonly one infant had identiﬁ able injuries (a case of blunt cran- of independent mobility, as was demonstrated in the cur-iocerebral trauma). rent study where only 15.6% of infants who had died had bruises. The likelihood of having a non-inﬂ icted bruise in aBruised infants child who is not independently mobile has been estimated toSeventeen (81%) of the total of 21 infants with bruises had be <1%.1 5 In addition, accidental bruises in pre-ambulatoryother injuries/lesions that consisted of facial and eyelid pete- infants are usually few.15 Certain areas are unlikely to bechial haemorrhages; anal, lip and gum lacerations; facial, chest bruised in accidental trauma including the chest, abdomen,and subgaleal subcutaneous bruises; recent and healed rib frac- back, buttocks, soft tissue of the face, ears and protectedtures; recent skull fractures; recent and healed upper and lower areas such as the neck, the genital area and the inner thighs. 2limb fractures; recent and old subdural haemorrhage; recent 3 16 17 Injuries to the lower legs are uncommon in childrensubarachnoid, optic nerve and retinal haemorrhage; intraven- <18 months of age, and <1% of children <3 years of age havetricular haemorrhage and epidural haemorrhage. There were lumbar bruises.18ﬁve homicide cases (23.8%), in which all infants had other In the current study, speciﬁc explanations for the bruisesinjuries. and other injuries were not sought, as the study was aimed In the bruised group, the incidence of other injuries was sig- at simply determining how useful bruises are in infants pre-niﬁcantly higher than that in the non-bruised group (p<0.001), senting to a forensic autopsy as markers of other injuries. The2 of 3 Ingham AI, Langlois NE, Byard RW. Arch Dis Child (2010). doi:10.1136/adc.2009.177469
Downloaded from adc.bmj.com on June 3, 2010 - Published by group.bmj.com Original articlestudy has shown that bruises are a signiﬁcant ﬁ nding, in that explanation, as certain forms of inﬂ icted trauma such as suffo-17 (81%) of the 21 infants with bruises had other injuries/ cation cannot be excluded on pathological grounds.lesions of concern (eg, fractures, lacerations and facial and con-junctival petechiae), and of the 114 non-bruised infants, only 9 Acknowledgements The authors would like to thank Dr David Butler of The University of Adelaide, for his assistance with statistical analyses.(8%) had other injuries/lesions (p<0.001). Although bruises had a high speciﬁcity as markers for other Competing interests None.injuries, they were less sensitive (65%). 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