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Keywords:

  • ageing bruises;
  • bruising;
  • child abuse;
  • review updates

Abstract

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Search
  6. Quality assessment
  7. Inclusion criteria
  8. Can you age bruises accurately in children?
  9. Are there patterns of bruising in childhood which are either diagnostic or suggestive of abuse?
  10. Conclusion
  11. Acknowledgements
  12. REFERENCES
  13. Appendix 1. Search strategy
  14. Appendix 2. Electronic databases searched

Background:

Dogma has long prevailed regarding the ageing of bruises, and whether certain patterns of bruising are suggestive or diagnostic of child abuse.

Objectives:

We conducted the first Systematic Reviews addressing these two issues, to determine the scientific basis for current clinical practice. There have been seven updates since 2004.

Methods:

An all language literature search was performed across 13 databases, 1951–2004, using >60 key words, supplemented by ‘snowballing’ techniques. Quality standards included a novel confirmation of abuse scale. Updates used expanded key words, and a higher standard for confirmation of abuse.

Results:

Of 1495 potential studies, only three met the inclusion criteria for ageing of bruises in 2004, confirming that it is inaccurate to do so with the naked eye. This was roundly rejected when first reported, generating a wave of new studies attempting to determine a scientifically valid method to age bruises, none of which are applicable in children yet. Regarding patterns of bruising that may be suggestive or diagnostic of abuse, we included 23 of 167 studies reviewed in 2004, although only 2 were comparative studies. Included studies noted that unintentional bruises occur predominantly on the front of the body, over bony prominences and their presence is directly correlated to the child's level of independent mobility. Bruising patterns in abused children, differed in location (most common site being face, neck, ear, head, trunk, buttocks, arms), and tended to be larger. Updates have included a further 14 studies, including bruising in disabled children, defining distinguishing patterns in severely injured abused and non-abused children, and importance of petechiae.

Conclusions:

Systematic Reviews of bruising challenged accepted wisdom regarding ageing of bruises, which had no scientific basis; stimulated higher quality research on patterns of bruises distinguishing abusive and non-abusive bruising patterns, and highlighted the benefits of regular updates of these reviews.

Editors' Note: Overviews of reviews, compiling evidence from multiple Cochrane reviews into one accessible and usable document, are a regular feature of this journal. Our aim for each overview is to focus on the treatment question. ‘which treatment should I use for this condition?’, and to highlight the Cochrane reviews and their results in doing so. It is our hope that the overview will serve as a ‘friendly front end’ to the Cochrane Library, allowing the reader a quick overview (and an exhaustive list) of Cochrane reviews relevant to the clinical decision at hand.

Background

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Search
  6. Quality assessment
  7. Inclusion criteria
  8. Can you age bruises accurately in children?
  9. Are there patterns of bruising in childhood which are either diagnostic or suggestive of abuse?
  10. Conclusion
  11. Acknowledgements
  12. REFERENCES
  13. Appendix 1. Search strategy
  14. Appendix 2. Electronic databases searched

Bruising remains the most common manifestation of physical child abuse yet one whose true aetiology is most difficult to determine. With this in mind, the first systematic reviews that the Cardiff Child Protection Systematic Review group undertook (previously named Welsh Child Protection Systematic Review Group, www.core-info.cardiff.ac.uk) were related to bruising. The two questions reviewed were those which clinicians urgently wanted answers to, namely: Can you age bruises accurately in children? 1 Are there patterns of bruising in childhood which are either diagnostic or suggestive of abuse? 2 Since their original publication, each of these reviews has been updated at least bi-annually, with a number of interesting developments. In this article, we set out our methods, the revisions made over the past 8 years as these updates have been run and what the newer literature is adding to the original findings.

Methods

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Search
  6. Quality assessment
  7. Inclusion criteria
  8. Can you age bruises accurately in children?
  9. Are there patterns of bruising in childhood which are either diagnostic or suggestive of abuse?
  10. Conclusion
  11. Acknowledgements
  12. REFERENCES
  13. Appendix 1. Search strategy
  14. Appendix 2. Electronic databases searched

The review was conducted in compliance with a recognised methodology for undertaking systematic reviews 3. Prior to commencing the review, potential questions as well as possible terminology, search terms, dates, databases, key authors and key publications relating to the questions were discussed. Following this, a pilot search of relevant databases, MEDLINE, EMBASE and CINAHL was conducted; this generated over 3000 articles. The references were scanned for significance to ensure that all relevant terms were captured and irrelevant search terms excluded from the search strategy. At this stage the questions were refined and the final search strategy was developed in Ovid Medline.

Search

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Search
  6. Quality assessment
  7. Inclusion criteria
  8. Can you age bruises accurately in children?
  9. Are there patterns of bruising in childhood which are either diagnostic or suggestive of abuse?
  10. Conclusion
  11. Acknowledgements
  12. REFERENCES
  13. Appendix 1. Search strategy
  14. Appendix 2. Electronic databases searched

The search strategy was developed using the following keyword sets: child terms; child abuse and non-accidental injuries terms; and bruising terms. The search strategy was adapted to search the rest of the databases also (Appendix 1). An all-language literature search was performed across 13 databases, within the date range of 1951–2004. In addition, textbooks and conference abstracts were searched (Appendix 2).

Over the years, the search strategy was modified according to the improvement of searching capabilities of the databases. With the expansion of biomedical literature, new databases were added to the search, while others were excluded for a variety of reasons, such as not retrieving relevant studies. With further updates, our range of ‘snowballing’ techniques expanded to increase the sensitivity of the search, and included checking the references of reviewed articles, to see if they may be relevant to the review, liaising with experts and key authors, and searching websites and relevant journal sites.

Quality assessment

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Search
  6. Quality assessment
  7. Inclusion criteria
  8. Can you age bruises accurately in children?
  9. Are there patterns of bruising in childhood which are either diagnostic or suggestive of abuse?
  10. Conclusion
  11. Acknowledgements
  12. REFERENCES
  13. Appendix 1. Search strategy
  14. Appendix 2. Electronic databases searched

Although the traditional approach of evidence-based medicine is dominated by the randomized clinical trial as the ‘gold standard’, there are types of research questions that can only be addressed through observational studies 4, 5. Clearly, in the context of discriminating abusive from non-abusive bruising in children, a randomized clinical trial would be impossible.

Critical appraisal forms were developed using questions which were adapted from validated sources 3, 6–8. Each study was appraised independently by two reviewers, and data was extracted by the lead reviewer. Our review panel consisted of trained reviewers, including child abuse paediatricians, specialist child abuse paediatric nurses and forensic pathologists.

Table I. Rank of abuse
RankingCriteria used to define abuse
1Abuse confirmed during case conference, family, civil or criminal court proceedings, admitted by perpetrator, independently witnessed or described by victim
2Abuse confirmed by stated/referenced criteria including multi-disciplinary assessment
3Abuse defined by stated criteria
4Abuse stated but no supporting detail given
5Suspected abuse

One aspect that is always controversial when critically appraising the literature with regard to child abuse is the risk of circularity, that is, how do we know whether the injuries that are the subject of the review have not in fact been relied upon to conclude that the child was abused? Clearly, in this field, there is no ‘gold standard test’ for the confirmation of abuse, and there are a very small minority of cases where the abuse has been independently witnessed to provide ‘external confirmation’. To address this, and minimize the risk that the authors have based their decision regarding abuse solely on the injury in question, we have developed a ‘rank of abuse’ (Table 1). Essentially, the higher ranked studies included either a multidisciplinary assessment of the case, taking into account social and historical factors beyond the presenting injury, or a perpetrator admission or independently witnessed abuse; whereas lower ranked studies used explicit criteria or a clinical confirmation of abuse. For the initial systematic reviews of bruising, we accepted studies where the rank was 1–4, that is, we excluded those studies where abuse had simply been ‘suspected’ owing to the very high risk of circularity. However, from 2008, we raised the cutoff to ranks 1–3 where the lowest ranking studies had used explicit stated criteria to confirm abuse, to bring it in line with our other systematic reviews.

Inclusion criteria

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Search
  6. Quality assessment
  7. Inclusion criteria
  8. Can you age bruises accurately in children?
  9. Are there patterns of bruising in childhood which are either diagnostic or suggestive of abuse?
  10. Conclusion
  11. Acknowledgements
  12. REFERENCES
  13. Appendix 1. Search strategy
  14. Appendix 2. Electronic databases searched

Ageing of bruises

We included studies that assessed the age of bruises clinically in children aged 0–18 years. We excluded post-mortem studies, single case studies, reviews and expert opinion pieces, and studies of adults and children where the data relating to children could not be extracted.

Patterns of bruising

We included studies that defined the pattern of bruising found in abused and non-abused children aged 0–18 years. Bites were excluded as they form part of a separate systematic review. We also excluded cases where confirmation of abuse did not meet our required ‘rank of confirmation of abuse’, or medical conditions with bruising as a manifestation of disease.

Can you age bruises accurately in children?

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Search
  6. Quality assessment
  7. Inclusion criteria
  8. Can you age bruises accurately in children?
  9. Are there patterns of bruising in childhood which are either diagnostic or suggestive of abuse?
  10. Conclusion
  11. Acknowledgements
  12. REFERENCES
  13. Appendix 1. Search strategy
  14. Appendix 2. Electronic databases searched

At the time of the original review, many standard texts cited a precise timetable of colour changes that occur in bruises, by which you could date the injury 9. A particular significance was associated with yellowish appearance, which was deemed to be indicative of a bruise that was at least 18 hours old 10. Having identified 6831 abstracts, following scanning this was reduced to 1495 abstracts, of which 167 underwent two independent reviews. And to the dismay of the clinical and forensic community, the review identified that there were in fact only three primary studies (a qualitative study 11, a cross-sectional study 12 and a case series; 13 which had addressed this issue in children (Langlois and Gresham's study could not be included, as it had included subjects aged 10–100 years, with no separate data on children; 10. The obvious conclusion from this evidence was that one could not accurately age bruises in children, with the naked eye, either in vivo or from a photograph. When we consider that the appearance of a bruise will vary depending on the force that caused it, the body part affected (e.g. soft tissues, dependent part of body), skin colour, and that we perceive colour differently, in particular as we get older 14, it is not surprising that this is not an exact science.

Although the significance of this review was acknowledged within the scientific literature 15, its conclusions were roundly disputed by clinicians and forensic scientists. This prompted others to conduct primary work to disprove it. A recent study attempting to determine the accuracy of forensic examiners ageing bruises generated in adults showed that only 48% of the age estimates were correct to within 24 hours 16. Over time, there has been a gradual acceptance of the review findings 17.

Since 2004, when the original literature search and systematic review was performed, we have updated our literature search seven times, most recently in July 2012 (Appendix 1). Over that time, we have identified a further 23 studies potentially addressing this question, yet none have met our inclusion criteria. This is not to suggest that there has been no valid scientific work in the field, on the contrary, there have been assiduous attempts to identify a more scientific method to age bruises. Some authors have explored the use of reflectance spectroscopy 18–20 while others have tried to combine a stochastic photon transport model in multilayer skin tissue combined with reflectance spectroscopy measurements 21. Although promising, to date however, these techniques are not applicable in clinical practice for children. Other techniques explored have included an evaluation of chromophore concentrations to determine age, but this technique was found to be unreliable 22. The most recent work has investigated the use of ultrasound to aid the assessment of bruises in post-mortem cases 23, as it was felt that a limiting feature in the potential application of spectrophotometry techniques may be the degree to which bruises vary depending on their depth and extent, which ultrasound may delineate 24. Thus, in conclusion, for practitioners this review appeared to make a negative contribution to the field of child abuse initially, but it has brought a more evidence-based approach to the assessment of abusive bruises, and importantly has stimulated a wave of scientific studies aiming to address this important clinical question.

Are there patterns of bruising in childhood which are either diagnostic or suggestive of abuse?

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Search
  6. Quality assessment
  7. Inclusion criteria
  8. Can you age bruises accurately in children?
  9. Are there patterns of bruising in childhood which are either diagnostic or suggestive of abuse?
  10. Conclusion
  11. Acknowledgements
  12. REFERENCES
  13. Appendix 1. Search strategy
  14. Appendix 2. Electronic databases searched

This review was originally conducted in 2004, and of the 167 studies undergoing review, 23 met the inclusion criteria (3 case–control, 5 cross-sectional, 15 case series; 2). Here the quality of evidence was better; however, only two studies included comparative data on bruising, one of which explicitly set out to identify distinguishing features between the two populations, abused and non-abused children 25. The other study containing comparative data was primarily aimed at assessing fractures, but noted bruises within this population 26. The primary findings of this original review were related to the described pattern of bruising in non-abused children, highlighting that bruising in children is directly correlated to their development, specifically to their degree of independent mobility. Those infants that are not independently mobile rarely sustain non-abusive bruises during day to day activities 12, 27, 28. In addition, it was noted that accidental bruises occur predominantly on the front of the body and over bony prominences 12, 27. The typical sites of non-abusive bruises were described consistently in the included studies, namely the knees and shins, head and forehead 27, 29, 30. It was clear that some sites were rarely bruised during day to day activities 2, namely the hands in children younger than 4 years, and back, buttocks, forearm, foot and abdomen (Figure 1; 31). These findings were supported by the applied quality standards.

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Figure 1. Patterns of accidental bruising

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The quality of studies relating to abusive bruising was weaker, as 13 of 16 studies included here were highly selective case series, written to describe specific patterns of abusive bruising, for example, vertical cleft bruising where the child had been hit horizontally 32. However, acknowledging the different populations studied, some stark differences were evident between the pattern of bruising found amongst the abused children and the non-abused; specifically, the most common site of bruising in the abused children was the head, including the face. The comparative study 25, which had a high ‘ranking of abuse’ thus minimizing circularity, highlighted certain sites that were bruised significantly more often amongst the abused children, namely the ear, neck, face, head, trunk, buttocks and arms. The abusive bruises also tended to be larger 25 and were frequently found amongst other soft tissue injuries 33, 34 (Figure 2; 31).

thumbnail image

Figure 2. Patterns of abusive bruising

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Another notable feature of the abusive bruises, not commented on amongst the non-abused children, was the presence of clusters of bruises 34, some of which were defensive (i.e. where the children had wrapped their arms around their flexed legs in an attempt to protect themselves, thus sustaining bruises to the upper arms or outer thigh) 33. Other features of note were directly linked to the implement used to inflict these injuries, for example, bruises interspersed with abrasions where a rope has been used 33, 34.

The gaps in the literature that were highlighted following this review included the need for large case–control studies of bruising patterns amongst abused and non-abused children, specifically encompassing a wide range of developmental stages, representing broad cultural and ethnic diversity, and studies addressing the specific patterns of bruising sustained from known accidental mechanisms. We also highlighted that there was not a single study of bruising patterns in disabled children, which was a significant gap, given their increased vulnerability to abuse.

Table II. Additional studies identified through updates
YearTotal number of studies reviewedNumber of studies included (patterns of bruising only)
200511 38
200611 41
200763 35, 40, 48
200843 43, 44, 47
200943 36, 37, 39
201063 42, 45, 46
201210

Since 2005, we have reviewed an additional 23 studies, resulting in 14 new included studies (Table 2) 35–48. Of these, there were two case–control studies 41, 45, one cross-sectional study 42 and the remainder case series or studies. To place this in context, the original review spanned 53 years, generating 23 studies, and the last 7 years have provided more than half this number again. More importantly, the quality of these studies has also been higher, with some specifically addressing the gaps identified in existing literature. Overall, the original findings hold true with regard to able-bodied children. Importantly, there have now been two studies conducted to determine the pattern of bruising in disabled children 37, 42. These have identified specific features, namely that in common with able-bodied children, the knees were frequently bruised, but contrary to these children, the feet, thighs, hands, arms and abdomen were also bruised. Some of this is attributed to the use of mobility aids. However, just as certain sites were rarely bruised accidentally amongst able-bodied children, specifically the ears, neck, anterior chest and genitalia were rarely bruised amongst the disabled. In stark contrast to the able-bodied, however, the chin and the lower legs were rarely bruised amongst disabled children. Clearly, these specific patterns need to be borne in mind by clinicians assessing possible abuse in disabled children, particularly in those with significant communication disorders. One study which separated the children according to their maximum level of mobility, namely unrestricted walker, restricted walker and wheelchair dependent, showed a clear correlation between increasing independent mobility and increased bruising (p = 0.001) 42. It would be beneficial if future studies of disabled and able-bodied children used this stratification by levels of mobility. There are still significant gaps in the literature with regard to disability; for example, there are no studies detailing accidental bruising patterns in visually impaired children, who may exhibit patterns very different from either the able-bodied or the physically disabled, owing to their innate caution in exploring their surroundings.

Addressing the other major gap in the literature identified in the original review is a new study by Mary Clyde Pierce and colleagues, a case–control study of bruising patterns amongst abused and non-abused children younger than 4 years, admitted to a Paediatric Intensive Care Unit with trauma 45. The basis on which cases were classified as abused or non-abused was clearly detailed in this study, as mixed ranks 2 and 3. They devised a clinical rule to distinguish abusive from non-abusive bruises in this population, by creating a regression tree through binary recursive partitioning. They noted that characteristics predictive of abuse were bruising on the torso, ear or neck (TEN) for a child up to 4 years of age and bruising in any region for an infant <4 months of age. They determined that this clinical rule had a sensitivity of 97% and a specificity of 84% for predicting abuse. Future work needs to validate this clinical rule, and determine if it holds true for children presenting with bruising in other settings, that is, those with minor injuries as opposed to major trauma.

Another valuable study conducted since the original review relates to the patterns of injuries found following slips, trips and falls amongst 750 children younger than 12 years 35. The peak age for ‘slips and trips’ was 1–2 years, and it is noted that the bruises that resulted from these injuries occurred predominantly in a T-shape across the forehead, nose, upper lip, and chin as well as over the occiput. A more detailed breakdown by age bands would have been valuable.

Two of the newly included studies feature ‘cautionary tales’, each highlighting three young infants in whom bruising was a critical finding, related to child abuse or haemophilia A (one case) 36, 46. Each author wished to draw attention to the rarity of accidental bruising in young infants, as we had identified in our original review.

The remaining studies highlight new features, which were not addressed prior to the first review. These include an important comparative study by Nayak et al. suggesting that the presence of petechiae in a child with bruising may be an indicator of an abusive origin 41.

These authors examined retrospective records pertaining to 190 children referred with suspected abuse and compared these to 263 children attending the emergency department recruited prospectively, all aged 0–17 years. They then ‘confirmed’ abuse by an independent assessment of the multidisciplinary information available. They also chose to take a conservative approach by combining the ‘inconclusive’ cases with the ‘confirmed abuse’ cases. Petechiae were noted in conjunction with bruising in 22% [95% confidence interval (CI) 15.6, 29.8] of the abused children versus 2.3% (95% CI 1.1, 5.0) of the non-abused. It was notable that in 23 of 28 abused children, the petechiae were found on the head and neck. Amongst the seven children with non-abusive injuries, the petechiae were on the limbs and trunk. Overall, they determined that the likelihood ratio of petechiae for abuse was 6.0 (95% CI 2.5, 14.1). However, the likelihood ratio for the absence of petechiae was not significant at 0.9 (95% CI 0.8, 1.0), thus when present in association with bruising, petechiae are a strong indicator of abusive aetiology, but their absence has no value in excluding abuse. This important piece of work needs to be validated in future studies.

Attention was drawn to a specific form of abusive injury; scalping which may present with a boggy swelling over the forehead or eyes 47, 48. Here the aponeurosis is effectively torn away, leading to extensive sub-aponeurotic bleeding, with tracking of the blood over the forehead resulting in the visible bruise. It is postulated that the children in question may have been swung by their hair. A further study of this condition reminds readers to actively screen for an underlying skull fracture 44. A similar injury has, however, been noted in Afro-Caribbean children who have their hair braided, and where excessive force has been used in combing the child's hair back 49. Further included studies address issues such as the clearly established fact that an absence of bruising does not mean that there is no underlying fracture 44. In this large case series, 58% of children with abusive fractures had no bruising, in fact when skull fractures are omitted, only 9% of fractures had nearby bruising. It is well recognized that rib fractures as a consequence of abuse, rarely have associated bruising to the skin, as the fracture occurs predominantly on the inner portion of the rib, thus any bruising present is sub-pleural, and will in fact only be seen on post-mortem examination if the pleura is reflected off the rib. Similarly, a fracture caused by a force applied distal to the site of the fracture may not result in bruising overlying the fracture itself. This has a very specific connotation in child protection, from the level of false reassurance that clinicians may have, whereby the absence of visible bruising discourages them from conducting a skeletal survey in suspected abuse, to ensuring that the courts understand that a fracture is no less significant when bruising is absent.

Conclusion

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Search
  6. Quality assessment
  7. Inclusion criteria
  8. Can you age bruises accurately in children?
  9. Are there patterns of bruising in childhood which are either diagnostic or suggestive of abuse?
  10. Conclusion
  11. Acknowledgements
  12. REFERENCES
  13. Appendix 1. Search strategy
  14. Appendix 2. Electronic databases searched

Despite bruising being a key indicator of physical abuse, there was very little pertinent literature addressing the most frequently asked clinical questions when the original systematic review was conducted in 2004. That review caused consternation by highlighting that there was no evidence to support the common practice of clinicians estimating the age of a bruise from its appearance, and most specifically its colour. Since that time, there is increasing acceptance of this, and although no further studies have met our inclusion criteria for this question, it is clear that a number of research groups are exploring a variety of scientific methods to address this question, thus potentially overcoming the limitations of subjective assessments by clinicians. With regard to the pattern of bruises in a child that may aid in distinguishing abuse from accidental injury, there was more evidence at the time of the original review (23 included studies); however disappointingly only two were comparative studies, one of which simply noted bruising patterns, although the main aim of the study was to compare fracture patterns. It is reassuring to note, however, that some of the gaps identified in the literature at the time of publication of this systematic review 2005 have been addressed subsequently, specifically the first studies examining accidental bruising patterns in children with disability, and have been published. There have also been further studies reiterating some of the original messages, that is, the clear link between a child's level of independent mobility and increasing levels of accidental bruises. Some important additional features have also been reported, such as the correlation between the presence of petechiae in association with bruising as indicative of abuse.

The subsequent research in this field highlights the need to constantly update systematic reviews, while continuing to apply rigorous standards of inclusion/exclusion criteria (ours actually became more rigorous, as we demanded a higher confirmation of abuse in the more recent updates), as new data may become available which can enhance or alter the findings originally reported. In a field which is as sensitive and contentious as child abuse, it is even more vital that health practitioners, social care workers and those involved in law enforcement are kept updated with the latest research findings, if they are to truly serve the best interests of all children.

REFERENCES

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Search
  6. Quality assessment
  7. Inclusion criteria
  8. Can you age bruises accurately in children?
  9. Are there patterns of bruising in childhood which are either diagnostic or suggestive of abuse?
  10. Conclusion
  11. Acknowledgements
  12. REFERENCES
  13. Appendix 1. Search strategy
  14. Appendix 2. Electronic databases searched
  • 1
    Maguire S, Mann M, Sibert J, Kemp A. Can you age bruises accurately in children? A systematic review. Arch Dis Child 2005; 90: 187189.
  • 2
    Maguire S, Mann MK, Sibert J, Kemp A. Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? Arch Dis Child 2005; 90: 182186.
  • 3
    NHS Centre for Reviews and Dissemination. Undertaking systematic reviews of research on effectiveness. CRD's guidance for those carrying out or commissioning reviews, CRD Report No. 4, 2nd edn. York: University of York; 2001.
  • 4
    Gülmezoglu AM, Say L, Betrán AP, Villar J, Piaggio G. WHO systematic review of maternal mortality and morbidity: methodological issues and challenges. BMC Med Res Methodol 2004; 5: 16.
  • 5
    Weaver N, Williams JL, Weightman AL, Kitcher HN, Temple JM, Jones P, et al. Taking STOX: developing a cross disciplinary methodology for systematic reviews of research on the built environment and the health of the public. J Epidemiol Community Health 2002; 56: 4855.
  • 6
    Critical Appraisal Skills Programme (CASP) (2012) Available at: http://www.phru.nhs.uk/Pages/PHD/CASP.htm [accessed on 8 November 2012].
  • 7
    Polgar A, Thomas SA. Critical evaluation of published research. In: Introduction to research in the health sciences. 3rd ed. Melbourne: Churchill Livingstone; 1995.
  • 8
    Weightman AL, Mann MK, Sander L, Turley RL. Health Evidence Bulletins Wales: A Systematic Approach to Identifying the Evidence. Project Methodology 5. Available at: http://hebw.cf.ac.uk/projectmethod/title.htm [accessed on 24 September 2012].
  • 9
    Wilson EF. Estimation of the age of cutaneous contusions in child abuse. Pediatrics 1977; 60: 750752.
  • 10
    Langlois NEI, Gresham GA. The ageing of bruises: a review and study of the colour changes with time. Forensic Sci Int 1991; 50: 227238.
  • 11
    Bariciak ED, Plint AC, Gaboury I, Bennett S. Dating of bruises in children: An assessment of physician accuracy. Pediatrics 2003; 112: 804807.
  • 12
    Carpenter RF. The prevalence and distribution of bruising in babies. Arch Dis Child 1999; 80: 363366.
  • 13
    Stephenson T, Bialas Y. Estimation of the age of bruising. Arch Dis Child 1996; 74: 5355.
  • 14
    Munang LA, Leonard PA, Mok JY. Lack of agreement on colour description between clinicians examining childhood bruising. J Clin Forensic Med 2002; 9: 171174.
  • 15
    Cabinum-Foeller E, Frasier L. Bruising in children. Lancet 2005; 365: 13691370.
  • 16
    Pilling ML, Vanezis P, Perrett D, Johnston A. Visual assessment of the timing of bruising by forensic experts. J Forensic Leg Med 2010; 17: 143149.
  • 17
    Dubowitz H, Bennett S. Physical abuse and neglect of children. Lancet 2007; 369: 18911899.
  • 18
    McMurdy JW, Duffy S, Crawford GP. Monitoring bruise age using visible diffuse reflectance spectroscopy. Proc SPIE; 2007; 6434
  • 19
    Randeberg LL, Haugen OA, Haaverstad R, Svaasand LO. A novel approach to age determination of traumatic injuries by reflectance spectroscopy. Lasers Surg Med 2006; 38: 277289.
  • 20
    Stam B, van Gemert MJ, van Leeuwen TG, Aalders MC. 3D finite compartment modeling of formation and healing of bruises may identify methods for age determination of bruises. Med Biol Eng Comput 2010; 48: 911921.
  • 21
    Kim O, McMurdy J, Lines C, Duffy S, Crawford G, Alber M. Reflectance spectrometry of normal and bruised human skins: experiments and modeling. Physiol Meas 2012; 33: 159175.
  • 22
    Duckworth MG, Caspall JJ, Mappus RL, Kong L, Yi D, Sprigle SH. Bruise chromophore concentrations over time (article no. 69152S). Proc SPIE 2008; 6915
  • 23
    Mimasaka S, Oshima T, Ohtani M. Characterization of bruises using ultrasonography for potential application in diagnosis of child abuse. Leg Med 2012; 14: 610.
  • 24
    Mimasaka S, Ohtani M, Kuroda N, Tsunenari S. Spectrophotometric evaluation of the age of bruises in children: measuring changes in bruise color as an indicator of child physical abuse. Tohoku J Exp Med 2010; 220: 171175.
  • 25
    Dunstan FD, Guildea ZE, Kontos K, Kemp AM, Sibert JR. A scoring system for bruise patterns: a tool for identifying abuse. Arch Dis Child 2002; 86: 330333.
  • 26
    Worlock P, Stower M, Barbor P. Patterns of fractures in accidental and non-accidental injury in children: a comparative study. Br Med J 1986; 293: 100102.
  • 27
    Sugar NH, Taylor JA, Feldman KW. Bruises in infants and toddlers; those who don't cruise rarely bruise. Puget Sound Pediatric Research Network. Arch Pediatr Adolesc Med 1999; 153: 399403.
  • 28
    Wedgwood J. Childhood bruising. Practitioner 1990; 234: 598601.
  • 29
    Mortimer PE, Freeman M. Are facial bruises in babies ever accidental? Arch Dis Child 1983; 58: 7576.
  • 30
    Tush BAR. Bruising in healthy 3-year-old children. Matern Child Nurs J 1982; 11: 165179.
  • 31
    Maguire S. Which injuries may indicate child abuse? Arch Dis Child Educ Pract Ed 2010; 95: 170177.
  • 32
    Feldman KW. Patterned abusive bruises of the buttocks and the pinnae. Pediatrics 1992; 90: 633636.
  • 33
    Brinkmann B, Püschel K, Mätzsch T. Forensic dermatological aspects of the battered child syndrome. Aktuelle Derm 1979; 5: 217232.
  • 34
    Sussman SJ. Skin manifestations of the battered-child syndrome. J Pediatr 1968; 72: 99101.
  • 35
    Chang LT, Tsai MC. Craniofacial injuries from slip, trip, and fall accidents of children. J Trauma 2007; 63: 7074.
  • 36
    Feldman KW. The bruised premobile infant; should you evaluate further? Pediatr Emerg Care 2009; 25: 3739.
  • 37
    Goldberg AP, Tobin J, Daigneau J, Griffith RT, Reinert SE, Jenny C. Bruising frequency and patterns in children with physical disabilities. Pediatrics 2009; 124: 604609.
  • 38
    Jappie F. Non accidental injuries in children. Aust Fam Physician 1994; 23: 11441150.
  • 39
    Mosqueda Peña R, Ardura García C, Barrios López M, Casado Picón R, Palacios CA. Ecchymotic injuries in upper extremity [Spanish]. Acta Pediatr Esp 2008; 66: 198200.
  • 40
    Murty OP, Ming CJ, Ezani MA, Yan PK, Yong TC. Physical injuries in fatal and non-fatal child abuse cases: A review of 16 years with hands on experience of 2 years in Malaysia. Int J Med Toxicol Legal Med 2006; 9: 3343.
  • 41
    Nayak K, Spencer N, Shenoy M, Rubithon J, Coad N, Logan S. How useful is the presence of petechiae in distinguishing non-accidental from accidental injury? Child Abuse Negl 2006; 30: 549555.
  • 42
    Newman CJ, Holenweg-Gross C, Vuillerot C, Jeannet PY, Roulet-Perez E. Recent skin injuries in children with motor disabilities. Arch Dis Child 2010; 95: 387390.
  • 43
    Patno K, Jenny C. Who slapped that child? Child Maltreat 2008; 13: 298300.
  • 44
    Peters ML, Starling SP, Barnes-Eley ML, Heisler KW. The presence of bruising associated with fractures. Arch Pediatr Adolesc Med 2008; 162: 877881.
  • 45
    Pierce MC, Kaczor K, Aldridge S, O'Flynn J, Lorenz DJ. Bruising characteristics discriminating physical child abuse from accidental trauma [published erratum appears in Pediatrics 2010; 125(4):861]. Pediatrics 2010; 125: 6774.
  • 46
    Pierce MC, Smith S, Kaczor K. Bruising in infants: those with a bruise may be abused. Pediatr Emerg Care 2009; 25: 845847.
  • 47
    Schultes A, Lackner K, Rothschild MA. “Scalping”: A possible indicator for child abuse [German]. Rechtsmedizin 2007; 17: 318320.
  • 48
    Seifert D, Puschel K. Subgaleal hematoma in child abuse. Forensic Sci Int 2006; 157(2–3): 131133.
  • 49
    Onyeama CO, Lotke M, Edelstein B. Subgaleal hematoma secondary to hair braiding in a 31-month-old child. Pediatr Emerg Care 2009; 25: 4041.

Appendix 1. Search strategy

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Search
  6. Quality assessment
  7. Inclusion criteria
  8. Can you age bruises accurately in children?
  9. Are there patterns of bruising in childhood which are either diagnostic or suggestive of abuse?
  10. Conclusion
  11. Acknowledgements
  12. REFERENCES
  13. Appendix 1. Search strategy
  14. Appendix 2. Electronic databases searched
Original search strategy—OVID Medline 1951–October 2004
  • 1.
    child.mp.
  • 2.
    child abuse.mp.
  • 3.
    child protection.mp.
  • 4.
    1 or 2 or 3
  • 5.
    bruis:.mp.
  • 6.
    contusion.mp.
  • 7.
    physical abuse.mp.
  • 8.
    serial abuse.mp.
  • 9.
    non-accidental injury.mp.
  • 10.
    non-accidental trauma.mp.
  • 11.
    (nonaccidental:and injur:).mp.
  • 12.
    (hematoma or haematoma).mp.
  • 13.
    physical punishment.mp.
  • 14.
    or/5–13
  • 15.
    (battered child or shaken baby or battered baby).mp.
  • 16.
    (dat: adj3 bruis:).mp.
  • 17.
    (bruis: adj3 child:).mp.
  • 18.
    (pattern: adj3 bruis:).mp.
  • 19.
    (ag: adj3 bruis:).mp.
  • 20.
    (hemosid: adj3 bruis:).mp.
  • 21.
    (petechiae adj3 child abuse).mp.
  • 22.
    (ecchymoses adj3 child abuse:).mp.
  • 23.
    ((petechiae or ecchymoses) and child abuse:).mp.
  • 24.
    ((petechiae or ecchymoses) and child protection:).mp.
  • 25.
    or/15–24
  • 26.
    4 and 14
  • 27.
    25 or 26
Update search strategy—OVID Medline 2012 (update July 2, 2012)
  • 28.
    child*.mp.
  • 29.
    baby.mp.
  • 30.
    (infant$ or baby or babies or toddler$).mp.
  • 31.
    exp child/
  • 32.
    1 or 3 or 4
  • 33.
    child abuse.mp.
  • 34.
    child protection.mp.
  • 35.
    child maltreatment.mp.
  • 36.
    (battered child or shaken baby or battered baby).mp.
  • 37.
    or/6–9
  • 38.
    soft tissue injur$.mp.
  • 39.
    physical abuse.mp.
  • 40.
    physical punishment.mp.
  • 41.
    serial abuse.mp.
  • 42.
    non-accidental injur$.mp.
  • 43.
    nonaccidental injur$.mp.
  • 44.
    non-accidental trauma.mp.
  • 45.
    nonaccidental trauma.mp.
  • 46.
    (nonaccidental: and injur:).mp.
  • 47.
    wound:.mp.
  • 48.
    “Wounds and Injuries”/
  • 49.
    *Skin/in [Injuries]
  • 50.
    “Soft Tissue Injuries”/di [Diagnosis]
  • 51.
    (or/11–23) and 5
  • 52.
    10 or 24
  • 53.
    exp Contusions/
  • 54.
    exp Purpura/
  • 55.
    Bruis*.mp.
  • 56.
    (hematoma or haematoma).mp.
  • 57.
    Hematoma/
  • 58.
    exp Scalp/
  • 59.
    (contusion or scalping).mp.
  • 60.
    or/26–31
  • 61.
    (bruis: adj3 child:).mp.
  • 62.
    (petechiae adj3 child abuse).mp.
  • 63.
    (ecchymoses adj3 child abuse:).mp.
  • 64.
    ((petechiae or ecchymoses) and child abuse:).mp.
  • 65.
    ((petechiae or ecchymoses) and child maltreatment).mp.
  • 66.
    ((petechiae or ecchymoses) and child protection).mp.
  • 67.
    ((petechiae or ecchymoses) and injur$).mp.
  • 68.
    ((petechiae or ecchymoses) adj3 injur$).mp.
  • 69.
    (hemosid: adj3 bruis:).mp.
  • 70.
    or/34–40
  • 71.
    33 or 43
  • 72.
    (dat: adj3 bruis:).mp.
  • 73.
    (pattern: adj3 bruis:).mp.
  • 74.
    (age: adj3 bruis:).mp.
  • 75.
    exp Time Factors/
  • 76.
    exp Color/
  • 77.
    exp Spectrophotometry/
  • 78.
    or/45–50
  • 79.
    5 and 51 and 33
  • 80.
    25 and 44 and 51
  • 81.
    limit 53 to yr = “2010 – 2012”

Appendix 2. Electronic databases searched

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Search
  6. Quality assessment
  7. Inclusion criteria
  8. Can you age bruises accurately in children?
  9. Are there patterns of bruising in childhood which are either diagnostic or suggestive of abuse?
  10. Conclusion
  11. Acknowledgements
  12. REFERENCES
  13. Appendix 1. Search strategy
  14. Appendix 2. Electronic databases searched
Databases—original searchTime period searched
ASSIA (Applied Social Sciences Index and Abstracts)1987–2004
Caredata1980–2004
Child Data1958–2004
CINAHL (Cumulative Index to Nursing and Allied Health Literature)1982–2004
EMBASE1980–2012
MEDLINE1951–2004
Pre-MEDLINE2004
SIGLE (System for Information on Grey Literature in Europe)1980–2004
PsycINFO1987–2004
Trip Plus1997–2004
Web of Knowledge—ISI Proceedings1990–2004
Web of Knowledge—ISI Science Citation Index1981–2004
Web of Knowledge—ISI Social Science Citation Index1981–2004
Databases update searchTime period searched
ASSIA (Applied Social Sciences Index and Abstracts)1987–2012
Child Data1996–2009*
CINAHL (Cumulative Index to Nursing and Allied Health Literature)1982–2012
Cochrane Central Register of Controlled Trials1960–2012
EMBASE1980–2012
HMIC (Health Management Information Consortium)1979–2012
MEDLINE1951–2012
MEDLINE In-Process and Other Non-Indexed Citations1951–2012
Open SIGLE (System for Information on Grey Literature in Europe)1980–2005
PsycINFO1987–2004
Scopus2009–2012
Social Care online (previously Caredata)1970–2012
Trip Plus1997–2012
Web of Knowledge—ISI Proceedings1990–2012
Web of Knowledge—ISI Science Citation Index1981–2012
Web of Knowledge—ISI Social Science Citation Index1981–2012
Journals ‘hand searched’ 
Child Abuse and Neglect1977–2012
Child Abuse Review1992–2012
Websites searchedDate accessed
  • *

    Institutional access terminated.

  • Ceased indexing.

  • No yield so ceased searching.

Child Welfare Information Gateway (formerly National Clearinghouse on Child Abuse and Neglect)July 2012
National Center on Shaken Baby Syndrome (NCSBS)July 2012