Bruising and Bleeding—What's Normal for Children?

Signs and Symptoms of Normal Bruising

Mother checking daughters injured elbow
J.A. Bracchi/Stone/Gett Images

Kids seem to bruise easily, whether it is a toddler taking his first steps or a preschooler who is rough-housing all of the time. Fortunately, although many parents worry that this bruising is a sign of a serious illness, most of the time it is normal.

Signs of Normal Bruising and Bleeding

Of course, it is important to separate the kids who have a serious bleeding disorder, such as hemophilia, from those who have normal easy bruising when they begin to cruise and walk around.

Normal bruising is usually found on a child's shins because they often bump their lower legs against things as they walk or run; these bruises are usually flat and smaller than the size of a quarter. Younger children often get bruises on their foreheads from bumping their heads and falling, too.

Frequent nosebleeds are another sign that often prompts parents to think that their child has a bleeding disorder, but without some of the signs listed below, like normal bruising, nosebleeds can be normal in young children.

Does Color Matter?

Typically when a person bruises, a red spot appears initially, which you may or may not notice. A day or so later, the deep purple or blue color appears that we commonly associate with bruising. As the bruise heals, it turns to green, yellow and possibly yellowish brown before disappearing. The process can take up to two weeks. If you notice bruises on your child that do not follow this typical pattern or do not heal, discuss it with the Pediatrician.

 

Signs of Abnormal Bruising and Bleeding 

Certain signs such as the size and location of bruises, or the time it takes for bleeding to stop, can be red flags that bruising and bleeding should be evaluated by a doctor. These include:

  • Large bruises that are raised and seem out of proportion to the injury that caused it. For example, a very large bruise for a small bump against a table.
  • Unexplained bruises that occur without any history of a fall or injury.
  • Bruises that seem to last too long (more than a few weeks).
  • A family history of bleeding or easy bruising in the family. Many bleeding disorders, such as von Willebrand disease and hemophilia, are genetic, so a family history of bleeding and easy bruising would raise suspicions that a child could have the same bleeding problem.
  • A bloody nose (epistaxis) that lasts longer than 15 minutes, after proper treatment with direct pressure.
  • Excessive bleeding after dental procedures or surgery.
  • Any bruises in infants who have not started to crawl, cruise, or walk yet.
  • Bruises in unusual places, like a child's chest, back, hands, ear, face, or buttocks.
  • In teens, menstrual periods that last longer than seven days or that are heavy for more than three days.
     

Tests for Abnormal Bruising and Bleeding

Most kids with normal bruising won't need any testing. When bruises are large or are associated with other signs that might suggest a bleeding disorder, then testing might be needed.

Common tests for kids with bruising can include:

  • Complete blood count (CBC). In addition to the number or red blood cells and white blood cells, a complete blood count will show the amount of platelets a child has, which are important in helping blood to clot.
  • Peripheral blood smear. This test looks at a child's blood under a microscope to check the quantity and quality of a child's blood cells.
  • PT and PTT, or prothrombin time and partial thromboplastin timeThese measures test how well blood is clotting and help determine whether a child could have a bleeding disorder, such as hemophilia.
  • Factor VIII, factor IX, and factor XI. These specific factors are missing or deficient in different types of hemophilia.
  • Fibrinogen.  This protein that helps blood to clot and a deficiency will lead to prolonged bleeding. 
  • Bleeding time. This test looks at how long it takes a child to stop bleeding.
  • PFA-100 platelet function screen. This test evaluates how well platelets are working and is replacing the less reliable bleeding time test in many labs.
  • Ristocetin cofactor activity and Von Willebrand antigen. These tests are used specifically to identify von Willebrand disease.

Other Causes of Bruising and Bleeding

As your toddler learns to walk, he will likely fall and bump into things a lot, getting quite a few bruises along the way. Older children tend to have bruises on their arms and legs from playing and being active. Bruises of this type are generally nothing to worry about. Other causes of bruising can include:

  • Falls and injury. Not surprisingly, severe injuries can often lead to extensive bruising. Instead of simply looking at the size of a bruise, it is more important to think about whether or not the bruise is proportionate to the injury. So you would expect a larger bruise if your child falls out of a tree than if he simply trips and falls on the grass.
  • Child abuse. Bruising on infants, unexplained bruises, bruises in unusual places (upper arms, hands, ears, neck, buttocks, etc.), and bruises in specific shapes, like a large bite mark, cigarette burn, or belt mark, can be signs of child abuse.
  • Von Willebrand disease. This is a common, although often mild, genetic bleeding disorder that can cause easy bruising, frequent nosebleeds, heavy menstrual bleeding, and bleeding after surgery.
  • Thrombocytopenia. This is the clinical name for a low platelet count, which can be caused when platelets aren't being produced, are being destroyed, or when they are being sequestered in an enlarged spleen.
  • Idiopathic thrombocytopenic purpura (ITP). An autoimmune disorder, ITP leads to the breakdown of platelets in the blood by antibodies and a low platelet count. It is usually thought to be triggered by a recent viral infection, after which young children develop large bruises and petechiae (small purple dots under the skin).
  • Henoch-Schonlein purpura (HSP). This immune disorder can cause abdominal pain, bloody stools, joint pain, and a distinctive rash on a child's arms, legs, and buttocks that look like bruises (purpura).
  • Hemophilia A (factor VIII deficiency) or hemophilia B (factor IX deficiency). Hemophilia is usually diagnosed before a child is two to five years old when kids may have easy bruising, bleeding in joints, or excessive bleeding after a cut or dental procedure.
  • Leukemia. In addition to easy bruising, bleeding, and a low platelet count, children with leukemia will usually have other signs and symptoms, such as a low red cell count, fever, and weight loss, for example.
  • Vitamin K deficiency. Not enough of either vitamin K1 or vitamin K2, which are needed for the clotting of blood because of an essential role in the production of prothrombin (a clotting factor), can lead to bleeding problems. 
  • Side effects of certain medications. Aspirin, seizure medicines, and some antibiotics can cause abnormal bruising or bleeding . 

A Word From Verywell

Although bruising is often normal in active children, if your child has excessive bruising or easy bruising and other signs of a bleeding disorder, it's important to talk to your pediatrician. A thorough exam and testing can put your mind at ease or help you and your child's physician determine what type of care and treatment is needed. Keep in mind that children bruise frequently and it's normal. Most of the time, there's no need to worry. 

Sources:

Hoffman R, Benz EJ, Silberstein LE, Heslop H, Weitz J, Anastasi J. Hematology: Basic Principles and Practice, 6th ed. Philadelphia, PA. Elsevier. 2013. 

Kliegman RM, Stanton B, St. Geme J, Schor NF. Nelson Textbook of Pediatrics, 20th ed. Philadelphia, PA. Elsevier. 2016.

Yee DL. Causes of thrombocytopenia in children. In: UpToDate. Armsby C (ed). UpToDate. 2016. 

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