Bruising in CP

A pilot study to test the
methodology for the investigation
of the prevalence and distribution
of bruising in children with
cerebral palsy.
Diana Jellinek
Therese Bennett
May 2008
1

The evidence: intentional injuries
to children
www.core-info.cf.ac.uk
2

Rationale
• A systematic review of studies examining the
prevalence and distribution of bruising in
able-bodied children and babies has provided
some information on size, distribution and
frequency of bruising in children 1 .
1. Maguire S, Mann MK, Kemp A. Are there patterns of bruising in
childhood which are diagnostic or suggestive of abuse A
systematic review. Arch Dis Child 2005; 90: 182-86.
3

Rationale
• There are no published studies
describing patterns of bruising in
children with disabilities.
• The aims of this study were:
– To test a method to ensure acceptability to children
with CP and their parents.
– To document any bruises seen by number, size and
location.
– To examine bruising patterns in children with CP in
order to provide a baseline for future studies.
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Definitions
Cerebral palsy (CP)
“an umbrella term covering a group of non-progressive but
often changing motor impairment syndromes secondary to
lesions or anomalies of the brain arising in the early stages
of its development” 2
Bruise
A bruise is an traumatic injury of the soft tissues which
results in breakage of the local capillaries and leakage of red
blood cells. In the skin it can be seen as a reddish-purple
discoloration that does not blanch when pressed upon. When a
bruise fades it becomes green and brown as the body
metabolizes the blood cells in the skin.
Websters Medical Dictionary
2. Mutch L, Ronal E. The Scottish Register of Children with a Motor Deficit of Central Origin. Report to the
Chief Scientist (Scotland)
K/OPR/2/2/C929. Glasgow University, Public Health Research Unit.
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Method
• Children with CP, aged 2-11, attending 2
Manchester specialist support schools.
• 4 paediatricians.
• Full skin examination and recording of marks
on a body chart, as part of the routine medical.
• Number, size and location of marks to be
recorded.
• An assessment of developmental level to be
made, including use of GMFCS.
• An explanation to be sought from child or
carer for any bruises seen.
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Method
• Bruises seen that raise a concern about nonaccidental
injury to be dealt with in the same
way as concerns arising in any medical
examination, (Manchester Safeguarding
Children’s Board policy).
• Pilot study approved by LREC
• Analysis of the process and the results was
undertaken by the main investigator who was
not be involved in the clinical assessments.
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data collection form
Mobility (using GMFM classification system):
Level 1 2 3 4 5
Hand function:
Normal - can play/write/draw etc
Mild - some difficulty with play/write/draw e.g unsteadiness, awkward release,
Moderate – considerable difficulty with play/write/draw, requires
Severe - Unable to use hand but can use switch system
Profound - unable to use switch system
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Gross Motor Function Classification
System
Between 6th and 12th Birthday
Level I Children walk and climb stairs without limitations. Children can
run and jump but speed, balance, and coordination are reduced.
Level II Children walk and climb stairs holding onto a railing but
experience limitations walking on uneven surfaces and inclines.
Children have minimal ability to run and jump.
Level III Children walk on a level surface with an assistive mobility
device. Children may climb stairs holding onto a railing. Children
propel a wheelchair manually or are transported long distances or
outdoors on uneven terrain.
Level IV Children may maintain levels of function achieved before age
6 or rely more on wheeled mobility at home, school, and in the
community. Children may achieve self-mobility using a power
wheelchair.
Level V Physical impairments restrict voluntary control of movement
and the ability to maintain antigravity head and trunk postures. All
areas of motor function are limited. Functional limitations in sitting
and standing are not fully compensated for through the use of
adaptive equipment and assistive technology. At level V, children
have no means of independent mobility and are transported. Some
children achieve self-mobility using a power wheelchair with
extensive adaptations.

Results
• 38 children eligible
• 20 children seen (Nov 2006 to Dec 2007)
• 18 boys
• Ages 3-12 (mean 7)
• Paediatric nurses very supportive (essential
as knew children and parents very well)
• Parents very supportive of study and had no
problems with methodology.
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Bruises: n=32 in 12 children
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Marks: n=49 in 12 children
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Bruises and mobility (n=12)
Child’s Level of mobility on
GMFCS ( 1 – 5)
Number of bruises
5 1
5 2
5 2
5 5*
5 6*
4 7
4 2
4 1
4 1
2 2
2 2
1 1
* Children with involuntary movements
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Weight
≤ 0.4 centile >0.4 ≤50 centile >50 ≤98 centile
Number of
children
Number of
children with
bruises
Total number of
bruises
8 7 4
5 3 3
17 9 4
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Summary
• Non-ambulant children in this pilot had a
substantial number of bruises unlike nonambulant
able-bodied infants.
• The methodology was acceptable (although
time consuming) to children, their parents and
the examiners.
• The measuring template was easy to use.
• A multi centre study is being designed,
recruiting approximately 250 children, to
ascertain the prevalence and distribution of
bruising in children with cerebral palsy.
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