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Sucking Bruises in Infancy

A Mimicker of Child Abuse
      To the Editor:
      Bruising is the most common manifestation of physical abuse,
      • Dubowitz H.
      • Bennett S.
      Physical abuse and neglect of children.
      and in pre-mobile infants is frequently associated with serious concurrent injury or future risk for serious or life-threatening injuries.
      • Sheets L.K.
      • Leach M.E.
      • Koszewski I.J.
      • Lessmeier A.M.
      • Nugent M.
      • Simpson P.
      Sentinel injuries in infants evaluated for child physical abuse.
      ,
      • Harper N.S.
      • Feldman K.W.
      • Sugar N.F.
      • Anderst J.D.
      • Lindberg D.M.
      Additional injuries in young infants with concern for abuse and apparently isolated bruises.
      Other etiologies of bruising in pre-mobile infants include underlying medical conditions
      • Patel B.
      • Butterfield R.
      Common skin and bleeding disorders that can potentially masquerade as child abuse.
      • Christian C.W.
      • States L.J.
      Medical Mimics of Child Abuse.
      • Kuehn B.M.
      AAP: consider blood disorders as well as abuse as cause of bleeding in children.
      (eg, leukemia) and witnessed accidental events. Rarely, infants can self-inflict bruises through forceful and repetitive sucking, commonly involving their forearms and hands, but reports describing this are limited.
      • Halpin-Evans R.
      • Wooding K.
      Did he really do that to himself?.
      • Venkata R.N.
      • Woolley C.
      Infantile sucking bruises.
      • Feldman K.W.
      • Tayama T.M.
      • Strickler L.E.
      • et al.
      A prospective study of the causes of bruises in premobile infants.
      Lack of familiarity with the appearance of self-inflicted sucking bruises may result in unnecessary medical and social services intervention, and their associated consequences. We describe a case of self-inflicted sucking bruises in a young infant.
      A healthy 3-week-old white female was referred to the emergency department for concerns about physical abuse after her primary care physician noted bruising on her right forearm. Two days prior, three bruises were noted on her right forearm after returning from a walk outdoors. Parents initially thought they were pressure marks from the infant carrier but became concerned when a fourth bruise appeared the next morning. The infant was born at term by uncomplicated vaginal delivery; she received vitamin K at birth and had an uneventful newborn nursery course. She was exclusively breastfed and receiving vitamin D supplementation. Her mother was not taking any medications. Family history was negative for bleeding disorders. Her parents were the sole caregivers.
      On physical examination, she was well-appearing. Her examination was unremarkable except for four curvilinear, erythematous bruises on the right lateral forearm (Figure).
      Figure thumbnail gr1
      FigureAnterior view of four curvilinear bruises over right lateral forearm.
      A complete blood count, coagulation profile, liver function tests, lipase level, head computed tomography scan without contrast, and a pediatric skeletal survey were normal. Hospital social work met with the family and no social concerns were identified. Parents reported that their daughter often sucked vigorously on her hands. A multidisciplinary team reviewed the case and concluded her bruises were consistent with sucking bruises of infancy. She was subsequently discharged home with her parents.
      To the best of our knowledge, our report here is one of only four in the literature to describe bruising in an infant due to self-inflicted sucking. Halpin-Evans and Wooding
      • Halpin-Evans R.
      • Wooding K.
      Did he really do that to himself?.
      described three breastfed infants ages 12 days to 4 weeks with unexplained forearm bruising. Two of the infants underwent complete medical and social evaluations for abuse, but self-inflicted sucking was accepted as a plausible explanation in all three cases. Venkata and Woolley
      • Venkata R.N.
      • Woolley C.
      Infantile sucking bruises.
      reported on a 4-week-old breastfed infant with forearm bruises who was filmed on his mother’s cell phone sucking on his forearm. Lastly, Feldman et al
      • Feldman K.W.
      • Tayama T.M.
      • Strickler L.E.
      • et al.
      A prospective study of the causes of bruises in premobile infants.
      briefly mention one infant who sustained a sucking bruise along the radial mid-forearm, but no further details are provided.
      Interestingly, numerous online parental support groups mention sucking bruises in infants.
      My baby gave himself a hickey
      BabyCenter website.
      However, the relative scarcity of similar reports in the medical literature can lead to unnecessary diagnostic testing, health care costs, parental anxiety, and involvement of child and family social services. We hope our report raises awareness among medical providers of this unusual manifestation of bruising in infancy.

      References

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        • Bennett S.
        Physical abuse and neglect of children.
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        • Sheets L.K.
        • Leach M.E.
        • Koszewski I.J.
        • Lessmeier A.M.
        • Nugent M.
        • Simpson P.
        Sentinel injuries in infants evaluated for child physical abuse.
        Pediatrics. 2013; 131: 701-707
        • Harper N.S.
        • Feldman K.W.
        • Sugar N.F.
        • Anderst J.D.
        • Lindberg D.M.
        Additional injuries in young infants with concern for abuse and apparently isolated bruises.
        J Pediatr. 2014; 165: 383-388.e381
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        • Butterfield R.
        Common skin and bleeding disorders that can potentially masquerade as child abuse.
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        • Christian C.W.
        • States L.J.
        Medical Mimics of Child Abuse.
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        • Kuehn B.M.
        AAP: consider blood disorders as well as abuse as cause of bleeding in children.
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        • Wooding K.
        Did he really do that to himself?.
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        • Woolley C.
        Infantile sucking bruises.
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        • Feldman K.W.
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        • Strickler L.E.
        • et al.
        A prospective study of the causes of bruises in premobile infants.
        Pediatr Emerg Care. 2020; 36: e43-e49
        • My baby gave himself a hickey
        BabyCenter website.