Bruising: systematic review

Child Protection Evidence is a resource for clinicians across the UK and internationally to inform clinical practice, child protection procedures and professional and expert opinion in the legal system.

Review Group Acknowledgments


Bruising is the most common injury in physical child abuse. The main diagnostic dilemma is distinguishing abusive from non-abusive bruises and practitioners may still be asked to determine the age of bruises.

This systematic review evaluates the scientific literature on abusive and non-abusive bruising in children published up until January 2019 and reflects the findings of eligible studies. The review aims to answer two clinical questions:

  1. What characteristics of bruising suggest physical child abuse?
  2. Can a bruise be accurately aged?

The 2019 update found two new published studies relating to the characteristics of bruises that met the inclusion criteria.

There are a number of possible clinical findings suggestive of abuse. These including bruising in pre-mobile children, bruises that are seen away from bony prominences and bruises that carry the imprint of an implement used or a ligature.

Child protection agencies are required to determine the likely timing of when an injury occurred. Clinicians may still be asked to estimate the age of bruises based on a naked eye assessment of colour which is not possible. There is currently no scientific basis for estimating the age of a bruise from its colour.

Key findings

  • Bruising was the most common injury in children who have been abused. It is also a common injury in non-abused children, the exception to this being pre-mobile infants where accidental bruising is rare (0-1.3%). The number of bruises a child sustains through normal activity increases as they get older and their level of independent mobility increases.
  • Cases have been reported where bruising was a “sentinel injury” in children prior to the recognition of child abuse, highlighting the importance of recognising abnormal characteristics of bruising in children, enabling detection as early as possible and potentially preventing escalation of abuse with avoidance of serious abusive injury or death.
  • In the most recent update, two new studies relating to the characteristics of bruises that met the inclusion criteria have been published.
  • There is no change in the evidence that it is not possible to age a bruise based on a naked eye assessment. There is, however, an increasing body of literature addressing optimal imaging of bruises which is highlighted in the ‘other useful resources’ section.
  • This review highlights the importance of recognising characteristics of bruising in children to enable the correct identification of abuse.
Disclaimer: This is a summary of the systematic review findings up to the date of our most recent literature search. If you have a specific clinical case, we strongly recommend you read all of the relevant references as cited and look for additional material published outside our search dates.

Original reviews and content © Cardiff University, funded by NSPCC

Published by RCPCH March 2020

While the format of each review has been revised to fit the style of the College and amalgamated into a comprehensive document, the content remains unchanged until reviewed and new evidence is identified and added to the evidence-base. Updated content will be indicated on individual review pages.

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