History and Clinical Examination :

To begin with, it is important to address the following questions in any child who is referred for bleeding. These include:

• Is it bleeding?
• If it is bleeding, then is it localized or generalized?
• If generalized, is it platelet type or coagulation type of bleeding?
• Is it congenital/hereditary or acquired disorder?
• What are the factors affected?
  
  

History and physical findings should enable the pediatrician to identify patients with a high likelihood of having a bleeding disorder. First of all, one needs to confirm whether there is true bleeding or is it some other lesion confused with bleeding e.g. fixed drug eruption, erythema nodosum, which may appear like ecchymoses. Fixed drug eruption appears at the same site each time a particular drug is taken. It does not change its color over time. Erythema nodosum occurs over extensor surfaces and are generally tender and red. Viral exanthem and mosquito bites may be confused with petechial rash; however petechial rash does not blanch on slide test. If it is bleeding, one needs to know whether it is local or generalized bleeding? If there is only a single site involved, it is more likely to be a localized bleeding rather than a generalized bleeding disorder. If epistaxis is from a single nostril and repeatedly from the same site, it is highly likely that there is a local cause for bleeding. On the other hand, if epistaxis is occurring from both the nostrils with or without evidence of bleeding from other sites it is likely a generalized disorder. If it is a generalized bleeding consider a bleeding disorder, but address the question is it congenital or acquired? Features of abnormal bleeding include a longer duration than routine bleeding episodes and more severe than routine bleeding. When a child has had previous surgery or dental extractions without bleeding complications, it is unlikely there is an underlying congenital hemorrhagic disorder.

The time of onset of symptoms is important. Acute onset over a period of days to weeks is suggestive of an acquired disorder, such as immune thrombocytopenic purpura (ITP) or vitamin K deficiency. Symptoms of a longer duration are indicative of a congenital disorder such as von Willebrand Disease (vWD) or coagulation-factor deficiencies. In case of infants with congenital coagulation disorders, bleeding manifestations sometimes occur at birth (following circumcision), appear in the first months of life (with immunizations) or most commonly, present when children become mobile and begin to experience mild trauma. Mild bleeding disorders may not become apparent until a person experiences surgery, dental extractions, trauma, or menstruation. In some children, bleeding with trauma is associated with good initial hemostasis, followed by a delayed oozing. This type of bleeding characteristically is seen with factor XIII deficiency and disorders of the fibrinolytic pathway.