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The past medical history was positive for intermittent bruising normal for daily life including shin or lower arm bruising. He had no problems clotting after a cut and cuts/bruises seemed to heal as usual. The family history was also negative for bleeding problems except for the mother who needed a blood transfusion after birth of a sibling. She had no bruising or other bleeding problems herself. The review of systems was negative.
The pertinent physical exam showed a well-appearing male with normal vital signs and growth parameters. His general examination was normal including all mucous membranes. His skin showed one 5 mm bruise in the right lower abdomen and a 6 cm roundish bruise on the high right upper thigh near the hip. Both were brown/black and appeared to be about the same stage of healing. There was no obvious petechiae.
The diagnosis of abnormal bruising was made. Additional history revealed that the boy did carry a backpack that he did use the belt clip for. He also wore different belts with different belt buckles. The examiner did not feel that this was inflicted trauma and thought that although this could be unrecognized trauma from the backpack or belt buckles, that this possibly could be an unrecognized platelet or bleeding factor problem. The hematologist by telephone consultation agreed and asked that some labs be repeated (i.e. complete blood count with platelets, PT, PTT, fibrinogen, complete metabolic profile, uric acid, lactate dehydrogenase) but wanted to wait on other labs until they saw the patient. The repeated labs were normal and the patient was awaiting the consultation at 2 week followup.
Discussion
Bruising is a common question asked by families. The toddler and young child who is playing and commonly falling will have bruises on the shins which may worry the family. Other places where a person will have bruises or even abrasions or cuts will be prominences such as the hands, elbows, knees, nose, forehead and occiput of the skull. Bruising in places where it would be expected to try to mitigate a fall are also common such as the outside of the arm or shoulder. Bruising on the spine prominences may also be because of a fall or trying to mitigate one. Injuries may be not recognized such as a bruise on the upper thigh, hip or lower abdomen from hitting the corner of a counter/table with bruise’s placement depending on the height of the individual. A stick could poke someone in the abdomen who didn’t recognize it as they were doing yardwork. Bruises could be the first sign of an underlying problem too such as idiopathic thrombocytopenic purpura or cancer.
Non-accidental trauma is always a potential concern and the age of the child along with the area of the bruising can give clues. Non-mobile children are less susceptible to trauma overall. For any person injuries that appear patterned, clustered or in areas where they are likely to be grabbed or hit such as top of head, face, ears, arms and upper legs are more concerning. Additional injuries such as oral or genital injuries or any head trauma also are more concerning for non-accidental trauma.
The history and physical examination of a patient with a history of abdominal or easy bruising is very important and helps to direct the evaluation. Questions about the personal and family history of bruising or bleeding, along with medications and supplements that are consumed and overall dietary history can be very helpful. Of course many questions need to be asked about potential accidental or non-accidental trauma. Less common problems and those that are qualitative problems may be more difficult to identify and often need specialty consultation.
Potential causes of bruising include:
Learning Point
Initial laboratory evaluation can include:
Questions for Further Discussion
1. List common congenital platelet problems. A review can be found here and here
2. What are the different types of von Willebrand disease? A review can be found here
3. What are some of the presentations of non-accidental trauma and neglect? A review can be found here
Related Cases
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews. Information prescriptions for patients can be found at MedlinePlus for this topic: Bruises
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Akintoye SO, Mupparapu M. Clinical Evaluation and Anatomic Variation of the Oral Cavity. Dermatologic Clinics. 2020;38(4):399-411. doi:10.1016/j.det.2020.05.001
Patel B, Butterfield R. Common skin and bleeding disorders that can potentially masquerade as child abuse. American Journal of Medical Genetics Part C: Seminars in Medical Genetics. 2015;169(4):328-336. doi:10.1002/ajmg.c.31462
Shah SN, Fong H fai, Haney SB, Harper NS, Pierce MC, Neuman MI. Has This Child Experienced Physical Abuse?: The Rational Clinical Examination Systematic Review. JAMA. 2025;334(2):160. doi:10.1001/jama.2025.2216
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
Date
January 26, 2026
The past medical history revealed a history of grade I vesicoureteral reflux (VUR) that was being monitored by urology and which had improved from grade II that was diagnosed around birth. He was not on prophylactic antibiotics. He had not had any urinary tract infections diagnosed in the past when he had catheterized urine specimens for febrile illnesses. The family history was positive for his older brother with grade III VUR.
The pertinent physical exam showed a happy appearing toddler who was afebrile, had normal vital signs and growth parameters. His examination showed mild rhinorrhea.
The diagnosis of a toddler with likely viral illness was made, but because of the history, urology recommended to continue to perform urinalysis and culture with febrile illnesses. His mother agreed to the urine catheterization saying, “With his brother maybe needing surgery, I would rather do the cath and know if we need to give him antibiotics or do something else.” The laboratory evaluation of the urinalysis showed no signs of urinary tract infection and his culture eventually returned with no growth of pathogens.
Discussion
Vesicoureteral reflux (VUR) occurs when urine ascends from the bladder into the ureter. Primary VUR is the most common congenital anomaly of the urinary tract with an incidence of ~1%. Causes are abnormalities of the anatomic and/or physiological functions of the urinary collecting system. Abnormal reflux can cause serious problems including renal scaring or chronic kidney disease. Secondary VUR usually develops because of increased bladder pressure (e.g. posterior urethral valves, meatal stenosis, neurogenic bladder, etc.) or surgical procedures. VUR can also be transient such as bladder infections or bladder bowel dysfunction.
VUR is most commonly identified after a urinary tract infection (UTI), for follow-up of a previously diagnosed urogenital anomaly or screening of a sibling. UTIs are the most common presentation. Professional consensus recommends that males with first UTI should be evaluated for congenital anomalies of the urinary system and VUR. For females, some will also recommend this for first UTIs especially if there are risk factors for possible congenital anomalies or VUR, and it is recommended for recurrent UTIs. For most ages, males have a higher risk of VUR than females when presenting with a febrile UTI. Evaluation usually is renal ultrasound and may include voiding cystourethrogram (VCUG) or other studies.
Prenatal ultrasound often will identify hydronephrosis. This often resolves by birth or soon afterwards, but may identify continued VUR that needs monitoring or intervention. Resolution is more likely with younger ages (<1 year), lower grade of reflux, and asymptomatic presentation (i.e. prenatal hydronephrosis or sibling with VUR). Resolution for grades I-II are up to 80% but only 30-50% for grades III-IV during follow-up for 4-5 years. As noted, higher grades may not resolve and may require intervention to improve functional drainage and decrease the risk of renal scarring. Renal scarring is more likely in males, after repeated febrile UTIs and higher VUR grade.
VUR is graded based on the reflux into:
Examples of VUR on VCUG can be found here.
Learning Point
The risk for VUR in a sibling or child of a known VUR patient is high.
The European Association of Urology noted that “[s]iblings of children with VUR had a 27.4% (3-51%) risk of also having VUR, whereas the offspring of parents with VUR had a higher incidence of 35.7% (21.2-61.4%).”
Another study cites rates of 32% for siblings and 66% for parents. They also cite that “…VUR in siblings revealed that 52% had resolution of reflux after 18 months of followup, with yearly resolution rates of 28%.”
Questions for Further Discussion
1. What are potential complications of acute pyelonephritis? A review can be found here
2. What are causes of gross hematuria? A review can be found here
3. What are the most common organisms causing UTI in neonates, toddlers, school age children and teenagers?
Related Cases
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews. Information prescriptions for patients can be found at MedlinePlus for these topics: Ureteral Disorders and Urinary Tract Infections.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Mattoo TK, Mohammad D. Primary Vesicoureteral Reflux and Renal Scarring. Pediatric Clinics of North America. 2022;69(6):1115-1129. doi:10.1016/j.pcl.2022.07.007
Hari P, Meena J, Kumar M, et al. Evidence-based clinical practice guideline for management of urinary tract infection and primary vesicoureteric reflux. Pediatric Nephrology. 2024;39(5):1639-1668. doi:10.1007/s00467-023-06173-9
Update and Summary of the European Association of Urology/European Society of Paediatric Urology Paediatric Guidelines on Vesicoureteral Reflux in Children – ScienceDirect. Accessed October 6, 2025. https://www-sciencedirect-com.proxy.lib.uiowa.edu/science/article/pii/S0302283823032980?ref=pdf_download&fr=RR-9&rr=98a632a73b77accf
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
The family history revealed that her mother had menarche at age 13, and also had no abnormal gynecological or obstetric problems. The patient had a younger sister who was age 10 years. Her father’s pubertal history was unknown. There was a maternal aunt with “early onset” hypothyroidism. The review of systems was negative for pelvic or abnormal pain, large changes in weight, cold/heat intolerance, constipation, headache, visual changes, or galactorrhea. She also denied any abnormal eating patterns or excessive exercise.
The pertinent physical exam showed normal vital signs with her weight and height around the 50%. She had increased her height by approximately 9 cm in the past year. She was Tanner IV for breast and pubic hair. Her external genital examination showed normal structures including an open hymenal ring.
The diagnosis of a healthy female with likely normal progression of puberty was made. She and her mother were quite anxious and wanted testing. Her pregnancy test was negative, and hormonal levels were normal for age/pubertal stage. The patient’s clinical course 3 months later showed some spreading of pubic hair. One month later her mother sent a message to the office that menses had started. By age 15 years 0 months, she had normal menstrual cycling.
Discussion
There is a wide range of normal pubertal development and “normality” is a common question that both patients and families have. Breast budding and testicular enlargement onset can be less obvious but menarche is usually more obvious and therefore families become concerned when menarche doesn’t occur at the time they expect. Delayed puberty is onset of secondary sexual characteristics occurring > 2 standard deviations from the mean for gender, which in females is age 13 for breast development and 14 years for testicular development in males. Pubertal onset range is usually 8-13 years in females and 9-14 years in males.
Primary amenorrhea is “…no period by age 14 years in the absence of growth or development of secondary sexual characteristics, or no period by age 16 regardless of the presence of normal growth and development with the appearance of secondary sex characteristics.” Primary amenorrhea initial evaluation usually includes history, physical examination, along with pregnancy testing, thyroid stimulating hormone, follicle stimulating hormone, and luteinizing hormone testing. Bone age may also be considered especially if constitutional delay is being considered. Pelvic ultrasound to determine if there is a uterus and ovaries or other anatomic abnormalities can also assist in the early evaluation. Karyotyping, testosterone levels, and imaging of the brain/pituitary/hypothalamus may also be needed as part of the evaluation. Consultation with endocrinology and/or gynecology can also be helpful for both clinicians and families.
Learning Point
The differential diagnosis of primary amenorrhea includes:
(Note: percentages do not include delayed puberty and pregnancy)
Questions for Further Discussion
1. What are causes of secondary amenorrhea? A review can be found here
2. Patients with Turner’s syndrome can have what types of problems? A review can be found here
3. What are potential causes of linear growth delay? A review can be found here
Related Cases
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews. Information prescriptions for patients can be found at MedlinePlus for this topic: Menstruation
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Heiman DL. Amenorrhea. Primary Care: Clinics in Office Practice. 2009;36(1):1-17. doi:10.1016/j.pop.2008.10.005
Kanabolo D, Rodriguez J, Waggoner D, et al. A Phenotypic Female Adolescent with Primary Amenorrhea and Dysmorphic Features. Pediatr Ann. 2019;48(12):e495-e500. doi:10.3928/19382359-20191118-02
Garg A, Vash-Margita A, Simoni MK. Abnormal Puberty and Amenorrhea: A Review. Pediatr Ann. 2025;54(9):e294-e301. doi:10.3928/19382359-20250707-03
Marsh CA, Grimstad FW. Primary amenorrhea: diagnosis and management. Obstet Gynecol Surv. 2014;69(10):603-612. doi:10.1097/OGX.0000000000000111
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
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