Hello, That is a very good question. Anytime we see petechiae on a patient, it can mean internal bleeding. The flat dots that you see are broken capillaries that can be due to straining. Now you said her appetite is decreased. Is she sick in any other way? Does she have a cough or fever? Petechiae inside the mouth can be from prolonged coughing or vomiting. Does she take any daily medications? There are a handful of medications that can lead to petechiae and skin bruising. Lastly, when a child comes into the office with skin bruising and petechiae, I would typically do a blood test to check for a fungal, viral or bacterial infections. Those include Cytomegalovirus (CMV) infection, Meningococcemia, Mononucleosis, Rocky Mountain spotted fever, Scarlet fever and of course Sepsis. A bunch of those can be ruled out upon physical examination but blood testing would be best. I hope this helps and if you have any other questions, let me know. :-)