Bruising in Babies and Children who are Not Independently Mobile
SCOPE OF THIS CHAPTER
This chapter highlights that babies who are not yet mobile, but are observed to have bruising, should be of particular concern in terms of child protection as the evidence shows this is very rare. Nevertheless, caution is advised even in children who are mobile: where there are concerns or doubts, a Consultant Paediatrician should be asked to evaluate the evidence. Emphasis is made on looking at any injury within the context of the child's social history and the parental/carer explanation. Also see: Section 3, Congenital Dermal Melanocytosis (Blue grey spots).
Section 5, What to do if Bruising/Unexplained Marks are seen on a Non-Mobile Child/Baby was updated in November 2020.This chapter is currently under review.
|1.1||This Multi-Agency Protocol is to be initiated by all staff to ensure the process for bruised babies and children who are not independently mobile are multi-agency with no delay regarding investigation.|
|1.2||Bruising is the commonest presenting feature of physical abuse in children. Recent Serious Case Reviews across the UK have indicated that staff working with children have sometimes underestimated or ignored the highly predictive value of the presence of bruising in children who are not independently mobile, (those not yet crawling, cruising or walking independently). As a result there have been a number of cases where bruised children have suffered significant abuse that might have been prevented if action had been taken at an earlier stage.|
|1.3||The NICE Guidance "When to suspect child maltreatment" (CG89, July 2009) states that bruising in any child not independently mobile should prompt suspicion of maltreatment.|
|1.4||This policy been developed for the assessment and management of bruising in children who are not independently mobile and the process by which such children should be referred to Children's Services and a Consultant Paediatrician for further assessment and investigation of potential child abuse.|
|1.5||All cases should be treated as non-accidental injury during investigation process.|
2. Research Base
|2.1||There is a substantial and well-founded research base on the significance of bruising in children. (See Cardiff Child protection Systematic Reviews, Core Info (Bruising)|
|2.2||Although bruising is not uncommon in older, mobile children, it is rare in infants that are immobile, particularly those under the age of six months. While up to 60% of older children who are walking have bruising, it is found in less than 1% of not independently mobile infants. The pattern, number and distribution of innocent bruising in non-abused children are different to that in those who have been abused.|
|2.3||Patterns of bruising suggestive of physical child abuse include:
|2.4||A bruise must never be interpreted in isolation and must always be assessed in the context of medical and social history, developmental stage and explanation given. A full clinical examination and relevant investigation must be undertaken.|
|2.5||The younger the child, the greater the risk that bruising is non-accidental and the further potential risk.|
|2.6||Mobile children: While accidental and innocent bruising is significantly more common in older mobile children, practitioners are reminded that mobile children who are abused may also present with bruising and suspicious injuries. If appropriate to the practitioner's role, knowledge and skills, they should seek a satisfactory explanation for all such bruising, and assess its characteristics and distribution, in the context of personal, family and environmental history, to ensure that it is consistent with an innocent explanation. In the event of an innocent explanation where the child and family require other support then an Early Help Assessment (see Early Help and Team Around the Child) should be carried out and the Team around the child (TAC) process implemented where appropriate.|
3. Congenital Dermal Melanocytosis (Blue grey spots)
Congenital Dermal Melanocytosis (Blue grey spotss), are flat, bluish to bluish grey, blue black or even deep brown skin markings that commonly appear at birth (or shortly thereafter). They appear commonly at the base of the spine, on the buttocks and back and can also appear on the shoulders and elsewhere. Blue grey spotss normally disappear 3 to 5 years after birth and almost always have disappeared by puberty.
Congenital Dermal Melanocytosis (Blue grey spotss) are benign markings and are not associated with any conditions or illnesses. See LSCP Congenital Dermal Melanocytosis Leaflet.
Congenital Dermal Melanocytosis (Blue grey spots) is a congenital developmental condition exclusively involving the skin. The blue colour is caused by melanocytes, melanin-containing cells, which are deep under the skin. Usually, as multiple spots or one large patch, it covers one or more of the lower back, the buttocks, flanks and shoulders. The condition is unrelated to gender; male and female infants are equally predisposed to Congenital Dermal Melanocytosis (Blue grey spotss).
Mongolian spots are most prevalent among infants of East Asian groups. Infants may be born with one or more Mongolian spots.
They also occur in:
- 90-95% of East African infants;
- 85-90% of Native American infants;
- 90% of Polynesian and Micronesian infants;
- 46% of Hispanic infants;
- 1-10% of Caucasian European infants.
Among those who are not aware of the background of Congenital Dermal Melanocytosis (Blue grey spotss), it may sometimes be mistaken for a bruise, possibly resulting in unfounded concerns about abuse. For this reason it is important to have a diagnosis confirmed by a doctor and the diagnosis documented in the child's record. This is usually diagnosed at birth and therefore should be recorded in the hospital discharge information in PHCHR (red book), however Congenital Dermal Melanocytosis (Blue grey spotss) can develop at a later date and therefore it is important to seek a diagnosis by the GP within 24 hours of it being discovered. (The practitioner should follow this up ensuring that the child was taken to the GP). If Congenital Dermal Melanocytosis (Blue grey spotss) is diagnoses then this should be recorded on the child's record and no further action is needed. If a diagnosis is not confirmed and the mark is still unexplained, then the processes described in section 5 should be followed by the GP.
Not Independently Mobile (NIM): a child who is not yet crawling, bottom shuffling, pulling to stand, cruising or walking independently. Includes all children under 6 months.
Bruising: discharge or escape of blood in the soft tissues, producing a temporary mark that does not disappear (non-blanching) when you press it, however faint and small with or without other skin abrasions or marks. This includes petechiae, which are red or purple non-blanching spots, less than two millimetres in diameter and often in clusters. A systemic review demonstrates that aging bruises is not accurate and should not be relied upon in child protection medicals (McGuire et al 2005).
Congenital Dermal Melanocytosis (Blue grey spotss), are flat, bluish to bluish grey, blue black or even deep brown skin markings that commonly appear at birth (or shortly thereafter). They appear commonly at the base of the spine, on the buttocks and back and can also appear on the shoulders and elsewhere. Congenital Dermal Melanocytosis (Blue grey spotss) normally disappear 3 to 5 years after birth and almost always have disappeared by puberty. See LSCP Congenital Dermal Melanocytosis Leaflet.
Children with a disability – bruising in a child who is not independently mobile, by reason of a physical disability, should result in further enquiry to rule out NAI. Disabled Children may have a higher incidence of abuse whether or not they are mobile.
5. What to do if Bruising/Unexplained Marks are seen on a Non-Mobile Child/Baby
|5.1||Discuss the bruise / unexplained mark with the parent /carer and enquire into its explanation, origin, characteristics and birth history(Any bruises/marks should be recorded in the child's red book). Detailed documentation of any such marks should be recorded and included in the referral to Children's Services Social Care, where there are concerns of a bruise or unexplained mark to a non mobile baby in line with Appendix 1: Pathway for Birthmark, Congenital Dermal Melanocytosis (Blue grey spots), Bruise or Unexplained Mark in a Child.
Health Practitioners should ensure accurate and careful documentation are made in the child's records. Services which utilise body maps must also describe the marks in the record.
|5.2||If the child has a twin or siblings, there must be careful risk management and paediatric assessment where appropriate.|
|5.3||Advise and explain to the parents/carers openly and honestly at an early stage why, in cases of bruising in non-independently mobile babies and children, additional concern, questioning and examination are required. Explain also the need to follow a protocol which is handled by the safeguarding team; this includes Social Care, the police and a paediatrician. This will assess the likelihood of non-accidental versus accidental injury and to arrange any necessary investigations to exclude a medical condition. The parents must be provided with the LSCP leaflet "Babies Bruises Be Concerned".|
|5.4||Where there is reasonable cause to suspect that a child is suffering or likely to suffer Significant Harm Children's Services Social Care should contact the police and convene a Strategy Discussion as per Working Together to Safeguard Children. Siblings must be considered in safety planning and medical assessment with a paediatrician.|
|5.5||The responsibility for arranging the paediatric medical remains with the Children Services Locality Social Care (FAST) team who should as a matter of priority contact the on-call Consultant Paediatrician (via secretary or on-call system).|
|5.6||Children's Services Social Care may choose to escort the child to the hospital and ask you to ensure the parents/carers are not left alone with the baby/child until a social worker arrives. Should the parents/carers not wish to allow this, inform the parents of the advice you have received. Should they remain adamant that they wish to leave or will not allow you to stay with them, then inform them that you will have to call the Police. If you have concerns about the personal safety of yourself or other staff or in relation to the safety of the child in these situations you should call the police immediately.|
|5.7||Record all discussions, decisions including a detailed description, and confirm your referral to Children's Services Social Care in writing as per the standard policy. A health professional (if involved) may also choose to speak to the paediatrician who will be doing the medical examination to explain your concerns and ensure they have all the relevant information This does not negate the medical professionals responsibility to make a safeguarding referral to Childrens Services Social Care where there is reasonable cause to suspect that a child is suffering or likely to suffer Significant Harm.|
|5.8||In the case of new-born infants where bruising may be the result of birth trauma or instrumental delivery, professionals should remain alert to the possibility of Physical Abuse even in a hospital setting. In this situation clinicians should take into account the birth history, the degree and continuity of professional supervision and the timing and characteristics of the bruising before coming to any conclusion. It is particularly important that accurate details of any such bruising should be communicated to the infant's general practitioner, health visitor and community midwife. If baby is still in the hospital setting post birth, where practitioners are uncertain whether bruising is the result of birth injury, they should refer immediately to the on-call Consultant Paediatrician. If concerns remain, a referral to Children's Services Social Care should be made. Wherever possible, the decision to refer should be undertaken jointly with the on call Consultant Paediatrician. However this requirement should not prevent an individual professional referring to Children's Services any child with bruising who in their judgement may be at risk of child abuse. If a referral is not made, the reason must be documented in detail with the names of the professionals taking this decision.|
|5.9||Any child who is found to be seriously ill or injured, or in need of urgent treatment or further investigation, should be referred immediately to hospital by ambulance (999). Such action should not be delayed by a referral to Children's Services Social Care; however, it is the responsibility of the professional first dealing with the case to ensure that a referral to Children's Services has been made.|
|5.10||In some circumstances General Practitioners (GP's) may decide to make a referral directly to the On-Call Paediatrician. Examples of circumstances are where the GP has a strong suspicion that the cause is organic as opposed to non-accidental. If the GP suspects non - accidental injury they should follow the same pathway - see Appendix 1: Pathway for Birthmark, Congenital Dermal Melanocytosis (Blue grey spots), Bruise or Unexplained Mark in a Child.|
6. Babies/Children Presenting at Accident and Emergency/Urgent Care/Out of Hours
|6.1||If the baby/child has been presented at a setting in an acute hospital, staff should ensure the child is reviewed promptly by the Consultant Paediatrician on call. A referral can then be made to Children's Services Social Care. All other sites should follow Section 4, What to do if Bruising/Unexplained Marks are seen on a Non-Mobile Child/Baby.|
7. Responsibility of Children's Services
Where a referral is made under the protocol, or where a bruise or unexplained mark is seen or reported on a non-mobile child/baby already subject to Social Care or Early Help involvement, Children's Services (Social Care) should, as a minimum:
8. Responsibility of On Call Consultant Paediatrician
Where a referral is made under the protocol, the On Call Consultant Paediatrician should, as a minimum:
Bruising – A systematic review. (September 2010) Welsh Child Protection Systematic Review Group.
Maguire S et al (2005) Can you age bruises accurately in children? A systematic review. Arch Dis Child; 90:187-189