Bruising in Babies and Children who are Not Independently Mobile

1. Introduction

Bruising is the most common presenting feature of physical abuse in children. The NICE guideline ‘When to Suspect Child Maltreatment (Clinical Guideline 89, updated October 2017) states that bruising in any child ‘not independently mobile’ should prompt suspicion of maltreatment (See: NICE Guidance)

In the light of these findings this protocol has been developed for the assessment and management of bruising in non independently mobile babies and children and the process by which such children should be referred to Children’s Social Care, who will ensure a senior paediatrician sees the child for further assessment and investigation of potential child abuse.

This protocol is necessarily directive. While it recognises that professional judgment and responsibility have to be exercised at all times, it errs on the side of safety by requiring that all non independently mobile babies/children (including all babies under 6 months of age with bruising be referred to Children’s Social Care and for a senior paediatric opinion where there is no obvious medical cause.

Child maltreatment should be considered where bruises or injuries in children are unexplained, without an acceptable explanation, have a concerning presentation or involve a child that is not independently mobile. These concerns should result in a referral to Children’s Social Care.

Any bruising, injury or mark on the skin that might look like bruising, in a child of any age or where a child is not independently mobile, that is observed by or brought to the attention of any professional must be taken as a matter for inquiry and concern.

1.1 Unacceptable Explanation

For the purposes of this guidance, an unacceptable explanation is one that is implausible or inconsistent with the child or young person’s:

• Presentation;
• Normal activities;
• Existing medical condition;
• Age or developmental stage;
• Presentation and account given by parent/carer.

An explanation based on cultural practice is also unacceptable because this should not justify hurting or maltreating a child or young person.

1.2 Identifications of Birth Marks/Birth Trauma

On occasions it can be difficult to know if a skin mark is suspicious or not - e.g.

• Birth mark: blue grey spots, (congenital dermal melanocytosis) previously known as Mongolian blue spots;
• Haemangioma or marks that may be associated with recent birth trauma/delivery;
• Subconjunctival haemorrhage (SCH).

If the presenting concern is observed by a Health Practitioner, all health records should be reviewed to confirm if there is any known notification of the skin mark (i.e. clear documentation of a birth mark, SCH).

Where there is no known recorded explanation and therefore diagnostic doubt regarding the nature of a skin mark, and consideration to wider vulnerability factors have been excluded the health practitioner should follow Appendix 1: Pathway for Birthmark, Congenital Dermal Melanocytosis (Blue grey spots), Bruise or Unexplained Mark in a Child.

Where the observing Health practitioner:

• Has the clinical expertise and competence underpinned by additional training (e.g GP/ HV /Midwife/ Paediatric Nurse or Doctor) to recognise/identify birth marks in babies; and
• Is confident that the skin mark is a birth mark or Congenital Dermal Melanocytosis (Blue grey spots).

they should reassure the parent/carer and ensure that this is clearly recorded (using a body map) in the baby’s/child’s health record. Where there is any doubt regarding the presentation NOT being a birth mark, an immediate referral to children’s services should be made.

If the observing professional is not from health and therefore cannot confirm that the presenting skin mark is a birthmark they should contact children’s services for further advice.

2. Definitions

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.

Self-Mobile: This phrase refers to babies, who are to some degree independently mobile e.g., crawling, bottom shuffling, pulling to stand, cruising or walking independently. Please note however that some babies can roll from a very early age, and this does not constitute self-mobility.

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 a non accidental injury. Disabled children may have a higher incidence of abuse whether or not they are mobile.

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.

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 spots): 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 spots) normally disappear 3 to 5 years after birth and almost always have disappeared by puberty. See LSCP Congenital Dermal Melanocytosis Leaflet.

Subconjunctival Haemorrhage (SCH): is bleeding under the conjunctiva, the transparent layer that covers the sclera (white part of the eye). The bleeding is due to rupture and leaking of blood vessels in the conjunctiva and may occur as a result of a normal birth process or non-accidental head injury.

3. Research Base

There is a substantial and well-founded research base on the significance of bruising in children. (See Bruising: systematic review – RCPCH Child Protection Portal)

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.

4. Congenital Dermal Melanocytosis (Blue grey spots)

Congenital Dermal Melanocytosis (Blue grey spots is a congenital developmental condition exclusively involving the skin), 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 spots normally disappear 3 to 5 years after birth and almost always have disappeared by puberty. The condition is unrelated to gender; male and female infants are equally predisposed to Congenital Dermal Melanocytosis (Blue grey spots).

Congenital Dermal Melanocytosis (Blue grey spots) are benign markings and are not associated with any conditions or illnesses. See LSCP Congenital Dermal Melanocytosis Leaflet.

Key points to remember

When investigating children with unexplained bruising do not offer to the family or other witnesses any options or suggestions as to how the child or young person may have acquired the bruise. Ask open ended questions and avoid leading or providing explanations.

Bruises sustained during normal childhood activities and play in pre-school children who are mobile occur in characteristic locations on the body (e.g bony prominences) whereas bruises caused by physical abuse are seen in a different distribution and may have other characteristics such as occurring in clusters or being in a pattern.

The age and stage of development of the baby/young child are crucial considerations in forming a professional judgement as to whether a referral to social care and a strategy discussion is required. Bruising is strongly related to mobility, and as such injuries and bruising to a non-independently mobile child, raises a significant concern about the possibility of physical abuse. In this age group further investigations for hidden injuries are also likely to be undertaken.

It is not possible to age bruising in babies, children, and young people by looking at its shape or colour.

Consider the voice of the child, where appropriate

• Listen and record verbatim any explanation given by the young child;
• Observe the baby/child's demeanour and any interactions between the child and parent/carer.

Congenital Dermal Melanocytosis (Blue grey spots), may sometimes be mistaken for a bruise. For this reason, it is important to have a diagnosis confirmed by a doctor (paediatrician/ GP) 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 spots) 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 spots) is diagnosed 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 6 should be followed by the GP.

See Appendix 1: Pathway for Birthmark, Congenital Dermal Melanocytosis (Blue grey spots), Bruise or Unexplained Mark in a Child.

5. Subconjunctival Haemorrhages

A subconjunctival haemorrhage (SCH) is bleeding under the conjunctiva, the transparent layer that covers the sclera (white part of the eye). The bleeding is due to rupture and leaking of blood vessels in the conjunctiva and may occur as a result of:

• Normal birth process;
• Non-accidental head injury.

More rarely they may be caused by:

• Accidental head injury;
• Forceful vomiting or coughing;
• Bleeding disorders;
• Eye infection.

Subconjunctival haemorrhages are a frequent finding in otherwise healthy new-born babies and may be caused during vaginal delivery. The extent of the bleeding may be large or small but is always confined to the limits of the sclera (white of the eye). Babies often do not fully open their eyes until a few days old and therefore subconjunctival haemorrhage may not be noted initially. They are asymptomatic, do not affect the vision and resolve in ten to fourteen days following the birth of the baby, however professional judgement should be used as this timeframe is not an absolute cut-off.

When subconjunctival haemorrhage is observed by professionals it warrants a thorough and systematic assessment of the infant and review of all available information. The results of this assessment should then inform further action

See Appendix 2: Pathway for Subconjunctival Haemorrhage.

Where there is suspicion or evidence of physical abuse Section 8, Multi-agency Response Following a Referral Under this Protocol should be followed.

6. What to do if Bruising/Unexplained Marks are seen on a Non-Mobile Child/Baby

• 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 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 as soon as possible;
• In some circumstances General Practitioners (GPs) 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 make a referral to Children’s Social Care via the Customer Service Centre on 01522 782111 or Out Of Hours 01522 782333 prior to referral to the on-call paediatrician unless the child is medically unwell;
• Discuss the bruise / unexplained mark with the parent and/or carer and enquire into its explanation, origin, characteristics and the child’s birth history. Consider the voice of the child. Any bruises/marks should be recorded in the child's red book (PCHR);
• Practitioners should follow the pathway as outlined in Appendix 1: Pathway for Birthmark, Congenital Dermal Melanocytosis (Blue grey spots), Bruise or Unexplained Mark in a Child;
• Where it is identified that the non- independently mobile baby/child has a bruise or unexplained mark a referral must be made to children’s social care;
• The decision to refer may be undertaken jointly with another professional or senior colleague. However this discussion should not delay an individual professional of any status referring to Children’s Services any child with bruising who, in their judgement, may be at risk of child abuse. An individual practitioner must not be afraid to challenge the opinion of a colleague if they believe in their own judgement that a child might be at risk of harm;
• 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. by the safeguarding team; this includes social care, the police and a paediatrician. The parents should be provided with the LSCP leaflet “Bruising in Babies”;
• 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 you have not received contact within one hour of your referral to advise of Children’s Services next steps it is the referring practitioner’s responsibility to contact Children Social Care for an update via the Customer Service Centre on 01522 782111 or Out Of Hours 01522 782333;
• 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.

7. Babies/Children Presenting at Accident and Emergency/Urgent Care/Out of Hours

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 must then be made to Children’s Services Social Care. All other sites should follow Section 6, What to do if Bruising/Unexplained Marks are seen on a Non-Mobile Child/Baby.

• A referral will be made to children’s social care for all not independently -mobile babies (all babies under 6 months of age) with identified bruising. A strategy discussion will be immediately convened (see Section 8, Multi-agency Response Following a Referral Under this Protocol).
• If there is an urgent medical need for the baby / child, an emergency 999 ambulance transfer will be arranged by the Urgent Treatment Centre for the transfer to acute hospital for treatment/ review by paediatrician.
• Whilst awaiting the outcome of the strategy discussion, the child and family should be retained within the department and supervised. Should they leave the department, the police / children’s services should be alerted.
• Following completion of the strategy discussion the outcome will be informed to the referrer of the actions agreed and plan. If the referrer has not received this outcome within 1 hour of the referral being made, they should re contact Children’s services. The agreed plan from the strategy discussion will include transportation to the hospital for the paediatric medical to be completed.
  (Where the contact has been made to Out of Hours via telephone consultation the above steps should be undertaken);
• In this situation it would be the expectation for the Clinician to direct the parent to take the baby to the nearest Urgent Treatment Centre / Emergency Department for a face-to-face contact and assessment to be completed. It is the responsibility of the clinician to contact the Urgent Treatment Centre / Emergency Department to inform them of the concerns and reasons for attendance and that children’s services / police will be required to be informed if the baby is not presented for assessment.
• If from the telephone assessment the clinician has concerns for the baby’s urgent medical need an emergency 999 ambulance transfer will be arranged by the clinician for the transfer to this setting. If the parent refuses an immediate referral to children’s services is required.
• If, however the parents have been directed to attend the A&E department, the practitioner is responsible to make contact with that department to advise of the details of the child, parents and issues of concern regarding the injury. If the child and family fail to attend as instructed, referrals to Police and update to children’s services are required for safe and well assessment.

8. Multi-agency Response Following a Referral Under this Protocol

• Children’s Social Care (CSC) will take any referral made under this protocol as requiring further multi-agency investigation. CSC will initiate Section 47 enquiries if needed and will involve all appropriate agencies such as police and health (this should include the referrer if a health professional and/or hospital paediatrician if the child is an inpatient in the hospital) as per protocol;
• If the meeting concludes the threshold for section 47 is met, then a Child Protection medical should be arranged;
• As there is a potential of issues regarding the decision to hold a medical, the obtaining of consent, communication difficulties or other factors which may make the paediatric medical examination complex then the consultant paediatrician should always be invited to the initial strategy discussion via the hospital switchboard;
• The discussion should involve the development of an interim safety plan for the child and consideration of siblings and transport/supervision arrangements for the child;
• The child protection medical should only be carried out during a section 47 investigation and can only be undertaken by a paediatrician. It cannot be undertaken by the family G.P or other medical professional;
• Siblings must be considered in safety planning and medical assessment with a paediatrician;
• The responsibility for arranging the paediatric medical remains with Children’s Social Care who should as a matter of priority contact the on-call Consultant Paediatrician (via the hospital switchboard - Lincoln County Hospital 01522 512512/ Boston Pilgrim Hospital 01205 364801).

9. Responsibility of On Call Consultant Paediatrician

Where a referral is made under the protocol, the On Call Consultant Paediatrician should, as a minimum:

• Decide, with Children’s Social Care, arrangements for and management of the medical examination
• The Consultant Paediatrician ensures that Children's Services Social Care are informed regarding the outcome of the initial assessment as soon as it is completed recognising that a final report will depend on the completion of all investigations, the timing of which may not be under the control of the paediatrician.
  Please note that where a skeletal survey is required this is a two-stage assessment approximately 14 days apart and final medical opinion cannot be provided until conclusion of this assessment.
• Medical assessments must be recorded and a written provisional report will be made available to police and Children’s Social Care at the time of the child protection medical examination.
• A comprehensive type written report with a full professional opinion will be dispatched to social care and the police if involved within 10 working days of the child or young person being seen. This may need to be provided sooner if needed for a court hearing.
• The consultant paediatrician ensures Children’s Social Care and other agencies are informed, if any of the medical investigations raise new concerns or identify new injuries. The Consultant Paediatrician ensures Children’s Social Care and other agencies are informed if the medical examinations cannot be completed for any reason and they are concerned about this. There will then be consideration of another Strategy Discussion to consider next steps.

10. References/Resources

• Bruising: systematic review – RCPCH Child Protection Portal;
• NSPCC 2011, All Babies Count: prevention and protection for vulnerable babies;
• Child Protection evidence: Systematic Review on Bruising (RCPCH 2020);
• Not making a referral after bruising to non-mobile babies – SCIE;
• Child Protection Evidence Systemaic Review on Bruising;
• Child maltreatment: when to suspect maltreatment in under 18s (NICE guidance 2017).

Appendices

Appendix 1: Pathway for Birthmark, Congenital Dermal Melanocytosis (Blue grey spots), Bruise or Unexplained Mark in a Child

Appendix 2: Pathway for Subconjunctival Haemorrhage