Multi-Agency Protocol for the management of bruising or other injury in babies and children who are not independently mobile

Warning

Scope

The purpose of this protocol is to provide all staff whose work brings them into contact with children and their families with a knowledge base and action strategy for the assessment, management and referral of children who are not independently mobile when they present with bruising or other concerning injuries or marks.

It is not always easy to identify with certainty whether a skin mark is a bruise. Practitioners should act in line with this guidance if they believe it is possible that the observed skin mark could be a bruise or could be the result of injury or trauma. 

While it is acknowledged that professional judgement must be exercised at all times, this protocol errs on the side of caution by requiring that all babies and children who are not independently mobile presenting with bruising or injury must be referred for a Consultant Paediatrician opinion.

This guidance must be read in conjunction with the Scottish Borders Child Protection Procedures

It is very unusual for babies who are not independently mobile to sustain bruising and/or injury accidentally, so bruising or injury in this group raises significant concerns about physical abuse.  

All bruising or injury to a non-mobile child, including older children who cannot move independently, requires assessment by a Paediatrician. 

Introduction

The protection and safety of children is everybody’s business.

Research shows that it is very unusual for babies who are not independently mobile to sustain bruises accidentally, so bruising in this age group raises significant concerns about physical abuse.

Studies suggest that young babies rarely have accidental bruises and there should be a clear explanation for these injuries.

National and local serious case reviews have highlighted the need for increased concern about bruising or injury in any child who is not independently mobile. It is important that any suspected bruising or injury is fully assessed, even if the parents provide an explanation for it. The younger the baby, the more serious the concern about how and why even very tiny bruises on any part of the child are caused.

There have been many cases in which an abused child’s first presentation is with a seemingly minor injury, but this has not been recognised as abuse and the child has gone on to experience serious harm. This highlights the importance of recognising abnormal characteristics of bruising in children, enabling early detection and preventing escalation of abuse with avoidance of serious abusive injury or death (Child Protection Evidence: Systematic review on bruising March 2020).

Health professionals should ‘suspect child maltreatment if there is bruising or petechiae (tiny red or purple spots) that are not caused by a medical condition (for example, a causative coagulation disorder) and if the explanation for the bruising is unsuitable… [including] bruising in a child who is not independently mobile.’ In such situations a healthcare professional ‘should refer the child… to children’s social care, following local multi-agency arrangements’ ( NICE Guidance).

As such, any actual or suspected bruising or other injury in a baby or child who is not independently mobile should be suspected as caused by physical abuse and needs to be assessed by a Consultant Paediatrician.

Parents or carers should be fully informed of reasons for the child protection referral and be included, as far as possible, in the assessment and decision-making process regarding their child, unless to do so would compromise the information gathering or pose a further risk to the child.

Although the majority of non-mobile children are babies, it is important to consider older children with a physical disability who are also non-mobile.

Definitions

Non-Independently Mobile: A child who is not yet rolling, crawling, bottom shuffling, pulling to stand, cruising or walking independently. This includes all children under the age of six months and most children under nine months. Please note that, while some babies can roll from a very early age, this does not constitute mobility. The term also includes children with a disability who are non-mobile.

Bruising: A collection of blood, visible to the naked eye as an area of discolouration, which has leaked into the surrounding tissues after vascular disruption. This occurs principally as a result of trauma, or occasionally as the result of a disease process. Typically, bruises are caused by blunt force trauma, although they may be associated with any type of impact and can accompany many different types of wounds.

Petechiae: A petechia is a small (<3 mm) red or purple spot on the skin or conjunctiva, caused by a bleed from broken capillary blood vessels. Petechiae cannot be pushed away using a glass spatula or a finger. Even under pressure, the reddening of the skin remains visible.

Birthmark: A birthmark is a permanent mark on the body that is present at, or soon after, birth – usually within the first month. Birthmarks can either be pigmented (coloured), hypopigmented (pale) or vascular (due to increased blood vessels in or under the skin). Some may blanch, but others may not and resemble a bruise.

These may not be present at birth and appear instead during the early weeks or months of life. Blue-grey spots (slate-grey naevus, formerly known as Mongolian blue spots) can look like bruising. Where a practitioner believes a mark is likely to be a birthmark but requires further advice to be certain, the practitioner should seek advice from a Consultant Paediatrician, who should arrange to see the child the same day. If there is still uncertainty, a referral should be made to Children and Families Duty Social Work.

Birth injury: Both normal birth and instrumental delivery may lead to bruising and to bleeding into the white of the eye (sub-conjunctival haemorrhage). However, staff should be alert to the possibility of physical abuse even within a hospital setting and follow this protocol if they believe the injury was not due to the delivery. Birth injuries should be documented by midwives caring for the infant and the handover to health visitors should include any birth injuries.

Sub-conjunctival haemorrhage (SCH): A subconjunctival haemorrhage (SCH) is bleeding occurring in the white of the eye. SCHs can be small and discrete or can cover the whole eye. They can occur in one or both eyes. A SCH is caused by rupture of blood vessels under the surface of the eye.

Self-inflicted injury: It is very rare for non-mobile infants to injure themselves. Suggestions that a bruise has been caused by the infant hitting themself with a toy, or hitting the bars of a cot, should not be accepted without detailed assessment by a Paediatrician and Social Worker. Sometimes, even when children are moving around by themselves, there can be concern about how a mark or bruise occurred and in these situations a referral should always be made to Children’s Services.

Injury from other children: It is unusual, but not unknown, for siblings to injure a baby. In these circumstances, the infant must still be referred for further assessment, which must include a detailed history of the circumstances of the injury and consideration of the parents’ ability to supervise their children.

Sentinel injuries are visible, minor, poorly explained injuries in young infants that raise concern about abuse. They may be a sign that another hidden injury is already present.

Physical Injuries in a non-independently mobile child

Physical injuries include:

  • Small, single bruises anywhere (e.g., on face, cheeks, ears, chest, arms or legs, hands or feet or trunk)
  • Bruised lip or torn frenulum (small area of skin between the inside of the upper and lower lip and gum) – See Appendix Oral Injury/torn Frenum in Young Children.
  • Lacerations, abrasions, or scars
  • Bite marks
  • Burns and scalds
  • Pain, tenderness or failing to use an arm or leg, which may indicate pain or discomfort and an underlying fracture
  • Small bleeds into the whites of the eyes (subconjunctival haemorrhage), or other eye injuries.

Occasionally an infant can be harmed in other ways, for example:

  • Deliberate/suspicious poisoning, which can present as sudden collapse or coma
  • Suffocation, which can present as collapse, cessation of breathing (apnoeic attack), bleeding from the mouth or nose.

Action to be taken on identifying an actual or suspected bruise or injury

If the child appears seriously ill or injured, emergency medical treatment should be sought immediately, without delay

  1. Any staff member (non-health) who identifies a bruise to a child who is not independently mobile should make a Child Protection Referral by telephone to the Children and Families Duty social work team without delay.

    Tel: 01896 662787 (business hours)
    Out of Hours: Emergency Duty Team 01896 752111
  2. Health Professionals should make a referral direct to the on-call Consultant Paediatrician for opinion/assessment. The Consultant will liaise directly with duty Child Protection Reviewing Officer (CPRO) at the Public Protection Unit or Emergency Duty Team (out with business hours) if there is a requirement to progress under Child Protection procedures.

The staff member making the referral should:

    • Record what they have seen and any explanation or comments offered by the parent(s)/carer(s), directly quoting their words.
    • Ensure that they have sufficient information to assist practitioners in responding to the referral. This includes basic details such as name, date of birth, address, details of parent(s)/carer(s) and any other relevant background information that is known at the time.
    • Where it is safe to do so, practitioners should explain to parent(s)/carer(s) why, in cases of injury in non-independently mobile babies and children, additional assessment and medical examination is requested and that a referral to Children and Families Social Services is required.

Give parent(s)/carer(s) a copy of the ‘Information for parents and carers: Bruising and injury in babies and children who are not independently mobile’ (appendix 4 )

Action if the child presents directly to the Emergency Department.

  • The child must be examined by an Emergency Department (ED) practitioner for immediate health needs.
  • The child should be referred to the on-call Consultant Paediatrician, available through switchboard, who will progress required medical assessments and discussions with Children and Families Duty Social Work, or Emergency Duty Team (EDT) out with business hours.

Action Following Referral

Children and Families Duty Social Work will liaise with the duty CPRO, Public Protection Unit to arrange an urgent paediatric assessment (unless this has already been done by the health professional making referral) and gather initial background information in relation to the family.

  • An Interagency Referral Discussion (IRD) will take place between Social Work, Police and health practitioners (Consultant Paediatrician and Child Protection Nurse)

  • If the child has not been seen, the IRD will co-ordinate arrangements for the assessment with the Consultant Paediatrician and agree whether a specialist medical examination or Joint Paediatric Forensic Examination is required, depending on the information shared

  • Arrangements should be confirmed regarding who will bring the child for assessment with the Paediatrician and exactly when. If necessary, a Social Worker will attend assessment with the family

  • The assessment will include a detailed history from the parent(s)/carer(s), review of past medical history and family history, including any previous reports of bruising, and enquiry about vulnerabilities within the family

  • Necessary investigations or treatment should be arranged promptly

  • Medical assessments should be recorded on the Child Protection Medical Proforma

  • The Consultant Paediatrician will liaise with Child Protection Nurses, Police and Social Work regarding the outcome of the assessment as soon as it is completed and decisions will be made about any additional child protection measures required

  • If admission to hospital is required, the child should be admitted to a visible space with the agreed level of supervision (agreed by the IRD decision-making group) to ensure the child is safe and that parenting is facilitated

  • Child protection procedures will be followed, and necessary actions taken, to ensure that both the presenting child and any other children at risk are safeguarded. This may include a Child Protection Order, alternative care arrangements and Police investigations

  • A full explanation should be given to the family regarding the outcome of the enquiry and assessment process

  • Following a full assessment of the child, if there are no concerns about child maltreatment/abuse, the child can be discharged. Arrangements for discharge should be discussed with IRD group to ensure coordinated planning
  • The Paediatrician should ensure that any follow-up and onward referrals are made as appropriate and parents have understood the decisions made

  • Information should be shared routinely with Health Visitors, the GP and other appropriate services

Appendix 1 Flowchart for bruising/injury in non-independently mobile children

Appendix 2 - Making a Child Protection Referral and seeking Advice

All referrals to Duty Children & Families Social Work should be directed to: Tel: 01896 662787 (business hours)

Out of Hours: Emergency Duty Team 01896 752111

All referrals should be followed up immediately by completing the Confirmation of Child Protection Referral form (see Scottish Borders Child Protection Procedures accessed at: http://onlineborders.org.uk/community/cpc)

Remember to email the Confirmation of Child Protection Referral form to the Duty Social Work Team and Duty Child Protection Reviewing Officer

Seeking Advice around Child Protection

NHS Borders Public Protection Team

Mon – Fri business hours

Tel: 01896 664580 (Public Protection Unit, Langlee, Galashiels)

On-call Consultant Paediatrician (24 hours per day)
Tel: 01896 826000 (Borders General Hospital)

Child Protection Reviewing Officer and Education Child Protection Officer (Mon-Fri 9am-5pm)

Tel: 01896 664159 (Public Protection Unit, Langlee, Galashiels)

Appendix 3 Oral Injury/Torn Frenum in Young Children

Key Evidence statements

  •  Young children do not commonly present with oral injuries. Accidental and inflicted causes should be considered.
  • Any part of the oral cavity can be injured due to physical abuse. Torn labial frenum, lip and oral bruising are the most reported abusive oral injuries.
  • A torn upper labial frenum (often referred to as frenulum) is described as the most common abusive injury to the mouth.
  • Any unexplained torn labial frenum should be fully investigated for physical abuse occult injuries.
  • Accidental causes of a torn labial frenum include falls or an accidental blow to the mouth.
  • Oral injuries due to physical abuse are usually caused by blunt force, which can present as an abrasion or contusion.
  • Where age was given, most children with intraoral injury due to physical abuse were less than five years old. Children < 1 year are particularly at risk.
  • Facial and intraoral injury have been described in 49% of infants and 38% of toddlers who have been physically abused.
  • The oral cavity should be examined in all cases of suspected physical abuse. Unexplained oral injuries with no history of trauma or inconsistent with history, or with other associated orofacial injuries, should be fully investigated and the possibility of an abusive cause considered.

(Oral Injuries: systematic review RCPCH 2023)

 

NB: Sexual Abuse can involve the mouth. Subtle signs of dental injury may be missed. If the examining Paediatrician is unsure the opinion of dental/orofacial surgical opinion should be considered

Appendix 4 Information for parents and carers: Bruising and injury in Babies and children who cannot move around by themselves (not independently mobile

You have been given this leaflet because your child has a bruise or injury.

Q.  Why are we concerned about your child’s bruise or injury?

A.  It is rare for children who cannot move around by themselves (independently mobile) to get a bruise or an injury during normal day-to-day activities such as feeding, nappy changing and normal handling.

A bruise may be related to an undiagnosed health condition. Bruising can also be due to deliberate injury.

Even when there is a simple explanation, it is important that your child is fully assessed.

Any professional who finds that a child who is not independently mobile is bruised or injured must take action. They are required to speak with a Paediatrician (children’s doctor) and Children’s Services (Social Worker).

Q. What will happen now?

A. We will arrange for your child to be seen by a Paediatrician as soon as possible (usually the same day). This assessment is normally carried out at the Borders General Hospital.

The Paediatrician will talk to you about your child, examine your child and decide whether to do any further tests. Tests can include blood tests, x-rays or scans. These tests can take time and may involve staying in hospital.

Q. Why does my child need to be seen by a Paediatrician?

A. A bruise can be a sign of a health condition. Sometimes, it also takes an expert to tell the difference between a bruise and certain types of birthmark. The Paediatrician will examine your child and discuss with you why there might be a bruise. The Paediatrician will rule out or diagnose an underlying health condition.

Q. Why do I need to be referred to Children’s Services?

A.  Although rare, bruising may be caused by deliberate injury. When this occurs, it is important to investigate as soon as possible so that we can support you and your family and protect the child. Referral to Children’s Services is not an accusation of wrongdoing.

Even if bruising is due to an accident, your family may benefit from advice and support on preventing accidents and improving home safety.

Q.  What will Children’s Services do?

A.  Children’s Services will make enquiries about you and your child. They will check whether you have received services from them in the past. They will also arrange to speak with you, either by phone or in person.

Children’s Services work closely with the healthcare team and Police. They will ask for information from your GP and Health Visitor. They will then discuss their findings with the Paediatrician and Police and decide together whether any further action needs to be taken. The Police may also want to speak with you

Q. I feel worried about this assessment.

A.  We understand that this can be very upsetting. However, the only way of picking up serious causes for bruising is to investigate every case of bruising in children who are not independently mobile.

You can be reassured that you will be treated respectfully and sensitively. Your explanations will be listened to. You will also be kept fully informed so that you know exactly what is going on and why. If you do not understand any part of the process and need further explanation, just ask the professionals involved. They can provide you with further information.

All professionals working with children are required to make sure that children are kept safe from harm. Where bruising or injury is not accidental, immediate steps can be taken to protect the child from further harm.

Q. What could the possible outcomes of the assessment be?

A. After a paediatrician and other agencies have considered all the information gathered, the following outcomes could occur:

No child protection concerns have been identified; no further action will be necessary.

Your child may need admission to hospital for further tests or examinations including taking photographs, bloods tests, X-rays and/or other scans, seeing other specialists. Your doctor will explain the reasons for this if they are needed.

There are child protection worries that need further assessment. This will be led by social work and the police.

It may be that immediate actions are required to keep your child/ren safe. Sometimes you will be asked who could supervise you with your baby and any other children during this time.

You will also be kept fully informed so that you know exactly what is going on and why. If you do not understand any part of the process and need further explanation, just ask the professionals involved. They can provide you with further information.

All Professional working with children are required to make sure that children are kept safe from harm. Where bruising or injury is not accidental, professionals will put a plan in place to protect your child from further harm.

 

Appendix 5 Paediatric Hospital Pathway

Editorial Information

Last reviewed: 01/08/2024

Next review date: 31/08/2026

Author(s): Pulman R, Ketteridge C Dr.

Version: Version 2

Author email(s): rachel.pulman@nhs.scot, Clare.ketteridge@nhs.scot .

Approved By: Paediatric CMT and Child Protection Delivery group

Reviewer name(s): NHS Borders Paediatrician’s and NHS Borders Public Protection Team .

References

Bruises in Infants and Toddlers those who don't cruise rarely bruise. Sugar NF et al. Archives of Pediatric and Adolescent Medicine (1999) 153: 399-403 https://jamanetwork.com/journals/jamapediatrics/fullarticle/346535

Child Protection Evidence: Systematic review on Oral Injuries 2023

Child Protection Scottish Clinical Guidelines: Bruising in Pre Mobile Infants December 2021

RCPCH Child Protection Companion. Paediatric Care On-line https://pcouk.org/ (access requires a subscription or RCPCH membership)

RCPCH Child Protection Evidence - Systematic review on Bruising https://www.rcpch.ac.uk/resources/child-protection-evidence-bruising

Hampshire, Isle of Wight, Portsmouth and Southampton. Protocol for the management of actual or suspected bruising or other injury in infants who are not independently mobile: February 2023.

Safeguarding Children and Young People: Roles and Responsibilities for Health care Staff. Intercollegiate Document. Fourth Edition

Sentinel Injuries in Infants Evaluated for Child Physical Abuse. Sheets LK et al Pediatrics (2013) 131: 701-707 5)

When to Suspect Child Maltreatment, NICE Clinical Guideline CG89 https://www.nice.org.uk/guidance/cg89