Report Abuse Report Abuse

1.3.9 Bruising and Injuries in Babies and Children who are not Independently Mobile

SCOPE OF THIS CHAPTER

This procedure will outline the response that should be taken when a pre-mobile baby or a child not independently mobile (which may be due to a disability cognitive or physical) is found to have:

  • Bruising (no matter how minor);
  • Suspicious marks;
  • Injuries that are not developmentally appropriate.

For all of the above, this is regardless of explanation or cultural practice.

RELATED GUIDANCE

What to Do If You Are Worried a Child Is Being Abused – Advice for practitioners (DfE, 2015)

Working together to Safeguard Children, HM Government (2015)

Information Sharing – Advice for practitioners providing safeguarding services to children, young people, parents and carers (2015)

RELATED CHAPTERS

Responding to Abuse and Neglect Procedure

Referrals to Children's Social Care Services Procedure

Strategy Discussions Procedure

Section 47 Enquiries Procedure

Paediatric Medical Assessments Procedure

Conducting a Section 47 Investigation: Use of the Community Paediatric Service and Strategy Discussions Procedure


Contents

  1. Key Messages
  2. Introduction
  3. Definition
  4. Research Base
  5. Recommended action when bruising or injuries are found on a pre-mobile baby or not independently mobile disabled older child
  6. Responsibility of Children’s Social Care
  7. Responsibility of Paediatric Registrar
  8. Conclusion
  9. References and links

    Appendix 1: LPT Health Visitor (HV) Guidance For Assessing & Recording Skin Discolouration In Infants Under 1 Year

    Appendix 2: Protocol For Injuries In Pre-Mobile Babies Flowchart;

    Appendix 3: Body Chart


1. Key Messages

  • Bruising is the most common presenting feature in physical abuse in children;
  • The younger the child the higher the risk that the bruising is non-accidental, especially where the child is under the age of 6 months;
  • Bruising in any child ‘not independently mobile’ should prompt suspicion of maltreatment;
  • Bruising in any pre-mobile baby should prompt an immediate referral to Social Care, who will arrange an urgent medical examination by a paediatrician (All professionals must confirm verbal and telephone referrals in writing within 24 hours of being made);
  • Cultural practices should not be used as a defence for physical abuse.


2. Introduction

This protocol provides frontline multi-agency professionals with a knowledge base and strategy for the assessment, management and referral of pre-mobile infants who present with bruising or otherwise suspicious marks, and for children not yet independently mobile (this could be due to a disability).

Target Audience – All frontline staff.

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. (Ages of concern: learning lessons from serious case reviews – A thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011)

In the past, advice to frontline professionals was that referral to Children’s Social Care should be made if bruising in babies was not plausibly explained. However, in light of the increasing evidence base and learning from case reviews both local and national, advice to frontline professionals has changed and is necessarily directive:

Bruising or injuries in any pre-mobile baby must result in an immediate referral to Children’s Social Care, who will arrange an urgent medical assessment by a paediatrician.

Innocent bruising in pre-mobile babies is rare. It is the responsibility of Children's Social Care and the paediatrician together to decide whether bruising is consistent with an innocent cause or not.


3. Definition

3.1 Pre-mobile Baby

A baby who is not yet crawling, bottom shuffling, pulling to stand, cruising or walking independently. This includes all babies under the age of six months and most infants aged 0-1 years. The younger the child the greater the risk the bruising is non-accidental and the greater potential risk. Please be aware that pre-mobile babies are unable to roll independently.

3.2 Not Independently Mobile

Children with a disability – older children who are not independently mobile by reason of a disability should be considered. Disabled Children may have a higher incidence of abuse whether or not they are mobile. This procedure does not apply to children with a disability who are independently mobile in a wheelchair and who can give a consistent plausible explanation for accidental bruising.

3.3 Older Children

Some older children have not achieved independent mobility and therefore the assessment should take into account if there is a delay in development; if there is, they should be treated as not independently mobile.

3.4 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.


4. Research Base

4.1 Bruising

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)). The Cardiff Child Protection Systematic Reviews have collated research from many research papers on bruising in childhood and are recognised as the authority in this area. The website link above will provide more detailed information and useful leaflets for practitioners.

Although bruising is not uncommon in older, mobile children, it is rare in infants who are pre-mobile, 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.

Patterns of bruising suggestive of physical child abuse include:

  • Bruising in a child who is not independently mobile;
  • Bruises seen away from bony prominences on soft tissue;
  • Bruising to the head including face including the mouth, ears and neck. This is by far the commonest site of bruising in child abuse;
  • Bruises to the face, back, abdomen, arms, buttocks, ears and hands;
  • Bruising around genitalia or anus;
  • Multiple bruises and or in clusters;
  • Multiple bruises of uniform shape;
  • Bruises with petechiae (dots of blood under the skin) around them;
  • Bruises that carry the imprint of an instrument or ligature, for example around the neck;
  • Large bruises;
  • Other injuries noted such as scars, scratches, bites, burns, scalds or abrasion;
  • Mouth injuries in babies particularly torn frenulum may be an indicator of forced feeding;
  • Cultural practices, such as cupping (a therapy in which heated glass cups are applied to the skin along the meridians of the body, creating suction and believed to stimulate the flow of energy), can sometimes be abusive in nature but each case needs to be considered individually.

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.

The younger the child, the greater the risk that bruising is non-accidental and the further potential risk.

Numerous serious case reviews, held following death or serious injury to a child in connection with abuse or neglect, have identified situations where children have died because practitioners did not appreciate the significance of what appeared to be minor bruising in a pre-mobile infant. National analysis of reports published as ‘New learning from serious case reviews’ (Department for Education 2012) reiterates the need for ‘heightened concern about any bruising in any pre-mobile baby… any bruising is likely to come from external sources. The younger the baby the more serious should be the concerns about how and why even very tiny bruises on any part of the child are caused’.

4.2 Cultural Practice

Cultural practices, such as cupping (a therapy in which heated glass cups are applied to the skin along the meridians of the body, creating suction and believed to stimulate the flow of energy), can sometimes be abusive in nature but each case needs to be considered individually. In addition massage used by many different cultures should not cause any injury to a child.

4.3 Disabled Children

Research evidence suggests that disabled children are more vulnerable to abuse than non-disabled children. A large scale American study that examined records of over 40,000 children found that disabled children were 3.4 times more likely to be abused or neglected than non-disabled children. Disabled children were 3.8 times more likely to be neglected, 3.8 times more likely to be physically abused, 3.1 times more likely to be sexually abused and 3.9 times more likely to be emotionally abused. Overall, the study concluded that 31% of disabled children had been abused, compared to a prevalence rate of 9% among the non-disabled child population (Sullivan, P.M. and Knutson, J.F. (2000) Maltreatment and Disabilities: A Population Based Epidemiological Study. Child Abuse and Neglect, 24, pp. 1257-1273).

Research in the UK has been limited but a number of studies have indicated similar levels of abuse and neglect to that found in the US. Higher levels of maltreatment of disabled young people than their non-disabled peers were found in a study of 3000 young people aged 18-24 (Safeguarding Disabled Children Practice Guidance 2009 DFE).


5. Recommended Action when Bruising or Injuries are Found on a Pre-Mobile Baby or not Independently Mobile Disabled Older Child

5.1

Refer immediately ensuring the following information is included:

  • Discuss the bruise / suspicious mark with the parent /carer;
  • Enquire into its explanation, characteristics and history;
  • Detailed documentation of this should be recorded and included in the referral to Children’s Social Care;
  • Health practitioners should ensure accurate and careful documentation is made in the child’s records. Recording injury on a body map is best practice; these should be signed, dated and record time of documentation;
  • The body map should be forwarded with the referral to Children’s Social Care.
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 pre-mobile babies and non-independently mobile children, additional concern, questioning and examination are required. Also of 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.
5.4 Where there is reasonable cause to suspect that a child is suffering or likely to suffer Significant Harm, Children's Social Care should contact the police (Child Abuse and Investigation Unit, CAIU) and convene a Strategy Discussion to include health as per Working Together to Safeguard Children 2015. Siblings must be considered in safety planning and medical assessment.
5.5

The responsibility for arranging the medical remains with Children's Social Care. It is essential the response is timely and the on-call Consultant Paediatrician is contacted as soon as possible. Please see the Paediatric Medical Assessments Procedure in the LLR LSCB procedures for the process to follow for request of a medical both in hours and out of hours.

In hours 9-5pm, please dial 0116 295 2524.

Out of hours, ring UHL switchboard and ask for children’s admission unit for on-call paediatric registrar.

5.6 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 the inform social services. If you have concerns about the safety of the child or yourself or other staff 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 Social Care in writing as per the standard policy.
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 Neonatologist. If concerns remain, a referral to Children’s Social Care should be made. Wherever possible, the decision to refer should be undertaken jointly with the on-call Consultant Neonatologist. However this requirement should not prevent an individual professional referring to Children's Social Care 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. Ensure that all findings are recorded on a body map, signed, dated and timed.
5.9 Birth Marks: may appear at birth or may appear later on. Mongolian Blue Spot can mimic bruising. It is particularly important that accurate details of any of the above should be included on a body map and should be communicated to the infant’s general practitioner, health visitor and domiciliary midwife, which should be included in the child’s records. For Health Visitors, the Leicestershire Partnership NHS Trust has produced a useful flowchart – please see Appendix 1: LPT Health Visitor (HV) Guidance For Assessing & Recording Skin Discolouration In Infants Under 1 Year.
5.10 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). The Paramedics to ensure that the receiving A&E is aware of any safeguarding concerns. 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 Social Care has been made and the police are informed. It is also best practice for the on-call paediatric registrar in the children’s admission unit to refer to Children’s Social Care.
5.11

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 can then be made to Children’s Social Care.


6. Responsibility of Children’s Social Care

Where a referral is made under the protocol, Children’s Social Care should, as a minimum:

  • Take and record full details of the case;
  • Check whether the child or family is known to Social Care;
  • Inform the police (CAIU) in order to consider joint investigation and evidence collation if required;
  • Promptly contact the paediatrician and decide whether further action is needed and arrangements for the medical examination;
  • Convene a strategy discussion to decide whether to initiate Section 47 enquiries;
  • Record the decision;
  • Ensure the parents/carers remain informed as appropriate;
  • Inform the referrer and appropriate practitioners of next steps;
  • Notify the GP of injury and outcome.

Timescales for action are as per Working Together 2015


7. Responsibility of Paediatric Registrar

Where a referral is made under the protocol, the Paediatric Registrar 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 Social Care are informed in regard to the outcome of the initial assessment as soon as it is completed;
  • Medical assessments should be recorded and a report produced which can be made available to police and Social Care.
See: Appendix 2: Protocol For Injuries In Pre-Mobile Babies Flowchart.

Appendix 3: Body Chart.


8. Conclusion

Child abuse is often an ongoing process. If the diagnosis is missed, children may go on to be more seriously abused, which can prove fatal. Therefore it is vital that referral for pre-mobile and not independently mobile children is the default position in order to ensure the safety of children.


9. References and Links


Appendicies

Appendix 1: LPT Health Visitor (HV) Guidance For Assessing & Recording Skin Discolouration In Infants Under 1 Year

Appendix 2: Protocol For Injuries In Pre-Mobile Babies Flowchart

Appendix 3: Body Chart

End