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1.3.10 Management of Marks of Concern in Pre-Mobile Babies and Non-Independently Mobile Children

SCOPE OF THIS CHAPTER

This procedure outlines the requirement to inform children’s social care when a pre-mobile baby (PMB) or a non-independently mobile child (NIMC) (which may be due to a disability cognitive or physical) is found to have marks and/or bruises

Considering the increasing evidence base and learning from both local and national case reviews, advice to frontline professionals is necessarily directive: It should always be taken into account that such marks are unusual and may be an indicator of child abuse regardless of whether there is an explanation about how the mark/bruise occurred.

This new chapter was added in April 2019.


Contents

  1. Target Audience
  2. Definitions
  3. In an Emergency
  4. Practitioners actions when Observing a Bruise or Mark on Pre-mobile Baby/ Child not Independently Mobile
  5. Contacting Children’s Social Care
  6. Children’s Social Care

    Appendix 1: Flowchart for Management of Concerns

    Appendix 2: Research Base

    Appendix 3: Related guidance, References and Links


1. Target Audience

All Frontline practitioners


2. Definitions

Pre-mobile Baby

A baby who is not yet rolling, 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.

Non-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.

Older Children

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


3. In an Emergency

Unexplained Bruising or marks on Pre-Mobile Babies and Non-Independently Mobile Children resulting in Seriously ill and/or Injured Babies or Children (who may require urgent medical treatment )should be referred immediately to hospital by ambulance (999).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.


4. Practitioners actions when Observing a Bruise or Mark on Pre-mobile Baby/ Child not Independently Mobile

Discuss the bruise/mark with the parent/carer;

  • Ask about the history of the mark:
    • When was it first noticed;
    • How did it first appear?
  • If it is reported this was an injury, ask:
    • What happened;
    • How it happened;
    • When it happened;
    • If anyone saw it happen;
    • What did they think about the injury and whether it was of concern;
    • What action they took at the time;
    • How the child responded to the incident and presented following this.

Work openly and honestly with the parents/Carers

  • Inform that you are required to make a contact with Children’s Social Care to share the information you have obtained and a decision will be made about what next steps should be taken;
  • If parents attempt to leave and you have concerns about the safety of the child or yourself in these situations you should call the police immediately.

Document all information

  • All practitioners should ensure accurate and careful documentation of all information is made in the child’s records;
  • Recording all marks found on the child on a body map is best practice; the date and time the marks were seen must be recorded on the body map including their size, shape and colour.

See guidance: Body Chart


5. Contacting Children’s Social Care

Any practitioner who finds any bruises/unexplained marks to a pre-mobile baby or non-independently mobile child, is required to make contact with Children’s Social Care to:

  • Engage in an initial professional discussion;
  • Share information;
  • Obtain background information;
  • Record and agree any necessary action in response to the presenting injury or mark.

This may include agreeing a time frame for health practitioners to seek information that clarifies whether the mark or bruise occurred during a medical procedure

See LLRSCB procedures


6. Children’s Social Care

On receipt of information from any agency /referring practitioner regarding an injury to a pre- mobile baby – including children with a disability CSC will record a contact and establish the actions taken by the referring agency. 

  • A manager will review the incoming information and ensure that timely decisions are made and authorised in line with statutory requirements;
  • As a minimum Children social care records will be checked and any background information considered;
  • Any additional enquiries with agencies who may have information to support robust decision making will be undertaken as directed by the manager;
  • Careful analysis of all available information provided by family and professionals will inform an initial decision.

Based on information shared if there are no safeguarding concerns and the explanation provided by parents supported by an additional information emerging from professional information sharing is accepted a shared decision will be made and the rationale recorded by involved agencies.

The outcome of the initial screening decision may at this stage result in no further action but this will only be the case if all agencies agree that there are no outstanding safeguarding concerns

In circumstances where the initial professional discussion of the presenting injury leads to reasonable cause to suspect that the child is suffering or is 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, and other bodies such as the referring agency as per Working Together to Safeguard Children 2018. Any siblings must be considered in safety planning and medical assessment.

See LLRLSCB procedure

In line with the procedure the outcome of the strategy discussion will inform any further action. This may include

  • No further Action;
  • Section 17 Assessment;
  • Section 47 enquiry.

See LLRLSCB procedures

When initiating Section 47 procedures it will be expected that a child protection medical is considered to assist an understanding of the presenting injury or mark.

See LLRLSCB procedure

Bruising in pre-mobile babies is rare. It is the responsibility of Children's Social Care and a paediatric medical lead together to decide whether bruising is consistent with an innocent cause or not.  A decision to take no further action in any presenting injury must never be taken by a single agency.


Appendix 1: Flowchart for Management of Concerns

Click here to view Appendix 1: Flowchart for Management of Concerns


Appendix 2: Research Base

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 common 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 is 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’.

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 several 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).


Appendix 3: Related Guidance, References and Links

Related Guidance

References and Links

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