Bruising, Marks, or Injury of Concern in Pre-Mobile Babies and Non-Independently Mobile Children
SCOPE OF THIS CHAPTER
This procedure outlines an assessment process for practitioners to determine 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 bruising, marks, or injury.Frontline professionals need to take into account the increasing evidence base and learning from both local and national case reviews, that such bruising, marks, or injury are unusual and may be an indicator of child abuse regardless of whether there is an explanation about how the bruising, marks, or injury occurred.
This chapter was amended throughout in June 2022 and should be reread.
1. Target Audience
All Frontline practitioners, managers, and practitioners with supervisory responsibilities.
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, mark or injury is non-accidental and the greater potential risk.
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, marks, or injury.
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.
Sub-conjunctival haemorrhages in newborn babies
Subconjunctival haemorrhages are normal physiological occurrences in newborn infants up to and including 14 days post birth, therefore isolated Subconjunctival haemorrhages are exempt from the actions required by the Management of Bruising, Marks, or injury of Concern in Pre-Mobile Babies and Non-Independently Mobile Children Procedure.
Subconjunctival haemorrhages seen after day 14 post birth, and in the absence of previous documentation by a health professional, require assessment in line with the Management of Bruising, Marks, or Injury of Concern in Pre-Mobile Babies and Non-Independently Mobile Children Procedure.
A sub-conjunctival haemorrhage 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. Sub-conjunctival haemorrhages are a frequent finding in otherwise healthy new-born infants and may be caused by rupture of sub-conjunctival vessels during delivery. The extent of the bleeding may be large or small but is always confined to the limits of the sclera. They are asymptomatic, do not affect the infant's vision and usually resolve in ten to fourteen days.
3. In an Emergency
Unexplained bruising, marks or injury to 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).
4. Non-Urgent Case
Many parents /carers seek advice by telephoning unscheduled health care (including 111 and their GP Practice) to report a bruise, mark, or injury. Following a telephone consultation by a clinician Parents may be advised depending upon the nature of the injury to take the baby to the most appropriate health care setting for examination. It is not the responsibility of the agency receiving the telephone call to notify Children's Social Care.
It is the responsibility of the professional first observing the bruise, mark, or injury to conduct the assessment in line with this procedure and notify/refer as appropriate Children's Social Care.
However, phone calls by parents that raise safeguarding concerns will be managed by the individual agencies internal safeguarding procedures.
5. Practitioners actions when Observing a Bruise,Mark, or Injury to a Pre-mobile Baby/ Child not Independently Mobile
Practitioners are to assess, and record information obtained from the following 4 areas of the assessment process (the assessment below is available in Appendix 3: Practitioners actions when Observing a Bruise, Mark, or Injury to a Pre-mobile Baby/ Child not Independently Mobile as a table for practitioners to print off or save and make notes):
|1||Vulnerability risk factors, (see Appendix 2: Contributory Vulnerability Factors in the Identification of Abuse)|
|2||The type of injury (see Appendix 4; Bruising, Marks and Injury: research base for determining Concern)|
The developmental stage of the baby/child:
The age and stage of development of the child are crucial considerations in forming a professional judgement as to whether a referral to social care and a strategy discussion is required.Accidental bruising is strongly related to mobility, and as such injuries and bruising to a non-independently mobile child, such as a baby who is not yet crawling, bottom shuffling or cruising, or child with a disability and who is not able to move independently, raises a concern about the possibility of child abuse.
|4||The Parent/carer explanation: Ask and record the parent/carer response about the history of the bruise, mark, or injury (ask open questions):|
|a||When was it first noticed?|
|b||How did it first look/appear?|
|c||How did it happen?|
|d||When did it happen?|
|e||Where did the incident occur?|
|f||If anyone saw it happen?|
|g||What did they think about the bruise, mark, or injury, were they concerned?|
|h||What action they took at the time?|
|i||How the baby/child responded?|
|j||Was the baby cared for by anyone else recently? - Record name of additional carers.|
|k||Observe the baby/child's demeanour and any interactions between the child and parent/carer.|
|l||Where possible and practicable further examine the child.|
- If practitioners are not satisfied with the assessment outcome and parental response – and the mark, injury or bruise, no matter how small, continues to raise suspicion and concern, an immediate contact with Children’s Social Care is required to discuss the information recorded and determine if further action is required. This should include agreement on feedback to the family/carers.
NB Where the mark may be due to birth trauma/medical intervention, contact must be made to the relevant hospital / UHL Safeguarding Children Team by Social Care to clarify this information from hospital record.
Practitioners are to undertake the following procedure:
- Work openly and honestly with the parents/Carers;
- Inform them that you are required to contact 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;
- Where practitioners do not feel competent to undertake the assessment –seek advice from Senior colleagues agency safeguarding leads, and or Childrens Social Care. Make a (referral to Children's Social Care as appropriate following these discussions;
- If practitioners consider that the above assessment provides a reasonable explanation, there will be no requirement to notify Children's Social Care;
- Always share information about the bruise, mark or injury with lead practitioners who are currently working with the family, this includes those in receipt of Early Support/ Early Help, Child in Need, Child Protection Plans and Looked After Children; Health Visitors and Midwives to triangulate the information to determine concern. This is regardless of parental explanation.
East Midlands Ambulance Services will continue to refer all pre-mobile babies and non-independently mobile children with bruises, marks, or injuries to Children's Social Care regardless of parental information as an immediate referral.
Leicestershire Police will consider both immediate safeguarding and referral mechanisms should officers identify injuries to any child following deployment to any incident. Where a child is considered to be at risk of immediate significant harm, consideration will be given to taking the child into police protection under section 46 of the Children's Act. In all cases officers will refer concerns to the Child Abuse Investigation Unit's Child Referral Team, either dynamically or by means of the Public Protection Notification process, who will in turn refer these to Children's Social Care via the appropriate route based upon risk and urgency.
Following the assessment practitioners are to document their decision making with clear rationale.
- 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
6. Children's Social Care
On receipt of information from any agency/referring practitioner regarding an injury to a pre-mobile baby or non-independently mobile child – 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 Leicester, Leicestershire and Rutland Safeguarding Children Partnership Procedure:
- Strategy Discussions 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 Leicester, Leicestershire and Rutland Safeguarding Children Partnership Procedure:
- Section 47 Enquiries Procedure.
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 Leicester, Leicestershire and Rutland Safeguarding Children Partnership procedure:
Bruising, marks, or injury in pre-mobile babies and non-independently mobile children is rare. It is the responsibility of Children's Social Care and a Paediatric medical lead together to decide whether bruising, marks or injury 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: Bruises, Marks and Injuries of Concern in Pre-Mobile Babies and Non-Independently Mobile Children Flowchart
Appendix 2: Contributory Vulnerability Factors in the Identification of Abuse
- Parent/carer delay in seeking medical advice;
- Was the bruise found incidentally during another contact or appointment (e.g. whilst giving immunisations);
- Inadequate explanation or unlikely (e.g. bruising on the chest from rolling onto a dummy);
- Explanation inconsistent over time or confused;
- Inconsistent with the child's development stage (e.g. sustained when rolled off bed when child not yet rolling);
- Is the bruise unexplained (especially in a baby or young child or with a significant injury);
- Involving other children or animals;
- Lack of parental supervision (including despite previous professional advice);
- Repeated episodes of presenting with bruises, marks and injuries;
- Risk factors: domestic abuse, mental health, substance abuse.
Share information with lead practitioners who are currently working with the family, this includes Early Support /Early Help, Health Visitors, Midwives to triangulate the information to determine concern.
Appendix 3: Practitioners actions when Observing a Bruise, Mark, or Injury to a Pre-mobile Baby/ Child not Independently Mobile
Appendix 4: Bruising, Marks and Injury: research base for determining Concern
There is a substantial and well-founded research base on the significance of bruising in children. The collated research from many research papers on bruising in childhood. This work is now overseen by the Royal College of Paediatrics and Child Health on their Child Protection Evidence Portal. See Bruising: systematic review - Child Protection Evidence.
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, and non-independently mobile children of any age. 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/face including the mouth, ears and neck;
- 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;
- Large bruises;
- Other injuries noted such as scars, scratches, bites, burns, scalds or abrasion;
- Mouth injuries in babies particularly unexplained 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;
- Bruising, marks or injury that may be due to the misuse of equipment;
- Bruises and marks in the shape of a hand, ligature, stick, teeth mark, grip or implement, for example around the neck.
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 a child's death may have been preventable had practitioners appreciated 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'.
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 5: Related Guidance, References and Links
- What to Do If You Are Worried a Child Is Being Abused – Advice for practitioners (DfE);
- Working Together to Safeguard Children - A guide to inter-agency working to safeguard and promote the welfare of children;
- Information Sharing – Advice for practitioners providing safeguarding services to children, young people, parents and carers;
- Bruising: systematic review - Child Protection Evidence.
References and Links
- CORE-INFO: Bruises on Children: NSPCC/Cardiff core-info (updated 2012);
- 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;
- Sullivan, P.M. and Knutson, J.F. (2000) Maltreatment and Disabilities: A Population Based Epidemiological Study. Child Abuse and Neglect, 24, pp. 1257-1273;
- New learning from serious case reviews: a two year report for 2009-2011 DfE;
- Safeguarding disabled children: Practice guidance 2009 DfE;
- Working together to safeguard children: A guide to inter-agency working to safeguard and promote the welfare of children.