Cumbria SCB Logo
Size: View this website with small text View this website with medium text View this website with large text View this website with high visibility

Introduction

Accidental bruising in a non-independently mobile baby is very rare

Any bruising (or a mark that might be bruising) in a baby or child of any age who is not independently mobile should raise concern and be subject to further enquiry by all professionals Unexplained bruising or any bruising in a child not independently mobile must always raise suspicion of maltreatment and should result in an immediate Referral the Safeguarding Hub and requires an urgent paediatric assessment.

It can be difficult to ascertain if bruising or skin lesions have been caused as a result of non-accidental injury (NAI) and a discussion must take place with the duty Consultant Paediatrician resulting in a clear decision about how to proceed.

Further discussion and advice should be sought from the Safeguarding Lead within your agency however this must not delay urgent medical treatment or any actions required to protect the child (or other children who may also be at risk).


Definition

Bruising is extravasation of blood in the soft tissues, producing a temporary, non-blanching discolouration of skin, however faint or small with or without other skin abrasions or marks. Colouring may vary from red/yellow/green/brown/purple and is not reliable in dating a bruise. Petechial bruising are red/purple non-blanching spots, less than two millimetres in diameter and often in clusters.

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. Babies and younger children are at increased risk of suffering significant harm if the bruising is non-accidental.

Children with a disability – bruising in a child who is not independently mobile by reason of a disability should result in further enquiry to rule out NAI. Disabled Children may have a higher incidence of abuse whether or not they are mobile.


Risks

Bruises

Bruising is the most common injury to a child who has been Physically Abused.

Bruising should prompt suspicion of maltreatment.

  1. In any child not independently mobile;
  2. Bruises seen away from bony prominences on soft tissue;
  3. Bruising to the head including face including the mouth, ears and neck. This is by far the commonest site of bruising in child abuse.

It is not always easy to recognise some marks as bruising – practitioners should take action in line with this protocol if they believe that there is a possibility that the observed skin mark could be a bruise or could be the result of injury or trauma. If in doubt seek medical advice and refer to Cumbria Safeguarding Hub.

CORE-INFO Bruises on Children July 2012, updated July 2014.

Situations of Particular Concern

Other risk factors that should raise concerns are;

  • Delayed presentation in reporting injury/seeking medical advice;
  • Admission of physical punishment by parents;
  • Inconsistent of absent explanation from parents/carers;
  • Associated family factors such as substance misuse, mental health problems and domestic abuse or an unrelated male in the household;
  • Other associated features of concern e.g. signs of neglect poor hygiene, presentation or nutrition;
  • Rough handling;
  • Difficulty in feeding/excessive crying;
  • Significant behaviour change;
  • Infant displays wariness or watchfulness;
  • Recurrent injuries or siblings having recurrent injuries;
  • Multiple injuries.

Facts on bruising

  • Bruising is related to mobility;
  • Children who are mobile sustain bruises from everyday activities and accidents;
  • Only one in five infants who is starting to walk by holding on to furniture has bruises;
  • Children have more bruises in the summer months;
  • Increased bruising with increased family size;
  • Bruising on the face is the commonest site for -accidental bruising but only 6% of accidental bruising occurs on the face.

To note:

  • No sex difference;
  • No socioeconomic differences.

Protection and Action to be Taken

Please see Appendix: 1 Flow Chart for the Management of Actual or Suspected Bruising in Babies and Children who are not Independently Mobile

Prioritise the child.

  • If the child or infant appears ill or injured (including head injuries) seek medical emergency treatment without delay. Arrange transportation via ambulance to the nearest appropriate hospital Emergency Department;
  • A contact to the Cumbria Safeguarding Hub should be made in accordance with the Multi-Agency Thresholds Guidance; the hub should contact the local police;
  • A referral to Children’s Social Care should be made either by Cumbria Safeguarding Hub or to the allocated Social Worker and their manager if there is bruising of any size, in any site in a baby or child who is not independently mobile;
  • Following the referral to Children’s Social Care the social worker must make a referral for a paediatric assessment and request that the child should be seen urgently;
  • Contemporaneous, comprehensive, accurate, dated timed records should be kept. A careful record of the carers/parents description of events and explanation for the bruising should be made in the notes. For health staff this includes the CWILTED risk assessment. In all cases mapping, description and recording of the size, colour characteristics, site pattern and number of bruises should be made on a body map -this needs to be sent with referral to Cumbria Safeguarding Hub to be shared with the paediatrician doing the assessment;
  • If there is a delay and the bruising has disappeared a referral to the Paediatrician is still required to assess for other injuries/ maltreatment or the possibility of an underlying medical condition;
  • The Paediatric assessment may include blood tests and a skeletal survey;
  • Liaison between the Paediatrician and Children Service’s is essential;
  • It is the responsibility of both Children’s Service and the Paediatrician to decide whether bruising is compatible with a NAI or not;
  • Other children within the family need to be considered in terms of their safety.

Implications for Practice

  • At all times the priority should be to ensure that any injury/condition has been medically assessed;
  • If in doubt refer for to the Cumbria Safeguarding Hub and ensure the child (or children) are safely transported to the Emergency Department;
  • Ensure that the voice of the child is heard through both non-verbal and verbal cues;
  • Birth injury can occur following a normal delivery or instrumental delivery, bruising could develop following birth and there could be minor bleeding into the eye;
  • New born baby; professionals should remain alert to the possibility of physical abuse even in a hospital setting;
  • Birth marks may appear at birth or may appear later on. Mongolian Blue Spot can look like 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, and should be included in the Child’s records.

  • Self-inflicted injury:- this is rare and the explanation of the injury should not be accepted without an assessment by Social Worker and paediatrician;
  • Injury from other children should also be referred for assessment which would include a consideration of the parent’s or carers ability to safeguard their children.


Appendix 1: Flow Chart for the Management of Actual or Suspected Bruising in Babies and Children who are not Independently Mobile

Click here to view Appendix: 1 Flow Chart for the Management of Actual or Suspected Bruising in Babies and Children who are not Independently Mobile



Amendments to this Chapter

In August 2016, this chapter was extensively updated and should be read in its entirety.

End.