4.35 Bruising Protocol for Immobile Babies and Children
For doctors in Pennine Acute Hospitals NHS Foundation trust please refer to NICE guidance When to Suspect Child Maltreatment.
In November 2015, additional information was added in to Section 1, Introduction and Context.
- Introduction and Context
- Definition of Terms used in the Procedure
- Involving Parents or Carers
Appendix 1: Supplementary Flowchart for use in Wigan
Any bruising, or a mark that might be bruising, in a child of any age who is not independently mobile, that is brought to the attention of any professional (including GPs) should be taken as a matter for inquiry and concern.
Unexplained bruising (or bruising without an acceptable explanation) in a child not independently mobile must always raise suspicion of maltreatment and should result in an immediate Referral to Children’s Social Care Services and an urgent paediatric opinion.
'It should be acknowledged that on occasions it can be difficult to know if a skin lesion is suspicious or not eg mongolian blue spot, haemangioma. Where there is diagnostic doubt regarding the nature of a skin mark or lesion, an immediate discussion should be had between the referrer and the Paediatrician on call or the child's GP. A decision should then be made about whether to proceed automatically to social care referral or obtain medical review (same day) of the lesion first.'
Any injury in a non-mobile infant causes concern. Of particular concern are injuries to infants six months and under.
Injuries to non-mobile infants
Any injuries are unusual in this age group, unless accompanied by a full consistent explanation. Even small injuries may be significant, and they may be a sign that another hidden injury is already present. Such injuries include:
- Small single bruises 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);
- Lacerations, abrasions or scars (see also section 2.5.6);
- Burns and scalds;
- Pain, tenderness or failing to use an arm or leg which may indicate pain and an underlying fracture;
- Small bleeds into the whites of the eyes or other eye injuries;
Occasionally an infant can be harmed in other ways, for example:
- Deliberate poisoning which can present as sudden collapse, coma
- Suffocation which can present as collapse, cessation of breathing (apnoeic attack), bleeding from the mouth and nose.
These infants are most at risk of serious deliberate harm and as such require careful consideration. Following the conclusions of three separate Serious Case Reviews, it has been decided that in the following situations, referral to Paediatrics should be AUTOMATIC:
Any evidence of physical injury in an infant aged SIX MONTHS AND UNDER, for example: bruise, thermal injury, clinical or radiological evidence of fracture, etc.
REMEMBER: An older infant with any of the above findings would also warrant CAREFUL consideration.
It is recognised that a small percentage of bruising in not independently mobile children will have an innocent explanation. Occasionally spontaneous bruising may occur as a result of a medical condition. Nevertheless because of the difficulty in excluding non-accidental injury, practitioners should seek advice from a consultant paediatrician via Children's Social Care Services in all cases. Child Protection issues should not delay the referral of a seriously ill child to acute paediatric services. If a child is in need of urgent medical care they should not delay sending them to hospital and the practitioner should inform social care so they can commence Section 47 Enquiries.
It is the responsibility of Children's Social Care Services in conjunction with the local acute or community paediatric department to decide whether the circumstances of the case and the explanation for the injury are consistent with an innocent cause or not. Children should NOT be referred to GPs for a decision as to whether any ‘bruising’ is accidental or otherwise.
SITUATIONS OF PARTICULAR CONCERN
Situations that should cause particular concern for professionals include:
- Delayed presentation / reporting of an injury;
- Admission of physical punishment from parents / carers, as no punishment is acceptable at this age;
- Inconsistent or absent explanation from parents / carers;
- Associated family factors such as substance misuse, mental health problems, and domestic abuse;
- Other associated features of concern e.g. signs of neglect such as poor clothing, hygiene and / or nutrition;
- Rough handling;
- Difficulty in feeding / excessive crying;
- Significant behaviour change;
- Infant displays wariness or watchfulness;
- Recurrent injuries;
- Multiple injuries at one time.
Not Independently Mobile: a child who is not yet crawling, bottom shuffling, pulling to stand, cruising or walking independently; includes all children under the age of six months. Children of an older age with a disability may also not have independence of mobility. For these children the loss of independent mobility may be permanent or it may be temporary and dependant on the condition and other factors. The loss of mobility may be complete or partial.
Bruising: 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 yellow, through green, to brown, or purple.
Bruising in immobile babies and children is rare and must always result in an immediate consultation with Children's Social Care.
It is the responsibility of the first professional to learn of or observe the bruising to make the referral. Wherever possible, the decision to refer should be undertaken jointly with another professional or senior colleague. However this requirement should not prevent an individual professional of any status referring to Children's Services 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.
All telephone referrals must be followed up in writing within 48 hours. Children's Social Care will co-ordinate multi-professional information sharing and assessment.
A bruise/injury must always be assessed in the context of medical and social history, developmental stage and explanation given. Assessments will be led by Children's Social Care and a lead medical professional (local acute or community Paediatrician) to determine whether bruising is consistent with the explanation provided or is indicative of non-accidental injury.
For contact details for each authority’s Children's Social Care please see Making Referrals to Children’s Social Care Procedure and Out of Hours Emergency Duty Teams.
As far as possible, parents or carers should be included in the decision-making process, unless to do so would jeopardise information gathering (e.g. information could be destroyed) or if it would pose a further risk to the child.
In particular staff and volunteers should explain at an early stage why, in cases of bruising in not independently mobile children, additional concern, questioning and examination are required.
If a parent or carer is uncooperative or refuses to take the child for further assessment, this should be reported immediately to Children's Social Care Services. If possible the child should be kept under supervision until steps can be taken to secure his or her safety.
Click here to view Appendix1: Supplementary Flowchart for use in Wigan.
Appendix 1: Supplementary Flowchart for use in Wigan