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2.2.15 Bruising in Non-Mobile Babies and Children

RELATED GUIDANCE

Bruises on Children (NSPCC)

RELATED CHAPTER

Paediatric Assessment for Section 47 Enquiry (Child Protection Medical) Procedure

This chapter was added to the manual in June 2017.


Contents

  1. Introduction
  2. Definition
  3. Process
  4. Action to Safeguard the Child
  5. Involving Parents or Carers
  6. The Medical Examination


1. Introduction

Any bruising, or a mark that might be bruising, in a child of any age who is not independently mobile, that is observed by or brought to the attention of any professional must 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. It should result in an immediate Referral to MASH (see Referring Safeguarding Concerns about Children Procedure and an urgent paediatric opinion.

On occasions it can be difficult to know if a skin lesion is suspicious or not - e.g. Mongolian blue spot, haemangioma. Where there is diagnostic doubt regarding the nature of a skin mark or lesion, an immediate discussion should take place between the referrer and a Paediatrician. A decision should then be made about whether to proceed to social care referral or obtain medical review (same day) of the lesion first.


2. Definition

2.1 Non-mobile or Not Independently Mobile

A child is considered non-mobile if they are not yet crawling, bottom shuffling, pulling to stand, cruising around furniture or walking independently; includes all children under the age of six months. An older infant or child with a disability with any of the risk indicators would also warrant careful consideration.

Non-Mobile: a baby (or older child with a disability) who cannot crawl, pull to stand, ‘cruise’ around furniture, or is toddling. Babies or children who can roll are classed as non-mobile for the purposes of this procedure. Professionals must use their judgement regarding babies who can sit independently but cannot crawl, depending on severity of the injury, the account of the parent or care giver and the plausibility.

2.2 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.

2.3 Physical Injuries

Any injury in a non-mobile infant or child causes concern of particular worry are injuries to infants six months and under. 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;
  • Bite marks;
  • Burns and scalds;
  • Pain, tenderness or failing to use an arm or leg which may indicate pain or discomfort 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.


3. Process

Any explanation for the injury should be critically considered within the context of:

  • The nature and site of the injury on the child;
  • The baby’s developmental stage and abilities;
  • The family and social circumstances including current safety of siblings/other children.

All people who live within the family home, including siblings and partners/significant others (such as aunts and uncles, grandparents, etc.) who do not live there but participate in any aspect of the child’s care, must be considered as part of the assessment.

Situations that should cause particular concern for professionals include:


4. Action to Safeguard the Child

Bruising in immobile babies and children is rare and must always result in an immediate consultation with MASH – see Referring Safeguarding Concerns About Children Procedure, Contact the MASH.

Where the baby is an open case to Social Care the practitioner should always contact the allocated Social Worker to make him / her aware of events and discuss any actions taken or required.

It is the responsibility of any partner agency practitioner who learns of or observes bruising on a non-mobile child to make the referral. Wherever possible, the decision to refer should be undertaken jointly with another professional or Named Professional or Designated Safeguarding Lead. However this requirement should not prevent a practitioner referring to Children's Services any child with bruising who in their judgement may be at risk of significant harm.

If a referral is not made, the reason must be documented in detail with the names of the practitioners taking this decision. All telephone referrals to MASH must be followed up in writing by completing a Multi-Agency Referral Form (MARF) within 24 hours – see Guidance for the Multi-Agency Referral Form (MARF).

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 potential maltreatment. Children should NOT be referred to GPs for a decision as to whether any ‘bruising’ is accidental or otherwise. A Strategy Meeting should be held to determine whether the child is at risk of Significant Harm. For more information see Strategy Discussions/Meetings Procedure.

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. Children's Social Care will co-ordinate multi-professional information sharing and assessment. For more information see Part 1.3, Assessment.


5. Involving Parents or Carers

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 or evidence 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.


6. The Medical Examination

For more information see Paediatric Assessment for Section 47 Enquiry (Child Protection Medical) Procedure.

The Paediatrician should take into account the developmental capabilities of the baby and all information provided when the cause of the injury is being assessed.

6.1 Accidental Cause

If the cause of the injury is assessed as accidental, the Paediatrician should still ensure that families of non-mobile babies are checked via MASH - see Referring Safeguarding Concerns About Children Procedure, Contact the MASH.

If the additional information suggests that the baby has been abused or neglected, or is at risk of significant harm, a referral to MASH should be made.

If after multi-agency checks it is judged that the injury is accidental but the baby already has an allocated Social Worker, the Paediatrician must ensure that the social worker is informed in writing of the outcome of the medical examination.

The Paediatrician must inform the referring professional and Primary Care (and other professionals as appropriate) of the outcome of the medical examination and of any support/safeguarding intervention being taken. This can be done via discharge summary.

6.2 Possible Non-Accidental Cause

The Paediatrician must take steps to immediately safeguard the baby if the injuries are assessed as non-accidental.

Where the baby is unknown to Social Care a referral should be made immediately. See Referring Safeguarding Concerns about Children Procedure. Discuss with the MASH Social Worker the outcome of the medical examination and any follow up action required. Both should be clear about what actions are to be taken and who is responsible for implementing these actions. Consider supervision of parent/carer on ward. See Contact between Parents and their Children in Hospital where there are Safeguarding Concerns Procedure.

A Strategy Meeting should be held as soon as possible – for more information see Strategy Discussions/Meetings Procedure.

If there is any disagreement between professionals regarding the safety of a child it must be resolved using the follow the escalation procedure as outlined in Practice Resolution Protocol: Resolving Professional Differences of Opinion in Multi-Agency Working with Children and their Families.

End