In January 2022, this chapter replaced the previous chapter entitled 'Bruising in Pre-Mobile Babies'.
Information was also added on Referring to Social Care and additional guidance was added into Further Information.
- What is the Aim of this Guidance?
- Who is this Guidance for?
- What is a Bruise?
- Why are We Worried about Bruises?
- What Factors are Important in Distinguishing Bruises Sustained through Normal Childhood Activity and Play from Physical Abuse?
- When to Refer?
- Strategy Discussion
- What is Required to Facilitate the Paediatric Medical Examination?
- Managing Differences of Opinion
- Further Information
1. What is the Aim of this Guidance?
Bruising is the commonest injury encountered when children have been physically abused, however, children will always sustain bruises in the course of normal childhood activities and play. There are some skin markings that can look similar to bruises and there are medical conditions that can cause bruising. This guidance aims to assist practitioners to:
- Understand the importance of bruising in babies and young children (less than two years of age) as an indicator of physical abuse;
- Clarify the arrangements between health and social care colleagues in relation to the investigation of bruising in children and young people.
2. Who is this Guidance for?
All professionals who work with children, young people, families, and carers. This guidance should be read alongside the NSCP/NCSCP Pathway for non-mobile baby with bruising or a suspicious mark.
3. What is a Bruise?
A bruise occurs when the blood comes out of the blood vessels into the soft tissues, producing a temporary discolouration of the skin, which is non blanching (i.e., does not fade when pressure is applied to the skin). The discolouration may be faint or small with or without other skin abrasions (scrape or graze to skin) or marks. The colour may vary and it is not possible to give any opinion on when an injury happened to cause a bruise from looking at its shape or colour.
It is sometimes difficult to distinguish between a bruise and another mark to the skin, such as a birthmark. Reviewing other sources of information (e.g., Parent Child Health Record (red book), SystmOne, asking the parents to look at earlier photos which show the mark) may make things clearer. Sometimes looking at whether the mark changes over time is the only way to be clear about this – bruises will change and fade over days whereas a birthmark will usually stay the same size and colour during this period. Where there is doubt as to the nature of a mark that may be a bruise, it is important that the baby is kept safe whilst further clarification is sought. In certain cases, this may involve a less experienced health care professional requesting advice / second opinion from a more experience practitioner within their own clinical or safeguarding team. If there remains reasonable doubt that the mark could be a bruise following this then the Bruising in Babies pathway should be followed (see Pathway for non-mobile baby with bruising or a suspicious mark (AKA: 'Bruising in Babies' pathway)).
4. Why are We Worried about Bruises?
A bruise, as well as being sustained in the course of normal childhood activities and play, may be an external indicator that a baby or young child is being abused. Information gathered as a result of an appropriate investigation may enable that baby or young child to be safeguarded.
In contrast to older children, babies and young children are more vulnerable to injuries of equivalent force The likelihood of a baby or young child having bruises is also closely linked to their level of independent mobility. A single mark or a bruise in a baby or young child may be an indicator of serious underlying injury. Research and serious case reviews (now known as Child Safeguarding Practice Reviews) confirm that relatively minor bruising may be a warning that an adult is under stress and/or that a baby may be at serious risk of further injuries; a lower threshold for referral for both medical and social care investigation is needed to effectively protect a baby or young child.
5. What Factors are Important in Distinguishing Bruises Sustained through Normal Childhood Activity and Play from Physical Abuse?
A bruise should never be interpreted in isolation and must always be assessed in the context of the child's medical and social history, developmental stage and the explanation given.
Look for factors that make infant and young children more vulnerable to abuse and neglect. These may be present in the child (e.g. premature birth, disability, and unwanted pregnancy) and/or the adults who care for the child (alcohol and substance use, domestic abuse, poor mental health, learning difficulties and poverty). Contrary to popular belief, boys do not sustain more bruises than girls
Consider the presentation of the bruise:
- Was the presentation delayed?
- Was the bruise found incidentally during another contact or appointment? (e.g., whilst giving immunisations)
- Was the bruise described to a professional and is no longer visible?
Is the explanation for the bruise:
- Not available/no explanation offered;
- Inadequate and unlikely (e.g., a bruise on the chest of a baby from rolling onto a dummy);
- Inconsistent with the child's development stage (e.g., sustained when rolled off bed when child not yet rolling);
- Inconsistent over time or confused.
Voice of the young child, where appropriate
- Listen and record verbatim any explanation given by the young child;
- Observe the baby/child's demeanour and any interactions between the child and parent/carer.
Age and stage of development of the baby/young child
Bruising sustained in the course of normal activity and play is strongly related to mobility. This is reflected in both national evidence and the learning from local serious case reviews (now known as Child Safeguarding Practice Reviews).
Bruising in babies (not yet walking independently)
A non-mobile baby, or one that has no independent mobility, for the purposes of this guidance and the associated bruising in babies pathway is a baby or young child who is not yet crawling, bottom shuffling, pulling to stand, cruising or walking independently.
- Bruising sustained in the course of normal childhood activities and play in a non-mobile baby, who has no independent mobility, is rare (prevalence 0.6-1.3%) - 'Those that don't cruise rarely bruise';
- Only one in five infants who is starting to walk by holding on to the furniture will sustain bruises;
- Even once children are mobile, significant unexplained bruising is unusual and requires exploration;
- Most children who are able to walk independently sustain bruises;
- Bruises usually happen when children fall over or bump into objects in their way.
Bruising in older infants (babies and infants who are walking and independently mobile)
The location or pattern of bruising
In mobile children bruising that suggests the possibility of physical child abuse includes:
- Bruises on any non-bony part of the body including the face, back, abdomen, arms, hands, eyes, ears and buttocks;
- Multiple bruises in clusters;
- Multiple bruises of uniform shape;
- Bruises in the shape of a hand, ligature, stick, teeth mark, grip or implement;
- Bruises with petechiae (dots of blood under the skin) around them;
- Bruising that may be due to the misuse of equipment.
6. When to Refer?
Bruising sustained in the course of normal childhood activities and play is strongly related to mobility. Bruising in non-mobile babies who are not independently mobile raises significant concern about the possibility of physical child abuse. A bruise or suspicious mark in this group, however small, which does not have a clear, consistent adequate explanation of a significant event, in keeping with the baby or young child's development, and an appropriate parent/carer response, should be referred to children's social care.
The age and stage of development of the baby/young child are crucial considerations in forming a professional judgement as to whether a referral to social care and a strategy discussion is required.
If a social care referral is deemed appropriate, it should be made immediately as per local procedures and should include up to date contact details for the family and the referrer. This referral should be followed up in writing as per procedures.
Professionals within the strategy discussion will have a discussion considering the relevant factors such as presentation, explanation, the voice of the child and any known vulnerability factors to support further decision making and safety planning.
If a social care referral is deemed appropriate, it should be made immediately as per local procedures (see Referrals Procedure) and should include up to date contact details for the family and the referrer. This referral should be followed up in writing as per procedures. This procedure should be followed for new cases and previously known children.
The referrer should discuss an immediate safety plan for the child ensuring that immediate contact details for the child and carer are shared. All discussions should be documented including the risks of not staying with the baby or young child until a social worker arrives. If there are immediate concerns about safety, the police should be called.
7. Strategy Discussion
The social worker/team manager should arrange a strategy discussion with police and health to discuss the need for section 47 enquiries. If the meeting concludes the threshold for section 47 is met, then a child protection medical should be arranged. If there are issues regarding the decision to hold a medical, the obtaining of consent, communication difficulties or other factors which may make the paediatric medical examination complex then consider including a consultant paediatrician in the initial strategy discussion. The discussion should involve the development of an interim safety plan for the child and consideration of siblings.
The child protection medical can only be carried out during a section 47 investigation and can only be undertaken by a paediatrician. It cannot be undertaken by the family G.P
For further information, please see the Child Protection Enquiries Procedure, Strategy Discussion / Meeting for guidance on strategy discussions.
8. What is Required to Facilitate the Paediatric Medical Examination?
Paediatric medical examinations for bruising/suspicious marks require informed consent from an individual with parental responsibility or in the absence of this, a court order directing that a paediatric medical examination takes place. If the injury is thought to have been caused by an implement where practicable this should be brought to the medical examination or images of the implement made available to the examining paediatrician.
Further information for families and professionals on what a child protection medical examination entails can be found in the patient information leaflet "Child Protection Medical Assessment for injuries and marks: A guide for Families".
9. Managing Differences of Opinion
There may be disagreement between different practitioners as to the most appropriate action to be taken at any stage in the process of assessment of a possible bruise. The Resolving Professional Disagreements (Escalation Procedure) exists to guide practitioners on how to manage such disagreements or differences of opinion. Pre-mobile babies and young children are extremely vulnerable to a serious outcome from physical abuse by virtue of their immaturity, and so it is important to ensure the safety of the baby whilst a decision is reached. In most cases (particularly those under 9 months), it will be appropriate to follow the Pathway for non-mobile baby with bruising or a suspicious mark (AKA: 'Bruising in Babies' pathway).
Key points to remember
Except in the rare circumstances where an infant or child requires urgent medical attention, the child should not be sent to hospital but instead a referral should be made to social care who will hold a discussion and if appropriate arrange a child protection medical examination.
When investigating children with unexplained bruising do not offer to the family or other witnesses any options or suggestions as to how the child or young person may have acquired the bruise. Ask open ended questions and avoid leading or providing explanations.
Bruises sustained in the course of normal childhood activities and play in pre-school children who are mobile occur in characteristic locations on the body whereas bruises caused by physical abuse are seen in a different distribution.
The age and stage of development of the baby/young child are crucial considerations in forming a professional judgement as to whether a referral to social care and a strategy discussion is required. Bruising is strongly related to mobility, and as such injuries and bruising to a non-independently mobile child, i.e. a baby who is not yet crawling, bottom shuffling, cruising, or independently walking raises a significant concern about the possibility of physical abuse. In this age group further investigations for hidden injuries are also likely to be undertaken.
It is not possible to age bruising in babies, children, and young people by looking at its shape or colour.The child protection medical examination of bruising in babies and young children forms an important part of the initial assessment, however it is only one part of the holistic assessment and the decision to proceed with child protection enquiries and hold a case conference should be made in the light of all the available multi agency information about the wellbeing of the baby, child or children.