5.3 A Multi-agency Protocol for the Management of Actual or Suspected bruising in Infants who are Not Independently Mobile
AIM OF PROTOCOL
The aim of this protocol is to provide all professionals with a knowledge base and action strategy for the assessment, management and referral of infants who are Not Independently Mobile (NIM) who present with bruising.
All practitioners should refer to the Procedures for Specific Circumstances for the process to follow if there are concerns for the safety and welfare of a child.
Relevant to all practitioners and professionals working in the Surrey area whose role brings them into contact with children and families.
- 1. Definitions
- 2. Research Base
- 3. Scope of Protocol
- 4. Action to be taken by Individuals and Agencies on Identifying Actual or Suspected Bruising
- 5. Specific Circumstances
- 6. Sharing Information and Consulting Colleagues
For the Purpose of this Protocol
Not Independently Mobile (NIM): is an infant who is not yet crawling, bottom shuffling, or cruising. It includes all infants less than 6 months.
Bruising: extravasations (leakage) 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 yellow through green to brown or purple or red. This includes petechiae, which are red or purple non-blanching spots, less than two millimetres in diameter and often in clusters.
Bruising is the commonest presenting feature of physical abuse in children. Recent serious case reviews, partnership reviews and individual child protection cases both nationally and locally have shown that frontline practitioners have sometimes underestimated or ignored the highly predictive value, for child abuse, of the presence of bruising in infants who are Not Independently Mobile. As a result there have been a number of cases where bruised infants have suffered significant harm or have died as a result of abuse that might have been prevented if action had been taken at an earlier stage. NICE guideline When to Suspect Child Maltreatment (Clinical Guideline 89, July 2009, updated October 2017) states Suspect child maltreatment if there is bruising in a child who is not independently mobile.
This Multi-agency protocol has been developed for all professionals, outlining the following:
- Assessment and management of bruising in infants who are Not Independently Mobile.
- The process by which such infants should be referred to children’s services;
- How to refer to paediatrician for further assessment and investigation of potential child abuse.
In the light of the NICE guideline, recurrent themes in serious case reviews and the research base outlined in section 2 this protocol is necessarily directive. While it recognises that professional judgement and responsibility have to be exercised at all times, it errs on the side of safety by requiring that all infants with bruising who are not independently mobile must be referred in to children’s services and for a paediatric opinion.
This protocol has been approved by SSCP Policy & Procedures group following consultation with partners.
2. Research Base
Research shows that it is very unusual for pre-mobile babies to sustain bruises accidentally and bruising in this age group raises significant concerns about physical abuse.
There is a substantial and well-founded research base on the significance of bruising in children:
- Child Protection Evidence | RCPCH
- Child Protection Evidence - Bruising | RCPCH March 2020.
- Child Protection Companion | Paediatric Care Online RCPCH (Updated on line).
- NICE Child maltreatment (CG 89): when to suspect maltreatment in under 18s. July 2009 and reviewed October 2017.Overview | Child maltreatment: when to suspect maltreatment in under 18s | Guidance | NICE
While accidental and innocent bruising is significantly more common in older mobile children, professionals are reminded that mobile children who are abused may also present with bruising (Baby P 2008). Body maps to record bruising should be completed in all cases where there are concerns about non accidental injury. This is to address the potential for inaccurate recording when there are multiple bruises / patterns of bruising over time, as identified in both national and local Serious Case Reviews.
Disabled children have a higher incidence of abuse whether mobile or not and concerns relating to potential abuse must be handled in accordance with SSCP Procedures.
The Research base demonstrates that bruising in Not Independently Mobile infants is very rare; particularly those under the age of six months. Bruising was the most common injury in children who have been abused. It is also a common injury in non-abused children, the exception to this being pre-mobile infants where accidental bruising is rare (0-1.3%). The number of bruises a child sustains through normal activity increases as they get older and their level of independent mobility increases. Reference: RCPCH Bruising systematic review.
Cases have been reported where bruising was a “sentinel injury” in children prior to the recognition of child abuse, highlighting the importance of recognising abnormal characteristics of bruising in children, enabling detection as early as possible and potentially preventing escalation of abuse with avoidance of serious abusive injury or death. Child Protection Evidence - Bruising | RCPCH
The pattern, number and distribution of innocent bruising in non-abused children is different to that in those who may have been abused.
Patterns of bruising suggestive of physical child abuse include:
- Bruising in children who are not independently mobile
- Bruises that are accompanied by petechiae, in the absence of underlying bleeding disorders.
- Bruises that are away from bony prominences
- Bruises to the face, eyes, ears, neck, trunk, arms, buttocks and hands
- Multiple bruises of uniform shape
- Bruises that carry the imprint of implement used or ligature
Reference: Child Protection Evidence - Bruising | RCPCH
A bruise cannot be aged accurately from clinical assessment or from a photograph
It is important to note that a bruise, whatever its size, must never be interpreted in isolation and must always be assessed in the context of medical and social history, developmental stage, explanation given and relevant investigations. A full clinical examination and relevant investigations. Reference Child Protection Evidence - Bruising | RCPCH
3. Scope of Protocol
This protocol relates only to bruising in infants who are Not Independently Mobile. It includes all infants less than 6 months.
It should be noted that infants may be abused (including sustaining fractures, serious head injuries and intra-abdominal injuries) with no evidence of bruising or external injury.
4. Action to be taken by Individuals and Agencies on Identifying Actual or Suspected Bruising
Referring Practitioner responsibilities:
If the infant appears seriously ill or injured:
- Seek emergency treatment at an Emergency Department (ED);
- Refer to children’s services / and if needed inform police of your concerns and the child’s location.
A transfer to hospital should not be delayed by a referral to children’s services, however it is the responsibility of the professional first dealing with the case and who has identified a concern to ensure that a referral to children’s services has been made.
In all other cases:
When a practitioner observes a bruise in an infant under 6 months of age who is not independently mobile, you must suspect non-accidental injury.
Seek an explanation, examine and record accurately in records and complete body maps (Appendix 1: Body Maps) note any features of abuse e.g. bruises on face and ‘soft’ areas, bruises in clusters or imprints
Professionals should explain at this stage why, in cases of bruising in infants who are not independently mobile, additional concern, questioning and examination are required. The requirement to refer to children’s services should be explained to the parents or carers frankly and honestly. Provide Parental leaflet “Bruising in Infants who are not independently mobile” SSCP Bruising-leaflet.pdf
A referral should be made to children’s services via the Children's Single Point of Access (C-SPA) or Emergency Duty Team (EDT) see Contact details). Referrals should be made using the Request for Support Form which replaces the MARF.
The referrer must document in the appropriate personal child health record (where available) and medical records, all decisions and actions taken and the joint action plan agreed with Children’s services.
Parents should not be given the responsibility of making arrangements to seek medical advice themselves.
If a parent or carer is uncooperative or refuses to take the child for further assessment, this should be reported immediately to the police and children’s services notified of this course of action. If possible the child should be kept under supervision until steps can be taken to secure his or her safety.
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 infant that is Not Independently Mobile with bruising.
Children’s services responsibilities:
Children’s services must make any referral made under this protocol as requiring further multi-agency enquiry. Children’s services will convene a strategy discussion involving police and health. This multi-agency discussion will decide whether to initiate S47 enquiries.
This investigation must also include a detailed history from the parent/carer, review of past medical history and family history including any previous reports of bruising, and enquiry about vulnerabilities within the family.
On receipt of the referral children’s services will arrange a safeguarding medical examination which will take place as soon as possible and always within 24 hours. Where a history of previous child protection concerns is present this information should be shared with the examining paediatrician.
Children’s services should refer cases to the on call locality Community Paediatric Teams (weekdays) or on call Paediatrician at the local hospital (after working hours, weekends or bank holidays). See Appendix 2
As far as possible, parents or carers should be included in the decision-making process unless to do so would jeopardise information gathering or pose a further risk to the child. Where consent is refused management direction should be sought.
Following the outcome of the medical, Children’s services will decide on the need for any further safeguarding actions, based on the opinion of the Consultant Paediatrician and in discussion with partner agencies.
Paediatrician responsibilities history taking and examination:
When a child is referred by children’s services under this protocol, the paediatrician will undertake the examination within 24 hours and should follow the SSCP Child Protection Medical Guidance for medical professionals, children’s services and police (copies of this form can be found on individual trust websites).
Where a referral is delayed for any reason, or where bruising is no longer visible, the paediatrician must still examine the child to assess, as a minimum, general health, signs of other injuries or pointers to maltreatment, and to exclude bleeding disorders.
Unintentional bruises in pre-mobile infants are rare, (0-1.3%) (Reference Child Protection Evidence - Bruising | RCPCH.
A cogent and credible explanation for the bruising should be sought at an early stage from parents or carers and recorded. It is important to undertake this with open questioning and to avoid leading questions.
The lack of a satisfactory, or consistent, explanation or an explanation incompatible with the appearance or circumstances of the injury, or with the child’s age or stage of development should raise suspicions of abuse. Inconsistencies or variations between carers or between interviews should raise suspicions of abuse.
A full physical examination of the completely undressed infant should be undertaken with appropriate consent. This should include the physical presentation of the child, including the state of their clothing and include growth parameters.
A review of the child's medical history, including any previous occurrence of bruising or injury, should be undertaken. Health visiting records and GP information or other relevant information should be actively sought and accessed by the examining paediatrician wherever possible to facilitate informed decision making. If in a hospital setting, records of previous ED attendances, outpatient visits and non-attendances should be actively searched for. Consideration should be given to identified vulnerabilities within the family such as domestic abuse, substance misuse, mental health issues and deliberate self-harm.
As with other injuries, any underlying medical condition that may predispose a child to easy bruising must be excluded. Other conditions that may mimic or present with bruising should be considered.
If child protection concerns are identified, the SSCP safeguarding children medical examination form should be used to document history, examination, findings, opinion and recommendations (copies of this form can be found on individual trust websites). The importance of signed, timed, dated, accurate, comprehensive and contemporaneous records cannot be overemphasised.
In all cases careful mapping, description and recording of the size, colour characteristics, site, pattern and number of the bruises should be made on a body map (as included in the SSCP safeguarding children medical examination form) and a careful record of the carers/parents description of events and explanation for the bruising made.
Where possible the paediatrician examining the child should discuss the findings and management plan with a colleague before advising children’s services and parents. If a trainee paediatrician sees the child it should be discussed with the supervising consultant paediatrician. If a career grade paediatrician (Consultant grade or SAS grade) examines the child it should, where possible be discussed with a suitably experienced colleague.
Where safeguarding concerns are identified, twins of infants presenting with bruising and any other siblings should be subjected to a medical examination and appropriate investigation.
Any non-independently mobile infant with unexplained bruising or where non accidental injury cannot be excluded should have:
- A Skeletal Survey in line with: The radiological investigation of suspected physical abuse in children | The Royal College of Radiologists. 2017 guidance (Revised November 2018).
- This should include a CT head scan in children under one year of age and a skeletal survey in children under 2 years of age and follow up imaging should be performed at 11-14 days as per the RCR protocol.
- Ophthalmology examination should be undertaken by an experienced ophthalmologist, to exclude any eye injury and retinal haemorrhages;
- Haematological and biochemical investigations including clotting studies, should be consistent with national guidance as specified in RCPCH Child Protection Companion. Paediatricians should work with their local haematologist to ensure age appropriate investigations are undertaken.
- Where significant injuries are identified in a child due to suspected physical abuse, any multiple birth siblings of an index case less than 2 years of age should have the same recommended imaging as the index case. Age appropriate imaging should be considered in all siblings and children less than 2 years’ old living in the same household as the alleged or suspected perpetrator on a case by case basis.
5. Specific Circumstances
Birth Injury: In the case of new-born infants where bruising may be the result of birth trauma, instrumental delivery, or medical procedures such as blood tests, professionals should remain alert to the possibility of physical abuse even in a hospital setting. In this situation professionals should take into account the birth history, the degree and continuity of professional supervision and the timing and characteristics of the bruising before coming to any conclusion. Where professionals are uncertain whether bruising is the result of medical causes (even before discharge from hospital), they should refer immediately to the on call consultant paediatrician or the named doctor for safeguarding for further advice. However, such discussion with the consultant or named doctor should not delay a referral under this protocol if a professional is concerned regarding the mechanism for the injury or the safety and welfare of an infant. Body maps must be completed.
In all cases accurate record keeping is paramount, and must include all discussions and decisions made between professionals including where there is professional disagreement. Accurate details of bruising from birth trauma and medical causes must be recorded in the appropriate medical records, infant health record, parent held record (red book) and maternity discharge summary and communicated to the infant’s GP, community midwife and health visitor.
Birthmarks: these may not be present at birth, and may appear during the early weeks and months of life. Certain birthmarks capillary haemangioma, congenital melanocytic naevi) and particularly Mongolian blue spots (congenital dermal melanocytosis) can mimic bruising. Where a professional requires confirmation of a birthmark they should in the first instance discuss with the GP. However, if there is any suspicion that the presenting feature is a bruise, professionals must refer the case in under this protocol.
In all cases birthmarks, including when present from birth, must be recorded in the appropriate records including the infant’s red book and maternity discharge summary.
Self-inflicted injury: it is exceptionally rare for non-independently mobile infants to injure themselves during normal activity. Suggestions that a bruise has been caused by the infant hitting him/herself with a toy, falling on a dummy or banging against an adult’s body should not be accepted without detailed assessment by a paediatrician and after a referral to children’s services as per this protocol.
Injury from other children: it is unusual but not unknown for siblings to injure a baby. In these circumstances, the infant must still be referred under this protocol for further assessment, which must include a detailed history of the circumstances of the injury, and consideration of the parents’ ability to supervise their children.
6. Sharing Information and Consulting Colleagues
Please refer to Managing Individual Cases section of these procedures.
If there are concerns about the decision making and management of the case, any professional has a duty to escalate concerns to the next level in line with the SSCP Inter-Agency Escalation Policy and Procedure.