Injuries and Bruising Protocol for Immobile Children 0-18 years

1. Introduction and Context

Injuries and bruising in immobile children 0-18 years is unusual

Any injury, bruising, or a mark that might be bruising, in an immobile child 0-18 years, that is brought to the attention of any practitioner (including GPs) should be taken as a matter for inquiry and concern.

Regardless of an explanation given or not given by a parent or carer in an immobile child 0-18 years this must always raise suspicion of maltreatment and should result in an immediate Referral to Children's Social Care and an urgent Paediatric opinion. Children who are immobile due to a disability have an increased risk of bruising/injury due to non-accidental injury. 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.

It should be acknowledged that it can be difficult to know if a skin lesion is suspicious or not, for example:

Congenital dermal melanocytosis (also referred to as a Mongolian Blue Spot or slate gray nevi, a harmless flat birthmark with wavy borders and irregular shape, most commonly blue, or blue-grey).

Haemangioma (a collection of blood vessels that form a lump under the skin; it is often called a 'strawberry mark' as it looks like the surface of a strawberry).

Where there is diagnostic doubt regarding the nature of a skin mark or lesion, an immediate discussion should take place between the referrer and Paediatrician on call or the child's GP. A decision should then be made about whether to refer automatically to Children's Social Care or obtain medical review (same day) of the lesion first. For more information, see NHS information on birthmarks.

Physical Injuries

Any injury and/or bruising in an immobile child 0-18 years causes concern. Of particular concern are injuries to infants six months and under.

Injuries to immobile children 0-18 years

Any injuries and/or bruising are unusual for immobile children, even small injuries/bruising 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, a child 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.

Immobile children 0-18 years are most at risk of serious deliberate harm and as such require careful consideration. Following the conclusions of three separate local Serious Case Reviews, it has been decided that in the following situations, referral to Children's Social Care and a S47 Enquiry/investigation is undertaken:

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 immobile child with any of the above findings would also warrant CAREFUL consideration.

See NICE Clinical Guideline 89.

It is recognised that a small percentage of bruising in immobile children 0-18 will have an innocent explanation. Occasionally spontaneous bruising may occur because 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 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, practitioners should not delay sending them to hospital and informing the relevant Children's Social Care, so they can commence Child Protection Enquiries - Section 47 Children Act 1989 Procedure.

It is the responsibility of Children's Social Care in conjunction with the local acute 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.

Practitioners should be alert to parental disguised compliance (see Working with Parents where Improved Outcomes for Children are not Achieved) particularly where parents have given a plausible explanation to a previous event and the child represents with the same or a similar pattern of bruising.

Situations of Particular Concern

Situations that should cause particular concern for practitioners 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;
• Child displays wariness or watchfulness;
• Recurrent injuries;
• Multiple injuries at one time.

2. Definition of Terms used in the Protocol

Immobile (this should be based on developmental rather than chronological age): a baby who is not crawling, bottom shuffling, pulling to stand, cruising or walking independently. Particular attention should be given to the risks in those children who are unable to roll over. Includes all children 0-18 years who are not able to move independently, have a disability.

Bruising: blood coming out of the blood vessels into 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, this includes petechiae, (tiny red or purple non-blanching spots, less than two millimetres in diameter and often in clusters).

Minor injuries may include (but are not confined to) torn frenulum (piece of tissue joining the upper lip to the gum); grazing; abrasions; minor cuts; blisters; injuries such as bruises, scratches, burns/scalds, eye and/or ear injuries e.g. sub-conjunctival haemorrhages (a bleed underneath the transparent layer which lies over the white of the eye. The haemorrhage usually appears suddenly as a red patch or spot on the white of the eye)/corneal abrasions, bleeding from the nose or mouth, bumps to the head.

Any bruising, fractures, bleeding and other injuries such as burns should be taken as a matter of enquiry and potential abuse unless otherwise evidenced.

Using Professional Judgement

This document is written on the understanding that practitioners are allowed to use their professional judgement and common sense. Professional judgement is based on your experience, training and role. However, it is important to remember that non-accidental injuries often occur in the same body areas as accidental ones, and practitioners can be seduced by plausible explanations.

Even senior, experienced practitioners should discuss cases with peers or senior colleagues even if they feel an injury has a plausible explanation. Such colleagues could be a practitioner's line manager, safeguarding lead, or a Consultant Paediatrician. Children's Social Care and Police checks should still be undertaken even if the cause of the injury is accidental to inform the decision making. Practitioners not working in Health should ALWAYS discuss an injury in an immobile child 0-18 years with Children's Social Care who will seek an opinion from a Paediatrician as soon as possible.

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, practitioners  should remain alert to the possibility of physical abuse even in a hospital setting. In this situation, practitioners should take into account the birth history, the degree and continuity of practitioner supervision and the timing and characteristics of the bruising before coming to any conclusion. Where practitioners 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 practitioner 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 practitioners including where there is professional disagreement. Accurate details of bruising from birth trauma and medical causes must be recorded in the appropriate medical records, child health record, parent held record (red book) and maternity discharge summary and communicated to the baby'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, particularly congenital dermal melanocytosis (Mongolian Blue Spot or slate gray nevi) can mimic bruising. Where a practitioner requires confirmation of a birthmark they should in the first instance discuss with the GP or an experienced Health Care Practitioner. However, if there is any suspicion that the presenting feature is a bruise a practitioner must refer the case under this protocol.

In all cases: birthmarks, including when present from birth, must be recorded in the appropriate records including the infants red book and maternity discharge summary.

Self-inflicted injury: it is exceptionally rare for immobile children 0-18 years to injure themselves during normal activity. Suggestions that a bruise has been caused for example by a baby 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 Social Worker.

Injury from other children: it is unusual but not unknown for siblings to injure an immobile child. In these circumstances, the child 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.

Body maps should be used if an accident occurs or if there is a safeguarding concern.

3. Process

Injury and/or bruising in immobile children 0-18 years is unusual. In all cases of an injury and/or bruising in immobile children 0-18 years there is:

• A review by a Paediatrician who has the appropriate expertise to assess the nature and presentation of the bruise, any associated injuries, and to appraise the circumstances of the presentation including the developmental stage of the child, whether there is any evidence of a medical condition that could have caused or contributed to the bruising, or a plausible explanation for the bruising;
• A multi-agency discussion to consider any other information on the immobile child and their family and any known risks, and to jointly decide whether any further assessment, investigation or action is needed to support the family or protect the immobile child. This multi-agency discussion should always include the health practitioner who reviewed the immobile child.

All Health practitioners should make a referral about the immobile child 0-18 years immediately to the relevant Hospital Paediatrician On-Call.

• Bedford Hospital:
  Contact the on-call Paediatrician Tel: 01234 355122 and ask for bleep 542;
• L&D Hospital:
  Before 22.00hrs contact on call Paediatric consultant via Switchboard 01582 491166.
  After 22.00hrs Contact on call registrar via Switchboard 01582 491166.

All other practitioners should refer the immobile child 0-18 years immediately to Children's Social Care to be considered for a Paediatric assessment:

• 01582 547760 - Luton MASH;
• 01234 718700 - Bedford Borough Integrated Front Door;
• 0300 300 8585 - Central Bedfordshire Access and Referral Hub.

All telephone referrals must be followed up in writing within 48 hours. Children's Social Care will co-ordinate multi-agency information sharing and an assessment.

It is the responsibility of the practitioner who was told of or observed the injury and/or bruising to make the referral. In particular, this practitioner should also explain at the point of referral why they are making the referral and that this will result in further questioning and examination as required. They should explain to the parents/carers frankly and honestly and provide them with the accompanying leaflet to help explain the process to them.

Wherever possible, the decision to refer should be undertaken jointly with another practitioner or senior colleague. However, this requirement should not prevent an individual practitioner of any status referring to Children's Social Care any immobile child 0-18 years with an injury and/or bruising whom 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 practitioners taking this decision.

An explanation for the injury/bruising should be sought at an early stage from parents/carers and recorded. It is important to undertake this with open questioning and to avoid leading questions. The parent/carer should be asked when it was first noticed. The lack of a satisfactory, or consistent, explanation or an explanation incompatible with the appearance or circumstances of the injury/bruising or with the immobile child's age or stage of development should raise concerns about abuse.

An injury and/or bruise 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 the local acute or community Paediatrician to determine whether the injury and/or bruising is consistent with the explanation provided or is indicative of non-accidental injury.

For contact details for Children's Social Care, please see Local Contacts and Recognising Abuse and Neglect, Making a Referral Procedure.

Disagreement between practitioners regarding the safety of an immobile child 0-18 years must be resolved using the Escalation Procedures.

4. Assessment of Injury by an Acute or Community Paediatrician

Babies under 6 months of age and children who are immobile due to a disability are particularly vulnerable as they have an increased risk of bruising due to non-accidental injury and must be referred to the appropriate hospital Paediatrician and Children's Social Care.

All health care practitioners should discuss cases with peers or senior colleagues and record those discussions. Such colleagues could be the practitioner's line manager, safeguarding lead, or a Consultant.

Examples where professional judgement to not report by a suitable experienced and trained practitioner may be appropriate in view of the observed finding being explained by:

• Review of the birth notes provides a plausible explanation which fits the clinical finding or bruising in the first week of life consistent with birth injury;
• The child is technically mobile (pulling themselves up, rolling) and has a minor injury consistent with explanation provided by parents: e.g. rolled into ornament and cut foot; a minor injury is consistent with explanation provided by parents: e.g. having nails cut;
• Identification of an emerging birth mark (e.g. congenital dermal melanocytosis - Mongolian Blue Spot or slate gray nevi);
• Bruising from an obvious medical procedure.

REMEMBER: A bruise or injury must always be assessed in the context of medical and social history and developmental stage and not based solely around the explanation given.

If health partners are uncertain about whether they need to make a referral to Children's Social Care they can contact them (ideally with parental consent but the call can still be made without this) to discuss the case. This discussion and advice will be recorded as a Contact on Children's Social Care records. If a referral is then made further checks will be undertaken proportionate to the concerns identified and progressed via the relevant Children's Social Care.

Not all children subject to non-accidental injury will have a social care history so an absence of knowledge of a family should not be taken as a reassurance.

The parent/carer should be informed by the practitioner who first observed the bruise/injury or at the earliest opportunity about the process and given the information leaflet for parents/carers (below) which explains what will happen next and why.

See: Bruising or Injury to immobile babies and children - Information for parents and carers leaflet.
Click here for a printable version of the leaflet.

Where there is any doubt about the cause of an injury a S47 Strategy Meeting/Discussion will be convened.

If required a Child Protection Medical Assessment will be arranged, as part of the actions of the Strategy Meeting/Discussion, to take place as soon as possible. The decision about the extent of the medical investigations will be proportionate to the circumstances and context of the injury and be made in consultation with colleagues from other agencies (for example, a skeletal survey or CT scan may not be appropriate or in the best interest of the child given the information available). This assessment will then inform the need for any further investigations.

Whilst the child protection medical assessment is taking place other work by practitioners in relation to the case for example, visiting the home or the Police talking to the parents/carers. All findings should be clearly documented.

The child should remain in hospital until all investigations are completed, results available and discussed in a re-convened Strategy Meeting/Discussion. The first Strategy Meeting/Discussion will have agreed the arrangements around supervision of the parents/carers during the investigation if they are considered to have caused the injury/bruising.

A child should not be allowed to return to the environment where the bruising/injury was caused or to the people who were caring for them at the time until the safeguarding issues are resolved or risk reducing measures are in place and/or a multi-agency discharge/safety plan agreed and shared with parents/carers.

5. Bruising in Non-Mobile Older Children e.g. A Child with a Disability

Bruising patterns in immobile disabled children such as on the dorsum of the feet, thighs, arms, hands and trunk are sites of unintentional bruising. This may be caused by knocks during transfers, bumps from wheelchair users or ill-fitting/misuse of equipment. If this is thought to be the cause then parents/carers should be provided with support and information in relation to the use of correct equipment.

Bruising on an immobile older child should be considered in the context of the child's development with specific care taken not to explain away the bruises because of health needs, health care or disability without careful checking.

Consideration should be given to repeat patterns of bruising and whether this might be indicative of non‐accidental injuries. Practitioners should be open to the possibility that an immobile child with a disability could potentially be harmed deliberately, and that there may be many underlying factors as to why this may be.

If a practitioner is identifying bruising to an immobile older child they should, along with others forms of assessment with regards to what they see, consider the following:

• Does the explanation for the bruise match the child's developmental capability and likely behaviour?
• Was the child developmentally capable of causing these injuries to him or herself?
• Does this pattern of bruising match the particular developmental capabilities of a child of this age with these particular developmental needs?
• For a child who is otherwise meeting developmental milestones, might a parental explanation for injuries be too readily accepted?
• Is there a full understanding of the caregiving the child receives?
• Keep Body maps of injuries/bruising observed and clearly date and time the maps.

When considering immobile children with complex health and physical disabilities, practitioners must, with parental consent, include staff in specialist educational provision and children's nurses and or inclusion nurses, who may be currently supporting the child and as such hold important information as to what the daily life of the child is like(3).

If following conversations with parents/carers and other practitioners as appropriate a practitioner feels that the immobile child is suffering, or at risk of suffering harm, they should contact the relevant Children's Social Care in line with this protocol, including gaining consent from the parents, unless there is a clear increased risk to the child by doing so. However, a contact should still be made if parents do not consent in order to safeguard the child. Practitioners should also consider the needs of other children in the family who may be affected and inform Children's Social Care in order that a Strategy Meeting/Discussion gives consideration to the possible need for child protection medical examinations of other children in the family.

6. Innocent Bruising

It is recognised that a small percentage of bruising in immobile children 0-18 years will have an innocent explanation (including medical causes). Nevertheless, because of the difficulty in excluding non-accidental injury, practitioners should make a referral to the Acute Consultant Paediatrician and Children's Social Care in all cases.

It is the responsibility of the Strategy Meeting/Discussion in conjunction with the local acute or community paediatric departments to decide whether the circumstances of the case and the explanation for the injury are consistent with an innocent cause or not.

In general practice any history of bruising should be flagged as a significant problem/risk factor and a referral made to the Acute Paediatrician and Children's Social Care immediately.

Occasionally spontaneous bruising may occur because of a medical condition such as a bleeding disorder, thrombocytopenia (deficiency of platelets in the blood. This causes bleeding into the tissues, bruising, and slow blood clotting after injury) or meningococcal any illness caused by bacteria called Neisseria meningitidis. These illnesses are often severe, can be deadly, and include infections of the lining of the brain and spinal cord (meningitis) and bloodstream) or other acute infection. Child protection issues should not delay the referral of a seriously ill child to acute paediatric services.

Practitioners should take into consideration cultural practices and racial characteristics when assessing bruising, including communication difficulties. However no cultural practice should harm a child.

7. Involving Parents or Carers

It is important that the referring practitioner explain openly and honestly, why they are making the referral and that this will result in further questioning and examination as required. This accompanying leaflet should be given to the parents/carers to help explain the process to them.

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 an injury and/or bruising in immobile children 0-18 years, 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. If possible, the child should be kept under supervision until steps can be taken to secure their safety.

If a child is admitted to hospital then a Strategy Meeting/Discussion is required to determine whether the parents/carers can have unsupervised access or how contact with their child will be managed.

Parents to be advised of the ICON programme which offers advice around crying babies which is completely normal and Cambridgeshire Community Services whose Health Visitors support the health and wellbeing of the whole family though the Healthy Child Programme.

8. Diversity Factors

Consideration should be given to cultural needs of all children, their families and carers; however, cultural practices that are abusive are never an acceptable reason for child maltreatment.

Practitioners should at all times be aware of and sensitive to any difficulties in communicating this protocol and pathway to parents/carers and children. This may be due to learning difficulty/disability, language barriers, disability or poor understanding of legislation in the UK. It is important that the immobile child 0-18 years be seen as swiftly as possible and therefore indicative that additional support and provision is made to assist effective communication but this should not hinder immediate referral.

An assessment should consider the child's skin colour and how this may influence the clinical assessment (Mukwende, 2020).

It is important that the child/ren are seen promptly with the required provision to assist effective communication and this should not delay immediate referral.

9. Decision Making

The key principle of this protocol is that where an immobile child 0-18 years, has sustained injuries as outlined in this document, decisions should not be made by a single practitioner.

As a minimum, decisions should be made by two practitioners (one of which must be a qualified health practitioner ) It should however be noted that this protocol does not seek to remove or undermine professional judgement, but instead support practitioners in making important decisions when safeguarding immobile children 0-18 years.

At the close of S47 Enquiries, Children's Social Care should have made an assessment in relation to whether the immobile child 0-18 years has suffered, or is at risk of suffering, significant harm. This assessment should have been developed in full consultation with all relevant partner agencies.

In some cases, the outcomes of the S47 Enquiry may not be clear e.g. the findings of the paediatric assessment may be inconclusive or agencies may hold differing views about the level of risk. In such cases, a further Strategy Meeting/Discussion should be convened in line with the Pan Bedfordshire Interagency Child Protection Procedures.

A child should not be allowed to return to the environment where the bruising/injury was caused or to the people who were caring for them at the time until the safeguarding issues are resolved or risk reducing measures are in place and/or a multi-agency discharge/safety plan agreed and shared with parents/carers.

The process of bringing the relevant practitioners together to discuss the case will contribute to better assessment and outcomes. The assessment will inform the action to be taken by Children's Social Care and/or the Police. Children's Social Care should also ensure that the outcome of the S47 Enquiry is shared with the family (unless to do so would place the immobile child at increased risk) and all relevant partners. In all agencies, the outcomes of the S47 Enquiry should be recorded in detail. This is particularly important where a decision is taken that no further action is required to protect the immobile child 0-18 years.

Appendix 1: Pan Bedfordshire Pathway and Protocol Summary for Injuries in Immobile Babies and Children

Appendix 1: Pan Bedfordshire Pathway and Protocol Summary for Injuries in Immobile Babies and Children