Injuries and Bruising Protocol for Immobile Babies and Children

1. Introduction and Context

Injuries and bruising in immobile babies and children is unusual

Any injury, bruising, or a mark that might be bruising, in an immobile baby or child of any age, that is brought to the attention of any professional (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 baby or child this must always raise suspicion of maltreatment and should result in an immediate Referral to Children's 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 e.g. congenital dermal melanocytosis, 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 Children's Services referral or obtain medical review (same day) of the lesion first.'

Physical Injuries

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

Injuries to immobile babies and children

Any injuries and/or bruising are unusual in this age group, 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 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 local Serious Case Reviews, it has been decided that in the following situations, referral to Children's Services and a S47 Enquiry/investigation is undertaken C:

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.

See NICE Clinical Guideline 89.

It is recognised that a small percentage of bruising in immobile babies and 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 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 Children's Services so they can commence Child Protection Enquiries Procedure.

It is the responsibility of Children's Services 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.

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.

2. Definition of Terms used in the Procedure

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. Includes all babies and children who are not able to move independently, including children with a disability. Babies who can roll or sit independently are classed as non-mobile;

• 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, which are 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; grazing; abrasions; minor cuts; blisters; injuries such as bruises, scratches, burns/scalds, eye and/or ear injuries e.g. sub-conjunctival haemorrhages/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 professionals 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 professionals can be seduced by plausible explanations.

Even senior, experienced professionals should discuss cases with peers or senior colleagues even if they feel an injury has a plausible explanation. Such colleagues could be your line manager, your safeguarding lead, or a consultant community paediatrician. Children's Services and police checks should still be undertaken even if the cause of the injury is accidental to inform the decision making. Professionals not working in Health should ALWAYS discuss an injury in an immobile baby or child with a Healthcare professional 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, 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, particularly 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 professional's 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 infants red book and maternity discharge summary.

Self-inflicted injury: it is exceptionally rare for immobile babies and children 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 social worker.

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.

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

3. Process

Injury and/or Bruising in immobile babies and children is unusual. All Health practitioners should make a referral about the child immediately to the relevant Hospital Paediatrician On-Call for Child Protection.

• 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 child immediately to Children's Services to be considered following the Paediatrician 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 Services will co-ordinate multi-professional information sharing and assessment.

It is the responsibility of the first professional to learn of or observe the injury and/or 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 an injury and/or 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.

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 Services and a lead medical professional (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 each authority's Children's Services, please see Local Contacts and Responding to Abuse and Neglect, Making a Referral Procedure.

Disagreement between professionals regarding the safety of a child must be resolved using the Escalation Procedures.

4. Assessment of Injury by a Medical Professional

Babies under 6 months of age are particularly vulnerable and this must be referred to the appropriate hospital Paediatrician and Children's Services.

All health care professionals should discuss cases with peers or senior colleagues and record it. Such colleagues could be your line manager, your safeguarding lead, or a consultant.

Examples where professional judgement to not report by a suitable experienced and trained professional 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);
• 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 MASH they are able to contact the Front Door (ideally with parental consent but the call can still be made without this). The case will be discussed and proportionate information will be shared to inform any decision to refer. This discussion and advice will be recorded as a Contact. If a Referral is then made further checks will be undertaken proportionate to the concerns identified and progressed via the relevant Children's Services.

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 about the process and given an information leaflet for parents, explaining what will happen next.

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 strategy discussion will be convened.

If required a Child Protection Medical Assessment will be arranged, as part of the actions of the Strategy 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 medical assessment is taking place other work by professionals in relation to the case should take place. For example, visiting the home or the police talking to the parents. All findings should be clearly documented.

From the child's perspective they will remain in hospital until all investigations are completed, results available and discussed in a re-convened Strategy Discussion. The multi-agency meeting will have concluded at the first meeting as to the arrangements around supervision of parents/carers during this time.

5. Innocent Bruising

It is recognised that a small percentage of bruising in immobile babies and children 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 hospital consultant paediatrician and Children's Services in all cases.

It is the responsibility of the multi-agency Strategy meeting 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.

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

Occasionally spontaneous bruising may occur as a result of a medical condition such as a bleeding disorder, thrombocytopenia or meningococcal 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.

6. 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 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 babies and 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 Services Services. If possible the child should be kept under supervision until steps can be taken to secure his or her safety.

If a child is admitted to hospital then a multi-agency decision is required to determine whether the parents 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. From antenatal visits until the child goes to school, they work to ensure that the child has the best start possible in life.

7. Diversity Factors

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

Professionals 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 child is 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.

8. Decision Making

The key principle of this protocol is that where a baby or child, particularly where they are immobile, 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 practitioner/ professionals (one of which must be a qualified health professional) 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 young people.

At the close of the S47 Enquiry, Children's Services should have made an assessment in relation to whether the baby or child 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 should be convened in line with the Pan Bedfordshire Interagency Child Protection Procedures.

A child/baby should not be discharged from hospital until a multi-agency strategy meeting has been held and a discharge plan agreed.

The process of bringing the relevant professionals together to discuss the case may contribute to better assessment and outcomes. This assessment will inform the action to be taken by Children's Social Care and/or Bedfordshire Police. Children's Services should also ensure that the outcomes of the S47 Enquiry are shared with the family (unless to do so would place the baby 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 baby.

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

Click here to view Appendix 1: Pan Bedfordshire Pathway and Protocol Summary for Injuries in Immobile Babies and Children.