11.7 Bruising in Children who are Not Independently Mobile

Bruising in Children who are Not Independently Mobile

Pan Cheshire & Merseyside Guidance for Assessment, Management and Referral by Practitioners September 2021

Appendix A Guidance on managing babies with suspected birth marks

Appendix C Full set body map bruising and skin marks

Aim of Guidance:

The aim of this guidance is to provide front line professionals and senior multi agency professionals with a knowledge base and action strategy for the assessment, management and referral of children who are Not Independently Mobile (NIM) who present with bruising or otherwise concerning marks.

“Those who don’t cruise, rarely bruise” N. Sugar 2011

It does not include nor replace the process to be followed once a referral to Children’s Social Care has been made. [Refer to your local safeguarding partnership procedures.]

Scope:

The target audience for this guidance is all front line staff working directly with children. This list is not comprehensive but includes including: all community and hospital paediatric clinical staff, general practitioners, sessional doctors, locums, GP trainees, primary care staff including practice nurses, health visitors, district nurses, school health advisers and midwives, community staff allied to medicine, clinicians in GP out of hours services, urgent care centres, minor injury units and emergency departments, dentists, pharmacists and North West Ambulance Service (NWAS). It also applies to allied non-health agencies, such as Children’s Social Care and education/nurseries.

This guidance must be read in conjunction with local Safeguarding Partnership procedures.

It is the responsibility of Children’s Social Care, in conjunction with the local paediatric department and Police, to decide whether the circumstances of the case and the explanation for the injury are consistent with an innocent cause or not. This would usually be as part of a strategy discussion or a strategy meeting prior to and/or after the child protection medical assessment.

Appendix A: Guidance on Managing Babies with Suspected Birth Marks, including blue/grey spots and other “innocent skin marks”.

Appendix B: Clinical Care Pathway re protocol for Innocent Marks on the Skin

Appendix C: Full Set Body Map

1 Definitions

Not Independently Mobile (non-mobile children): this includes those children who have not reached the developmental stage of crawling, shuffling, pulling to stand, cruising or walking independently. Not independently mobile children also include those children who are older but have limited mobility due to a medical condition or disability.

Caution needs to be applied if a child is non-verbal, as they cannot provide their own separate explanation for a bruise.

Bruising is the extravasation of blood in the soft tissues, producing a temporary, non-blanching discolouration of skin, however, faint or small, with or without associated injuries eg abrasions.

The colouring of a bruise is wide ranging and is reliant on the observer. There is no set timing or sequence for the colour of a bruise making it almost impossible to age a bruise.

Causes include blunt force trauma, prolonged straining, some medications or specific medical conditions e.g. infection, vasculitis, bleeding disorders.

Petechiae are red or purple tiny less than two millimetres non-blanching spots, often in clusters, as a result of damage to capillaries or smaller blood vessels.
Birthmarks are a congenital, mainly benign, irregularity on the skin which is present at birth and is apparent shortly after birth and usually by a month. They can occur anywhere on the skin. Birthmarks are caused by overgrowth of any or all of blood vessels, melanocytes, smooth muscle, fat, fibroblasts, or keratinocytes. They are usually brown, pink, red or purplish colour or in the case of blue/grey spots (previously known as Mongolian blue spots), a diffuse blue/grey colour.

See Appendix A: Guidance on Managing Babies with Suspected Birth Marks, including Blue/Grey Spots and other “innocent skin marks”.)

If there is any uncertainty about the cause of any of these marks then advice should be sought.

2 Introduction

Bruising is the commonest presenting feature of physical abuse in children and must not be ignored. Learning from child protection cases indicates that the presence of bruising in children who are not independently mobile is highly predictive for further child abuse. There are several cases in which a child with bruising (sentinel injury) has later suffered significant harm that might have been prevented if action had been taken at the time of the earlier injury.
The NICE Guideline (NG76) October 2017 “When to Suspect Child Maltreatment” states that bruising in any child not independently mobile should prompt suspicion of maltreatment. See: https://www.nice.org.uk/guidance/ng76/chapter/Recommendations
Considering the above learning and guidance, this guidance has been developed for practitioners for the assessment and management of bruising in children who are not independently mobile and the process by which such children should be referred to Children’s Social Service.

In the light of the NICE guidance and the available research, this guidance is necessarily directive. It recognises that professional judgement and responsibility have to be exercised at all times. However, it errs on the side of safety by requiring that the majority of children not independently mobile who present with bruising should be discussed with social care as a minimum, to inform decision making and next steps. There is an expectation that most cases will result in a referral to Children’s Social Care.

Referral to social care enables a multiagency discussion regarding the need for a child protection medical assessment by a specialist paediatrician, facilitating a medical opinion regarding the likelihood or not of abuse.

Professionals must always have a degree of suspicion when a child is injured and no explanation is offered, explanations change or there is a delay in presentation. If the child is not independently mobile and/or non-verbal, and has a bruise, the level of suspicion must be higher.

It is not always easy to differentiate with certainty if a skin mark is a bruise or birth mark.

Independent mobility is not age dependant and includes those children who are older but have limited mobility due to a medical condition or disability.

3 Research Base

There is a substantial and well-founded research base on the significance of bruising in children. Child Protection Evidence Systematic Review on Bruising (March 2020): https://childprotection.rcpch.ac.uk/child-protection-evidence/bruising-systematic-review/

Accidental bruising is common in older mobile children, up to 60% of older children who are walking have bruising. However it is rare in infants that are immobile, particularly those under the age of six months and is found in less than 1% of not independently mobile infants.

The pattern, number and distribution of innocent bruising in non-abused children maybe different to that in those who have been abused. Innocent bruises in mobile children are more commonly found over bony prominences and on the front of the body, much less frequently on the back, buttocks, abdomen, upper limbs or soft-tissue areas such as cheeks, around the eyes, ears, palms or soles.

Patterns of bruising that should raise concern of suggestive of physical abuse include:

bruising in children who are not independently mobile
bruising in babies
bruises that are away from bony prominences
bruises to the face, back, abdomen, arms, buttocks, ears and hands
multiple or clustered bruising
imprinting and petechiae within bruising (petechiae alone can be due to a medical cause, or inflicted e.g. suffocation)
symmetrical bruising
bruising in intimate areas, that also raises the possibility of sexual abuse

The younger the child the greater the risk that bruising is non-accidental and the greater potential risk to the child.

4 Clinical assessment / determination of the significance of bruising

A bruise must never be interpreted in isolation. Bruising requires must always be assessed in the context of medical and social history, developmental stage and explanation given. A full clinical examination and relevant investigations must be undertaken. Only then can a conclusion be reached as to whether or not an explanation offered is plausible and credible.

Where a bruise is noted there needs to be a mechanism of trauma to explain the damage to the blood vessels, resulting in bruising. Most bruising is due to trauma, usually blunt force trauma or occasionally suction trauma. A cautionary note: lying on a surface or object, even prolonged, is not sufficient to cause trauma so it cannot always be accepted as a valid explanation for a bruise.

In a few cases bruising may be associated with an underlying medical condition e.g. infection, haematological condition, vasculitis or connective tissue disorder. The opinion and differential diagnosis is the responsibility of an appropriately experienced doctor. If a medical cause is suspected advice should be sought from the local paediatrician on call for safeguarding

A review of the child’s medical history, including any previous occurrence of bruising or injury should be undertaken.

A health practitioner should undertake a full physical examination of the completely undressed child. This should include weighing, observation of general demeanour, interaction with carer / parent, cleanliness, infestations, nourishment and body proportion, as well as looking for other bruising or evidence of injury. If available, the child’s growth chart should be examined.

A strong plausible and credible explanation for the bruising must 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, with responses documented verbatim. If possible history should be sought from more than one carer separately or more than once from the same carer. Inconsistencies or variations between carers or between interviews should raise suspicions of abuse. There must be consideration of other siblings who may also be at risk of harm.

The lack of a consistent explanation or an explanation that is incompatible with the appearance or circumstances of the findings or with the child’s age or stage of development should raise suspicion of abuse. In most instances it is expected that this will result in a formal referral to Children’s Social Care.

5 Initial practitioner decision: is the bruising significant?

Consult Appendix A: birth marks and other innocent marks to consider differential diagnoses.

Features indicating an increased risk that bruising is due to abuse rather than to accidental or medical reasons:

Bruising on the head especially the face, ears and neck, abdomen, upper limbs (especially arms and hands), back, buttocks and around the anus or genitals
Bruises in clusters
Large bruises
Bruising on soft tissues (away from bony prominences)
Multiple bruising especially of uniform shape or symmetrical positions
Imprints and patterns e.g. fingertip bruising, hands, rods, ropes, ligatures, belts and buckles. In some areas of the body, such as the cleft of the buttocks and the ears, bruising caused by an object or implement may not always show a typical imprint of the injuring object.
Bruising with associated petechiae
Boggy forehead swelling with peri-orbital oedema (violent pulling of the child’s hair, head butt)
Accompanying injuries such as scars, scratches, abrasions, burns or scalds
Bruising in non-mobile children and / or bruising in disabled children

5.2 Features more commonly associated with innocent bruising:

Shins and the knees in mobile children
Back of the head, the front of the face, including the forehead, the nose, upper lip and chin as a result of trips and falls
Bruising to the forehead in children who are pulling to stand

However, these features may also occur in abused children and it is important to re-emphasise that any bruising in a child not independently mobile is unusual: “those who don’t cruise rarely bruise”.

A small percentage of bruising in children not independently mobile will have an innocent explanation or medical cause.

Innocent bruising, medical causes and non-accidental injury are not mutually exclusive.

6. Sharing information and consulting colleagues

It is a safeguarding risk for professionals without appropriate expertise and experience to diagnose “innocent bruising” in non-mobile children. Specialist review and investigations are often required.

A referral to social care must not be delayed if timely advice is not available from a colleague.

Child protection issues are necessarily complex and seeking advice from a colleague to protect against professional optimism and promotes safe practice.

Because of the difficulty in excluding non-accidental injury, practitioners should seek advice from Children’s Social Care in cases without an obvious innocent explanation, to establish if the child and/or family are already known to services in respect of any ongoing or previous concerns. However this must not influence a decision to refer if there are initial concerns.

Colour of the bruise cannot be used to accurately time the bruising

Any bruising in a non-mobile child, regardless of age, must raise a suspicion of a non-accidental injury.

If the case raises any suspicion, and the case is not referred to social care, the findings must be shared and discussed with another professional or senior colleague and the safeguarding children lead.

For a non-health practitioner advice must be sought from a health practitioner with sufficient experience and expertise to assist in the further management of the child.

In primary care a general practitioner may discuss concerns with their safeguarding lead or Named GP for advice, provided this is timely and causes no undue delay in referral. Concerns must also be notified to the child’s health visitor and vice versa.

In the general practice out of hours service such a discussion must take place either with the clinical director of the service, with a senior colleague or if not available the paediatrician on call. The named GP for safeguarding and the family GP must be informed of the discussion.

In the hospital emergency department, clinic or ward, the discussion must be with the most senior clinical colleague available.

Health staff can also seek advice or discuss the case with their own Safeguarding Children Team. If unavailable they must be informed of concerns / referral as soon as possible.

An individual practitioner must not be afraid to challenge the opinion of a colleague if they believe in their own judgement that a child might be at risk of harm. Any disputes must follow the local escalation policy.

The referral to Children’s Social Care, to inform the paediatrician undertaking the safeguarding, must include all information known at presentation and include a body map of findings. This will assist in the final interpretation of a finding and opinion of whether the findings are non-accidental or accidental injury or innocent marks.

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

The referral should also include a review of the child’s medical history, including any previous occurrence of bruising or injury. Other relevant family health records may need to be reviewed. Consideration must be given to identify vulnerabilities within the family such as domestic abuse, substance misuse, and mental health issues and deliberate self-harm.

Where a history of previous child protection concerns is given by Children’s Social Care this information must be recorded in all the health records relating to the child.

It is unlikely that all the above information will be available to the referrer when initial concerns arise but will assist in provision of an expert opinion.

The importance of signed, timed, dated, accurate, factual, and contemporaneous records cannot be over emphasised. In all cases careful mapping, description and recording of the size, colour characteristics, site, pattern and number of the bruises must be made preferably on a body diagram (Appendix A), and a careful verbatim record of the carers/parents description of events and explanation for the bruising made in the clinical notes. GP records must be flagged as “at risk” if concerns remain.

If a child safeguarding medical examination takes place under child protection procedures the relevant hospital documentation must be completed.

7. Medical needs first / emergency admission to hospital

7.1 Any child who is found to be seriously ill or injured, or in need of urgent treatment or further investigation, should be referred immediately to hospital for management of medical needs first.

7.2 Such a referral should not be delayed by a referral to Children’s Social Care, which, if necessary, should be undertaken from the hospital setting. However, it is the responsibility of the professional first dealing with the case to ensure that, where appropriate, a referral to Children’s Social Care has been made and concerns shared with the paediatrician on call for safeguarding.

7.3 Of note children may be abused (including sustaining fractures, serious head injuries and intra-abdominal injuries) with no evidence of bruising or external injury.

8. Involving Parents or Carers

The decision to refer to Children’s Social Care and a paediatrician should be explained clearly, frankly and honestly with consideration of professional transparency.

In the interest of duty of candour, whenever possible, parents / carers should be included in the decision-making process, unless it poses a further risk to the child or to do so would jeopardise information gathering.

Professionals should explain to carers at an early stage why the bruising or marks cause concern, particularly in not independently mobile children, and discuss the need for further questioning and examination by “a specialist” paediatrician.

Professionals should inform the carer/parent of the referral. Whenever possible consent should be sought for the referral unless the practitioner feels this would place the child at risk of further harm. However, the carer/parent does not need to consent, and lack of consent must be overridden in the best interest of the child as the “welfare of the child is paramount”.

8.5 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 CSC, and a place of safety / safety plan mutually agreed.

9 Referral to Children’s Social Care

9.1 When a referral to social care is necessary, it is the responsibility of the first professional who was made aware of or observed the bruising to make the referral in line with Safeguarding Procedures including own organisation’s procedures with immediate telephone referral for urgent cases.

If a referral to social care is not made, the reason must be justified and documented, with detail of the names of the professionals taking this decision.

9.2 Referral should, in the first instance, be made by phone. A place of safety pending contact by social care with the child must be mutually agreed between referrer and social worker. During office hours (9.00am – 5.00pm, Mon – Friday) Integrated Front Door: 0151 606 2008 At all other times (including weekends and over Bank Holidays) Emergency Duty Team: 0151 677 6557.

9.3 All telephone social care referrals must be followed up with completion of a Multi-Agency Referral form for Children’s Social Care within 24 working hours.

The referrer will receive an update of the outcome of the referral. If no update provided the referrer should request an update. If there are any issues regarding the feedback that cannot be resolved with the IFD Manager then the referrer should follow the WSCP escalation policy located on the WSCP website: wirralsafeguarding.co.uk

As discussed whenever possible, the child’s parent or carer must be informed before sharing confidential information. However if this would incur delay, or if to do so would put the child or the professional at risk, then practitioners can be reassured that confidential information may be lawfully shared if it can be justified in the public interest and accounting for GDPR “Information Sharing: Advice for practitioners providing safeguarding services to children, young people, parents and carers July 2018”. Public interest includes belief that a child may be suffering, or be at risk of suffering, significant harm. (Working Together to Safeguard Children, HM Government 2018).

10 Conclusion

Bruising is the commonest presenting feature of physical abuse in children.

The younger the child the greater the risk that bruising is non-accidental.

The less mobile the child the greater the risk that bruising is non-accidental.

“Those who don’t cruise rarely bruise”.

It is important that a plausible and credible explanation for the bruising/finding should be sought at an early stage from parents or carers and recorded. Enquiry regarding explanation must be with open questioning (not leading questions) in transparent manner with parents /carers.

The lack of a consistent explanation or an explanation that is incompatible with the appearance or circumstances of the mark within the child’s age or stage of development should raise suspicions of abuse and the usual child protection procedures must be followed.

The child’s medical records, including general practice, any history of bruising must be flagged as a significant problem/risk factor in the notes.

Further Reading / Guidance

Further guidance can be found in the policies and procedures, paediatric assessment section of the Child Protection S47 Enquiries.

Working Together to Safeguard Children, HM Government, 2018, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/779401/Working_Together_to_Safeguard-Children.pdf

What to Do If You Are Worried a Child Is Being Abused, HM Government, 2015

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/419604/What_to_do_if_you_re_worried_a_child_is_being_abused.pdf

Child Protection Companion, Royal College of Paediatrics & Child Health, on line resources

https://www.rcpch.ac.uk/resources/child-protection-companion-about

Child maltreatment: when to suspect maltreatment in under 18s (NICE Clinical Guideline 89, Oct 2017) https://www.nice.org.uk/guidance/cg89

PROTOCOL FOR INJURIES IN NON-MOBILE CHILDREN1 INJURIES IN NON-MOBILE CHILDREN

Bruising is the commonest presenting feature of physical abuse in children. The younger the child the greater the risk that bruising is non-accidental. There is a substantial and well-founded research base on the significance of bruising in children. RCPCH systemic reviews.

Protocol Summary

The protocol provides all agency professionals with a knowledge base and action strategy for the assessment, management are non-mobile children who present with injuries (including bruising or suspicious marks).

Professional observes an INJURY, BRUISE OR SUSPICIOUS MARK: You Must Suspect Child Maltreatment

Any child who is found to be seriously ill or injured, or in need of urgent treatment or further investigation, must be referred immediately to hospital before referral to Children’s Social Care.

Any injury, bruising, or mark that might be bruising, in a child of any age that is brought to the attention of a Professional should be taken as a matter of concern. Injuries in a non-mobile child must raise suspicion of maltreatment and must result in an immediate referral to Children’s Social Care and an urgent paediatric opinion. NICE Clinical Guideline 89: http://guidance.nice.org.uk/CG89/Guidance/pd f/English
Explain to carers the reason for immediate referral to Children’s Social Care

An injury must never be interpreted in isolation and must always be assessed in the context of medical and social history, developmental stage and explanation given. A full clinical examination and relevant investigations must be undertaken by a paediatrician.

ACTIONS:

Seek an explanation, examine and record accurately.
This must include details of social history including other children and carers
Refer to Children’s Social Care
A Child who is seriously ill must be referred to the hospital immediately

APPENDICES