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BarnsleySafeguarding Children Partnership Policies and Procedures Manual

Procedure for bruising or injury to a baby or child who is not independently mobile (non-mobile)

AMENDMENT

Appendix C, flowchart of action to be taken, was updated in April 2023.

Contents

  1. Introduction
  2. Aim of Procedure
  3. Audience
  4. Definitions and Considerations
  5. Research Base
  6. Guiding Principles
  7. Action to Safeguard the Child in the Community
  8. Identification of Birth Marks/Birth Trauma
  9. Bruising in Non Mobile older Children e.g. a child with a disability or complex needs
  10. Children presenting in the Emergency Department (ED)
  11. Involving Parents or Carers
  12. Escalation
  13. Specific Considerations
  14. Appendices
  15. Further Information

1. Introduction

Bruising is the most common injury in physical child abuse and a common injury in non-abused children, the exception to this being in non-mobile infants where accidental bruising is rare (<1%). Diagnostic dilemmas centre on distinguishing abusive from non-abusive bruises - Child Protection Evidence: Systematic Review on Bruising (RCPCH - 2020). The need to strike a balance and react appropriately to protect children whilst not overreacting and putting children and families through unnecessary procedures is extremely difficult, and one that this procedure aims to support.

Recent safeguarding practice reviews and individual child protection cases across the UK have indicated that clinical staff have sometimes underestimated or ignored the highly predictive value, for child abuse, of the presence of bruising in babies who are not independently mobile. As a result, there have been a number of cases where children have suffered significant abuse that might have been prevented if action had been taken at an earlier stage.

Indeed, the National Institute of Clinical Excellence guidance (NICE) Clinical Guideline 89 (2009, updated October 2017) states that bruising in any child not independently mobile should prompt suspicion of maltreatment (see Child maltreatment: when to suspect maltreatment in under 18s).

All such bruising should be suspected by professionals to be an indicator of potential physical abuse and should be thoroughly investigated. A decision that the child has not suffered abuse must be made with extreme caution and should not be made in isolation, remembering the motto “Those who don’t cruise, rarely bruise” N. Sugar (2011).

2. Aim of Procedure

This procedure provides frontline practitioners with knowledge and guidance to support the assessment, management and referral of children who are not independently mobile and who present with bruising, injury or otherwise suspicious marks. The primary focus will be on babies; however, Section 9 covers older children with disabilities or complex needs (see Section 9, Bruising in Non Mobile older Children e.g. a child with a disability or complex needs).

In the light of the NICE guidelines “When to Suspect Child Maltreatment” (2009), this procedure 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 and caution.

3. Audience

The procedure is aimed at all staff who work with children and families.

4. Definitions and Considerations

4.1 Non-Mobile or Not Independently Mobile

A Non-Mobile Child is one who is not independently crawling, bottom shuffling, pulling to stand, cruising or walking independently. This includes children with disabilities.

Babies or children who can roll are classed as non-mobile for the purposes of this procedure. Professionals must use their judgement regarding babies who can sit independently but cannot crawl. Consideration in these cases should take into account, severity of the injury, the account of the parent or carer given and the plausibility.

4.2 Bruising

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.

4.3 Physical Injuries

Any injury in a non-mobile infant or child causes concern; of particular concern are injuries to infants six months and under. Any injuries are unusual in this age group. Even small injuries could be significant, and 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;
  • Bite marks;
  • Burns and scalds;
  • Pain, tenderness or failing to use an arm or leg which may indicate pain or discomfort and 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.

Please note where a bruise or injury is reported, but cannot be seen, this same procedure should be followed. This stems from learning relating to two Barnsley babies who have previously presented as having HAD a bruise or injury that was not SUBSEQUENTLY visible to the practitioner. When examined both were found to have fractures caused by non-accidental injury and highlighted the importance of taking all reports of bruising/injury seriously even if those injuries are NO LONGER visible.

4.4 Birthmarks

Birthmarks are congenital, mainly benign, irregularity on the skin which is present at birth and is apparent shortly after birth and usually within a month. They can occur anywhere on the skin. Birthmarks are caused by overgrowth of blood vessels, melanocytes, smooth muscle, fat, fibroblasts or keratinocytes. They are usually brown, pink, red or purplish colour or in the case of Congenital Dermal Melanocytosis a blue/grey colour (previously known as Mongolian blue spots or blue/grey spots).

4.5 Unacceptable Explanation

For the purposes of this guidance, an unacceptable explanation is one that is implausible, inadequate or inconsistent with the child or young persons;

  • Presentation;
  • Normal activities;
  • Existing medical condition;
  • Age or developmental stage;
  • Presentation and account given by parent/carer.

An explanation based on cultural practice is also unacceptable, as this does not justify hurting or maltreating a child or young person.

Any explanation for the injury should be critically considered within the context of:

  • The nature and site of the injury on the child;
  • The baby/child’s developmental stage and abilities;
  • The family and social circumstances including previous and current safeguarding concerns and current safety of siblings/other children.

All people who live within the family home, including siblings and partners/significant others (such as aunts and uncles, grandparents, etc) who do not live there, but participate in any aspect of the child’s care, must be considered as part of the assessment.

Situations that should cause particular concern for professionals include:

  • Delayed presentation/reporting of an injury;
  • Admission of physical punishment from parents/carers – no physical punishment is acceptable;
  • Inconsistent or absent explanation from parents/carers;
  • Associated family factors such as substance misuse, mental health problems and domestic abuse;
  • Other associated features of concerns e.g. signs of neglect;
  • Open to other services;
  • Difficulty in feeding/excessive crying;
  • Significant behaviour change;
  • Infant displays wariness or watchfulness;
  • Recurrent injuries;
  • Multiple injuries at one time.

4.6 Petechiae

Petechiae are tiny, circular, non-raised patches that appear on the skin or in a mucous or serous membrane. They occur as the result of bleeding under the skin.

5. Research Base

Although bruising is not uncommon in older mobile children, it is rare in infants that are immobile, particularly those under the age of six months. While up to 60% of older children who are walking have bruising, it is found in less than 1% of non-independently mobile infants, moreover, the pattern, number and distribution of innocent bruising in non-abused children is different to that in those who have been abused. In mobile children innocent bruises sustained due to accidents, such as a result of exploring their environment, are more commonly found over bony prominences and on the front of the body; they are rarely found on the back, buttocks, abdomen, upper limbs or soft-tissue areas such as cheeks, around the eyes, ears, palms of the hands or soles of the feet.

Infants under one year are over three times more likely to have child protection plans for physical abuse as children over one. Almost half of all safeguarding reviews involve a child less than a year old.

Patterns of bruising suggestive of physical child 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;
  • Symmetrical bruising.

See Evidence & reviews (RCPCH).

For more details.

A bruise must never be interpreted in isolation and must always be assessed in the context of medical and social history, developmental stage and explanation given.

6. Guiding Principles

  • Bruise, mark, burn or injury.

Child maltreatment should be considered where bruises/injuries in children are unexplained, without an acceptable explanation, have a concerning presentation or involve a child that is not independently mobile. These concerns must result in an immediate referral to Children’s Social Care in the form of a telephone referral (01226 772423) supported with the Record of Contact Barnsley Children’s Social Care Record of Contact within 24hrs. The only exception to this would be those seen in the Emergency Department (ED), who having followed the internal procedure do not raise concern, please see Appendix A: Bruise, mark or injury in non-independently mobile child. Or those clearly identified as a birth mark/trauma (see Section 8, Identification of Birth Marks/Birth Trauma).

Any bruising, suspected bruising or reported bruising or injury, in a baby/child who is not independently mobile, that is observed by or brought to the attention of any professional must be taken as a matter for inquiry and concern, and caution should be exercised.

7. Action to Safeguard the Child in the Community

Please see Appendix C for flowcharts summarising these processes.

Action to be taken on identifying actual, reported or suspected bruising/injury in the community for a baby/child who is not independently mobile.

If the baby/child appears seriously ill or injured:

  • Seek immediate emergency treatment at an Emergency Department of via a 999 call requesting an ambulance and notifying the Police of the incident;
  • Notify Children’s Social Care of your concerns and the child’s location as soon as possible by ringing 01226 772423.

In all other cases:

If the family already have an allocated social worker, the allocated social worker should be contacted in the first instance, if they are unavailable the Team Leader should be contacted without delay.

When making the referral, the referrer and social care will consider jointly whether the referring practitioner is to remain in the home or wait outside in the car until Children’s Social Care arrive; or whether it is deemed safe to leave the visit and return to their normal duties. This will depend on the level of perceived risk to the child and practitioner. This discussion should be clearly documented by both practitioners.

In some circumstances, due to perceived risk or health need of the children, arrangements may be made to transport the child via ambulance. Where the level of risk is perceived as significant, consideration should be given to asking the Police to attend.

Children’s Social Care will hold a strategy discussion, including Police and health, this will agree the next steps including:

  • Arrangements for the child and family to be visited. In most cases Children’s Social Care should attend the home (or setting where the child is i.e., childcare setting) as soon as possible following the referral being made, generally within an hour;
  • Making arrangements for the child to attend the hospital for a child protection medical to take place (where agreed). Children’s Social Care would usually accompany the child to the hospital. For details of how to arrange a Child Protection Medical please see: The Management of Child Protection Medicals for All Children And Procedures for the Discharge of Children Under 2 Years of Age.

If the risk is perceived to be low. i.e. a potential birth mark or injury from birth (see Section 8, Identification of Birth Marks/Birth Trauma), and it is agreed the family can take the child to the hospital unaccompanied, then a timeframe for the family taking the child to the hospital should be agreed. This should be as soon as possible, but to avoid delay and take into consideration making child care arrangements and arranging transport etc, this should be no longer than 2 hours. The agreed timeframe should be communicated to the hospital so they can make social care aware if the child does not present. Please note for clarity - this timeframe is for the family to make their way to the hospital and present the child, not a timeframe for the medical to take place. Due to pressures and competing priorities it is not possible to set a timescale for the medical to be conducted. However, there is a clear expectation this would be the same day and that the child would be seen by nursing staff on admission to check that the baby/child appears safe and well.

Due to the various scenarios and scale of perceived risk, it is difficult to be prescriptive regarding the exact response required. However, caution, clear consideration of risks and agreement between all parties is advised. All considerations should be documented by all practitioners. Ultimately, the lead decision maker will be Children’s Social Care, however, agreement will be the clear objective.

In order to support the assessment process, Children’s Social Care will initiate the gathering of further information from other sources such as the GP, midwife or health visitor.

It may be useful for the referring practitioner to speak directly with the practitioner undertaking the medical in order to provide more detail regarding the concerns and what has been said by the family.

The child should attend the Hospital, for a child protection medical, as soon as possible following Children’s Social Care receiving the referral. The assessment will include a detailed history from the carer, review of past medical and developmental history, family history including any previous reports of bruising, and enquiry about vulnerabilities within the family. The paediatrician should explain the findings of the assessment to the parents and provide an initial summary to the social worker. Please also refer to the management of child protection medicals for under 2’s.

A further strategy meeting/discussion should then take place between the social worker, police, hospital representative and other involved agencies and the outcome should be explained to the parents. Decision making regarding the required Child Protection investigations will be agreed at the strategy meeting/discussion. The risks for any siblings, significant children or vulnerable adults living in the same household should also be considered and safeguarding processes followed accordingly. If bruising due to injury is confirmed or suspected, this must be considered in the light of other information available from health (including the GP), Children’s Social Care and police records, and local safeguarding procedures followed.

A bruise/injury 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 a paediatric medical professional to determine whether bruising is consistent with the explanation provided or is indicative of non-accidental injury. Children's Social Care will co-ordinate multi-professional information sharing and assessment. No investigation or assessment should be completed or closed down if there remains any outstanding concerns or questions that have not been answered to the satisfaction of all relevant agencies/practitioners. Timely feedback should also always be provided to those raising questions or concerns.

It is the responsibility of any partner agency practitioner who learns of or observes a bruise or injury on a non-independently mobile child to make a referral. Where appropriate the referring practitioner may want to discuss their concerns with another professional, Named Professional or Designated Safeguarding Lead. However, this discussion should not delay a practitioner referring to Children's Services any child with bruising who in their judgement may be at risk of significant harm.

A decision not to refer to social care and follow the process described above i.e. in case of suspected birth mark or trauma (see Section 8, Identification of Birth Marks/Birth Trauma) should be made with extreme caution. If the decision is not to refer, the reason why a referral has not been undertaken must be documented in detail in the child’s records.

Please note: It is the responsibility of Children's Social Care Services in conjunction with the hospital paediatric department to decide whether the circumstances of the case and the explanation for the injury/presenting concern are consistent with an innocent cause or potential maltreatment. Children should NOT be referred to GPs for a decision as to whether any ‘bruising/injury’ is accidental or otherwise.

8. Identification of Birth Marks/Birth Trauma

8.1 Birth Injury

Both normal births and assisted deliveries may lead to development of bruising and to minor bleeding into the sclera (white of the eye). However, staff should be alert to the possibility of physical abuse even within a hospital setting and follow this protocol if they believe the injury was not due to the delivery.

8.2 Birthmarks

These may not be present at birth and appear during the early weeks and months of life. Certain birthmarks, particularly Congenital Dermal Melanocytosis (previously known as Mongolian blue spots or blue /grey spots), can look like bruising. These are rare in children of white European background, but very common in children of African, Middle Eastern, Mediterranean or Asian background.

On occasions it can be difficult to know if a skin mark is suspicious or not – e.g. birth mark, Congenital Dermal Melanocytosis, haemangioma or marks that may be associated with recent birth trauma/delivery. If the presenting concern is observed by a health practitioner, health records should be reviewed to confirm if there was any known notification of the skin mark previously (i.e. clear documentation of the birth mark or birth injury). When there is no recorded explanation of birth mark or trauma and therefore diagnostic doubt regarding the nature of the skin mark, an immediate discussion should take place between the health practitioner and a paediatrician (contact the Paediatric Consultant of the week via switchboard 01226 730000). A decision should then be made to obtain a review to confirm observation of the birth mark/birth trauma (within the day). Following this review in the case of a suspected birth mark, there should be follow up arrangements made to see the child in 10 days to check that mark is still visible. The original body map should be used as a comparator. This will normally be completed by the referring practitioner (i.e. midwives or health visitor).

Where there is any doubt regarding the presentation NOT being a birth mark, a referral to Children’s Social Care should be made via telephone (01226 772423) and supported with a Record of Contact Barnsley Children’s Social Care Record of Contact within 24hrs.

If the observing professional is not from health and therefore cannot confirm that the presenting skin mark is the birth mark, they must contact Children’s Social Care for further advice.

9. Bruising in Non Mobile older Children e.g. a child with a disability or complex needs

Whilst this policy primarily focuses on non-mobile babies, it should be noted that children with disabilities or complex medical needs may also be classed as non-mobile and the following section highlights issues to be considered when observing babies in this group.

Any bruising noted in non-mobile children, 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 a child with a disability could potentially be harmed deliberately, and there may be many underlying factors as to why this may be.

If a practitioner is identifying bruising with a non-independently mobile older child, they should consider the following:

  • Does the explanation for the bruise or pattern match the child’s developmental capacity (physical ability) and likely behaviour or with particular needs?
  • Was the child developmentally capable of causing these injuries to him or herself?
  • 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?

When considering children with complex health and physical disabilities, front line practitioners must 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.

10. Children presenting in the Emergency Department (ED)

For those children who present to ED directly with a reported bruise or injury or where a bruise or injury is noted whilst in the department, the process described in Appendix A: Bruise, mark or injury in non-independently mobile child should be followed.

11. 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 to the parents/carers. 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, e.g. information or evidence could be destroyed, or if it would pose further risk to the child. Professionals must explain to carers at an early stage why the bruising or marks cause concern, and discuss the need for further examination by “a specialist” i.e. 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 can be overridden in the best interest of the child as the “welfare of the child is paramount”. 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, and a safety plan mutually agreed.

Parents should be provided with ‘Bruising in babies – Information for parents and carers’ leaflet and any questions they may have should be answered as far as possible.

Bruising in young babies (barnsley.gov.uk)

12. Escalation

If at any stage of this process there is any disagreement between professionals regarding the safety of a child, it must be resolved using the escalation procedure as outlined in Escalation Policy - Process for Resolution of Professional Disagreements Relating to the Safeguarding & Protection of Children.

13. Specific Considerations

13.1 Self-inflicted injury

It is exceptionally rare for non-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 or the bars of a cot, should not be accepted without detailed assessment by a paediatrician and social worker. Sometimes, even when children are moving around by themselves, there can be concern about how a mark or bruise occurred and in these situations a referral will always be made to Children’s Social Care.

13.2 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 for further assessment, by the paediatrician and Children’s Social Care which must include a detailed history of the circumstances of the injury, and consideration of the parents’ ability to supervise their children.

13.3 Reported bruising

Where a bruise or injury is reported, but cannot be seen, this same procedure should be followed. This stems from learning relating to two Barnsley babies who have previously presented as having HAD a bruise or injury that was not SUBSEQUENTLY visible to the practitioner. When examined both were found to have fractures caused by non-accidental injury and highlighted the importance of taking all reports of bruising/injury seriously even if those injuries are NO LONGER visible.

Appendices

Appendix A: Bruise, mark or injury in non-independently mobile child

Appendix B: Body Map

Appendix C: Flowcharts