Bruising in Non-Mobile Babies and Children
Bruising and other injuries in Non-Mobile Babies and Non-Mobile Children
Practice Guidance for Assessment, Management and Referral
The aim of this guidance is to support professionals in the management and referral of non – mobile babies and non – mobile children who have presented with bruising or other injuries. It does not reiterate the process to be followed once a referral to children’s social care services has been made.
Date revised: May 2023
Review date: May 2026
Introduction
Bruising is the commonest presenting feature of physical abuse in children. Reviews of the research conclude that bruising is strongly related to mobility and that bruising in a baby who is not yet crawling, and therefore has no independent mobility, is very unusual. It is found in less than 1% of infants who are not independently mobile. The younger the baby, the greater the risk that bruising is non-accidental and the greater the potential risk to the baby.
In light of the research evidence this guidance has been developed to inform professionals about the appropriate management of bruising seen in babies who are not independently mobile.
It is recognised that bruising to very young babies may be caused by medical issues e.g. birth trauma or blood abnormality however this is rare. In addition, some medical conditions can cause marks to the skin in very young babies that may resemble a bruise e.g. Congenital dermal melanocytosis (benign skin mark/blue grey spots, all previously referred to as Mongolian Blue Spots).
Not Independently Mobile: A child of any age who is not yet crawling, bottom shuffling, pulling to stand, cruising or walking independently. It should be noted that this guidance applies to all babies under the age of six months and children who are immobile, for example those with immobility due to disability/illness.
A Bruise is caused by the leakage of blood into surrounding soft tissue. This produces a temporary, nonblanching 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 red or purple spots, less than two millimetres in diameter and often in clusters.
Skin marks could be a birth mark or similar benign medical skin condition therefore professionals are encouraged to check birth record. Birth marks or injuries caused by birth should be recorded in the child’s record / red book. Blue grey spots are not always present at birth and can develop up to 3 months of age.
It is essential that when these are observed at medical checks, that they are documented in the child’s health records.
If a bruise is seen on a baby of less than six months of age, or older if still not independently mobile, the professional observing the bruise / mark should always enquire as to the cause of the mark. A record should be made of the characteristics, position and explanation given for the bruise / mark.
If the baby is unwell or there are other indicators of a possible medical cause for bruising, then appropriate medical intervention should be sought. The doctor who sees the child will consider whether a referral to Staffordshire Childrens Advice and Support Service is required and make a referral as appropriate.
If the baby is well and there is no other indication of a medical cause the professional who has seen the bruise/mark should ascertain the explanation for the bruise/mark from the parent/carer. The practitioner is required to consider explanation (mechanism of injury), family history, environment and voice of the child (behaviour in infants) as well as the possibility of medical conditions.
A bruise in a non-mobile baby/ child, where the cause has not been independently witnessed requires referral to Staffordshire Childrens Advice & Support Service. Multi-agency discussion is essential.
It is important to be open and honest with parents regarding the concern raised by bruising in non-mobile babies and children and the potential need to discuss this with the Staffordshire Childrens Advice and Support Service. The exception to this would be if such a disclosure would increase the risk of harm to the baby. If a parent or carer is uncooperative this should be reported immediately to the Staffordshire Childrens Advice and Support Service.
If in doubt, contact the Staffordshire Childrens Advice and Support Service Tel: 0300 111 8007
This section refers to presentation of other injuries such as burns, fractures or bites. Professionals are more likely to recognise other injuries such as burns, fractures or bites in a non-mobile child as abusive, just as they would in a child of any age. However, the same principle applies. The professional should always enquire as to the cause of the injury and record the characteristics, position and explanation.
If the child needs medical attention, then this should be sought immediately and a referral made to Staffordshire Childrens Advice and Support Service if there are safeguarding concerns.
If the child is well and does not need medical attention then a referral should be made to Staffordshire Childrens Advice and Support Service, unless there is good evidence that there is satisfactory accidental explanation.
Keep contemporaneous notes detailing the findings, any explanation and analysis of the contact and actions taken giving clear rationale. Early Help or Child Protection referrals and the information shared should be recorded and filed in the baby’s / child’s record used by that particular agency.
At no time must professional disagreement detract from ensuring that the baby/child is safeguarded. The baby/child’s welfare and safety must remain paramount throughout. If there is a disagreement regarding the management / care of the baby / child e.g., Child Protection Medical deemed unnecessary when there are signs of injury and bruising, the practitioner must consider applying the SSCB Escalation Policy in order to reach a resolution.
If there are immediate safeguarding concerns and agencies do not believe there are suitable plans in place to ensure the immediate safety of a child, they have a duty to escalate this to the appropriate manager outside of the usual escalation process.
CG 89- When to Suspect Child Maltreatment (December 2009; updated 2017); National Institute of Health and Clinical Excellence.
NG76- Child Abuse and Neglect guideline (October 2017); National Institute of Health and Clinical Excellence.
Bruising – A systematic review (September 2010) Welsh Child Protection Systematic Review Group. http://www.core-info.cf.ac.uk/bruising/index.html
NSPCC – Bruises on children, core information leaflet; https://learning.nspcc.org.uk/researchresources/pre-2013/bruises-children-core-info-leaflet
The Child Safeguarding Practice Review Panel – Bruising in Non-mobile Infants