Procedure for Bruising or Injury to a Baby or Child who is not Independently Mobile (Non-Mobile)

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).

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.

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

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.

• 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.

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:

• Record what is seen, using a body map in line drawing (Appendix A: Bruise, mark or injury in non-independently mobile child)
• Record any explanation or comments provided by the parent/career word for word as soon as possible
• Refer to Children’s Social Care by phoning 01226 772423 (follow up in writing later using the Record of Contact Form Barnsley Children’s Social Care Record of Contact).

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.

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.

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.

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)

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 (2024).

Appendix A: Procedure for Emergency Department Staff

Appendix B: Body Map

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

Appendix D – Action to be Taken Following a Referral from the Community

Non-accidental Injuries in Infants Attending the Emergency Department (Healthcare Safety Investigation Branch)