5.4 Bruising in Babies and Children

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5.4 Bruising in Babies and Children

AMENDMENT

This chapter was updated in November 2024 in line with local procedure.

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1.	Introduction
2.	Recognition of Bruising
3.	Distinguishing Bruises Sustained from Physical Abuse
4.	When to Refer / Pathways
5.	Paediatric Medical Examination
6.	Strategy Discussion
7.	Managing Differences of Opinion
	Further Information

1. Introduction

Bruising is the commonest injury encountered when children have been physically abused, however, children will always sustain bruises in the course of normal childhood activities and play. There are some skin markings that can look similar to bruises and there are medical conditions that can cause bruising. This guidance aims to assist practitioners to:

Understand the importance of bruising in babies and children as an indicator of physical abuse;
Clarify the arrangements between health and social care colleagues in relation to the investigation of bruising in children and young people.

2. Recognition of Bruising

A bruise occurs when the blood comes out of the blood vessels into the soft tissues, producing a temporary discolouration of the skin, which is non blanching (i.e., does not fade when pressure is applied to the skin). The discolouration may be faint or small with or without other skin abrasions (scrape or graze to skin) or marks. The colour may vary and it is not possible to give any opinion on when an injury happened to cause a bruise from looking at its shape or colour.

It is sometimes difficult to distinguish between a bruise and another mark to the skin, such as a birthmark. Reviewing other sources of information (e.g., Parent Child Health Record (red book), asking the parents to look at earlier photos which show the mark) may make things clearer. Sometimes looking at whether the mark changes over time is the only way to be clear about this – bruises will change and fade over days whereas a birthmark will usually stay the same size and colour during this period. Where there is doubt as to the nature of a mark that may be a bruise, it is important that the baby is kept safe whilst further clarification is sought. In certain cases, this may involve a less experienced health care professional requesting advice / second opinion from a more experienced practitioner within their own clinical or safeguarding team.

3. Distinguishing Bruises Sustained from Physical Abuse

A bruise, as well as being sustained in the course of normal childhood activities and play, may be an external indicator that a baby or child is being abused. Information gathered as a result of an appropriate investigation may enable that baby or child to be safeguarded.

In contrast to older children, babies and young children are more vulnerable to injuries of equivalent force. The likelihood of a baby or young child having bruises is also closely linked to their level of independent mobility. A referral for both medical and social care investigation is needed to effectively protect a baby or young child.

Child Maltreatment: When to Suspect Maltreatment in Under 18s (NICE) and RCPCH Child Protection Evidence Systematic Review on Bruising set out a number of possible clinical findings suggestive of abuse. These include:

Suspect child maltreatment if a child or young person has bruising in the shape of a hand, ligature, stick, teeth mark, grip or implement;
Suspect child maltreatment if there is bruising or petechiae (tiny red or purple spots) that are not caused by a medical condition (for example, an underlying bleeding disorder) and if the explanation for the bruising is unsuitable. Examples include:
- Bruising in a child who is not independently mobile;
- Multiple bruises or bruises in clusters;
- Bruises of a similar shape and size;
- Bruises on any non-bony part of the body or face including the eyes, ears and buttocks;
- Bruises on the neck that look like attempted strangulation;
- Bruises on the ankles and wrists that look like ligature marks.

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

Vulnerabilities

Look for factors that make infants and children more vulnerable to abuse and neglect. These may be present in the child (e.g. premature birth, disability, and unwanted pregnancy) and/or the adults who care for the child (alcohol and substance use, domestic abuse, poor mental health, learning difficulties and poverty). Contrary to popular belief, boys do not sustain more bruises than girls.

Presentation

Consider the presentation of the bruise:

Was the presentation delayed?
Was the bruise found incidentally during another contact or appointment? (e.g., whilst giving immunisations);
Was the bruise described to a professional and is no longer visible?

Is the explanation for the bruise:

Not available/no explanation offered;
Inadequate and unlikely (e.g., a bruise on the chest of a baby from rolling onto a dummy);
Inconsistent with the child's development stage (e.g., sustained when rolled off bed when child not yet rolling);
Inconsistent over time or confused.

Voice of the young child, where appropriate

Listen and record verbatim any explanation given by the young child;
Observe the baby/child's demeanour and any interactions between the child and parent/carer.

Age and stage of development of the baby/young child

Bruising sustained in the course of normal activity and play is strongly related to mobility. The number of bruises a child sustains through normal activity increases as they get older and their level of independent mobility increases. Most children who are able to walk independently sustain bruises. Bruises usually happen when children fall over or bump into objects in their way.

A non-mobile baby, or one that has no independent mobility, for the purposes of this guidance is a baby or child who is unable to move independently through crawling, bottom shuffling, pulling to stand, cruising or walking independently.

Bruising sustained in the course of normal childhood activities and play in a non-mobile baby, who has no independent mobility, is rare (prevalence 0.6-1.3%) (RCPCH Child Protection Evidence Systematic review on Bruising)- 'Those that don't cruise rarely bruise';
Only one in five infants who is starting to walk by holding on to the furniture will sustain bruises;
Even once children are mobile, significant unexplained bruising is unusual and requires exploration.

4. When to Refer / Pathways

Refer to flowcharts below

Pan Lancashire Pathway – Bruising or Injury to Non-Mobile Infants

Pan Lancashire Pathway – Bruising or Injury to Infants Becoming Mobile

Pan Lancashire Pathway – Bruising or Injury to a Fully Mobile Child

The Child Safeguarding Review Panel Bruising in non-Mobile Infants guidance recommends that in all cases of bruising in children who are not independently mobile there is:

A review by a paediatrician who has the appropriate expertise to assess the nature and presentation of the bruise, any associated injuries, and to appraise the circumstances of the presentation including the developmental stage of the child, whether there is any evidence of a medical condition that could have caused or contributed to the bruising, or a plausible explanation for the bruising;
A multi-agency discussion to consider any other information on the child and family and any known risks, and to jointly decide whether any further assessment, investigation or action is needed to support the family or protect the child. This multi-agency discussion should always include the health professional who reviewed the child.

Bruising sustained in the course of normal childhood activities and play is strongly related to mobility. Bruising in non-mobile babies and children who are not independently mobile raises significant concern about the possibility of physical child abuse.

A bruise or suspicious mark in this group, however small, which does not have a clear, consistent adequate explanation of a significant event, in keeping with the baby or young child's development, and an appropriate parent/carer response, should be referred to children's social care.

The referral should be made immediately as per local procedures (see Referrals Procedure) and should include up to date contact details for the family and the referrer. This procedure should be followed for new cases and previously known children.

The age and stage of development of the baby/ child are crucial considerations in forming a professional judgement as to whether a referral to social care and a strategy discussion is required.

The referrer should discuss an immediate safety plan for the child (Supervision, Medical Assessment & Transport) ensuring that immediate contact details for the child and carer are shared.

All discussions should be documented including the risks of not staying with the baby or child until a social worker arrives. If there are immediate concerns about safety, the police should be called.

Next step – refer to on call paeds – decision to suspect or exclude NAI.

5. Paediatric Medical Examination

A review by the on call hospital paediatrician who has the appropriate expertise to assess the nature and presentation of the bruise, any associated injuries, and to appraise the circumstances of the presentation including the developmental stage of the child, whether there is any evidence of a medical condition that could have caused or contributed to the bruising, determine if there is a plausible explanation for the bruising and to exclude or suspect NAI.

Paediatric medical examinations for bruising/suspicious marks require informed consent from an individual with parental responsibility or in the absence of this, a court order directing that a paediatric medical examination takes place. If the injury is thought to have been caused by an implement where practicable this should be brought to the medical examination or images of the implement made available to the examining paediatrician.

6. Strategy Discussion

The social worker/team manager should arrange a strategy discussion/meeting with police and health to discuss the need for section 47 enquiries. The strategy discussion/meeting should always include the health professional who reviewed the child.

Professionals within the strategy discussion will have a discussion considering the relevant factors such as presentation, explanation, the voice of the child and any known vulnerability factors to support further decision making and safety planning.

If the discussion/meeting concludes the threshold for section 47 is met, then a child protection medical should be arranged. If there are issues regarding the decision to hold a medical, the obtaining of consent, communication difficulties or other factors which may make the paediatric medical examination complex then consider including a consultant paediatrician in the initial strategy discussion. The discussion should involve the development of an interim safety plan for the child and consideration of siblings.

The child protection medical can only be carried out during a section 47 investigation and can only be undertaken by a paediatrician. It cannot be undertaken by the family G.P.

For further information, please see the Child Protection Enquiries Procedure, Strategy Discussion / Meeting for guidance on strategy discussions.

7. Managing Differences of Opinion

There may be disagreement between different practitioners as to the most appropriate action to be taken at any stage in the process of assessment of a possible bruise. The local Conflict Resolution Policy exists to guide practitioners on how to manage such disagreements or differences of opinion.

Pre-mobile babies and young children are extremely vulnerable to a serious outcome from physical abuse by virtue of their immaturity, and so it is important to ensure the safety of the baby whilst a decision is reached.