Please note that the NICE guidance was last updated October 2017.
Definitions and Terminology
Front-line practitioners: in line with “Working Together to Safeguard Children” (2018) this includes: teachers, GPs, nurses, midwives, health visitors, school nurses, early years practitioners, youth workers, police, paediatricians, voluntary and community workers and social workers.
Not Independently Mobile (NIM): A child who is not yet crawling, bottom shuffling, pulling to stand, cruising or walking independently, this includes all children under the age of six months. Please note however that some babies can roll from a very early age and this does not constitute self-mobility. Consideration should be given to children with physical disabilities whom are also not independently mobile.
Bruising: Is the extravasation of blood in the soft tissues producing a temporary, non- blanching discolouration of the skin. This can be faint or small and 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 non-blanching spots, less than two millimetres in diameter and often in clusters.
Medical Bruising: bruising to very young babies may be caused by medical issues e.g. birth trauma however this is rare. In addition, some medical conditions can cause marks to the skin in very young babies that may resemble a bruise. An example of medical bruising is Congenital Dermal Melanocytosis (formally known as Mongolian Blue Spot) - see Appendix 3 for further details - but this should be confirmed by a registered health practitioner and documented in the child’s records.
In all cases, unless the specific mark that has been identified is already confirmed by a health practitioner as arising from a medical condition, this protocol should be followed to enable multi-agency assessment of the suspected bruise.
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. 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 but rarely 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.
In 2019 13% of all children on a child protection plan for physical abuse was under 1 year old (DFE).
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.
Also see https://childprotection.rcpch.ac.uk/child-protection-evidence/
A bruise must never be interpreted in isolation and must always be assessed in the context of medical & social history, developmental stage, explanation given, and this should always be shared with the Paediatrician. A full clinical examination and relevant investigations must be undertaken.
The younger the child the greater the risk that bruising is non-accidental, while accidental and innocent bruising is significantly more common in older mobile children, practitioners are reminded that mobile children who are abused may also present with bruising (Baby P, 2008). They should seek an explanation for all such bruising, and assess its characteristics and distribution, in the context of personal, family and environmental history. However, it must be borne in mind that there have been many serious case reviews in which carers have offered “satisfactory explanations” and the child has turned out to have been physically abused. History from the caregivers is only one piece of the jigsaw in all areas of child protection. In fact the NICE guidance on when to suspect child maltreatment states, “Do not rely solely on information from the parent or carer in an assessment.”
Contacts to Children Social Work Services (CSWS) and Paediatric Opinion
Non-Healthcare Staff: This protocol requires any front-line practitioner who identifies a potential bruise to a baby who is not yet self-mobile to make a contact to CSWS Duty and Advice. This is because there is a significant possibility that the bruising may have arisen as a result of abuse or neglect. This contact will allow a multi-agency discussion to take place and consideration as to whether or not a referral will be made to an Area Social Work Team.
Healthcare Staff: Any Healthcare practitioner who identifies a potential bruise to a baby not yet independently mobile should seek the advice of another health practitioner and the decision to make a contact to CSWS Duty and Advice should be undertaken jointly with another practitioner or senior colleague.
When a decision to make a contact to CSWS Duty and Advice is decided it is the responsibility of the first practitioner who observed the bruising to make the contact. However, this requirement should not prevent an individual practitioner of any status contacting CSWS Duty and Advice with regards to any child with bruising who in their judgement may be at risk of child abuse.
Contacts to CSWS Duty and Advice: Contacts to CSWS Duty and Advice should be made in line with the local procedure, including gaining consent from the parents, unless there is a clear increased risk to the child by doing so. However a contact should still be made if parents do not consent in order to safeguard the child.
Practitioners should also consider the needs of other children in the family who may be affected and inform CSWS Duty and Advice in order that a strategy discussion gives proportionate consideration to the possible need for child protection medical examinations of other children in the family.
If the family are already known to CSWS then the front-line practitioner should inform the named Social Worker as soon as is possible.
Paediatric Opinion: When a child is referred to CSWS Duty and Advice under this protocol, CSWS should, if not already requested, undertake a referral to the Community Paediatric Department for an assessment of the bruise or mark and a detailed physical examination of the child (Child Protection Medical).
Note: This excludes children in accident and emergency, or within the hospital setting, where cases should be referred directly to the Paediatric Medical team, who will comprehensively assess the child, incorporating Consultant Paediatrician & social care opinion.
For a paediatric opinion contact:
- During office hours (8.30am – 5.00pm): Tel: 0113 843 2001
- At all other times: Call the on-call Paediatrician for the hospital (Tel: 0113 2432799 ) and ask switchboard to bleep the ‘on-call paediatrician’.
The Consultant Community Paediatrician must liaise with CSWS with regard to the outcome of the assessment as soon as it is completed and an immediate written summary of the Child Protection Medical should be offered to the allocated Social Worker.
The contact should be made, and the child seen, on an urgent and immediate basis. If there are barriers to the child and family attending the assessment a discussion should be had between relevant services and assistance provided as necessary.
It is expected that all contacts to CSWS Duty and Advice (and notification to any existing Social Worker) under this protocol, will be responded to and assessment commence, on the same day that the request is received.
Where a contact is delayed for any reason, or where bruising is no longer visible, a Consultant Paediatrician must still examine the child to assess, as a minimum, general health, signs of other injuries or pointers to maltreatment, and to exclude bleeding disorders
Bruising in Non-Mobile Older Children eg a child with a disability
Studies of bruising patterns in disabled children showed that the dorsum of the feet, thighs, arms, hands and trunk are sites of unintentional bruising. This is thought to be due to knocks during transfers, bumps from wheelchair users or ill-fitting / misuse of equipment. Where appropriate parents / carers should be provided with support and information in relation to the use of correct equipment. Bruising to the hands, arms and abdomen were significantly more common in disabled than able-bodied children. Bruising increases with increasing independent mobility2.
Bruising which occurs on an immobile older child will not automatically require a contact to CSWS Duty and Advice, however the pattern of bruising 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 that there may be many underlying factors as to why this may be.
If a practitioner is identifying bruising within a non-independently mobile older child they should, along with others forms of assessment with regards to what they see, consider the following:
- Does the explanation for the bruise match the child’s developmental capability and likely behaviour?
- Was the child developmentally capable of causing these injuries to him or herself?
- Does this pattern of bruising match the particular developmental capabilities of a child of this age with these particular developmental needs?
- 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, with parental consent, 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(3).
If following conversations with parents / carers and other practitioners as appropriate a practitioner feels that a child or young person is suffering, or at risk of suffering harm they should contact Duty and Advice in line with the local procedure, including gaining consent from the parents, unless there is a clear increased risk to the child by doing so. However a contact should still be made if parents do not consent in order to safeguard the child.
Practitioners should also consider the needs of other children in the family who may be affected and inform CSWS Duty and Advice in order that a strategy discussion gives consideration to the possible need for child protection medical examinations of other children in the family.
