Bruising is the most common 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.

Accidental bruising in a non-mobile baby is very rare. Any bruising (or a mark that might be bruising) in a baby or child of any age who is non-mobile should raise concern and be subject to further enquiry by all professionals.

Unexplained bruising or any bruising in a child who is not independently mobile must always raise suspicion of maltreatment, and should result in an immediate referral to Cumberland Children Advice & Support Service and requires an urgent paediatric assessment.

Definitions:

A child is considered non- mobile if they are not yet crawling, bottom shuffling, pulling to stand, cruising around furniture or walking independently;
A baby or child who is becoming mobile: A child who can pull to stand, cruise around furniture, is able to roll, crawl but cannot walk;
A child is considered mobile if they can walk independently.

2. Respectful Uncertainty

When working with babies, children and young people, respectful uncertainty should be explored. Respectful uncertainty means maintaining an open, questioning approach when assessing a bruise in a child, acknowledging that while there may be an innocent explanation, we cannot assume and must explore all possibilities to safeguard the child.

3. 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. There are other factors which may make it difficult for practitioners to assess a mark on the skin, such as the presentation of jaundice and ethnicity, where the presence of an emerging birth mark may look darker, due to the skin tone.

4. 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 single mark or a bruise in a baby or young child may be an indicator of serious underlying injury. Research and serious case reviews (now known as Child Safeguarding Practice Reviews) confirm that relatively minor bruising may be a warning that an adult is under stress and/or that a baby may be at serious risk of further injuries; a lower threshold for 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.

4.1 Blue/Grey Spots and Congenital Dermal Melanocytosis

If a mark on a non-mobile baby is clearly a birthmark, then this needs to be clearly documented in both medical records and PHCHR to include body maps.

Congenital dermal melanocytosis is a common, harmless, pigmented birthmark. Formerly, it was known as Mongolian blue spot. Sometimes, it is also called lumbrosacral dermal melanocytosis. It is usually seen at birth or shortly afterwards. It typically disappears before the age of 6.

Consequently, it is important to note that not all birthmarks are present at birth and may take a number of weeks to become fully visible. It should also be noted that slate grey naevi or blue spot can be present on any area of the body, not just buttocks and back. If the clinician has difficulty in deciding if a mark is a birthmark or injury, then arrangements should be made with the on-call Paediatrician at the local Paediatric Department for a Paediatric Review.

4.2 Vulnerabilities

Practitioners should 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.

4.3 Presentation

Practitioners should consider the presentation of the bruise, including whether there is anything to suggest that attempts may have been made to hide this:

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.

Where an explanation is offered, this should be documented verbatim by the person hearing the information first hand. This initial explanation provided by the carer may change overtime or circumstance.

4.4 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.

4.5 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.

NICE Guidelines state that a non-mobile baby, child or young person, or one that has no independent mobility, for the purposes of this guidance is a baby, child or young person who is unable to move independently through crawling, bottom shuffling, pulling to stand, cruising or walking independently. This includes all babies under the age of 6 months.

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.

5. When to Contact Children's Social Care

Children who are mobile are more prone to bruising in the course of their normal childhood activities. Bruising in non-mobile babies who are not independently mobile raises significant concern about the possibility of physical child abuse. If a bruise or suspicious mark in this group is found, 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, a 'Contact' should be made to Children's Social Care and they should advise that a Paediatric Review is undertaken. Any pertinent safeguarding information known/held in respect of involvement with the family should be requested and provided to the Paediatrician.

If a referral to Children's Social Care is deemed appropriate, it 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.

If a Strategy Discussion/Meeting is required, Professionals will consider 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.

The age and stage of development of the baby/child are crucial considerations in forming a professional judgement as to whether a referral to Children's Social Care and a Strategy Discussion/Meeting is required.
The referrer should discuss an immediate Safety Plan (including safe transportation) for the baby/child, ensuring that immediate contact details for the child and carer are shared. If there are immediate concerns about safety, the police should be called via 999.

Please refer to the flowcharts below for further guidance of what action should be taken:

Bruising or injury to non-mobile infants;
Bruising or injury to infants becoming mobile;
Bruising or injury to a fully mobile child.

6. Findings from National Panel

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

A review by a health professional 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.

7. Paediatric Medical Examination

A Paediatric Medical Examination is a review by the on call hospital Paediatrician, who has the appropriate expertise to assess the nature and presentation of the bruise and any associated injuries. The Paediatrician will also appraise the circumstances of the presentation, including the developmental stage of the child, along with whether there is any evidence of a medical condition that could have caused or contributed to the bruising. This allows them to determine if there is a plausible explanation for the bruising and to exclude or suspect non accidental injury.

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.

8. Strategy Discussion

The initial Strategy Discussion/Meeting should be attended by all agencies to agree what the initial Safety Plan is for the child and any siblings cared for by the same adults, who are the identified carers for the baby/child with the mark/bruise. The initial Safety Plan needs to be robust and clearly communicated to all professionals to ensure it remains in place until all clinical reviews are reported on. This includes a peer review of any radiological investigations undertaken.

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/Meeting 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 Strategy Discussion/Meeting concludes the threshold for Section 47 is met, consideration should be given to arranging a child protection medical. 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/Meeting. 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 undertaken by a Paediatrician. It cannot be undertaken by the family GP.

For further information, please see the Child Protection Enquiries Procedure for guidance on Strategy Discussions.

9. 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 Escalation Policy exists to guide Practitioners on how to manage such disagreements or differences of opinion.

Non-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 or children, whilst a decision is reached.

10. Key Points to Remember

When investigating children with unexplained bruising, Practitioners should not offer to the family or other witnesses any options or suggestions as to how the child or young person may have acquired the bruise. They should ask open ended questions and avoid leading or providing explanations.

Bruises sustained in the course of normal childhood activities and play in pre-school children who are mobile occur in characteristic locations on the body, whereas bruises caused by physical abuse are seen in a different distribution.

The age and stage of development of the baby/young child are crucial considerations in forming a professional judgement as to whether a referral to Children's Social Care and a Strategy Discussion/Meeting is required. Bruising is strongly related to mobility and, as such, injuries and bruising to a non-independently mobile child, i.e. a baby who is not yet crawling, bottom shuffling, cruising, or independently walking raises a significant concern about the possibility of physical abuse. In this age group, further investigations for hidden injuries are also likely to be undertaken.

It is not possible to age bruising in babies, children, and young people by looking at their shape or colour.

The child protection medical examination of bruising in babies and young children forms an important part of the initial assessment. However, it is only one part of the holistic assessment and the decision to proceed with child protection enquiries and hold a case conference should be made in the light of all the available multi-agency information about the wellbeing of the baby, child or young person.