Bruising and Injuries in Non-Mobile Infants a Multiagency Procedure

 

1. Introduction

1.1 Injuries in non-mobile infants are rare, and therefore, there is a significant risk that an injury may indicate abusive or neglectful care. Unfortunately, nationally and locally, injuries, including bruising, are not always responded to appropriately by professionals.

 

2. Background

2.1 It is recognised that the likelihood of an infant sustaining accidental injuries increases with increased mobility. However, infant safeguarding practice reviews have identified that professionals sometimes fail to recognise the highly predictive value of child abuse of the presence of injuries to non-independently mobile infants.

2.2 Severe child abuse is 6 times more common in infants aged under 1 year than in older children. Infants under the age of one are more at risk of being killed at the hands of another person (usually a carer) than any other age group of children in England and Wales. 

2.3 35% of serious incidents reported to the national child safeguarding practice review panel involve serious harm to babies, the vast majority physical injury or death. 

2.4 Local and national child safeguarding practice reviews have shown that infants are often seen by professionals in the weeks leading up to abusive head trauma or serious injury. Staff in these cases have sometimes underestimated the significance of the presence of bruising or minor injuries in infants who are not independently mobile.2 They have, therefore, not considered what appears to be a rather minor injury as an indicator or precursor to significant injuries or death of an infant. Early recognition and action in such cases is key to preventing further injuries.”

2.5 A sentinel injury is a visible or detectable minor injury in a pre-cruising infant that is poorly explained and, therefore, suspicious for physical abuse.  These include bruises, subconjunctival haemorrhages, and intra-oral injuries.  Practitioners must be vigilant when a bruise or any intraoral bleeding is identified in an infant because these may be 'warning injuries' for possible abuse.

2.6 Bruising and other minor injuries (may present as unusual marks) in non-mobile or non-independently mobile infants may be a sign of an injury and SHOULD   be treated as such until further assessment, which MUST include a medical opinion from a paediatrician.

2.7 Full assessment of these infants and their families presents an opportunity to intervene and protect children from future harm. In cases of significant non-accidental injuries in infants, up to 30% have previously attended a healthcare setting with sentinel injuries.3

2.8 Any injuries are unusual in this age group.  Even small injuries may be significant and a sign that another hidden injury is already present.

2.9 Such injuries include:

  • Torn frenulum (small area of skin between the inside of the upper and lower lip and gum) 
  • Bleeding from ears, nose or throat or history of these
  • Lacerations, abrasions or scars 
  • Burns and scalds. 
  • Pain, tenderness or failure to use an arm or leg, which may indicate pain and an underlying fracture.
  • Small bleeds into the whites of the eyes or other eye injuries

 

3. Definitions and Terminology

3.1 Professionals:  All individuals from all agencies working with children and families either directly or indirectly 

3.2 Non-mobile Infant: A child who is not yet walking, crawling, pulling to stand or bottom shuffling independently. This includes all infants under six months old as although some can ‘roll over’ from a very early age this does not constitute self–mobility. The current evidence base concludes that accidental bruising is uncommon in an infant who is not independently mobile, particularly in those who are younger and unable to roll and crawl.

3.3 Non-independently Mobile: - an infant who is unable to move independently through crawling, cruising or bottom shuffling. 

3.4 Injuries: It is recognised that bruising is the most common presentation in children who have been physically abused (Maguire, 2010). However, for the purpose of this protocol, ‘injury’ will be taken to mean any bruise, mark that may be an injury, burn, scald, laceration, cut, abrasion, suspected fracture, unexplained bleeding or any other apparent injury to a child.

3.5 Infant: A child from the age 0-1 year. 

 

4. Responsibilities of the Multi-Disciplinary Workforce

4.1 Any injury or mark that might be bruising in an infant who is not independently mobile and brought to the attention of any professional should result in an immediate referral to Children’s Social Care and an urgent child protection paediatric assessment. This includes all non-mobile infants, even if the bruise/mark has faded or no longer visible.

4.2 If the infant is already open to children's services such as Early Help, Child in Need, or Child Protection, a referral to Children's Services is still required to ensure a prompt consistent response.

Regardless of the explanation regarding the injury, all cases must be referred to Children's Social Care, and the child must be seen by a Consultant Paediatrician.

4.3 If an infant needs urgent medical care, the practitioner should not delay sending the infant to the hospital. The practitioner should also inform Children's Social Care so they can commence child protection inquiries.

Infants should NOT be referred to GPs for a decision as to whether any ‘injury’ is accidental or otherwise.

Please click this link to access following information on the following:

  • Injury
  • Referral
  • Transfer
  • Assessment

 

5. Responsibilities of Health Professionals only

5.1 Birthmarks: Where health practitioners are confident that a child has a birthmark of some type, including Congenital Dermal Melanocytosis /Slate Grey Naevi (Mongolian Blue Spot) this should be recorded in the child’s medical record and parent-held record and the GP informed.  

5.2 In cases where the practitioner thinks it is likely that it is a birthmark or Congenital Dermal Melanocytosis /Slate Grey Naevi (Mongolian Blue Spot) or a medical cause including birth injury but is not sure and nothing is recorded in the child’s record, the health practitioner should if available first seek advice from a senior colleague that same day. If uncertainty remains and the health practitioner is not sure regarding the nature of a skin mark or lesion, a referral should be made to the on-call paediatrician for a same day assessment. The outcome and findings from these consultations should be documented in the child’s medical notes (Primary Care and/or hospital records) and Parent Held Record. 

 

Pathway Flowchart 

 

6. Referral

6.1 It is the responsibility of the first professional to learn of or observe the bruising/injury to make the referral.

6.2 If a referral is not made, the reason must be documented in detail with the names of the professionals taking this decision.

6.3 All telephone referrals must be followed up in writing on a Safer Referral Form. The written referral must contain the same information that has been shared verbally. Children's Social Care will coordinate multi-professional information sharing and assessment.  

6.4 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 consultant Paediatrician to determine whether bruising or injury is consistent with the explanation provided or is indicative of non-accidental injury.

7. Involving Parents / Carers

7.1 Parents or carers should be included in the decision-making process as far as possible unless doing so would jeopardise information gathering (e.g., information could be destroyed) or if it would pose a further risk to the child or professional.

7.2 This can be a very stressful time for parents and carers; therefore, it is important to explain the rationale for the examination and referral to social care. 

7.3 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.

Hartlepool and Stockton-on-Tees Children's Hub: 01429 284284 / 01642 130080 / childrenshub@hartlepool.gov.uk

Middlesbrough MACH: 01642 726004 / MiddlesbroughMACH@middlesbrough.gov.uk

Redcar and Cleveland MACH: 01642 130700 / RedcarMACH@redcar-cleveland.gov.uk

Emergency Duty Team number for all 4 LA’s: 01642 524552

8. Useful Guidance Pathway Tools, Contacts and Websites:

9. Contact Details - On-call Paediatrician - Switchboard Numbers

  • South Tees Foundation Trust: 01642850850 - ask for consultant paediatrician daytime if 9-5pm and on call if after 5
  • North Tees & Hartlepool Foundation Trust: 01642617617 - ask for consultant paediatrician daytime if 9-5pm and on call if after 5