Bruising or injury in Non-Independently Mobile Babies and Children
Related guidance
- Paediatric Assessment for Section 47 Enquiry (Child Protection Medical)
- Bruises on Children (NSPCC)
- Child Protection Evidence: Systematic Review on Bruising (RCPCH - 2020)
- CG89: Child maltreatment: when to suspect child maltreatment in under 18s
- RCPCH Child Protection Service Delivery Standards 2020
- Non-accidental Injuries in Infants Attending the Emergency Department (Healthcare Safety Investigation Branch)
Bruising in non-independently mobile babies and children is unusual and is highly suggestive of non-accidental injuries. National Reviews of Serious Cases and local incidences have underestimated the significance of bruising or minor injuries in children who are not independently mobile. Early recognition and action in such cases is key to preventing further harm.
Non-independently mobile babies rarely cause injuries to themselves and, therefore, consideration must be given to whether they have been significantly harmed and / or are at risk of significant harm. Bruising or injury should never be interpreted in isolation and crucially must always be assessed in the context of medical and social history, developmental stage and the explanation given by those who care for the child.
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 around distinguishing abusive from non-abusive bruises and determining the age of the bruise (see Child Protection Evidence: Systematic Review on Bruising (RCPCH - 2020)).
Any bruising, injury or mark on the skin that might look like bruising, in a child of any age or where a child 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.
Child maltreatment should be considered where bruises or injuries in children are unexplained, without an acceptable explanation, have a concerning presentation or involve a child that is not independently mobile. For non-health professionals, These concerns must result in an immediate Referral to MASH (see Referring Safeguarding Concerns about Children Procedure) and an urgent paediatric opinion.
On occasions it can be difficult to know if a skin mark is suspicious or not - e.g.
- Birth mark: blue grey spots, (congenital dermal melanocytosis) previously known as Mongolian blue spots. Whilst this terminology is becoming outdated, it may still be used in medical parlance. For more information, see NHS information on birthmarks;
- Haemangioma or marks that may be associated with recent birth trauma/delivery.
If the presenting concern is observed by a Health Practitioner, health records should be reviewed to confirm if there is any known notification of the skin mark (i.e., clear documentation of a birth mark). Where there is no known recorded explanation and therefore diagnostic doubt regarding the nature of a skin mark and consideration to wider vulnerability factors have been excluded (see: Multi-agency Threshold descriptors) an immediate discussion should take place between the Health practitioner and on call Paediatrician. A decision should then be made to obtain a same day paediatric review to confirm observation of a birth mark/birth trauma.
Where the observing Health practitioner:
- Has the clinical expertise underpinned by additional training to recognise/identified birth marks in babies/young children (which is recognised by the Safeguarding Partnership);
and - Is confident that the skin mark is due to a previously unidentified birth mark
they should reassure the parent/carer and ensure that this is clearly recorded (using a body map) in the baby’s/child’s health record. Where there is any doubt regarding the presentation NOT being a birth mark, action should be taken as outlined in Section 4, Action to Safeguard the Child
If the observing professional is not from health and therefore cannot confirm that the presenting skin mark is a birth mark they should contact MASH for further advice.
See also: Appendix 1: Pathway for Identification of Suspected Birthmark.
A child is considered non-independently mobile if they are not yet crawling, bottom shuffling, pulling to stand, cruising around furniture or walking independently; includes all children under the age of 6 months. An older infant or child with a disability or developmental delay, with any other risk indicators would also warrant careful consideration. Babies or children who can roll are classed as non-mobile for the purposes of this procedure.
Professionals must use their judgement regarding babies who can sit independently but cannot crawl, depending on severity of the injury, the account of the parent or care giver and the plausibility.
Bruising can be defined as blood in the soft tissues; producing a temporary, non-blanching discolouration of skin however faint or small with or without other skin abrasions or marks. Colouring may vary from red, yellow, through green, to brown, or purple.
Any injury in a non-independently mobile baby or child causes concern.
Any injuries are unusual in this age and development group, unless accompanied by a full consistent explanation. Even small injuries may be significant, and they may be a sign that another hidden injury is already present. Such injuries include:
- Small single bruises e.g., on face, cheeks, ears, chest, arms or legs, hands or feet or trunk;
- Bruised lip or torn frenulum (small area of skin between the inside of the upper and lower lip and gum);
- Lacerations, abrasions, or scars;
- Bite marks;
- Burns and scalds;
- Pain, tenderness or failing to use an arm or leg which may indicate pain or discomfort and an underlying fracture;
- Small bleeds into the whites of the eyes or other eye injuries.
Occasionally an infant can be harmed in other ways, for example:
- Deliberate poisoning which can present as sudden collapse or coma;
- Suffocation which can present as collapse, cessation of breathing (apnoeic attack), bleeding from the mouth and nose.
Any explanation for the injury should be critically considered within the context of:
- The nature and site of the injury on the child;
- The baby or child’s developmental stage and abilities;
- The family and social circumstances including current safety of siblings/other children;
- Any previous history of concern raised about this child or older siblings.
All people who live within the family home, including siblings and partners/significant others (such as aunts and uncles, grandparents, etc.) who do not live there but participate in any aspect of the child’s care, must be considered as part of the assessment.
Situations that should cause particular concern for professionals include:
- Delayed presentation / reporting of an injury;
- Admission of physical punishment from parents / carers - no physical punishment is acceptable;
- Inconsistent or absent explanation from parents / carers;
- Associated family factors such as substance misuse, mental health problems, and domestic abuse – for more information, see:
- Safeguarding Children of Alcohol Misusing Parents Procedure;
- Safeguarding Children of Drug Misusing Parents Procedure;
- Children of Parents with Learning Disabilities Procedure;
- Safeguarding Children at Risk where a Parent has a Mental Health Problem Procedure;
- Safeguarding Children at Risk because of Domestic Abuse Procedure.
- Other associated features of concern e.g., signs of neglect such as poor clothing, hygiene and / or nutrition – for more information, see the Neglect Procedure;
- Difficulty in feeding / excessive crying;
- Significant behaviour change;
- Infant displays wariness or watchfulness;
- Recurrent injuries;
- Multiple injuries at one time.
Bruising or injury in non-independently mobile babies and children is rare. For non-health professionals, this must always result in an immediate referral to MASH for information sharing and medical assessment as a minimum – see Referring Safeguarding Concerns About Children Procedure, Contact the MASH.
For health practitioners, bruises or other injuries on a non-mobile child should lead to an information check phone call with MASH to inform medical assessment and decision making for the next steps.
Any injuries in a non-mobile child presenting to the Urgent Emergency Care Centre (UECC) should be fully undressed, and a medical assessment undertaken. Any injuries should be considered in the context of the information shared from MASH and the explanation of the injuries given by the parents or carers.
Decisions made at this time should be made by the Senior UECC Clinician / Paediatrician. The decision may be to make a referral to MASH if there are concerns the child may be at risk of significant harm; or to take no further action or refer the child for additional health or early help services if there is adequate explanation and no background concerns. For more information, see Early Help Guidance: Integrated Working With Children, Young People and Families With Vulnerable or Complex Needs.
If the decision by the Senior UECC Clinician / Paediatrician is that the child may be at risk of significant harm, an immediate referral to MASH must be made. Joint discussion and decision making should then take place for the next steps. In some instances, a full paediatric medical assessment will be required prior to a strategy meeting to determine at that stage if there are any medical underlying medical reasons for the injury.
It is the responsibility of any partner agency practitioner who learns of or observes bruising or injury on a non-mobile/mobile child to make an immediate referral to MASH. Where appropriate the referring practitioner may want to discuss the concerns to refer with another professional or Named Professional or Designated Safeguarding Lead. However, this discussion should not delay the practitioner referring to MASH. A same day assessment from the paediatrician will be requested and the procedure followed as above as if the child presented at UECC.
It is the responsibility of children's social care in conjunction with the paediatrician and police service to decide whether the circumstances of the case and the explanation for the injury/presenting concern are consistent with the explanation provided or is indicative of non-accidental injury. Children should NOT be referred to GPs for a decision as to whether any ‘bruising/injury’ is accidental or otherwise.
If the child is at risk of significant harm, social care will arrange for a strategy discussion/meeting to take place. For more information, see Strategy Discussions/Meetings Procedure. Decision making regarding the required child protection investigations will be agreed at the Strategy Discussion / Meeting. The risks for any siblings or other children living in the same household should also be considered and safeguarding processes followed accordingly.
If the Strategy Meeting determines the child is at risk of significant harm, the child will be admitted to children’s ward and an assigned paediatrician will undertake a child protection medical investigation, see Paediatric Assessment for Section 47 Enquiry (Child Protection Medical and see RCPCH Child Protection Service Delivery Standards.
A bruise/injury must always be assessed in a multi-agency arena in the context of medical and social history, developmental stage and explanation given. Assessments will be led by Children's Social Care and the Paediatrician. Children's Social Care will co-ordinate multi-agency professional information sharing and assessment. For more information, see Part 1.3, Assessment.
Where the baby/child is an open case to Social Care in addition to contacting the MASH, practitioners should always contact the allocated Social Worker to make them aware of events and discuss any actions taken or required
As far as possible, parents or carers should be included in the decision-making process. Whilst it is good practice to be transparent and to inform parents that information is being shared because there are safeguarding concerns about their child, (e.g., making a referral) it is not necessary to seek consent in these circumstances. Parents or carers should not be told when a referral is being made only if this will put the child at risk or further risk of harm. 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 services and / or the police service. If possible, the child should be kept under supervision until steps can be taken to secure his or her safety.
Where admission to hospital is required, the necessity to supervise the parent/carer’s contact with the child to protect from further risk should considered. This supervision arrangements will be coordinated by children’s social care and should be clearly documented in Health records for clarity. See Contact between Parents and their Children in Hospital where there are Safeguarding Concerns Procedure.
If there is any disagreement between professionals regarding the safety of a child it must be resolved using the follow the escalation procedure as outlined in Practice Resolution Protocol: Resolving Professional Differences of Opinion in Multi-Agency Working with Children and their Families.
Last Updated: January 18, 2024
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