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1.5.2 Bruising in Pre-Mobile Infants (Babies) Protocol

SCOPE OF THIS CHAPTER

This protocol provides frontline multi-agency professionals with a knowledge base and action strategy for the assessment, management and referral of pre-mobile infants who present with bruising or otherwise suspicious marks. For further guidance on process to follow when a child is referred to Northumberland Children’s Services with concerns, practitioners should follow the Referrals Procedure.

Target Audience - All front line staff: general practitioners including sessional doctors, locums and GP trainees; primary care staff including practice nurses; health visitors, district nurses, school nurses and midwives; community staff allied to medicine; clinicians in GP out of hours services, walk-in centres, minor injury units and emergency departments; all community and hospital paediatric clinical staff, including consultants, social workers, police, early years workers, carers for vulnerable families, mental health workers, probation.

RELATED CHAPTERS

Recognition of Significant Harm Procedure

Referrals Procedure

This chapter was introduced into the manual in February 2016.


Contents

  1. Introduction
  2. Scope of Protocol
  3. Referral to Children’s Services
  4. Transfer to Hospital for a Paediatric Assessment
  5. Paediatric Assessment
  6. Communication with Parents or Carers
  7. Sharing Information and Consulting Colleagues
  8. Other Injuries
  9. Birthmarks


1. Introduction

Bruising is the commonest presenting feature of physical abuse in children. The younger the child, the higher the risk that bruising is non-accidental, especially where the child is under the age of 6 months (see Cardiff Child Protection Systematic Reviews website - Bruising). NICE guidance When to Suspect Child Maltreatment (Clinical Guideline 89, July 2009) states that bruising in any child ‘not independently mobile’ should prompt suspicion of maltreatment.

A not independently mobile or pre-mobile infant is a baby who is not yet crawling, bottom shuffling, pulling to stand, cruising or walking independently. This includes all babies under the age of 6 months.

Recent serious case reviews and individual child protection cases both nationally and locally have indicated that clinical staff have sometimes underestimated the potential significance of bruising in pre-mobile babies. Babies with bruising have been found to have multiple other injuries on further investigation or have presented again later with more serious injuries, including inflicted brain injury.

In the past, advice to frontline professionals was that referral to Children’s Services should be made if bruising in babies was not plausibly explained. However, in light of the increasing evidence base and learning from case reviews, advice to frontline professionals has changed and is necessarily directive:

Bruising in any pre-mobile infant should prompt an immediate referral to Children’s Services, who will arrange an urgent medical assessment by a senior paediatrician.

Innocent bruising in pre-mobile infants is rare. It is the responsibility of Northumberland Children's Services and the paediatrician to decide whether bruising is consistent with an innocent cause or not.


2. Scope of Protocol

This protocol focuses on bruising in pre-mobile babies.

The information in this protocol is also relevant to older children who are not independently mobile, by reason of disability. Bruising in any child ‘not independently mobile’ should prompt suspicion of maltreatment. If in any doubt, professionals should discuss the case further.


3. Referral to Children’s Services

A referral to Northumberland Children’s Services should be made by the first professional to learn of or observe the bruising. All telephone referrals must be followed up within 48 hours with a written referral.

Children’s Social Care will take any referral made under this protocol as requiring further multi-agency investigation.

Children’s Social Care will take responsibility for making an urgent referral to paediatric services. For the paediatric opinion, they will contact the duty paediatrician by phoning Northumbria Healthcare NHS Foundation Trust switchboard (0344 8118111).

If a professional is unsure whether to make a referral they should seek urgent advice from their line manager or safeguarding team.

The referrer should make a record of their concerns, discussion with the family and the joint action plan agreed with Northumberland Children's Services, including any health follow-up. The importance of signed, timed, dated, accurate, comprehensive and contemporaneous records cannot be overemphasised.


4. Transfer to Hospital for a Paediatric Assessment

The professional making the referral and the social worker receiving the referral must reach a decision about whether or not the child can be safely transported to hospital by the child’s parent/adult carer alone, or whether the child should be transported to hospital by some other method.

In most cases where bruising to pre-mobile baby has been noted, the professional who has noted the bruising and made the referral to Children’s Services should stay with the family until a Social Worker has arrived to accompany the family to hospital for the paediatric assessment. Paediatric assessments will take place at Northumbria Specialist Emergency Care Centre, Cramlington.

Non-attendance at the hospital should initiate immediate Child Protection procedures between Children’s Social Care and the Police.

Any child who is found to be seriously ill or injured, or in need of urgent treatment or further investigation, should be referred immediately to hospital at the same time as referral to Children’s Services. Such a referral should not be delayed by a referral to Northumberland Children's Services. However, it is the responsibility of the professional first dealing with the case to ensure that, where appropriate, a referral to Northumberland Children's Services has been made and that acute hospital services are made aware of the child protection concerns.


5. Paediatric Assessment

This will take place at Northumbria Specialist Emergency Care Hospital, Cramlington. The infant will be under the care of a senior paediatrician. A history and examination will be undertaken and the paediatrician will give an opinion about the injury. Further medical investigations may be required. It may be necessary to admit an infant to hospital whilst the investigations are completed. Where bruising is unexplained and/or raises significant concern about non-accidental injury a safety plan will be put into place by Children’s Services ensuring supervision of the infant whilst the medical investigations and assessments by other agencies are carried out.


6. Communication with Parents or Carers

Parents and carers should be included as far as possible in the decision-making process providing this does not pose a further risk to the child.

In particular, professionals should explain at an early stage why they are concerned about bruising in a pre-mobile baby and that further assessment is required. The decision to refer to Northumberland Children's Services should be clearly explained.

If a parent or carer is uncooperative or refuses to take the child for further assessment, this should be reported immediately to Northumberland Children's Services. If possible the child should be kept under supervision until steps can be taken to secure his or her safety.


7. Sharing Information and Consulting Colleagues

Please refer to the Information Sharing and Confidentiality Procedure.

If there are concerns about the decision making and management of the case, any professional has a duty to escalate concerns to the next level in line with individual organisations escalation policies.

When an infant has been referred to Children’s Services due to bruising, information should be shared with the child’s GP and Health Visitor.


8. Other Injuries

The evidence base for other injuries to pre-mobile babies, e.g. scratches, other marks, is less clear. If a professional notices any injury to a pre-mobile baby, an explanation should be sought. If a practitioner has any concerns about any mark, caution should be exercised and discussion should be had with Children’s Services and/or paediatric services.


9. Birthmarks

It is not always easy to identify with certainty a skin mark as a bruise in young babies. Less clear cut lesions such as Mongolian Blue Spots or birthmarks should be promptly discussed with the child’s Health Visitor or GP.

Other Sources of Guidance and Information

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