PG5. Bruising

1. Introduction

Caption: Introduction

1.1	Bruising is the most common injury to a child who has been physically abused. It is therefore vital to differentiate accidental from non-accidental bruises and other suspicious injuries, and to avoid assumptions about such injuries which cannot be substantiated. The possibility of child maltreatment or neglect must be considered.
1.2	Bruising is strongly related to mobility. Bruising in a baby who is not independently mobility, is unusual; once children are mobile, they sustain bruises from everyday activities and accidents. Most children who can walk independently will have bruises which usually happen when children fall over or bump into objects. Children tend to have more bruises during the summer months. See Appendix B for a reminder of how mobile children are likely to be in their early years.
1.3	Bruising from an accidental injury is most likely to be seen on the shins and the knees when children are walking or starting to walk. Infants who are just starting to walk unsupported may bump and bruise their heads – usually the forehead, nose, centre of their chin or back of the head. Most accidental bruises are seen over bony parts of the body – such as the knees and elbows – and are often seen on the front of the body. Accidental bruising in children with disability may be related to the child’s level of mobility, equipment used, muscle tone and learning ability.
1.4	A bruise should never be interpreted in isolation. It must always be assessed in the context of medical and social history, developmental stage, explanation given and, where appropriate, full clinical examination and relevant investigations. If at any point you are unsure on the action to take, consult your line manager or designated safeguarding lead. The characteristics of bruising that are suggestive of physical abuse are: Bruising in children who are not independently mobile; Bruises that are seen away from bony prominences (i.e., areas of bone that are close to the skin surface); Bruises to the face, back, abdomen, arms, buttocks, genitalia, ears, neck, and hands; Multiple bruises in clusters; Multiple bruises of uniform shape; Bruises that carry the imprint of an implement and/or a ligature; Bruises that are accompanied by petechiae (tiny dots of blood under the skin), in the absence of underlying bleeding disorders; Petechiae (tiny dots of blood under the skin), in the absence of bruising, may occur as a consequence of suffocation; Petechiae (tiny dots of blood under the skin), are located on the skin of the face and throat, the upper chest, the shoulders and inside the mouth.
1.5	When should you be concerned? There are some patterns of bruising that may mean physical abuse has taken place: Abusive bruises often occur on soft parts of the body – such as the abdomen, back and buttocks; The head is by far the commonest site of bruising in child abuse. Other common sites include the ear and the neck; As a result of defending themselves, abused children may have bruising on the forearm, upper arm, back of the leg, hands or feet; Clusters of bruises are a common feature in abused children. These are often on the upper arm, outside of the thigh, or on the body; Bruises which have petechiae (dots of blood under the skin) around them are found more commonly in children who have been abused than in those injured accidentally; Abusive bruises can often carry the imprint of the implement used or the hand; Non-accidental head injury or fractures can occur without bruising; Severe bruising to the scalp, with swelling around the eyes and no skull fracture, may occur if the child has been “scalped” – ie, had their hair pulled violently.
1.6	Can you determine the age of a bruise accurately? No. Estimates of the age of a bruise are based on an assessment of the colour of the bruise with the naked eye. The accuracy of observers who estimate the age of a bruise visually is no better than 50 per cent. The evidence is that we cannot accurately age a bruise from an assessment of colour – from either a clinical assessment or a photograph. A practitioner who offers a definitive estimate of the age of a bruise in a child by assessment with the naked eye is doing so from their own experience without adequate published evidence.
1.7	If there is agreement that the history given is consistent with the bruise/mark / injury observed, the infant/child’s developmental age, and mobility, ensure you: Review all previous records for any similar history or risk factors. Document all observations and what has been reported by the infant/child and parent/carer (s) records. Document clearly bruising/marks observed on a body map (Appendix 1) and record in the infant/child’s Parent Held Record. Consider safety assessment and advice to prevent further incident/s. Share relevant information with Health Visiting/School Nursing Service, GP or any other relevant agency.
1.8	To assist in making an accurate record of any injury that is of concern, it is helpful to make use of a body may to record the details of the injury. See Appendix C.

2. Response

Caption: Response

2.1	Professionals working in any agency should discuss bruising or injuries with their line manager, supervisor or safeguarding lead[1] . If it appears that the explanation given is consistent with the bruise/mark/injury observed, the infant/child’s developmental age, and mobility, make a record of the observation and the explanation, as set out above. If there is any concern, refer to children’s social care. [1] Unless the professional concerned has a recognised expertise in this area of work. Bear in mind that children become mobile over a period of time; see the guidance in Appendix B and read the summary of the research in Appendix A
2.2	If the baby/child appears to be in need of medical attention, then emergency services should be contacted immediately, prior to any referral.
2.3	Children’s Social Care
2.3.1	Children’s Social Care will consider any referral about a baby/child in line with normal safeguarding practice.
2.3.2	For non-mobile children with suspicious injury or bruising a strategy meeting/discussion should be convened to determine whether there is a risk of significant harm to the child.
2.3.3	For mobile children Social Care should assess the level of risk and consider whether a strategy meeting/discussion is required if the threshold for significant harm may be met.
2.3.4	Consideration should be given as to whether to undertake a Child Protection Medical. This will usually be an action following a strategy discussion/meeting but may be arranged prior to the strategy discussion/meeting, depending on the seriousness of the injury. If a child needs immediate medical attention, that should be arranged without delay.
2.3.5	If a Child Protection Medical is not required: the Social Worker should consider the medical needs of the infant/child, following discussion with relevant health practitioners, and ascertain whether a medical assessment is still required.
2.3.6	If the Child Protection Medical is delayed (for any reason) and the bruising /mark is no longer visible, a Paediatrician may need to examine the child/ren to assess general health, signs of other injuries or maltreatment and to exclude any medical cause and the outcomes to be shared with Social Worker
2.4	Police
2.4.1	The Police on receipt of a referral will consider the need for any immediate action to safeguard the infant/child.
2.4.2	Instigate further multi-agency investigation by notifying children’s social care and other partner organisations of the referral and the requirement for a strategy meeting to be convened.
2.4.3	Collate all available information to share during attendance at the strategy meeting.
2.4.4	Undertake such actions to ensure the safety of all identified infants and child/ren and if deemed appropriate secure and preserve evidence in accordance with legislation and best practice.

3. Children in Specific Circumstances

Caption: Children in Specific Circumstances table

3.1.1	Consideration should be given to the cultural needs of infant / child, young people, parent/s, family, and carer/s. However, cultural practices that are abusive are not acceptable reasons for child maltreatment.
3.1.2	The assessment should consider the infant/child’s skin colour and how this may influence the clinical assessment (Mukwende, 2020).
3.2	Birth Marks
3.2.1	Congenital dermal melanocytosis (flat blue-grey skin marking) and strawberry marks or haemangioma are present at birth or appear in the first few days of life and can be seen anywhere on the body. These should be recorded in the infant’s health records, parental held child’s health record (‘red book’) and body map.
3.2.2	If a practitioner is unsure regarding whether a mark is a birthmark, then the child should be reviewed by a doctor to confirm this.
3.3	Children with Disabilities
3.3.1	Children with disabilities are at increased risk of suffering maltreatment therefore practitioners should ensure: Effective communication – awareness of need to identify assistance that is required to support the infant/child (e.g., Makaton, British sign language, braille); Inability to speak, read or write English – practitioners to seek assistance of independent interpreter; Disability should not hinder the assessment of suspicious marks or bruises on infant/child; Health practitioners should contact the learning disabilities nurse /safeguarding team if further advice or support is required; The child’s presentation should be taken into account when assessing any injuries sustained or bruising. This is to determine whether there is a pattern of injuries or bruising which could be considered as neglectful or abusive or if they are directly related to their individual disability.

4. Clinical Assessment

Caption: Eligibility table

4.1	Where required, a full clinical assessment and relevant investigation must be undertaken at the earliest opportunity and should include the: Nature and site of injury; History provided by accompanying adult; Plausibility of the explanation given; Timing/age of the alleged injury and any delay in seeking medical attention for which there is no satisfactory explanation; Infant/child’s appearance, behaviour, and demeanor; Infant/child’s development; Interaction between parent/s, carer/s, and infant/child; Family and social circumstances and other relevant information available on the infant/child’s records.
4.2	An explanation for an injury or presentation must be questioned if implausible, inadequate, or inconsistent: With the infant/child’s presentation, normal activities, existing medical condition, age, or developmental stage, when compared to the account given by parent/carer/s; Between parent/s or carer/s; Accounts differing in details over time; If no explanation can be given by the parent or carer; Based on cultural practice.
4.3	If you are unsure on what action to take, consult your line manager or designated safeguarding lead.

5. When should Parent/s and Carer/s be Informed

Caption: Informed table

5.1	Parent/s and carer/s should be informed at an early stage of any concerns including: The nature of the concern; Progress of decision-making process and reasons for this - unless to do so will jeopardise information gathering or pose further risk to the infant/child.
5.2	This process should be carried out sensitively and in a private place to avoid further distress to parent/s or carer/s.
5.2	In communicating with the infant/child, parent/s, or carer/s, consideration should be given to any learning difficulty / disability, language barriers (including the need for an independent interpreter) or lack of awareness/knowledge of UK legislation.

6. Escalation Process

Caption: escalation table

6.1	If you are concerned about the lack of response to a safeguarding concern from any agency, discuss with your Safeguarding Lead / Line Manager who will assist to review own agency Safeguarding /Child Protection procedure/s escalation process with the support of the Local Safeguarding Children Partnership. See Chapter PA4, Resolving Professional Differences.

Appendix A: Research

This guidance has been written with reference to the following guidance and research:

Child maltreatment: when to suspect maltreatment in under 18s (October 2017) - NICE (National Institute for Health and Care Excellence);
Bruising - Systemic Review (March 2020) - RCPCH (Royal College of Paediatrics and Child Health);
Bruising in non-mobile infants (September 2022) - Child Safeguarding Practice Review Panel;
Bruises in Pre-mobile Infants: A Contested Area of Research, Policy and Practice (November 2022) - Andy Bilson (Emeritus Professor of Social Work at the University of Central Lancashire) and Alessandro Talia (Wellcome Research Associate at the Department of Public Health and Primary Care of the University of Cambridge).

The NICE guidance, CG89 (originally published in 2009, updated 2017) says that:

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, a causative coagulation 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.

The key findings from two Royal College of Paediatrics and Child Health (RCPCH, 2020a; RCPCH, 2020b) systematic reviews provide evidence that:

Bruising was the most common injury in children who have been abused and a common injury in non-abused children, the exception to this being in pre-mobile infants where accidental bruising is rare (<1%);
Bruising can be viewed as a common presentation in children; however, this should trigger professional curiosity to exclude more severe underlying injuries;
This highlights the importance of recognition of abnormal patterns of bruising in young infants, enabling detection as early as possible and potentially preventing escalation of abuse with avoidance of serious injury or death;
In a study of 77 infants with abusive fractures, 32% had missed opportunities for the diagnosis of child abuse. The most common sign on examination was bruising or swelling;
In another study of 146 infants less than six months of age presenting to child abuse physicians with an isolated bruise, 23.3% had skull fractures identified on skeletal survey;
Absence of abdominal bruising does not rule out a significant abdominal injury just as the absence of bruising does not preclude Abusive Head Trauma (AHT) (RCPCH, 2019).

The Child Safeguarding Practice Review Panel (the Panel) reviews cases where children have died or been seriously harmed, and abuse or neglect is known or suspected. A large proportion of the serious incidents notified to the Panel are about young infants. For example, 37% of serious incident notifications in 2020 were about children less than a year old.

In the rapid reviews and local child safeguarding practice reviews (LCSPRs) submitted to the Panel, there are often cases where young infants have previously presented with apparently minor injuries – with visible minor bruising – and a failure to follow established guidance, or inconsistencies within such guidance, have been highlighted as potential contributory factors to a subsequent serious incident or, ultimately, the child’s death.

The Panel comment on variations in the way in which the NICE guidance (and the associated RCPCH systemic reviews upon which it is based) is interpreted and used to inform practice. They make specific reference to the need for greater clarity about what is meant by a child not being independently mobile, 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.

The Panel also underlines the need for a multi-agency strategy discussion / meeting to consider the information known about the child and family before determining whether further action is required. They do not support blanket policies that require a Section 47 enquiry in the absence of such an appraisal of the circumstances.

Professor Bilson’s report is referenced by the Panel. Bilson comments that “many policies require all pre-mobile children found with a bruise to be seen urgently by a paediatrician and in some all bruised children are subject of a formal child protection investigation regardless of the explanations for the bruise or the views of front-line practitioners. However, the research on bruises in pre-mobile children on which these policies were based was found to be limited and contradictory and did not fully support the guidance given”. On examining the research upon which the RCPCH review is based, Bilson suggest that some of it should be discounted because of limitations in methodology and the data recorded (age, gender and ethnicity), that there is a lack of clarify about the definition of pre-mobile children, that most of the evidence relates to children with white skin and that any differences arising from other skin colouring have not been accounted for and finally, that the research data is not definitive about the frequency of bruising to pre-mobile children. The very low rate of accidental bruising to pre-mobile children cited by both the RCPCH and referenced by the Panel (around 1% of children “found” to have a bruise) is based primarily on “one off” observations, i.e. it is reporting on the incidence of bruising on that day. There is only report of the prevalence of bruising to non-mobile children, i.e. over a period of time, that found that 27% of those children had an accidental bruise over a 7 week period.

Appendix B: The Growing Child

Children do not all develop at the same rate; children with a health condition or those with a disability may well be significantly behind other children; some parents may engage in a range of activities with their children that encourages them to develop earlier than others. It is therefore important to take account of the child’s age, development, and circumstances rather than using blanket terms. In general:

Pre-mobile:

By 2 months, a baby is likely to be able to:
- Whilst laying on tummy, turn their head to the side;
- Whilst laying on back, wave arms, legs and wiggle / squirm;
- Briefly holds a toy when placed in their hand;
- Follows an object or person with both eyes.

Early Movement

By 4 months, a baby is likely to be able to:
- When laying on tummy, hold their head straight up and look around;
- When in a sitting position, hold their head steady, without support;
- Whilst laying on back, bring hands together over the chest, touching their fingers;
- When in a sitting position, start to reach for a toy close by;
- When baby has a toy in their hand, they will hold it whilst looking at it, waving it about and attempting to chew it;
By 6 months, a baby is likely to be able to:
- Roll from their back to their tummy;
- Sit up with support;
- Get into a crawling position;
- Grasp a toy using both hands at once;
- Reach a small object using their finger and pick it up using their thumb and all fingers;
- Be able to pick up a small toy with one hand and pass it to the other;
- Plays with feet when laying on back.

Early Mobile

By 9 months, a baby is likely to be able to:
- Sit without support;
- Get into sitting position from lying down;
- Pull to stand and take weight on feet;
- May crawl;
- Roll over both ways.
By 12 months, a baby is likely to be able to:
- Sit well and gets into sitting position alone;
- Pull to stand from sitting position and sit down again;
- Walk around furniture;
- May crawl or bottom shuffle;
- May stand alone;
- Help turn the pages of a book;
- Throw a small ball;
- Be able to pick up a piece of string with first finger and thumb.

Mobile

By 18 months, child is likely to be able to:
- Walk well;
- Walk upstairs holding an adults hand;
- Stack blocks on top of each other;
- Turn the pages of a book;
- Put a small spoon in their mouth, right side up.
By 2 years, a child is likely to be able to:
- Try to kick a ball;
- Run well;
- Jump with both feet leaving the floor at the same time;
- Hold a pencil by using thumb and first two fingers;
- Can string small items such as beads, pasta onto a string;
- Drinks from a cup with no lid.
By 3 years, a child is likely to be able to:
- Walk on tip toes when shown;
- Walk upstairs with alternate feet, still puts both feet on each step when coming down;
- Catch a large ball;
- Pedal a tricycle;
- Climb walls.
At about 4 years, a child is likely to be able to:
- Walks up and down stairs using alternate feet;
- Good on a tricycle;
- Hops and stands on one foot;
- Can throw, catch and kick well;
- Draws a person with recognisable body parts eg head, arms and legs;
- Uses a fork and spoon well.
At about 5 years, a child is likely to be able to:
- Balance and stand on one foot for about 10 seconds;
- Hop;
- Dance;
- Swing and climb;
- Slides down a slide;
- Can now get dressed and undressed by self.

Appendix C: Body Map

Body Map Guidance

Body Maps should be used to document and illustrate visible signs of harm and physical injuries.

Always use a black pen (never a pencil) and do not use correction fluid or any other eraser.

Do not remove clothing for the purpose of the examination unless the injury site is freely available because of treatment.

At no time should a professional take photographic evidence of any injuries or marks to a child’s person, the body map below should be used. Any concerns should be reported and recorded without delay to the appropriate safeguarding services, e.g. Social Care direct or child’s social worker if already an open case to social care. Photographs should only be taken by the police (for evidential purposes) or by clinicians treating the injury.

When you notice an injury to a child, try to record the following information in respect of each mark identified e.g. red areas, swelling, bruising, cuts, lacerations and wounds, scalds and burns:

Exact site of injury on the body, e.g. upper outer arm/left cheek.
Size of injury - in appropriate centimetres or inches.
Approximate shape of injury, e.g. round/square or straight line.
Colour of injury - if more than one colour, say so.
Is the skin broken?
Is there any swelling at the site of the injury, or elsewhere?
Is there a scab/any blistering/any bleeding?
Is the injury clean or is there grit/fluff etc.?
Is mobility restricted as a result of the injury?
Does the site of the injury feel hot?
Does the child feel hot?
Does the child feel pain?
Has the child’s body shape changed/are they holding themselves differently?

Importantly the date and time of the recording must be stated as well as the name and designation of the person making the record. Add any further comments as required.

Ensure First Aid is provided if required and recorded; seek urgent medical treatment if there is any significant concern for the child’s wellbeing.

A copy of the body map should be kept on the child’s record.

Click here to view the Bodymap Form.

7. Further Information

NSPCC
Core Information - Bruises on Children (July 2012)

NICE (National Institute for Health and Care Excellence)
Child maltreatment: when to suspect maltreatment in under 18s (October 2017)

RCPCH (Royal College of Paediatrics and Child Health)
Bruising - Systemic Review (March 2020)

Bruises in Premobile Infants: A Contested Area of Research, Policy and Practice (November 2022)
Andy Bilson (Emeritus Professor of Social Work at the University of Central Lancashire) and Alessandro Talia (Wellcome Research Associate at the Department of Public Health and Primary Care of the University of Cambridge)