Bruising in Babies and Children
Not Independently Mobile (NIM): is an infant who is not yet crawling, bottom shuffling, or cruising. Particular attention should be given to the risks in those children who are unable to roll over. It includes all infants less than 6 months.
Bruising: extravasations (leakage) of 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 yellow through green to brown or purple or red. This includes petechiae, which are red or purple non-blanching spots, less than two millimetres in diameter and often in clusters. It may not be possible to give an opinion on when an injury happened to cause a bruise from looking at its shape or colour.
Children, who are mobile, will 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. However, bruising is the commonest presenting feature of physical abuse in children. Vulnerabilities can include children who are not mobile, children with disabilities, living in a household where there is mental health issues, substance and alcohol misuse, learning disabilities, and domestic abuse The aim of this protocol is to provide all professionals with a knowledge base and action strategy for the assessment, management and referral of children who present with bruising.
Recent serious case reviews, partnership reviews and individual Child Protection children both nationally and locally have shown that frontline practitioners have sometimes underestimated or ignored the highly predictive value, for child abuse, of the presence of bruising in infants who are Not Independently Mobile. As a result, there have been a number of times where bruised infants have suffered significant harm or have died as a result of abuse that might have been prevented if action had been taken at an earlier stage. NICE guidelines on when to suspect child maltreatment NICE guidelines on when to suspect child maltreatment states suspect child maltreatment if there is bruising in a child who is not independently mobile.
This multi-agency protocol has been developed for all professionals, outlining the following:
- Assessment and management of bruising;
- The process by which such children/ infants should be referred to Children's Social Care;
- How to refer to Paediatrician for further assessment and investigation of potential child abuse.
In the light of the NICE guideline, recurrent themes in Child Safeguarding Practice Reviews (local and national) and the research base outlined in section 2 this protocol is necessarily directive. While it recognises that professional judgement and responsibility have to be exercised at all times, it errs on the side of safety by requiring that all infants with bruising who are not independently mobile must be referred into Children's Social Care and for a Paediatric opinion.
All practitioners should refer to the Referrals Procedure for the process to follow if there are concerns for the safety and welfare of a child.
It is sometimes difficult to distinguish between a bruise and another mark to the skin, such as a birthmark or pigmentation. Reviewing other sources of information (e.g., Parent Child Health Record (red book), requesting earlier photos which identify the mark) may make things clearer, reviewing medical records and liaising with health practitioners, particularly maternity and neo natal services. Sometimes looking at if the mark changes over time may offer some clarity – bruises will change and fade over days whereas a birthmark will usually stay the same size and colour during this period. Where there is doubt as to the nature of a mark that may be a bruise,
it is important that the baby is safeguarded whilst further clarification is sought. In certain situations, this may involve a less experienced health care professional seeking advice from a more experienced practitioner within their own clinical or safeguarding team.
Research shows that it is very unusual for pre-mobile babies to sustain bruises accidentally and bruising in this age group raises significant concerns in relation to physical abuse.
There is a substantial and well-founded research base on the significance of bruising in children:
- Child Protection Evidence – Bruising RCPCH;
- Child Protection Evidence – Child Protection Companion;
- NICE Child maltreatment (CG 89): when to suspect maltreatment in under 18s. July 2009 and reviewed October 2017. NICE guidelines on when to suspect child maltreatment.
There is also a national repository of National Case Reviews (NSPCC) which provides a national picture of concerns. NSPCC National Case Review Repository.
While accidental and innocent bruising is significantly more common in older mobile children, professionals are reminded that mobile children who are abused may also present with bruising (Baby P 2008). Body maps to record bruising should be completed in all children where there are concerns about non accidental injury. This is to address the potential for inaccurate recordings when there are multiple bruises/ patterns and sizes of bruising over time, as identified in both national and local case reviews.
Disabled children have a higher incidence of abuse whether mobile or not and concerns relating to potential abuse must be handled in accordance with SSCP Procedures.
The Research base demonstrates that bruising in Not Independently Mobile Infants is very rare; particularly those under the age of six months. Bruising was the most common injury in children who have been abused. It is also a common injury in non-abused children, the exception to this being pre-mobile infants where accidental bruising is rare (0-1.3%). The number of bruises a child sustains through normal activity increases as they get older, and their level of independent mobility increases. Reference: RCPCH Bruising Systemic Review.
There have been reports where bruising was a “sentinel injury1” in children prior to the recognition of child abuse, highlighting the importance of recognising abnormal characteristics of bruising in children, enabling detection as early as possible and potentially preventing escalation of abuse with avoidance of serious abusive injury or death. RCPCH Child Protection Evidence – Bruising.
The pattern, number, and distribution of innocent bruising in non-abused children is different to that in those who may have been abused.
Patterns of bruising suggestive of physical child abuse include:
- Bruising in children who are not independently mobile;
- Bruises in clusters;
- Bruises on ankles and/ or wrists that look like ligature marks;
- Bruises that are accompanied by petechiae, in the absence of underlying bleeding disorders. (Petechiae – tiny red/ purple spots under the skin or in the mucous membranes (mouth or eyelids));
- Bruises that are away from bony prominences;
- Bruises to the face, eyes, ears, neck, trunk, arms, feet, buttocks, and hands;
- Multiple bruises of uniform shape;
- Bruises that carry the imprint of hand shape, stick, teeth marks, implement used or ligature.
Reference: Child Protection Evidence - RCPCH Child Protection Portal.
A bruise cannot be aged accurately from clinical assessment or from a photograph. Please refer to RCPCH Clinical Guidelines.
It is important to note that a bruise, whatever its size, must never be interpreted in isolation and must always be assessed in the context of medical and social history, developmental stage, explanation given and relevant investigations. A full clinical examination and relevant investigations. Reference: Child Protection Evidence RCPCH.
Consider the presentation of the bruise:
- Was the presentation delayed?
- Was the bruise found incidentally during another contact or appointment? (e.g., whilst giving immunisations, a home visit, when treating other family members);
- 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/toy, bruises caused by safety straps etc);
- Inconsistent with the child's development stage (e.g., sustained when rolled off bed when child not yet rolling);
- Inconsistent explanation over time or a confused account.
Professionals should be aware that children with disabilities, (who are more vulnerable than non-disabled children by virtue of their disability) may present with bruising for a number of different reasons.
Children with disabilities may have bruising due to:
- Medical conditions (e.g., clotting disorders, skin fragility, or conditions affecting bone strength) that may predispose them to bruising;
- Mobility challenges that may increase the likelihood of accidental injuries (e.g., falls, pressure sores, bruising from wheelchair use or medical equipment);
- Use of restrictive practices (e.g., physical restraint) which, if not conducted appropriately, may result in bruising;
- Use of specialist equipment (e.g. gaiters) which may cause unintentional, accidental marks or bruising from pressure or touch point.
Professionals need also to be aware that bruising could also be caused by non-accidental/ intentional harm and therefore need to be curious and consider multiple hypotheses. Children with disabilities are more vulnerable: there may be communication barriers that may prevent a child from disclosing harm or seeking help. There is also increased dependency on (sometimes multiple) caregivers across different settings which can increase the risk of neglect, inappropriate handling, or physical abuse. Caring for a child with a disability can be challenging and this might increase parental stress or frustration.
In some instances, Fabricated or Induced Illness (FII)/Perplexing Presentations, when a caregiver may cause or fabricate symptoms, including bruising, as part of a wider safeguarding concern and professionals should be astute to the Fabricated or Induced Illness / Perplexing Presentation Procedure.
Do not make assumptions that bruising is a normal occurrence for a child with disabilities. Each situation should be assessed on its own merits. Consider reasonable adjustments to ensure the child's voice is heard, using alternative communication methods, advocacy, or specialist assessments as needed.
If the infant or child appears seriously ill or injured:
- Seek emergency treatment at an Emergency Department (ED) in liaison with parent/ carer;
- Refer to Children’s Social Care via Children's Single Point of Access (C-SPA) and if appropriate contact the Police.
A transfer to hospital should not be delayed by a referral to Children’s Social Care, however it is the responsibility of the professional who had the initial contact with the child and who identified a concern to ensure that a referral to children’s Social Care has been made.
In all other children:
When a practitioner observes a bruise in an infant under 6 months of age who is not independently mobile, you must suspect non-accidental injury and make a referral as a matter of urgency.
Seek an explanation, examine, and record accurately in the child’s records and complete body maps, note any features of abuse e.g. bruises on face and ‘soft’ areas, bruises in clusters or imprints. See above list of concerning bruises under “research base” and seek advice from your agencies Safeguarding Lead as to whether to make a referral.
If appropriate and able to, gain the voice of the child, by communicating in a way appropriate to their age and understanding:
- Avoid questions that are leading or suggestive;
- 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.
Professionals should explain at this stage why - when concerns are raised about the bruise or bruising in infants who are not independently mobile - additional concern, questioning and examination are required. The requirement to refer to Children’s Social Care should be explained to the parents or carers frankly and honestly. Provide Parental leaflet “Bruising in Infants who are not independently mobile” where necessary.
A referral should be made to Children’s Social Care via C-SPA, or Emergency Duty Team (EDT) see Contact Details. Referrals should be made using the Request For Support Form and following the Referral Procedure.
The referrer must document in the appropriate personal child health record (where available) and medical records, all decisions and actions taken, and the joint action plan agreed with Children's Social Care.
It is important that the Paediatrician who is referred to by Children's Social Care sees the child in the first instance. Parents may wish to seek medical advice themselves, but this should not replace the work of the referred Paediatrician.
If a parent or carer is uncooperative or refuses to take the child for further assessment (and it is deemed an immediate health necessity or an infant who is not independently mobile), this should be reported immediately to the Police and Children's Social Care notified of this course of action. If possible, the child should be kept under supervision until steps can be taken to secure his or her safety.
Wherever possible, the decision to refer should be undertaken jointly with another professional or senior colleague. However, this requirement should not prevent an individual professional of any status referring to Children's Social Care any infant that is Not Independently Mobile with bruising.
Any referral received for bruising will be processed by the C-SPA. For an infant that is Not Independently Mobile, a decision will be made whether the threshold has been met for a multi-agency enquiry through a Strategy Discussion involving Police and Health. This should include siblings/ interim safety plans. This will decide whether to initiate Child Protection Section 47 Enquiries. See Strategy Discussions and Child Protection Enquiries - Section 47 Children Act 1989 procedure. Section 47 Enquiries must also include a detailed history from the parent/carer, the child's voice, review of past medical history and family history including any previous reports of abuse, and all vulnerabilities within the family.
On receipt of the referral, Children's Social Care will when necessary and in line with procedure arrange a safeguarding medical examination (Child Protection Medical) (unless parent/ carer has already taken the child to a Paediatrician/ hospital). This will take place within 24 hours. A Paediatrician will complete the medical examination, with consent from an individual who has Parental Responsibility or via a Court order. The GP is not able to complete a Child Protection medical. Where a history of previous Child Protection concerns is present this information should be shared with the examining Paediatrician. If safeguarding concerns are raised, consideration should be given to twins/ siblings of the child having a Child Protection medical also.
Children's Social Care should refer children to the on-call locality Community Paediatric Teams (weekdays) or on call Paediatrician at the local hospital (after working hours, weekends, or bank holidays). See Appendix 2: Health Contacts
As far as possible, parents or carers should be included in the decision-making process unless to do so would jeopardise or compromise any criminal investigation or pose a further risk to the child. Where consent is refused management direction should be sought.
Following the outcome of the medical, Children's Social Care will decide on the need for any further safeguarding actions, based on the opinion of the Consultant Paediatrician and in discussion with partner agencies.
In relation to other children within the family environment, Children's Social Care staff will decide whether a Strategy Discussion is required, or if the next steps should be information & advice, Early Help support or a statutory Child & Family Assessment in line with Referrals Procedure. Strategy Discussions and Meetings should include the Health Professional who reviewed the child.
When a child is referred by Children's Social Care under this protocol, the Paediatrician will undertake the examination within 24 hours and should follow the Child Protection Medical Assessments for Appropriate Professionals in Children’s Services, Police and Health (copies of this form can be found on individual trust websites).
Where a referral is delayed for any reason, or where bruising is no longer visible, the Paediatrician must still examine the child to assess, as a minimum, general health, signs of other injuries or pointers to maltreatment, and to exclude bleeding disorders.
A clear and credible explanation for the bruising should be sought at an early stage from parents or carers and recorded. It is important to undertake this with open questioning and to avoid leading questions. See Child Protection Medical Assessments for Appropriate Professionals in Children’s Services, Police and Health for further information. A parent or carer with Parental Responsibility should be present at Child Protection Medicals however there may be times a parent will not be present in the room, e.g. a Gillick competent child does not consent to them being there.
The lack of a satisfactory, or consistent, explanation or an explanation incompatible with the appearance or circumstances of the injury, or with the child’s age or stage of development should raise suspicions of abuse. Inconsistencies or variations between carers or between interviews should raise suspicions of abuse.
A full physical examination of the child’s body should be undertaken with appropriate consent, This should include the physical presentation/appearance of the child, including the state of their clothing and include growth parameters.
A review of the child's medical history, including any previous occurrence of bruising or injury, should be undertaken. Health visiting records and GP information or other relevant information should be actively sought and accessed by the examining Paediatrician wherever possible to facilitate informed decision making. If in a hospital setting, records of previous ED attendances, outpatient visits and non-attendances should be reviewed. Consideration should be given to identified vulnerabilities within the family such as domestic abuse, substance misuse, mental health issues and deliberate self-harm of family members.
As with other injuries, any underlying medical condition that may predispose a child to bruising must be excluded. Other conditions that may mimic or present with bruising should be considered.
If Child Protection concerns are identified, the SSCP safeguarding children medical examination form should be used to document history, examination, findings, opinion, and recommendations (copies of this form can be found on individual trust websites). The importance of signed, timed, dated, accurate, comprehensive, and contemporaneous records cannot be overemphasised.
In all children careful mapping, description and recording of the size, colour characteristics, site, pattern, and number of the bruises should be made on a body map (as included in the SSCP safeguarding children medical examination form) and a careful record of the carers/parent’s description of events and explanation for the bruising made.
Where possible the Paediatrician examining the child should discuss the findings and management plan with a colleague before advising Children's Social Care and parents. If a trainee Paediatrician (Registrar grade) sees the child, it should be discussed with the supervising Consultant Paediatrician.
Where safeguarding concerns are identified, twins of children presenting with bruising and any other siblings should be subjected to a medical examination and appropriate investigation.
Any non-independently mobile infant with unexplained bruising or child where non accidental injury cannot be excluded should have:
- A Skeletal Survey in line with the Radiological Investigation of Suspected Physical Abuse in Children (The Royal College of Radiologists. 2017 guidance, revised November 2018;
- This should include a CT head scan in children under one year of age and a skeletal survey in children under 2 years of age and follow up imaging should be performed at 11-14 days as per the RCR protocol. If a child is not bought to follow up appointments without a justifiable reason this should be a cause for concern and escalated to social care;
- Ophthalmology examination should be undertaken by an experienced Ophthalmologist, to exclude any eye injury and retinal haemorrhages;
- Haematological and biochemical investigations including clotting studies, should be consistent with national guidance as specified in RCPCH Child Protection Companion. Paediatricians should work with their local haematologist to ensure age-appropriate investigations are undertaken;
- Where significant injuries are identified in a child due to suspected physical abuse, any multiple birth siblings of an index case less than 2 years of age should have the same recommended imaging as the index case. Age-appropriate imaging should be considered in all siblings and children less than 2 years’ old living in the same household as the alleged or suspected perpetrator on a case-by-case basis.
Birth Injury: For new-born infants where bruising may be the result of birth trauma, instrumental delivery, or medical procedures such as blood tests, professionals should remain alert to the possibility of physical abuse even in a hospital setting. In this situation professionals should take into account the birth history, the degree and continuity of professional supervision and the timing and characteristics of the bruising before coming to any conclusion. Where professionals are uncertain whether bruising is the result of medical causes (even before discharge from hospital), they should refer immediately to the on-call consultant Paediatrician or the named Doctor for safeguarding for further advice. However, such discussion with the Consultant or named Doctor should not delay a referral under this protocol if a professional is concerned regarding the mechanism for the injury or the safety and welfare of an infant. Body maps must be completed.
In all children accurate record keeping is paramount and must include all discussions and decisions made between professionals including where there is professional disagreement. Accurate details of bruising from birth trauma and medical causes must be recorded in the appropriate medical records, infant health record, parent held record (red book) and maternity discharge summary and communicated to the infant’s GP, community Midwife and Health Visitor.
Birthmarks: these may not be present at birth and may appear during the early weeks and months of life. Certain birthmarks capillary haemangioma, congenital melanocytic naevi) and particularly Mongolian blue spots (congenital dermal melanocytosis) can mimic bruising. Where a professional requires confirmation of a birthmark, they should in the first instance discuss with the GP. However, if there is any suspicion that the presenting feature is a bruise, professionals must refer the child in under this protocol.
In all children birthmarks, including when present from birth, must be recorded in the appropriate records including the infant’s red book and maternity discharge summary.
Reminder that not all birth injury markings or birth marks will be visible immediately upon birth, so review of medical records and medical opinion of the marking is necessary.
Self-inflicted injury: it is exceptionally rare for non-independently mobile infants to injure themselves during normal activity. Suggestions that a bruise has been caused by the infant hitting him/herself with a toy, falling on a dummy or banging against an adult’s body should not be accepted without detailed assessment by a Paediatrician and after a referral to Children's Social Care as per this protocol.
Injury from other children: it is unusual but not unknown for siblings to injure a baby. In these circumstances, the infant must still be referred under this protocol for further assessment, which must include a detailed history of the circumstances of the injury, and consideration of the parents’ ability to supervise their children.
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 Surrey Escalation Policy (FaST – Finding a Solution Together) exists to guide practitioners on how to manage such disagreements or differences of opinion. If there are concerns about the decision making and management of the child, any professional has a duty to escalate concerns to the next level in line with the SSCP. See Surrey Escalation Policy (FaST – Finding a Solution Together).
Pre-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 whilst a decision is reached.
It is the responsibility of the professional who identified the bruise to activate this policy and submit a referral to C-SPA but also to ensure the parent/carer is advised to send their child to the nearest hospital. If the parent/ carer refuses to seek medical support then to make an urgent referral to C-SPA and if the child is in immediate danger or risk of health, then to contact the Police as per section 5 Action to be taken.
Referral should be made to Children’s Social Care by submitting a Request for Support Form Surrey Children’s Social Care Request for Support Form - Surrey Safeguarding Children Partnership (surreyscp.org.uk) and referencing the Continuum of Support. They will hold a discussion and if appropriate arrange a Child Protection medical examination.
When investigating children with unexplained bruising do 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. 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 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 its 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 conference should be made in the light of all the available multi agency information about the wellbeing of the baby, child or children
Appendix 3: Leaflet: SSCP Bruising in Infants who are not independently mobile.
Bruising: systematic review - RCPCH Child Protection Portal
Bruising in non-Mobile Infants (Child Safeguarding Review Panel)
Child Maltreatment: When to Suspect Maltreatment in Under 18s (NICE)
RCPCH Child Protection Evidence Systematic review on Bruising
NSPCC: Core - Info: Bruises on children
Surrey Children’s Social Care: Report a Concern About a Child or Young Person: Report a concern about a child or young person - Surrey County Council (surreycc.gov.uk)
The radiological investigation of suspected physical abuse in children | The Royal College of Radiologists 2017 guidance (Revised November 2018).
Last Updated: June 9, 2025
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