Bruising in Babies and Children
Bruising is the commonest injury encountered when children have been physically abused, however, children will always 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. This guidance aims to assist practitioners to:
- Understand the importance of bruising in babies and children as an indicator of physical abuse;
- Clarify the arrangements between health and social care colleagues in relation to the investigation of bruising in children and young people.
A bruise occurs when the blood comes out of the blood vessels into the soft tissues, producing a temporary discolouration of the skin, which is non blanching (i.e., does not fade when pressure is applied to the skin). The discolouration may be faint or small with or without other skin abrasions (scrape or graze to skin) or marks. The colour may vary and it is not possible to give any opinion on when an injury happened to cause a bruise from looking at its shape or colour.
It is sometimes difficult to distinguish between a bruise and another mark to the skin, such as a birthmark. Reviewing other sources of information (e.g., Parent Child Health Record (red book), asking the parents to look at earlier photos which show the mark) may make things clearer, reviewing medical records and liaising with health practitioners, particularly maternity and neo natal services . Sometimes looking at whether the mark changes over time is the only way to be clear about this – 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 kept safe whilst further clarification is sought. In certain cases, this may involve a less experienced health care professional requesting advice / second opinion from a more experienced practitioner within their own clinical or safeguarding team.
A bruise, as well as being sustained in the course of normal childhood activities and play, may be an external indicator that a baby or child is being abused. Information gathered as a result of an appropriate investigation may enable that baby or child to be safeguarded.
In contrast to older children, babies and young children are more vulnerable to injuries of equivalent force. The likelihood of a baby or young child having bruises is also closely linked to their level of independent mobility. A single mark or a bruise in a baby or young child may be an indicator of serious underlying injury. Research and Child Safeguarding Practice Reviews confirm that relatively minor bruising may be a warning that an adult is under stress and/or that a baby may be at serious risk of further injuries; a lower threshold for referral for both medical, social care and potentially police investigation is needed to effectively protect a baby or young child.
Child Maltreatment: When to Suspect Maltreatment in Under 18s (NICE) and RCPCH Child Protection Evidence Systematic Review on Bruising set out a number of possible clinical findings suggestive of abuse. These include
- 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, an underlying bleeding 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.
A bruise should never be interpreted in isolation and must always be assessed in the context of the child's medical and social history, developmental stage and the explanation given.
Look for factors that make infants and children more vulnerable to abuse and neglect. These may be present in the child (e.g. premature birth, disability, and unwanted pregnancy) and/or the adults who care for the child (alcohol and substance use, domestic abuse, poor mental health, learning difficulties and poverty). While this procedure 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 Surrey Children’s Social Care and for a paediatric opinion.
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 over time or confused.
- 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.
Bruising sustained in the course of normal activity and play is strongly related to mobility. The number of bruises a child sustains through normal activity increases as they get older and their level of independent mobility increases. Most children who are able to walk independently sustain bruises. Bruises usually happen when children fall over or bump into objects in their way.
A non-mobile baby, or one that has no independent mobility, for the purposes of this guidance is a baby or young child who is unable to move independently through crawling, bottom shuffling, pulling to stand, cruising or walking independently.
- Bruising sustained in the course of normal childhood activities and play in a non-mobile baby, who has no independent mobility, is rare (prevalence 0.6-1.3%) (RCPCH Child Protection Evidence Systematic review on Bruising)- 'Those that don't cruise rarely bruise';
- Only one in five infants who is starting to walk by holding on to the furniture will sustain bruises;
- Even once children are mobile, significant unexplained bruising is unusual and requires exploration.
Bruising sustained in the course of normal childhood activities and play is strongly related to mobility. Bruising in non-mobile babies who are not independently mobile raises significant concern about the possibility of physical child abuse. A bruise or suspicious mark in this group, however small, which does not have a clear, consistent adequate explanation of a significant event, in keeping with the baby or young child's development, and an appropriate parent/carer response, should be referred to Surrey Children’s Social Care as a matter of urgency via the Children's Single Point of Access (C-SPA) or Emergency Duty Team (EDT). Referrals should be made using the Request for Support Form: Report a concern about a child or young person - Surrey County Council (surreycc.gov.uk).
Bruising in non-Mobile Infants (Child Safeguarding Review Panel) recommends that in all cases of bruising in children who are not independently mobile there is:
- Professionals should explain at this stage why, in cases of bruising in infants who are not independently mobile, additional concern, questioning and examination are required. The requirement to refer to Surrey 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;
- 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;
- All babies who are suspected suffering from a bruise should be referred to Paediatric A&E and reviewed by a senior paediatrician (Registrar or above);
- If child protection concerns are identified, the SSCP safeguarding children medical examination form should be used to document history, complete a body map, 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 overemphasized;
- Where safeguarding concerns are identified, twins of infants presenting with bruising and any other siblings should be subjected to a medical examination and appropriate investigation;
- If a parent or carer is uncooperative or refuses to take the child for further assessment, this should be reported immediately to the police and children’s services 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;
- A multi agency discussion should be arranged by Surrey Children’s Social Care to consider any other information on the child and family and any known risks, and to jointly decide whether any further assessment, investigation or action is needed to support the family or protect the child. This multi agency discussion should always include the health professional who reviewed the child.
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 Surrey Children’s Social Care and a strategy discussion is required.
Professionals within the strategy discussion will have a discussion considering the relevant factors such as presentation, explanation, the voice of the child and any known vulnerability factors to support further decision making and safety planning.
If a referral to Surrey Children’s Social Care is deemed appropriate, it should be made immediately as per local procedures (see Referrals Procedure) and should include up to date contact details for the family and the referrer. This procedure should be followed for new cases and previously known children.
The referrer should discuss an immediate safety plan for the child ensuring that immediate contact details for the child and carer are shared. All discussions should be documented including the risks of not staying with the baby or young child until a social worker arrives. If there are immediate concerns about safety, the police should be called.
The social worker/team manager should arrange a strategy discussion/meeting with police and health to discuss the need for section 47 enquiries. The strategy discussion/meeting should always include the health professional who reviewed the child.
If the discussion/meeting concludes the threshold for section 47 is met, then a child protection medical should be arranged by utilising the Child Protection Medical Form (CP1) (see Local Resources). If there are issues regarding the decision to hold a medical, the obtaining of consent, communication difficulties or other factors which may make the paediatric medical examination complex then consider including a consultant paediatrician in the initial strategy discussion. The discussion should involve the development of an interim safety plan for the child and consideration of siblings.
The child protection medical can only be carried out during a section 47 investigation and can only be undertaken by a paediatrician. It cannot be undertaken by the family G.P.
For further information, please see the Child Protection Enquiries Procedure, Strategy Discussion / Meeting for guidance on strategy discussions.
Paediatric medical examinations for bruising/suspicious marks require informed consent from an individual with parental responsibility or in the absence of this, a court order directing that a paediatric medical examination takes place. If the injury is thought to have been caused by an implement where practicable this should be brought to the medical examination or images of the implement made available to the examining paediatrician.
Any non-independently mobile infant with unexplained bruising or 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.
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 local 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 case, 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.
Except in the rare circumstances where an infant or child requires urgent medical attention, the child should not be sent to hospital but instead a referral should be made to Surrey 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 Contiuum 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 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 case conference should be made in the light of all the available multi agency information about the wellbeing of the baby, child or children
Legislation, Statutory Guidance and Government Non-Statutory Guidance
Bruising: systematic review - RCPCH Child Protection Portal
Bruising in non-Mobile Infants (Child Safeguarding Review Panel)
Good Practice Guidance
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: November 15, 2024
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