Bruising in Children who are Not Independently Mobile

A 4LSCB Protocol for Assessment, Management and Referral by Health Practitioners (The 3B Protocol)

Bruising is the commonest presenting feature of physical abuse in children and therefore bruising in a child of any age is a matter for enquiry and concern. While a high proportion of bruising in older children will be of accidental origin, bruising in children who are not independently mobile (that is not crawling, pulling to stand or walking or confined by disability) is highly predictive of maltreatment. Bruising occurs in less than 1% of children in this group.

In 2008 an independent management review (IMR) by NHS Hampshire indicated that health professionals, and social work staff, often underestimate the significance of bruising in children not independently mobile and are ready to accept the explanations of parents or carers that the bruising was accidental. In fact, babies rarely sustain innocent bruising unless involved in major trauma or subject to medical conditions such as haemophilia or acute infection.  Bruising in this group should lead to a suspicion of maltreatment. as the recent NICE Guidance 89, When to Suspect Child Maltreatment, July 2009 makes clear.

As a result of the NHS Hampshire IMR findings the PCT set up a working group to produce guidance for health professionals on the assessment, management and referral of children not independently mobile who present with bruising. After wide consultation the final protocol and an accompanying summary/flowchart was published, and widely distributed, in May 2010 under the 3B logo (Baby? Bruising? Be concerned!).

The protocol has been adopted by the four LSCBs of Hampshire, Portsmouth, Southampton, and Isle of Wight.  

• It draws attention to the significance of bruising in babies.
• It advises health practitioners on the actions to take, including referral in every case for an acute paediatric and social service assessment.
• It includes sections on history taking and examination, recording, the sharing of information and the involvement of parents and carers.
• It includes contact numbers for Children's Services, and for a paediatric opinion, for each area.