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1.3.29 Bruising, Burns and Injuries in Non Mobile Children Protocol


Contents

  1. Introduction
  2. Definition
  3. Recommended Action
  4. Burns
  5. Oronasal Bleeding
  6. Contact Information
  7. Flowcharts

    Amendments to this Chapter


1. Introduction

Bruising, bleeding, fractures and possible injuries in Children who are not independently Mobile

The aim of the protocol is to provide frontline and senior practitioners with a strategy for the assessment, management and referral of children who are not independently mobile who present with bruising or otherwise suspicious marks; bleeding from the nose / mouth; fractures (which may present as a swelling e.g. on the head or with reduced movement of a limb); possible non accidental head injury (NAHI) or a burn / scald.


2. Definition

Not Independently Mobile: a child who is not yet crawling, bottom shuffling, pulling to stand, cruising or walking independently. Includes all children under the age of six months or children with reduced independent mobility due to disability. The protocol does not apply to children with a disability who are independently mobile in a wheelchair and who can give a consistent plausible explanation for accidental bruising.


3. Recommended Action

While the guidance recognises that practitioner judgement and responsibility have to be exercised at all times, it errs on the side of safety by requiring that:

  • All not independently mobile children* with bruising or a burn or scald should be referred to Paediatrics AND to Children’s Social Care;

    *See full protocol (sections 1.8 and 3.2) for definition and significant exclusions.
  • All not independently mobile children with bleeding (including oronasal bleeding), a swelling of the head or a reduction in movement of a limb (which may indicate a fracture at that site) should be discussed with a consultant paediatrician. There should be a low threshold for referring to both Paediatrics and Children’s Social Care;
  • Where a health visitor (or other non- hospital based practitioner) identifies a skin mark /lesion and they are unsure whether this is a bruise / burn / other injury, it is acceptable to refer to the GP in the first instance. This referral should take place on the same day and not cause undue delay. If the GP is unable to distinguish between a bruise or other reason for the mark, or has concerns, then a referral should be made to Paediatrics under this protocol.  If the GP identifies a bruise, then this should be referred to Paediatrics and Children’s Social Care, as per the protocol. If a child is seen by the GP but not referred on and the health visitor continues to have concerns a paediatric opinion should be sought.

It is not always easy to identify with certainty a skin mark as a bruise or a burn. Practitioners should take action in line with this protocol if they suspect that the observed skin mark could be a bruise or burn or could be the result of injury or trauma.

Other marks, abrasions or presentations in children not independently mobile always require an explanation, and action should be based on practitioner judgement and usual safeguarding practice. Practitioners should not suggest a possible reason for the bruising / bleeding / swelling but ask an open question to seek an explanation from the parent / carer.

For suspected injuries brought to the attention of medical practitioners there should be an appropriate examination and the completion of body maps. In infants (< 12 months of age) an appropriate examination would include undressing the infant.

Records must be signed, timed, dated, accurate, comprehensive and contemporaneous.


4. Burns

The assessment of burn and scald injury presents specific difficulties. Accurate assessment of such injuries will ultimately influence the nature of any intervention capable of safeguarding the injured child and any vulnerable siblings. It is therefore imperative that a comprehensive and timely assessment is undertaken.

Burns and scalds to children are common.

  • The majority of burn or scald injuries result from non-intentional injury, which may involve varying degrees of parental inattention;
  • Some cases are the result of neglect;
  • Some cases involve deliberate abuse.

Staff in accident and emergency, plastic surgery and children’s burns units see the more severe injuries at the time of presentation and their records and observations are vital to the overall assessment of the case.

If there are any concerns re possible abuse or neglect then a referral to an appropriate Paediatrician is required.

In cases of concern any burn dressings/coverings present upon admission or first presentation should be retained. Such dressings may well be the subject of further examination (forensic) as they may contain valuable evidence which supports a non-accidental or deliberate cause (e.g. cigarette ash residue, chemical residues, paint deposits resulting from contact with heat sources).

The paediatrician will need to liaise with those responsible for the treatment of the burns and ensure that appropriate referrals to partner agencies have been made. Less severe injuries may not be seen in hospital but may present to GPs, health visitors and school nurses or are discovered, for example, by nursery nurses or school teachers. The need to ensure these cases are properly assessed is equally important.

It should be borne in mind that most accidental burns and scalds in childhood occur in pre-school children and these should be preventable.


5. Oronasal Bleeding

Oronasal bleeding is uncommon in infants (<12 months) and is rarely seen in emergency departments in children under the age of 2 years. It may be due to serious medical disorders, minor ailments or abuse. Any non-independently mobile child presenting with oronasal bleeding, particularly in the first year of life should be referred for urgent paediatric assessment This is likely to involve blood tests to exclude serious disorders and must include consideration of safeguarding issues. Where no clear cause is established the child should be admitted to hospital for further medical and multiagency assessment.


6. Contact Information

Please refer to the Health section in the Local Directory.


7. Flowcharts

Click here to view Flowchart 1: Non – Health Care Professionals Joint Protocol for assessment of bruising / burn / scald / possible injury in a child who is not independently mobile

Click here to view Flowchart 2: Joint Protocol for assessment of bruising / burn / scald in a child who is not independently mobile (Health)

Click here to view Flowchart 3: Joint Protocol for assessment of an unexplained mark in a child who is not independently mobile

Click here to view Flowchart 4: Joint Protocol for assessment of bleeding from nose or mouth in an infant who is not independently mobile

Click here to view Flowchart 5: Joint Protocol for assessment of swelling on head or reduced limb movement in a child who is not independently mobile


Amendments to this Chapter

This chapter was reviewed and updated in August 2016. A new Section 5, Oronasal Bleeding has been added.

End.