‘Why child protection policies on bruising to babies need to change’

Professor Andy Bilson explains how his research demonstrates how existing protocols on pre-mobile bruising mislead staff and risk exposing parents to damaging and unnecessary child protection action

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By Andy Bilson

In a recent report, the Child Safeguarding Practice Review Panel (“the panel”) asked safeguarding partners to review their policies on bruising in non-mobile infants “to check for consistency with the evidence base and national guidelines.”

The panel acknowledges that there are a small number of children who are seriously harmed or die, where bruises have been seen by staff with a responsibility to protect children before more serious injuries have taken place. So why does the panel require these policies to change and what should they say?

Is a bruise ‘reasonable cause to suspect significant harm’?

My research with a colleague, published this week, reviewed policies covering 148 of England’s 152 local authorities and found most risked misleading staff by exaggerating the risk that a bruise was non-accidental. Almost a quarter treated any bruise in a pre-mobile baby as “reasonable cause to suspect significant harm” without any assessment of the case. Seven of these required all bruised babies to be investigated under section 47 of the 1989 Children Act and 28 required a strategy discussion.

The harm to children and families by this investigative orientation is discussed below.

Most standalone procedures had the rationale that bruising in pre-mobile babies was very rare and likely to be “highly predictive” of non-accidental injury. This view was used to justify removing discretion from frontline staff. It also orients staff towards thinking that such bruises are highly likely to be non-accidental. The evidence does not support this.

What the evidence on bruising says

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According to the panel, research shows that between 0.6% and 5.3% of children not yet crawling had an accidental bruise on any single observation. My article shows that the lowest finding would mean there would be almost 2,000 accidental bruises for every infant placed on a child protection plan for physical abuse. Further, a UK study found that 27% of pre-mobile babies had an accidental bruise over an average of eight weekly observations.

This challenges the idea that bruises alone are a reliable sign that physical abuse is ongoing or is likely and shows bruising is far from rare.

Research into parents’ explanations of non-accidental bruises in pre-mobile children found causes:

“… included bumping into mother’s tooth, falling asleep on a dummy, banging themselves with a fist or rattle and a toy that was dropped on one baby …[and] 12 children who had fallen or toppled over, 7 rolled into something, 4 banged into an object and 6 hit themselves with an object.”

Twenty three local authority procedures directly contradicted this, as in the following two examples:

“Infants do not bruise themselves by lying on a dummy or banging themselves with rattles and other infant toys or by flopping forwards and banging their heads against their parents’ faces.”

“Any explanation that any injury, barring a small scratch, is self-inflicted should not be accepted.”

These contradictions and exaggerations orient staff to believe that there is no valid explanation for bruises or that valid reasons cannot be accepted, reducing curiosity and exploration of alternative explanations. They lead to interventions, including child protection investigations and taking children into care, which can themselves harm children and families.

Harming children and families

For my latest article, we consulted four sets of parents who had been investigated because of bruises in pre-mobile children and found not to have harmed their child.

One family took their five-month-old to a hospital with what they thought was a rash on his knee, and were told that it was an unexplained bruise. The mother had to remain with her child for further examinations under threat that the police would be called and legal action taken. The examinations took four days, with the mother staying with her baby whilst the father cared for their 20-month-old child. The hospital carried out a full skeletal survey, involving multiple x-rays, along with a CT scan of the child’s head, which found no injuries. A social work investigation quickly found no reason for further action, but the local policy mandated repeating these tests two weeks later. This process was only halted when the parents employed a lawyer at considerable expense to challenge this because of their concern at the risk to their child of unnecessary exposure to the high levels of radiation.

Another parent, who lived in a local authority that mandated a child protection investigation for all bruises in pre-mobile babies, had her child removed for four months based on a small bruise on his arm, which she had pointed out to a health visitor. The child was breastfed and the mother continued to pump milk and deliver it to the child’s carer. She was given limited, supervised access, not even daily. Almost three years later, she still had flashbacks to her experiences and needed treatment for post-traumatic stress disorder.

Parents stressed that investigations caused significant harm to their children and them. In a case where a child was placed in care, her four-year-old sibling:

“…has gone from a confident little girl to a nervous wreck asking for [her sibling] all the time; hysterical if she can’t see a family member by her at all times (in the house or outdoors); saying don’t leave me, or don’t let anyone take me; waking up throughout the night.”

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Parents and grandparents reported frequent bouts of crying, not sleeping, having nightmares and flashbacks. They worried that their child might be subject to further investigations or removed, long after their involvement with children’s services was over, and even experienced physical illnesses due to anxiety.

Parents were concerned at the effect of a record of an investigation remaining on file, including one couple who were considering adopting a child in the future. One parent worked in social care and was concerned that the investigation might affect their future career. These experiences fit with a range of research into children and their families’ harmful experiences of involvement in child protection.

All the bruises in these cases were initially unexplained and parents had voluntarily raised them with a medical professional because of concern about their child’s health. One child had a small bruise on their arm and was taken to hospital for tests and a section 47 investigation commenced. During the initial stages they continued to say that they did not know the cause of the bruise, a statement that the social worker said in their report was implausible. However,

“a day or so after our hospital stay we observed our son vigorously suckling his forearm … which we came to realise through our own online research could well be the cause of the mark.”

The hospital paediatrician accepted this as a reasonable explanation, validated by articles in medical journals. Despite this, it took two months to complete the investigation, a time during which the parents were extremely upset, unsettled and frightened. Thus, the lack of an explanation is not evidence that a bruise is likely to be non-accidental and more research is needed in this area.

It is also important to explore medical conditions that make a child susceptible to bruising. A video, made in response to my earlier research, graphically demonstrates the impact on a mother and her family when an infant’s susceptibility to bruises due to Ehlers Danlos Syndrome was not diagnosed speedily. Her son, Theo, was removed into care and remained there for more than a year. She says:

“Me, Theo and my mum are now in a hostel because we were made homeless … I had to leave my job in the end because of the stress. Me and Theo’s dad broke up because we became distant because of it all. We couldn’t stop arguing. We just lost everything!”

What policies should say

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Staff will need to unlearn some of the messages of earlier policies and training, particularly that bruises in pre-mobile babies are not “highly predictive” of abuse and are not “extremely rare”. The Royal College of Paediatrics and Child Health should also change its statement that “accidental bruising is rare (0-1.3%)” to fit with the research quoted above.

I agree with the panel that no policies should mandate a child protection investigation or strategy meeting in every case, and a standard definition of pre-mobile should be agreed, based on developmental stage, not age. What Kemp et al’s research shows is that some children start to be mobile (crawling, bottom shuffling, cruising etc) from the age of four months and some babies start to roll before that age. They show that rolling is an important stage as babies who are not mobile but can roll had a bruise in almost 10% of observations, whilst before being able to roll, bruises were found in 2.2% of observations.

There are some key messages for policy which can be summarised as follows:

  • Where a pre-mobile baby is bruised, staff should be curious and explore with parents the cause in a fair and balanced manner, considering whether the child has been abused.
  • Whilst bruising is less common in babies who cannot roll or crawl than in mobile infants, accidental bruising is still many times more common than non-accidental injuries.
  • Once a baby can roll the chances of an accidental bruise increase.
  • A bruise alone is not sufficient cause to suggest a baby has been or is at risk of significant harm and does not reach the threshold for a child protection investigation, strategy discussion or interim care order without other indicators of risk of significant harm.
  • Parents who have not harmed their child may not have a plausible explanation for bruising. This does not mean that there isn’t one, or that they are hiding abuse.

Panel recommendations 

The panel recommends:

  • A review by a health professional who has the appropriate expertise to assess the nature and presentation of the bruise and 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.
  • A multi-agency discussion 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.

It is prudent to check with other agencies if there is any cause to suspect abuse, but these multi-agency discussions will only help accurate decision-making if their members are aware of the mistakes and misleading content of earlier policies and training.

This request to review policies is an opportunity to improve the use of research and encourage an approach to families based on relationship building and curiosity. This change is particularly needed in the current climate of high stress and limited resources in children’s social care and health services.

Andy Bilson is emeritus professor of social work at the University of Central Lancashire 

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5 Responses to ‘Why child protection policies on bruising to babies need to change’

  1. Dr. Tony Spinks November 16, 2022 at 3:13 pm #

    Let’s not forget that brusiing is bleeding under the skin not just a ‘mark” – If a non-ambulatory infant sustains a bleed under the skin this should rightly trigger professional concern and enquiry. Time and time again we are reminded as Social Workers of the critical need for a multi-agency approach and effective information sharing amongst involved professionals in such cases and this is excatly what a strategy meeting and S47 investigation are designed to achieve. Whether that S47 investigation results in a child protection conference rests on the outcome of that S47 investigation and on professional information sharing. These are necesssary and important child protection safeguards to ensure that physical abuse and/or neglect is not missed. Asking professionals to move away from such protective processes is fraught with risk for the children concerned

    • Professor Andy Bilson November 18, 2022 at 5:32 pm #

      Dr Spinks, the Children Act and Working Together rightly say a strategy meeting and section 47 investigations should only be called where there is sufficient cause to suspect that a child is suffering or likely to suffer significant harm. This safeguard is in place to protect children and their families from the significant harm to them of being drawn into the child protection system unnecessarily. Since it is far more likely that a bruise in a premobile baby is accidental, policies should abide by this statutory safeguard and not automatically mandate a strategy meeting or formal investigation in all cases. This is why the Child Safeguarding Practice Review Panel have asked for these policies to change.

      I also found that policies exaggerated risk and misled professionals about how bruises might be caused in a way that is unhelpful to all involved who wish to make an accurate judgement of the risk to a child. It is time for them to change and for accurate and helpful guidance to be put in place

  2. dk November 16, 2022 at 4:22 pm #

    I’ve recently left LA social work after nearly 10 years and the mandated response to babies with bruises was one of a litany of frustrations that contributed to that decision. This is all clearly good sense and just, but I would say … Good luck getting a health professional to make the call on whether or not there is reason to good reason to worry and (effectively) that child protection or court proceedings are warranted. Everyone expects social workers to hold the reputational risk of those decisions on their shoulders, and that is not a construct that is going to shift any easier than those around what bruising might indicate.

  3. B Wood November 16, 2022 at 9:09 pm #

    This sounds like good sense.
    It is good that new evidence is being used to bring practice up to date, and to protect babies and families who stand to be significantly damaged by overzealous and excessive child protection procedings.
    Yes bruising should be investigated.
    The default assumption should never be abuse, or to assume the parent is hiding information.
    In practice i have found that,
    commonly accepted blanket statements, to the effect that ‘bruising on a non mobile baby’ and
    ‘a child having two black eyes’
    inevitably indicate physical abuse,
    Is repeated by trainers and professionals
    But i know this may well be an unsafe assumption.
    As I child I sustained two black eyes when lying in the garden on my tummy and my brother tripped over me , both his feet making contact with my eyes.
    My mother took me to the doctor to be sure I was OK but decades later would likely have been wrongly referred to child protection procedures.
    I have also seen a bruise left on skin from an infant suckling, this was seen on a breast where baby had latched other than on a nipple, but also on a sibling’s arm.
    Professional curiosity is the mantra today.
    Let us not assume parents are abusers as the first option.
    Referral for thorough medical assessment would help identify some of the rare conditions which may lead to tendencies to bruising.
    The best person to protect the child I believe does still remain the parent.
    There must be strong evidence to interrupt that precious bond.
    Services should be there to support, not undermine parents.


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