Bruises and Birth Marks in Young Infants - April 2009

Written by Dr Charles Holme, Designated Doctor Child Protection, Devon PCT

Time to be careful
A reminder of the differential diagnosis of unusual markings on infants in the first few months of life:

• Haemangioma, café au lait spots, blue spots, prominent veins
• Ink, paint, dye or dirt - try soap and water!
• Bleeding disorders, e.g. haemorrhagic disease of the newborn (vitamin K dependent bleeding)**
• Infection, e.g. meningococcal septicaemia**
• Physical abuse**

** All of these are life threatening.
40% of child abuse deaths occur in infants of less than 12 months age

Is the mark a bruise?

• Bruising may be in the form of single or clustered lesions with a variety of colours, red, purple, brown, yellow or grey. It is not possible to date a bruise with any accuracy.
• Sometimes the bruising may be petechial or intradermal, especially if there is trauma and the blow causing the bruise is with the flat of the hand or transmitted through clothing.

Could the bruising be due to child abuse?

• Why should a young infant who is not yet rolling over or sitting alone show signs of bruising?
• A small number of infants with bruises due to trauma may have a consistent witnessed history of accidental injury
• But if there is no medical cause and no history of a witnessed injury, the bruising is unlikely to be self-inflicted and you should consider the probability of abuse, even if the infant appears well and smiling.
• Even small bruises on infants in sites such as the face, neck, ears, back, abdomen and limbs can be highly significant and may be associated with shaking.

Suggested action

• If you suspect non-accidental injury you must share your concerns with Social Services immediately, having notified the parents/carers of the child first, unless by doing so you place the child/young person in more danger.
• For suspected non-accidental head injury, apart from blood tests, there will be a need for a skeletal survey and an urgent CT or MRI head scan and examination of the retinae.
• Follow your local protocol or refer to “What to do if you’re worried a child is being abused”, HM Government, 2006  - Link - http://tinyurl.com/yr2bgp

Get on the phone to arrange an urgent assessment by the paediatricians the same day, whatever arrangements are made for the child's safety by Social Services.  Speak to the duty paediatric consultant or specialist registrar. Notify the liaison Health Visitor for your practice and feel free to discuss the problem with the named doctor or nurse for child protection in your PCT if you want further advice.

• Follow your phone call with a faxed referral letter giving full details of your concerns to the consultant paediatrician. Check that the child arrives in the Emergency Department
• Remember that if you suspect abuse you are duty bound to disclose risk factors in the family such as domestic violence, mental illness or substance mis-use.

Dr Charles Holme, Consultant Paediatrician
Designated Doctor Child Protection, Devon PCT, County Hall, Topsham Road, Exeter EX2 4QQ
Tel: 07968 101063       Email: charles.holme@nhs.net

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