1.4 Section 47 Protocol for Responding to Concerns about Injuries or Abuse in Infants under Two Years Old

1. Introduction

Analysis of serious case reviews where children died or were seriously injured or harmed noted the high proportion of children under one year old (Brandon et al, 2009).

This procedure contains information to help workers who encounter injuries or other possible types of abuse in this age group, to decide if there may be cause for concern and if so it outlines the procedures that should be followed. See Section 7, Action to take if you are Concerned about an Infant. Where a child under two has been admitted to hospital as a result of concerns there should be a Strategy meeting chaired by a Children's social care Senior Fieldwork Manager to determine the action to be taken.

Remember: it is not your role to diagnose or prove abuse. Your responsibility is to identify and report any concerns.

Mobility developmental stages in infants, such as crawling, walking, vary considerably, particularly if they have either learning or physical disabilities or any other health problems. Some babies may crawl before they start walking, others may go almost immediately to walking via pulling themselves up on furniture. On average, young children start walking between the ages of 13 and 15 months, however some may take their first steps as early as 9 months. Therefore infants under the age of one can be divided into two groups: a) non-mobile and b) mobile or partially mobile. This distinction is important because there are certain injuries that do not usually occur as a result of an accident by non-mobile infants, such as a baby rolling on its dummy.

In relation to cognitive development, again infants progress at different rates when learning how to verbally and non-verbally interact with others and how to play.

Whilst the developmental progress of an individual baby may not be relevant to the actions of a worker who is concerned about possible abuse, it may be relevant to the subsequent assessment of that infant. Therefore developmental achievements by infants, or indeed lack of them, should always be recorded by staff working with them.

As well as giving consideration to the different developmental stages of individual babies, other equalities issues should also be taken into account. This includes infants with learning or physical disabilities and those from black and ethnic minority families (see below).

2. Physical Injuries

Generally, any injury in a non-mobile infant causes concern. However, in view of the limited mobility and the vulnerability of this age group, you should have a lower threshold for action.

Any injury should have a clear, acceptable and logical explanation that is consistent with the history and the infant's age and developmental abilities. In infants with any injury the possibility of a non-accidental injury (NAI) should always be considered, even if you then immediately discount the idea.

Situations of Particular Concern

Situations that should cause particular concern for professionals include:

• Delayed presentation / reporting of an injury;
• Admission of physical punishment from parents / carers, as no punishment is acceptable at this age;
• Inconsistent or absent explanation from parents / carers;
• Associated family factors such as substance misuse, mental health problems, and domestic abuse;
• Other associated features of concern e.g. signs of neglect such as poor clothing, hygiene and / or nutrition;
• Rough handling;
• Difficulty in feeding / excessive crying;
• Significant behaviour change;
• Infant displays wariness or watchfulness;
• Recurrent injuries;
• Multiple injuries at one time.

Injuries to non-mobile Infants

Any injuries are unusual in this age group, unless accompanied by a full consistent explanation. Even small injuries may be significant, and they may be a sign that another hidden injury is already present. Such injuries include:

• Small single bruises e.g. On cheeks, ears, chest, arms or legs, hands or feet or trunk;
• Bruised lip or torn frenulum (small area of skin between the inside of the upper and lower lip and gum);
• Lacerations, abrasions or scars (see also Lacerations, abrasions or scars);
• Burns and scalds;
• Pain, tenderness or failing to use an arm or leg which may indicate pain and an underlying fracture;
• Small bleeds into the whites of the eyes or other eye injuries.

Occasionally an infant can be harmed in other ways, for example:

• Deliberate poisoning which can present as sudden collapse, coma;
• Suffocation which can present as sudden death, collapse, cessation of breathing (apnoeic attack), bleeding from the mouth and nose.
  
  

Injuries to Mobile Infants

Infants under one year old will vary in their degrees of mobility. Most will either start crawling or walking before they reach their first birthday. Any explanation of injuries they sustain must be consistent with their developmental stage.

Bruises

Mobile infants can sustain accidental bruises, usually on their foreheads but occasionally in other areas, during the course of daily activities. However, some characteristics of bruises cause concern, even if the carer gives an explanation. Concerning injuries include:

• Site - bruising in unusual places or not over bony prominence's for example ears, neck, inner thighs, soft part of cheeks, trunk, arms or mouth;
• Shape - bruises of characteristic shape, for example parallel lines suggestive of a slap or grip mark, crescent shaped bruising of bite marks;
• Multiple bruises of the same or varying colour;
• Clusters of small round bruises suggestive of a grip.

It should be noted that bruising in black infants and some minority ethnic babies may be more difficult to see. Tenderness or minor swelling over the area of injury is important.

Dark pigmentation (commonly known as blue spot), usually over the lower central back or sacral areas, is normal and common in infants with pigmented skin and usually fades as the infant grows.

Lacerations, Abrasions or Scars

Workers should be alert to the fact that lacerations, abrasions or scars are not common in infants under one year, without a consistent explanation. Such injuries that would cause increased concern include:

• Site - the inner arms, legs, eyes, ears and sides of face or on areas usually covered by clothing;
• Shape - for example, on the neck, ankles and wrists that look like ligature marks;
• Multiple injuries or those which are symmetrically distributed on the infant's body.

Burns and Scalds

Accidental burns and scalds only occasionally occur in non-mobile and mobile infants who can pull to standing or can walk. They can occur if an infant reaches out to grip a hot object such as heated curling tongs or pull over a container of hot liquid such as a cup of tea or coffee. However, even these accidents are more common in families where there are concerns about parents coping and lack of supervision. Specialist advice should be sought if in doubt.

Burns and scalds can be a manifestation of abuse and the concerning features are:

• Site - burns and scalds to trunk and lower limbs; contact burns especially on the backs of hands and soles of feet, back and usually protected areas such as inner arms; contact burns in the shape of an implement for example a cigarette lighter, iron or cigarette burn;
• Shape - scalds in a glove and /or stocking distribution which suggests submersion; symmetrical burns to limbs;
• Scalds with clearly defined borders.

Fractures

Frontline staff may suspect a fracture or injury from seeing an infant who is not using a limb or who is obviously in pain.

Children do sustain fractures from accidental injury, but the majority of these are seen in those older than 5 years of age. They are rarely caused by accidental injury in babies under one. They do occur in this age group; as a result of non-accidental injury. Some are only found by X-rays and scans. A non-accidental fracture represents a serious assault and must be investigated.

Diagnosis is only by investigation and therefore can only be made by a doctor. A skeletal survey - X-rays of the whole body - is carried out in all infants who present with any concerning injury, even a small bruise.

Skull fractures can present as soft boggy swellings on one or both sides of the head, but may be without any symptoms.

Shaking Injuries

Shaking injuries can result in severe brain damage, or death for infants. Shaken babies can present with other physical injuries as described above. However, they may have no external signs or symptoms initially, and / or present with apparent medical problems such as:

• Sub-conjunctival haemorrhages (bleeds into the white of the eye);
• Sudden cessation of breathing (apnoeic attack);
• Sudden collapse or fits.

Other Injuries

Occasionally an infant can be harmed in other ways, for example:

• Deliberate poisoning which can present as sudden collapse, coma;
• Suffocation which can present as sudden death, collapse, cessation of breathing (apnoeic attack), bleeding from the mouth and nose.

3. Neglect

Practitioners need to be aware of the possibility of parents / carers neglecting to adequately care for their children. Factors of neglect in an infant may include:

• Parents / carers not giving their child prescribed treatment for a medical condition that has been diagnosed;
• Repeated failure by parents / carers to take their child to essential follow-up medical appointments;
• Persistent failure by parents / carers to engage with relevant child health promotion programme's such as immunisation, health and development reviews, and screening;
• Not seeking medical advice when necessary, jeopardising their health and wellbeing, particularly if they are in pain;
• Being cared for by a person who is not providing adequate care, including hygiene, either through inability or negligence;
• Not feeding properly, or being fed an inadequate or inappropriate diet;
• Suffering severe and / or persistent infestations such as scabies or head lice;
• Being consistently dressed in inappropriate clothing for example, for the weather or their size;
• Being persistently smelly and / or dirty;
• As a result of being inadequately supervised;
• An incident that suggests a lack of supervision, such as sunburn or other burn, ingestion of a harmful substance/s near-drowning, a road traffic accident or being bitten by an animal.

If you are see an infant or young child and you are worried in relation to any of the above please seek advice (see Referrals Procedure).

Workers should also be alert to the possibility that the infant is being neglected:

• If s/he appears fearful or unusually quiet or withdrawn for this age;
• Is s/he is excessively clingy, inappropriately distressed or inconsolably crying;
• If there is known past maltreatment or the infant or a sibling.

If a child has been abandoned by their parent / carer, you should immediately make a referral to Children's Social Care (see Referrals Procedure).

4. Emotional Abuse

Staff should be aware of potentially harmful interactions of a parent / carer towards their child. At this age their ability to communicate their needs is limited. However, most infants will respond to how adults are interacting with them, and this may have an impact on them and their development. Therefore workers should have cause for concern if they feel parents / carers:

• Are negative or hostile towards the infant;
• Reject them or use them as a scapegoat;
• Have inappropriate interactions with them, including threats or attempt to discipline them;
• Use them to fulfil their own needs (for example, in marital disputes);
• Fail to promote their development, by not providing appropriate stimulation, or isolating them from other children / adults as applicable;
• Are emotionally unavailable to the infant, by being withdrawn or unresponsive, for example (emotional neglect).

5. Sexual Abuse

Sexual abuse of infants under one year old is not common. However, in the following situations workers should be alert to the possibility of:

• Discharge, bleeding or other injury in girls and boys genital / anal area, or other injuries that may be sexual, for example bite marks on buttocks or bruises on inner thighs.

6. Fabricated or Induced Illness

Fabricated or induced illness is suspected when a baby's history or physical or psychological presentation leads to a discrepancy with a recognised medical condition. Some of the features include:

• Symptoms only being reported when as occurring in the presence of the parent / carer;
• Unexpectedly poor response to medical treatment;
• New symptoms occurring as old ones disappear;
• History or progress of condition is unexpected, and not usually that seen by medical staff;
• Repeated requests for second opinions, even when professionals agree on the cause of the condition / illness.

For further information, see: Fabricated or Induced Illness / Perplexing Presentations Procedure.

7. Action to take if you are Concerned about an Infant

7.1 You Should

• Write down any information or history, using the words which it was told to you;
• Record your observations;
• Complete a body map (print off Body Maps) by drawing the injury to the relevant part of the body and put it in your notes;
• Not take photographs of marks / injuries, as this is inappropriate (complete Body Maps as noted above);
• Encourage  photographs to be taken at the Childrens Hospital when a child is taken for examination. Getting photographic documentation is very important, as having good photo-documentation will help support opinion as well as any future decision making;
• Make sure you sign all your records and include the date and time of when events took place and the date and time that you write your records;
• Seek advice from your line manager and / or other specialist agencies (see box below);
• Record what advice you are given;
• Refer to children's specialist services, if appropriate (see Referrals Procedure, Making a Referral);
• Where a child under two years old is admitted to hospital as a result of the concerns, a Strategy meeting should take place chaired by a Manager (Safeguarding Service);
• Record what action happens as a result of referring the infant.

7.2 It is important that you do not

• Attempt to make a diagnosis or prove abuse;
• Take photographs of marks / injuries, as this is inappropriate (complete Body Maps as noted above).

8. References

NICE Guidance

Postnatal care up to 8 weeks after birth (NICE guidelines, July 2006)

Treatment and Management of Assault (2006) (Warwick University)

Understanding Serious Case Reviews and their Impact: A Biennial Analysis of Serious Case Reviews 2005- 2007