Investigation of injuries or bruising in the non-mobile child

Investigation of Injuries or Bruising in the Non-Mobile Child

Parent and Carer Information

Directorate of Child Health

• Author ID:           VJ
• Leaflet Ref:         CH 072
• Version:              1
• Leaflet title:         Investigation of Injuries or bruising in the non-mobile child
• Date Produced:   April 2024
• Expiry Date:        April 2026

Introduction

Any child who is unable to move by crawling, bottom shuffling, cruising or walking independently is identified as being non-mobile. This definition can include older children with a disability. Babies who can roll fall in between the two categories.

Bruising or injury in this group of children is unusual. There is established national guidance on how such an injury is approached by professionals. Some examples of an injury include bruise, bite, bone fracture, head trauma, burn, scald or eye injury. 

An experienced paediatrician is required to perform a comprehensive review if a non-mobile child presents with an injury. Sometimes this may be due to an underlying medical condition. Sometimes it may be a birth related mark or injury. Very occasionally the injury may be deliberate.

By ensuring a national standardised medical assessment is performed on all non-mobile children with injuries, no serious causes are missed.

What will the medical assessment involve?

This involves an experienced paediatrician taking detailed history about all aspects of the child’s health and home environment, with particular focus on developmental milestones achieved, and any explanation for injury that the parent/carer provides. An underlying medical condition will always be a consideration as a part of the assessment.

Your consent will be sought prior to a full body examination of the child. This will involve undressing, taking measurements of injury, and photographs. Separate consent will be taken explaining the purpose of photographs.

What happens after the doctor examines my child?

Once the paediatrician has completed their assessment, they may be able to discuss the next steps with you immediately. In some cases, they may need to discuss with another colleague which may take some time. In all cases, discussion with Social Services is required.

If further investigations are indicated to fully understand the circumstances or extent of injury, then hospital admission is required. The paediatrician will be able to explain this to you. Any recommendation from Social Services will be directly communicated to families by a social worker.

What are the further investigations?

Investigations are done according to standard national guidance, to rule out an underlying medical condition and also to investigate for any other associated injury which may not be visible externally. Previously diagnosed medical conditions and investigations are taken into account during the assessment process. 

These include: 

1.         Blood tests – particularly to investigate for easy tendency to bruise or bone fracture. 

2.         Head scans – In the majority of cases, this is a CT scan. The scan itself is done quickly, but preparation may take time, especially if the child is unlikely to sleep and lie still during scanning. Sedation may be needed for this purpose. In some cases, a more detailed MRI scan of the head and spine may be needed after the CT scan. This is a long procedure and more likely to require sedation. Your consent for all radiology procedures will be taken and there will be opportunity to discuss further with staff in the radiology department.

3.         Skeletal survey – This involves a series of X-rays done two weeks apart, to detect and confirm any bone injury. This will involve up to 20 separate X-rays and will take 1-2 hours. Sometimes, recent injury is not visible and can only be detected on an image taken later. Your child’s arms, legs, or body will have to held in certain positions to get all the necessary images. Two radiographers assist in the process. Another appointment for a second skeletal survey will be made within two weeks. This is a shorter process, and only limited images are taken. This procedure is not painful, but some children and babies may get upset during holding. You will be able to comfort your child. 

4.         Eye examination – This involves looking at the back of eye with a special instrument by a suitably trained ophthalmologist. It requires putting some drops into each eye. For this examination, your child will require to be taken to Boston House. Transport and escort will be arranged by the hospital. If you have a car seat, it may be useful to bring it in, as you may be taken to Boston House in a taxi.

Will these tests cause my child to be upset? Are these tests safe?

Doctors, nurses and radiographers routinely take measures to minimise distress caused to babies during these investigations.

The risk from radiation exposure during scan and X-rays is very small. The X-ray doses are kept as low as possible. Careful consideration is given and these tests are only requested when the benefit from completing the investigation outweighs the very small risk from additional radiation.

All this is very upsetting. I feel as though I am being accused of hurting my child. Why do I have to be put through this?

We understand that this process can be very upsetting for parents and caregivers, but the only way for us not to miss a serious underlying cause of bruising/injury in such vulnerable children is by investigating each case as it presents. The paediatric team will keep you informed at each step and provide explanations honestly and frankly. Please do not hesitate to ask for further clarifications from your child’s nurse or consultant during ward rounds.

How long will I be in hospital with my child?

Overall stay is usually between 3-5 days and occasionally longer. This is because most of the tests require specially trained staff, not only to perform the tests, but also to interpret them. In some cases, specialists from other hospitals are required to provide an opinion, which introduces some delay. If your child is admitted on a Friday, it is likely that they wait until the following week to complete the tests.

What happens when all the tests are done?

Once all results are received, a meeting is required to take place between all professionals involved in the care of your child, along with social care and police. This is standard procedure and is called a Strategy Meeting. The aim is to achieve a clearer understanding of the circumstances of injury and identify any risk to the welfare of children involved.

You will be informed about the outcome of the meeting by the paediatric team and/or the social worker. Any follow-up plans from the social care or medical team will be explained at discharge. 

Usually there is requirement of a repeat visit to complete the second skeletal survey within 2 weeks. The paediatric team will aim to provide a date prior to discharge. The result, once ready, will be communicated to you by one of the doctors involved.

What support can I ask for if I find it all too much or I am not happy with the care?

The paediatric team recognise the frustration, worry and anxiety families can feel while going through this process. Although your child’s doctor and nurse should keep you up to date, you can ask to speak to the sister in-charge/ward manager or the matron, to raise any specific issue. You can also request to speak to the consultant who is overseeing your child’s case.

The hospital has a patient advice and liaison service (PALS) and you can ask the nursing staff to help you to get in touch with them.