A 3-month-old baby boy is referred by the GP who noticed a number of bruises when the baby was seen for their routine immunizations.
The baby attends with both parents. There is a 1-cm circular bruise to the left cheek and two similar-size bruises to the abdomen. The baby is a little quiet and it is mentioned that his feeds have reduced that day but he is otherwise well. There is no history of any injury.
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(a) What further history is needed?
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A detailed family health and social history is needed to understand the baby’s pattern of care, who has been involved, the family’s background, whether there are any other children and whether there have been any previous child protection issues. It is important to ask about risk factors for child abuse such as domestic violence and substance abuse. It is important to ask whether there is any family history of bleeding disorders such as Von Willebrand’s disease or other indicators of familial bleeding tendencies such as maternal heavy menstrual bleeding.
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(b) What specific signs should be checked on examination?
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Baby's general health, weight gain, head circumference, conscious level. Any signs of injuries in hidden areas such as the frenulum of the tongue. Any sign of bone pain when the baby is handled. Any other soft tissue injury signs. Fundoscopy to look for retinal haemorrhages
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(c) What investigations should be performed?
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Blood count and clotting to exclude thrombocytopenia or coagulation disorder. Ophthalmology review to examine for retinal haemorrhages. Skeletal survey to check for any recent or old bone fractures. Brain imaging should be considered to check for any subdural bleeding. The bruises should be photographed.
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(d) What safeguarding process should occur?
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If signs of possible inflicted (non-accidental) injury are present then the case must be jointly managed with local authority social work professionals and police to investigate the presentation and agree a plan for the future safeguarding of the child before discharge from hospital.
