🧭 When to suspect

Bruising is the commonest injury of childhood – and also the commonest injury in physical child abuse. The whole clinical task in primary care is to separate the everyday bruise of an active child from the bruise that signals maltreatment or an underlying medical condition (a bleeding disorder, leukaemia or a vasculitis). A seemingly trivial bruise can be a sentinel injury: a high proportion of infants later seriously or fatally abused had an earlier, overlooked minor injury, so the small bruise in the wrong child is an opportunity, not a footnote.

The single most powerful discriminator is independent mobility. Accidental bruising is rare in a child who cannot yet move themselves – 0–1.3% of pre-mobile infants – which is the basis of the maxim “those who don’t cruise rarely bruise.” The other discriminators are site and pattern (accidental bruises sit over bony prominences such as shins, knees and the toddler forehead; concerning bruises sit on soft, protected sites) and whether the explanation fits the injury and the child’s development. NICE updated the definition of “independently mobile” in December 2025 to remove the long-standing guesswork over borderline infants.

A child is “independently mobile” (NICE CG89, December 2025) if they can do any of:
• Crawl, bottom-shuffle, or pull themselves up to stand using an object such as furniture.
• Stand unaided, cruise (move from place to place holding onto furniture), or climb (for example onto furniture or stairs).
• Walk using a push-along walker, or walk unaided.
• Children under 12 weeks typically lack the strength and coordination to move independently – but age alone must not decide it; assess the child’s actual motor ability.

🧠 Clinical pearl – TEN-4-FACESp

For the under-4s, the validated TEN-4-FACESp bruising rule is a useful aide-mémoire for high-risk sites: Torso, Ears, Neck; bruising on any infant ≤ 4 months; plus Frenulum, Angle of jaw, Cheeks, Eyelids, Subconjunctivae, and any patterned bruise. A bruise in any of these categories should prompt evaluation for abuse rather than reassurance.

Source: NICE CG89 · RCPCH Child Protection Evidence

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