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Non-Accidental Head Trauma and Implementing an Evidenced Based Prevention Program. Rebecca Sullivan, RN Stacey Henley, RN Cook Children’s Medical Center 682-885-3953. Photo courtesy of National Center on Shaken Baby Syndrome. Educational Objectives.

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Non-Accidental Head Trauma and Implementing an Evidenced Based Prevention Program

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Non accidental head trauma and implementing an evidenced based prevention program l.jpg

Non-Accidental Head Trauma and Implementing an Evidenced Based Prevention Program

Rebecca Sullivan, RN

Stacey Henley, RN

Cook Children’s Medical Center

682-885-3953

Photo courtesy of National Center on Shaken Baby Syndrome


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Educational Objectives

After attending this activity, the participant will be able to:

1. Describe the background, significance, & diagnosis of abusive head trauma/shaken baby syndrome (AHT/SBS)

2. Discuss the Period of PURPLE Crying

3. List the lines of evidence behind the Period of PURPLE Crying

4. Describe the Period of PURPLE Crying 3 dose implementation strategy


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Abusive Head Trauma (AHT) Definition

  • Terms used interchangeably

    • AHT, shaken baby syndrome (SBS), non-accidental head injury, inflicted traumatic brain injury, shaken impact syndrome, whiplash shaken baby syndrome, inflicted childhood neurotrauma

  • Set of symptoms caused by violent shaking from a frustrated caregiver, usually in response to infant crying

    • May have impact injuries

    • May have other associated injuries

    • May not have any outward signs of abuse


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AHT Significance

  • Infants less than 1 year most commonly abused age group- 21.7 per 1,000 infants (CDC, 2010a)

  • AHT leading cause of death in child abuse cases; babies less than 4 mo at highest risk for AHT (CDC, 2010b)

  • Most common cause of death from TBI in children less than 2 yr (Kochanek, 2007); 43% of infant deaths r/t head trauma from abuse (Bruce & Zimmerman, 1989);most serious head injuries in infants are abusive (US Dept Health & Human Services, 1999)


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AHT Significance

  • Recession

    • Berger, et al. (2011)

      • Hospitals in Pennsylvania, Ohio, Kentucky, & Washington

      • Jan, 2004 to June, 2009

      • Accidental head trauma rate steady; AHT rate increase from 8.9 per 100,000 to 14.7 per 100,000

    • Huang, et al., (2011)

      • Rainbow Babies and Children’s Hospital

      • Dec, 2007 to June, 2010

      • 101.4% increase in AHT and increased severity of AHT


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AHT Significance

CCMC, Trauma Services, 2012


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AHT Significance

  • Actual incidence unknown

    • 150 children shaken for every known case (Theodore, et al., 2005);6% of parents admit to smothering, slapping, or shaking their baby in response to infant crying (Reijneveld, et al., 2004)

    • May not seek care if no apparent injuries

    • With subtle signs/symptoms, correct diagnosis of AHT only 1:5(Jenny, et al., 1999)


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AHT Significance

  • Mortality rate 25-30%

    (Nat’l Center on SBS)

  • Morbidity rate 50-65%

    (King, et al., 2003; Sinal & Ball, 1987; Ludwid, 1984)

    • Long term effects

      • Brain damage, blindness, severe learning and behavioral problems, cerebral palsy, seizures, deafness, permanent vegetative state

  • Cost for AHT survivor can be as high as $3 million for first 5 years (Center for Health Promotion, n. d.)


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AHT Background

  • Victims

    • Majority < 6 mo

      • Highest risk

        • colicky babies,

          premature babies,

          special needs infants

      • More vulnerable

        • Heavy head

        • Weak neck muscles

        • Larger intracranial space

        • Brain not myelinated

        • Perpetrator much bigger and stronger than infant

    • Male > female


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AHT Background

  • Perpetrators

    • 67-70% male

    • Caregivers experiencing stress of any kind at higher risk for abuse

      • Unemployment, domestic violence, drug abuse, financial stress

    • Caregiver frustrated- expectations exceed child’s developmental level

      • Trigger for shaking a baby almost always CRYING (Barr, et al., 2006; Biron & Shelton, 2005; Brewster, et al., 1998; CDC 2010b; Dias, et al., 2005; Dykes, 1986; Lee et al., 2007; Ludwig, 1984; Reijneveld, et al., 2004; Talvik, Alexander, & Talvik, 2008)

      • Other triggers

        • Toilet training, feeding problems, interrupting

    • No traditional profile


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Clinical Diagnosis

  • Cerebral edema

  • History of minor trauma or no trauma

  • Subdural hematomas & Subarachnoid hemorrhages

  • Cerebral Edema

  • Retinal hemorrhages

  • Impact injury & Associated injuries

  • as

  • Subarachnoid hemorrhages


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AHT Diagnosis

Mild

Symptoms

Severe Symptoms

Limp/posturing

Respiratory distress

Altered LOC/Coma

Death

Seizures

  • Irritability

  • Poor Feeding

  • Vomiting

  • Lethargy


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AHT Diagnosis

Intracranial bleeding

Bridging veins torn

during shaking

Subdural hematoma &

subarachnoid hemorrhage

*Different than other forms of injury


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AHT Diagnosis

Axonal injuries

Shearing forces applied during shaking

Neuronal pathways are damaged

Neurotoxic transmitters are released


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AHT Diagnosis

Cerebral Edema

Direct trauma to the brain during

shaking, intracranial bleeding,

diffuse axonal injuries

Swelling and increased intracranial pressure causing

more brain injury

Hypoxia heightens brain injury


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AHT Diagnosis

Impact injuries

Bruising

Skull fractures

Often no external sign of injury


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AHT Diagnosis

  • Retinal hemorrhages

    • Important marker for trauma

    • Bleeding in the retina and along the optic nerve sheath

    • Multilayer hemorrhages to the periphery

      • Can also occur in childbirth*, severe trauma


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AHT Diagnosis

Impact injuries- May or may not be present

Bruising

Skull Fractures


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Associated Injuries

  • Rib Fractures

    • Most common type of

      abusive fracture

    • Posterior rib fractures

      are highly likely to be

      abuse

    • Accidental causes are

      rare, especially with

      different stages of healing


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Associated Injuries

Classic Metaphyseal Lesions

flailing and jerking of

limbs during severe

shaking

causes shear fractures

through the metaphysis


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AHT Prevention

  • CryingAHT

    Opportunity for intervention through a cultural change?

    “The hypothesis of the PURPLE program is that in order to achieve a long term sustained reduction in shaken baby syndrome, we need to create a cultural change in the way society understands both the meaning of increased crying in early infancy, and the danger of shaking as a response to the frustration with that crying.”

    National Center on Shaken Baby Syndrome

    Photo courtesy of National Center on Shaken Baby Syndrome


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3 Lines of Evidence

1.Crying , even inconsolable crying, is part of normal infant development

  • Photo courtesy of National Center on Shaken Baby Syndrome


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3 Lines of Evidence

2. Shaking an infant is dangerous

Photo courtesy of National Center on Shaken Baby Syndrome


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3 Lines of Evidence

3.Crying is stimulus for shaking a baby

Photo courtesy of National Center on Shaken Baby Syndrome


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AHT Prevention

  • What is the Period of PURPLE Crying?

    • Evidence based program (Barr, Barr, et al., 2009; Barr, Rivera, et al., 2009)

      • Improves caregiver knowledge

        • Infant crying

        • Dangers of shaking a baby

        • Ok to walk away during inconsolable crying

      • Increased caregiver sharing of knowledge

    • Provides information of interest to all parents about infant crying, regardless if they would ever shake their baby.

Photo courtesy of National Center on Shaken Baby Syndrome


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ALL parents of newborns receive the Period of Purple Crying DVD and booklet

  • Individual or classroom introduction by nurse

  • Parents watch a 10 minute DVD

  • Parent and nurse discuss information

  • Parents take home DVD and a booklet

  • Parents now have coping and soothing component on DVD

    The Period of PURPLE Crying: Keeping Babies Safe in North Carolina - YouTube

AHT Prevention

How is Period of PURPLE Crying given to parents?


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AHT Prevention

The Period of PURPLE Crying program was designed and approved by pediatricians, public health nurses, child development experts, and parents. The program is:

  • Educational and attractive to parents of newborns.

  • Relevant for all parents while emphasizing the dangers of shaking a baby.

  • Clear, memorable, and meaningful with a positive message.

  • Designed to be interesting and relevant for both males and females.

  • Presented at a grade 3 language level.


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AHT Prevention

  • Representative of multicultural and ethnic backgrounds.

  • Acceptable to public health nurses; no bottles or blankets.

  • Available in ten languages and includes closed captioning.

  • Economical with large quantity orders available as low as $2 per package, which includes both the full color 11-page booklet and 10-minute DVD.

  • The PURPLE program model requires that each family receives the materials in the hospital or at the time of their child’s birth so they can review the program when needed and share it with other caregivers.


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AHT Prevention

Courtesy of National Center on Shaken Baby Syndrome


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AHT Prevention: Three Dose Strategy

  • Dose 1*

    • Hospital setting

  • Dose 2*

    • Pre and postnatal primary health setting

  • Dose 3*

    • Public education and media campaign

  • Reinforcements and enhancements*

    • ED, childcare providers, foster care workers, advice and hot line personnel


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AHT Prevention

  • Prevention programs can be effective

    • Prevention programs can reduce incidence by 47% (Dias, et al., 2005)

    • Ongoing research regarding Period of Purple Crying effectiveness

      • Decreases in AHT in ages up to 3 years

      • 90% decrease in all forms of PA in 0-6 month range

    • SBS prevention advocated by AAP

      • Specifically programs that address parent coping with stressors, including infant crying

        Photo courtesy of National Center on Shaken Baby Syndrome


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Take Home Messages

  • To recognize abuse, child abuse must be considered as a possibility

    • When evaluating an infant/toddler with non-specific symptoms, be alert for signs of trauma; is the history consistent?

      http://pediatrics.aappublications.org/content/125/1/67.full.html

  • Child abuse is preventable!

    • Implement prevention programs that teach parents about normal child development

      • For more information on how to implement Period of PURPLE Crying, please contact the National Center on Shaken Baby Syndrome at www.dontshake.org

        Or

      • Rebecca Sullivan at [email protected]


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References

American Academy of Pediatrics. (2001). Shaken baby syndrome: Rotational cranial injuries- technical report. Pediatrics, 108, 206-210. doi:10.1542/peds.108.1.206

Bard, K. (2000). Crying in infant primates: insights into the development of crying in chimpanzees. Crying as a sign, a symptom and a signal: Clinical, Emotional, and Developmental Aspects of Infant and Toddler Crying by Barr, R. G., Hopkins, B., Green, J. London, United Kingdom: MacKeith Press.

Barlow, K. M. & Minns, R. A. (2000). Annual incidence of shaken impact syndrome in young children. Lancet 356, 1571-1572. doi:10.1016/S0140-6736(00)03130-5

Barr, R. G., Konner, M., Bakeman, R., Adamson, L. (1991). Crying in !Kung San infants; a test of the cultural specificity hypothesis. Developmental Medicine and Child Neurology, 33, 601-610. doi:10.1111/j.1469-8749.1991.tb14930.x

Barr, R. G., Trent, R. B., & Cross, J. (2006). Age-related incidence curve of hospitalized shaken baby syndrome cases: Convergent evidence for crying as a trigger to shaking. Child Abuse & Neglect, 30, 7-16. doi:10.1016/j.chiabu.2005.06.009

Barr, R. G., Barr, M., Fujiwara, T., Conway, J, Catherine, N, & Brant, R. (2009). Do educational materials change knowledge and behavior about crying and shaken baby syndrome? A randomized controlled trial. Canadian Medical Association Journal, 180, 727-733. doi:10.1503/cmaj.081419

Barr, R. G., Rivera, F. P., Barr, M., Cummings, P, Taylor, J., Lengua, L. J., & Meredith-Benitz, E. (2009). Effectiveness of educational materials designed to change knowledge and behaviors regarding crying and shaken-baby syndrome in mothers of newborns: A randomized, controlled trial. Pediatrics, 123, 972-980. doi:10.1542/peds.2008-0908

Berger, R. P., Fromkin, J. B., Stutz, H., Makoroff, K., Scribano, P. V., Feldman, K., Tu, L. C., & Fabio, A. (2011). Abusive head trauma during a time of increased unemployment: A multicenter analysis. Pediatrics, 128, 637-643. doi: 10.1542/peds.2010-2185

Biron, D. & Shelton, D. (2005). Perpetrator accounts in infant abusive head trauma brought about by a shaking event. Child Abuse & Neglect, 29, 1347-1358. doi:10.1016/j.chiabu.2005.05.003

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Brewster, A. L., Nelson, J. P., Hymel, K. P., Colby, D. R., Lucas, D. R., McCanne, T. R., & Milner, J. S. (1998). Victim, perpetrator, family, and incident characteristics of 32 infant maltreatment deaths in the United States Air Force. Child Abuse & Neglect, 22, 91-101. doi:10.1016/S0145-2134(97)00132-4

Bruce, D. A., & Zimmerman, R. A. (1989). Shaken impact syndrome. Pediatric Annals, 18, 482-494. Retrieved from http://www.pediatricsupersite.com/issue.aspx?pubid=PedAnn 

Canadian Paediatric Society. (2001). Joint statement of shaken baby syndrome. Paediatric Child Health, 6, 663-667. Retrieved from http://www.cmaj.ca/

Center for Health Promotion. (n.d.). Shaken baby syndrome in the United States. Retrieved from http://fha.maryland.gov/ohpetup/eip_shknbaby.cfm


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References

Centers for Disease Control and Prevention. (2010a). Child maltreatment: Facts at a glance. Retrieved from http://www.cdc.gov/violenceprevention/pdf/CM-DataSheet-a.pdf

Centers for Disease Control and Prevention. (2010b). Heads up: Prevent shaken baby syndrome. Retrieved from http://www.cdc.gov/concussion/HeadsUp/sbs.html

Cook Children’s Medical Center. (2011). Fiscal year 2011. First and second quarter [Power Point Slides]. Retrieved from Trauma Services, CCMC.

Dias, M. S., Backstrom, J., Falk, M., & Li, V. (1998). Serial radiography in the infant shaken impact syndrome. Pediatric Neurosurgery, 29, 77-85. doi:10.1159/000028694

Dias, M. S., Smith, K., deGuehery, K., Mazur, P., Li, V., & Shaffer, M. L. (2005). Preventing abusive head trauma among infants and young children: A hospital-based, parent education program. Pediatrics, 115, e470-e477. doi:10.1542/peds.2004-1896

Dykes, L. J. (1986). The whiplash shaken infant syndrome: What has been learned? Child Abuse & Neglect, 10, 211-221. doi:10.1016/0145-2134(86)90082-7

Hadley, M. N., Sonntag, V. K., Rekate, H. L., & Murphy, A. (1989). The infant whiplash-shake injury syndrome: A clinical and pathological study. Neurosurgery, 24, 536-540. doi:10.1227/00006123-198904000-00008

Huang. M. I., O’Riorden, M. A., Fitzenrider, E., McDavid, L., Cohen, A. R., & Robinson, S. (2011). Increased incidence of nonaccidental head trauma in infants associated with the economic recession Clinical article. Journal of Neurosurgery: Pediatrics, 8, 2, 171-176. doi: 10.3717/2011.5PEDS1139

Hoffer, M. A., Masmela, J. R., Brunelli, S. A. (1999). Behavioral mechanisms for active maternal potentiation of isolation calling in rat pups. Behavioral Neuroscience, 113(1), 51-61. doi:10.1037//0735-7044.113.1.51

Hunziker, U. A., Barr, R. G. (1986). Increased carrying reduces infant crying: a randomized controlled trial. Pediatrics, 77, 641-648. Retrieved from http://pediatrics.aappublications.org/content/77/5/641.full.pdf+html

Jenny, C., Hymel, K. P., Ritzen, A., Reinert, S. E., & Hay, T. (1999). Analysis of missed cases of abusive head trauma. Journal of the American Medical Association, 282, 621-629. doi: 10.1001/jama.281.7.621

King, W. J., MacKay, M., Sirnick, A., with the Canadian Shaken Baby Study Group. (2003). Shaken baby syndrome in Canada: Clinical characteristics and outcomes of hospital cases. Canadian Medical Association Journal, 168, 155-159. Retrieved from http://www.cmaj.ca/cgi/content/full/168/2/155 

Kochanek, P. M. (2007). Inflicted childhood neurotrauma: New insight into the detection, pathobiology, prevention, and treatment of our youngest patients with traumatic brain injury. Journal of Neurotrauma, 24(1), 1-4. doi:10.1089/neu.2006.0209

Lee, C., Barr, R. G., Catherine, N., & Wicks, A. (2007). Age-related incidences of publicly reported shaken baby syndrome cases: Is crying a trigger for shaking. Journal of Developmental & Behavioral Pediatrics, 28, 288-293. doi:10.1097/DBP.0b013e3180327b55


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Ludwig, S. (1984). Shaken baby syndrome: A review of 20 cases. Annals of Emergency Medicine, 13(2), 104-107. doi:10.1016/S0196-0644(84)80571-5

National Center on Shaken Baby Syndrome. (n. d.). All about shaken baby syndrome/abusive head trauma. Retrieved from http://www.dontshake.org/sbs.php?topNavID=3&subNavID=317

Pettijohn, T. F. (1979). Attachment and separtion distress in the infant guinea pig. Developmental Psychobiology, 12(1), 73-81. doi:10.1002/dev.420120109

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