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Educational Objectives. After attending this activity, the participant will be able to:1. Describe the background, significance,

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non accidental head trauma and implementing an evidenced based prevention program

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

Rebecca Sullivan, RN

Stacey Henley, RN

Cook Children’s Medical Center


Photo courtesy of National Center on Shaken Baby Syndrome

educational objectives
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

abusive head trauma aht definition
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
aht significance
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)
aht significance5
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
aht significance6
AHT Significance

CCMC, Trauma Services, 2012

aht significance7
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)
aht significance8
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.)
aht background
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
aht background10
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
clinical diagnosis
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
aht diagnosis
AHT Diagnosis



Severe Symptoms


Respiratory distress

Altered LOC/Coma



  • Irritability
  • Poor Feeding
  • Vomiting
  • Lethargy
aht diagnosis13
AHT Diagnosis

Intracranial bleeding

Bridging veins torn

during shaking

Subdural hematoma &

subarachnoid hemorrhage

*Different than other forms of injury

aht diagnosis14
AHT Diagnosis

Axonal injuries

Shearing forces applied during shaking

Neuronal pathways are damaged

Neurotoxic transmitters are released

aht diagnosis15
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

aht diagnosis16
AHT Diagnosis

Impact injuries


Skull fractures

Often no external sign of injury

aht diagnosis17
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
aht diagnosis18
AHT Diagnosis

Impact injuries- May or may not be present


Skull Fractures

associated injuries
Associated Injuries
  • Rib Fractures
    • Most common type of

abusive fracture

    • Posterior rib fractures

are highly likely to be


    • Accidental causes are

rare, especially with

different stages of healing

associated injuries20
Associated Injuries

Classic Metaphyseal Lesions

flailing and jerking of

limbs during severe


causes shear fractures

through the metaphysis

aht prevention
AHT Prevention
  • Crying AHT

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

3 lines of evidence
3 Lines of Evidence

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

  • Photo courtesy of National Center on Shaken Baby Syndrome
3 lines of evidence23
3 Lines of Evidence

2. Shaking an infant is dangerous

Photo courtesy of National Center on Shaken Baby Syndrome

3 lines of evidence24
3 Lines of Evidence

3.Crying is stimulus for shaking a baby

Photo courtesy of National Center on Shaken Baby Syndrome

aht prevention25
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

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?

aht prevention27
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.
aht prevention28
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.
aht prevention29
AHT Prevention

Courtesy of National Center on Shaken Baby Syndrome

aht prevention three dose strategy
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
aht prevention31
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

take home messages
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?

  • 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



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