"We are living through the greatest time in history in terms of material prosperity, but it will be a commentary on our times and our individual and collective lives if we do nothing about these horrors known as child abuse. Here, in the greatest county in the world, I ask you- How can we honestly proclaim ourselves the stewards of our time if we allow this to go on?" - News Commentator Tom Brokaw.
In the United States, an estimated 4 children die each day as a result of abuse and neglect.1
Abusive head trauma (AHT) is the most common cause of morbidity and mortality in physically abused infants, with a peak incidence at 6 months of age.2-3
AHT encompasses inflicted central nervous system (CNS) injuries, including mechanisms of both shaking and impact, commonly referred to as Shaken Baby Syndrome (SBS). The classic findings include: subdural hemorrhages, retinal hemorrhages, and fractures of long bones or ribs. Victims have presenting signs and symptoms along a continuum ranging from decreased responsiveness, irritability, and lethargy to convulsions, unresponsiveness and death. Survivors have serious neurological consequences.4,5,6
John Caffey first described AHT as long bone fractures and subdural hematomas.7 This concept was further developed with descriptions of shaking mechanisms by Guthkelch and Caffey.8,9 Since that time there has been continued debate over whether shaking alone or shaking with impact is required to generate the forces causing the lesions seen in AHT. Published reports support both therories.10-15
Because the outcomes for victims remain poor,16,17 the quest is to identify preventive strategies. Ray Helfer and C. Henry Kempe stated, "For many, the most exciting and encouraging aspect of this total problem lies in the area of prevention."18
Prevention efforts are defined within three categories, primary, secondary and tertiary. Primary prevention refers to approaches applied to the general population, without targeting a particular high-risk group. Secondary prevention includes those programs directed toward people considered high risk for a particular condition. Tertiary prevention efforts are implemented after a condition has been identified, and is synonymous with treatment. The goal of a tertiary program is to prevent recurrence or other negative consequences. These definitions are discrete; most actual prevention plans traverse these definitions. Support for primary and secondary prevention has been stronger due to the limited success of strategies implemented once maltreatment has occurred.19
Dr. John Caffey recommended primary prevention through a massive public educational program on the dangers of shaking. Three obstacles impeded the momentum to implement prevention programs for AHT. First, experts disagreed initially on the importance of educating the public about the dangers of shaking: many professionals believed that the dangers of shaking were common knowledge. Studies completed between 1982 and 1990 refuted this theory. These studies demonstrated that a significant percentage (25-50%) of adolescents and adults did not know that shaking was dangerous. These findings strongly supporting a general awareness prevention strategy.20-23 Second, shaking was often precipitated by inconsolable crying combined with caretakers' impulsivity; in short, it was not a premeditated plan. Thirdly, most other prevention strategies were aimed at populations with certain risk factors. Although there are clearly certain risk factors for AHT, including poverty and social stressors, 24,25 race and socioeconomic class do not skew the incidence of AHT. Despite these initial obstacles, prevention strategies have prevailed as the current focus for AHT. This prevention focus has recently been supported by the American Academy of Pediatrics (AAP), with recommendations to devote resources to the prevention of AHT.26
Several prevention programs have been shown to prevent the occurrence of devastating and often fatal cases of AHT. Although not specifically designed as a prevention strategy, the establishment of Child Fatality Review Teams has benefited prevention efforts. These teams have improved multidisciplinary communication, death scene investigations, fatality classification and creation of preventative recommendations.27,28
A cornerstone of many prevention programs is the education of medical professionals to recognize the signs and symptoms of inflicted head injury, to avoid misdiagnosis and further injuries. Diagnosing child victims of AHT can be difficult due to the variation in presenting symptoms. In 1999, Jenny published a review in which 31% (54/173) of child victims were evaluated by physicians who did not recognize the diagnosis of AHT. Fifteen children (27.8%) were re-injured after the missed diagnosis, and four of those children died. These cases represent missed AHT diagnosis and missed opportunities for tertiary prevention interventions.29
Many documented primary prevention strategies include education for parents of newborns. Showers conducted an educational campaign in 1989, providing educational information to parents. The parents concluded that the campaign was worthwhile, 30 but due to lack of funding, further data were not collected to evaluate efficacy.
Likewise, in New York, Dias, a pediatric neurosurgeon, initiated an in-hospital program to raise awareness of SBS to parents of newborns. His program included distribution of the AAP "Preventing Shaken Baby Syndrome" leaflet and viewing the videotape "portrait of promise". This program, although consistent with a primary prevention model, incorporated secondary prevention techniques by targeting fathers since they were among identified high-risk groups.31 Just after giving birth, parents are most receptive to information.
The New York program received national attention when The New York Times published program information and reported the associated 75% decrease in the incidence of SBS.32 New York State law now includes a provision that SBS information must be added to an already existing general information brochure received by all new parents.33
Primary prevention has also included public advertisements. The phrase "Never, never, never shake a baby" is on posters, magnets and door hangers. (The magnet was intended to remind frustrated caretakers to prevent shaking..} Additionally, SBS candlelight vigils and the display of SBS memorial quilts have heightened community awareness.
Other strategies have been implemented with success. In 2001, Milwaukee aired a public service announcement simultaneously on 18 Milwaukee area radio stations. Simultaneous broadcast assured that listeners would not change the radio channel and miss this message. The 60-second PSA featured a baby crying inconsolably for 50 seconds followed with a voiceover that said, "No matter how much she cries. No matter how tired you are. No matter how frustrated you get. Never, ever shake a baby". 34
Innovative prevention programs have sought to include not only information, but strategies to help parents cope with the frustration and stress of caring for an infant. In Central Massachusetts a comprehensive countywide effort to reduce infant death and disability due to SBS was initiated in 2001. This program has included elements of primary, secondary and tertiary prevention strategies. Education programs include an in-hospital intervention for parents modeled after the New York program, with additional programs designed for health care professionals, adolescents, and provisions to incorporate education programs into the training and licensing programs of children an family service agencies. The program seeks to help parents and caretakers cope with crying infants. It includes an 800 number to call for help and support, available twenty-four hours a day. There are also plans to establish support groups for SBS victims and their families. Although researchers are tracking evaluation data, no results have been reported to date.
Continued research is needed on all aspects of AHT to improve diagnosis and outcomes. In addition, research is needed to evaluate the effectiveness of prevention strategies, because prevention remains crucial to the efforts to eradicate AHT.
REFERENCES
1. US Department of Health and Human Services, Children's Bureau: Child Maltreatment 1996: Reports from the States to the National Child Abuse and Neglect Data System. U.S. Government Printing Office, Washington, D.C., 1998.
2. Levitt CJ, Smith WL, Alexander RC. Abusive head trauma. In Reece RM, ed. Child Abuse: Medical Diagnosis and Management. Philadelphia, PA: Lea & Febiger. 1994: 1-22.
3. Billmire ME, Meyers PA. Pediatrics 1985; 75:340-2.
4. Hadley MD, Sonntag VKH, Rekate HL, Murphy A. Neurosurg 1989; 24:536-40.
5. Sinal SH, Ball MR.. South Med J 1987; 80:1505-12.
6. Haviland J, Russell R. Arch Dis Child 1997; 77:505-7.
7. Caffey J. Am J Rentgenol 1946; 56:163-73.
8. Guthkelch AN. Br Med J 1971; 2:430.
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10. Duhaime AC, Gennarelli TA, Thibault LE, et al.. J Neurosurg 1987; 66: 409-15.
11. Alexander R, Sato Y, Smith W, Bennett T. Amer J Diseases Children 1990; 144:724-6.
12. Ommaya AK, Faas F, Yarnell P. JAMA 1968 204: 285-9.
13. Gennarelli TA, Thibault LE, Adams JH, et al. Ann Neurol 1982; 12: 564-74.
14. Alexander R, Sato Y, Smith W, Bennett T. Am J Dis Child 1990; 144: 724-6.
15. Bruce DA, Zimmerman RA. Shaken impact Syndrome. Pediatric annals 1989; 18: 482-94.
16. Frank Y, Zimmerman R, Leeds N. Dev Med Child Neurol 1985; 27:312-6.
17. Duhaime AC, Christian C, Moss E, Seidl T. Pediatric neurosurg 1996; 24:292-8.
18. Helfer R, Kempe CH. A History of Child Abuse and Infanticide. The Battered Child. University of Chicago Press 1968.
19. Dubowitz H. Pediatricians role in prevention child maltreatment. In Reece RM, ed. The pediatric clinics of North America 1990; 37: 989-1002.
20. Showers J. Child: Care, Health and Develop 1989; 15: 401-15.
21. Showers J. Child Abuse and Neglect 1991; 15:313-6.
22. Showers J. Johnson C. J School Health 1984; 54: 122-5.
23. Showers J. Johnson C. Health Educat 1985; 16: 37-41.
24. Newburger EH, Reed RB, Daniel JH, et al. Pediatrics 1977; 60: 178-85.
25. Drugman R, Lenherr M, Betz L, Fryer G. Child Abuse & Neglect 1986; 10:415-8.
26. American Academy of Pediatrics Policy Statement. Shaken baby syndrome: rotational cranial injuries-technical report (T0039). 2001; 108(1): 206-10.
27. Durfee M, Durfee DT, West MP. Child Abuse & Neglect 2002; 26: 619-36.
28. Bass M, Kravath RE, Glass L. NEJM 1986; 315: 100-5.
29. Jenny C, Hymel KP, Ritzen A, et al. JAMA 1999; 28: 621-6.
30. Showers J. Child Abuse & Neglect. 1992; 16:11-8.
31. Starling SP, Holden JR, Jenny C. Pediatrics. 1995; 95: 259-62.
32. Foderaro L. A simple video finds success against shaken baby abuse. The New York Times. May 29, 2001.
33. New York Passes New SBS Law The National Center on Shaken Baby Syndrome, SBS Quarterly. Winter 2001.
34. Wisconsin: Unique Prevention Programs in Action The National Center on Shaken Baby Syndrome, SBS Quarterly. Spring 2002.
Christine C. Barron, MD
Christine C. Barron, MD, is Assistant Professor of Pediatrics at the University of Massachusetts Medical Center in Worcester.
CORRESPONDENCE:
Christine C. Barron, MD
University of Massachusetts Memorial Medical Center
Department of Pediatrics, S^-840
University Campus
55 Lake Avenue North
Worcester, MA 01655
Phone: (508) 856-6629
Fax: (508) 334-7399
e-mail: barronc@ummhc.org
Copyright Rhode Island Medical Society Dec 2003
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