Effectiveness of a Statewide Abusive Head Trauma Prevention Program in North Carolina

The Pediatrician's Role in Preventing Child Maltreatment: Clinical Report

Pediatricians have always seen the value of preventing health harms; this should be no less true for child maltreatment than for disease or unintentional injuries. Research continues to demonstrate that maltreatment can be prevented, underscoring the vital roles of both the family and society in healthy childhood development and the importance of strong, stable, nurturing relationships in preventing maltreatment and building the child's resilience to adversity. This clinical report elaborates the pediatrician's multitiered role in supporting relational health from infancy through adolescence, from universal interventions assessing for maltreatment risks and protective factors to targeted interventions addressing identified needs and building on strengths. When maltreatment has already occurred, interventions can prevent further victimization and mitigate long-term sequelae. Advice is provided on engaging community resources, including those that provide food, shelter, or financial support for families in need.

Shaking Up Our Approach: The Need for Characterization and Optimization of Pre-clinical Models of Infant Abusive Head Trauma

Traumatic brain injuries (TBIs) are a large societal and individual burden. In the first year of life, the vast majority of these injuries are the result of inflicted abusive events by a trusted caregiver. Abusive head trauma (AHT) in infants, formerly known as shaken baby syndrome, is the leading cause of inflicted mortality and morbidity in this population. In this review we address clinical diagnosis, symptoms, prognosis, and neuropathology of AHT, emphasizing the burden of repetitive AHT. Next, we consider existing animal models of AHT, and we evaluate key features of an ideal model, highlighting important developmental milestones in children most vulnerable to AHT. We draw on insights from other injury models, such as repetitive, mild TBIs (RmTBIs), post-traumatic epilepsy (PTE), hypoxic-ischemic injuries, and maternal neglect, to speculate on key knowledge gaps and underline important new opportunities in pre-clinical AHT research. Finally, potential treatment options to facilitate healthy development in children following an AHT are considered. Together, this review aims to drive the field toward optimized, well-characterized animal models of AHT, which will allow for greater insight into the underlying neuropathological and neurobehavioral consequences of AHT.

The Effectiveness of Parenting Programs in Preventing Abusive Head Trauma: A Systematic Review and Meta-Analysis

Parenting programs are the most common intervention for preventing the lethal form of child maltreatment, abusive head trauma (AHT). However, certain results of the effects of these programs have not yet been compared across studies. A systematic review with meta-analysis is warranted to quantitively synthesize the available evidence to identify effective elements and strategies of the programs for preventing AHT. This review aims to estimate AHT preventive parenting programs' pooled effect on the reduction of AHT incidence, the improvement of parental knowledge, and the increased use of safe strategies in response to infants' inconsolable crying. Studies published in English and Mandarin were searched and retained if they were randomized control trials (RCTs) or with a quasi-experimental design, included an AHT preventive parenting program, and provided data that quantified targeted outcomes. Eighteen studies were included in this review. AHT preventive parenting programs had a pooled effect on improving parents' knowledge and increasing the use of safe coping strategies in response to inconsolable crying but not on the incidence of AHT and parents' emotional self-regulation. Subgroup analyses showed that the intervention effects were mostly present across study designs or measurements and emerged in the reduction of AHT incidence compared with historical controls. The findings suggest that AHT preventive parenting programs enhance parenting knowledge and skills to provide safe care for infants. Further efforts to evaluate AHT parenting programs on the reduction of AHT incidence are necessary for decision-making on allocating and disseminating interventions.

The Measurement of Intimate Partner Violence Using International Classification of Diseases Diagnostic Codes: A Systematic Review

Intimate partner violence (IPV) is challenging to measure yet systematic surveillance of IPV is critical to informing public health prevention and response efforts. Administrative medical data provide opportunities for such surveillance, and often use the International Classification of Diseases (ICD). The primary purpose of this systematic review was to document which ICD codes have been used in empirical literature to identify IPV, understand the justification used to select specific codes to develop IPV case definitions, and identify the data sources and types of research questions addressed by the existing literature. We searched 11 databases and of the initial 2182 results, 21 empirical studies from 2000 to 2020 met the study inclusion criteria including using ICD codes to measure IPV. The majority of these studies (90.5%) used either national samples of data or population-based administrative data from emergency departments (52.4%) or inpatient hospitalizations (38.1%). We found wide variation of ICD diagnostic codes to measure IPV and categorized the sets of codes used based on the number of codes. The most commonly used ICD-9 codes were E967.3, 995.81, 995.80, 995.85 and the most common ICD-10 codes were T74.1 and Z63.0. Few studies validated the ICD codes used to measure IPV. Most included studies (81.0%) answered epidemiological research questions. The current study provides suggestions for future research, including justifying the selection of ICD codes and providing a range of estimates based on narrow and broad sets of codes. Implications for policy and practice, including enhanced training for healthcare professionals in documenting IPV, are discussed.

ICD-10 codes for surveillance of non-fatal abusive head trauma in Aotearoa New Zealand: a retrospective cohort study

OBJECTIVES

To assess the validity of an International Classification of Diseases (ICD) code based definition of non-fatal head trauma caused by child abuse (abusive head trauma) for population surveillance in New Zealand.

DESIGN

A retrospective cohort study of hospital inpatient records.

SETTING

A tertiary children's hospital in Auckland, New Zealand.

PARTICIPANTS

1731 children less than 5 years of age who were discharged after a non-fatal head trauma event over a 10-year period from 1 January 2010 to 31 December 2019.

OUTCOME MEASURES

The outcome of assessment by the hospital's multidisciplinary child protection team (CPT) was compared with the outcome of ICD, Tenth Revision (ICD-10) discharge coding for non-fatal abusive head trauma (AHT). The ICD-10 code definition of AHT was derived from an ICD, Ninth Revision, Clinical Modification definition developed by the Centers for Disease Control, Atlanta, Georgia, which requires both a clinical diagnosis code and a cause-of-injury code.

RESULTS

There were 1755 head trauma events with 117 determined as AHT by the CPT. The ICD-10 code definition had a sensitivity of 66.7% (95% CI 57.4 to 75.1) and specificity of 99.8% (95% CI 99.5 to 100). There were only three false positives but 39 false negatives, with 18 of the false negatives coded with X59 (exposure to unspecified factor).

CONCLUSIONS

The ICD-10 code broad definition of AHT is a reasonable epidemiological tool for passive surveillance of AHT in New Zealand but it underestimates the incidence. Its performance could be improved by clear documentation of child protection conclusions in clinical notes, clarifying coding practice and removing the exclusion criteria from the definition.

Abordaje de la violencia sexual infantil: un llamado a la acción para los profesionales de América Latina

El objetivo de esta comunicación es delinear los elementos clave de la capacitación en violencia sexual infantil (VSI) para profesionales de la salud en diferentes disciplinas medicina, psicología, odontología, enfermería, trabajo social, nutrición, fisioterapia, terapia ocupacional, química, bioquímica y obstetricia incluidas las parteras, entre otras y el desarrollo de protocolos de atención con base en las prácticas basadas en evidencia, así como proporcionar recursos que permitan optimizar ambos procesos. La capacitación sobre la violencia sexual hacia niñas, niños y adolescentes (NNA) es esencial para enfrentar este gran desafío en América Latina y permitir al personal de salud cumplir su función en defensa de la seguridad y el bienestar de NNA. El desarrollo de protocolos ayuda al personal de salud a definir las funciones y responsabilidades de los miembros del personal, resumir los posibles indicadores de VSI y describir las estrategias para identificar y abordar mejor las necesidades de salud y seguridad del paciente y su familia, por lo que deben incluir el enfoque informado sobre el trauma. El trabajo futuro debe centrarse en desarrollar y evaluar estrategias nuevas para aumentar la capacidad del sector de la salud para atender a los NNA que experimentan VSI y optimizar las formas de capacitar al personal. Apunta, también, a mejorar la generación de investigación y evidencia sobre la epidemiología y atención de la VSI en América Latina, incluidos los niños y adolescentes varones, grupos minoritarios y de atención prioritaria (p. ej. NNA migrantes, con discapacidad, en situación de calle, privados de la libertad, pertenecientes a comunidades indígenas y a la comunidad LGBTIQ+).

Shaken Baby Syndrome Education for Mothers Awaiting Appointments in Rural OB/GYN Office

A partnership between a nursing program and a rural obstetric office provided education to pregnant and postpartum women about coping with infant crying and the dangers of shaking a baby. Undergraduate nursing students delivered the Period of PURPLE Crying (PURPLE) educational program to 148 mothers. Change in knowledge about infant crying and the community clinical experience was evaluated. Pre and post intervention data were collected. Descriptive statistics indicated higher scores on mothers' posttest for knowledge about normal newborn crying behaviors and coping strategies. Students further developed the role of educator and researcher. These findings suggest the intervention contributed to mothers' improved knowledge about infant crying. Results of the pilot study are encouraging because the intervention had a significant effect on mothers' knowledge about infant crying and Shaken Baby Syndrome (SBS).

Traumatic head injury due to child maltreatment: epidemiology, cost analysis, and impact of prevention

BACKGROUND

Traumatic head injury due to child maltreatment (THI-CM), also known as abusive head trauma (AHT), is a significant public health problem due to the wide array of consequences affecting multiple domains of a child's health and development. Several studies have evaluated its cost on healthcare systems, families, and societies. Many jurisdictions have implemented caregiver education programs to prevent THI-CM.

OBJECTIVES

This paper aims to provide a brief overview of the epidemiology and cost analysis of THI-CM and discuss its prevention and the intergenerational transmission of child maltreatment.

METHODS

Although not systematic, a literature search of original articles published from 2000 to 2022 in English and French was undertaken using the following databases: PubMed, EMBASE (Ovid), and PsycINFO (OVID). The search combined terms related to traumatic head injury and child maltreatment, with terms related to its cost and prevention. Studies of children aged 0-5 years old were included. The authors completed a screen of the titles and abstracts to determine relevance with respect to this article.

RESULTS

Globally, although THI-CM accounts for a small proportion of cases of child maltreatment, there is a high incidence of death and neurological sequelae compared to other causes of head trauma.The incidence of THI-CM is likely underestimated due to the lack of standardized definitions, differences in reporting, and challenges in identifying less severe cases. Cost analysis studies reveal the significant short- and long-term costs associated with THI-CM. Caregiver education programs have been studied and implemented in many centers and have shown varying but promising results.

CONCLUSION

A multi-pronged approach to prevention efforts should be considered to support families and help to prevent THI-CM and maltreatment throughout childhood.

Educational interventions to prevent paediatric abusive head trauma in babies younger than one year old: A systematic review and meta-analyses

BACKGROUND

Paediatric abusive head trauma (AHT) occurs in young children due to violent shaking or blunt impact. Educational and behavioural programmes modifying parent/infant interactions may aid primary prevention. This systematic review aims to assess the effectiveness of such interventions to prevent AHT in infants.

METHODS

We searched Embase, MEDLINE, PsycINFO, The Cochrane library, CINAHL databases and trial registries to September 2021, for studies assessing the effectiveness of educational and behavioural interventions in preventing AHT. Eligible interventions had to include messaging about avoiding or dangers of infant shaking. Randomised controlled trials (RCTs) reporting results for primary (AHT, infant shaking) or secondary outcomes (including parental responses to infant crying, mental wellbeing), and non-randomised studies (NRSs) reporting primary outcomes were included. Evidence from combinable studies was synthesised using random-effects meta-analyses. Certainty of evidence was assessed using GRADE framework. PROSPERO registration CRD42020195644.

FINDINGS

Of 25 identified studies, 16 were included in meta-analyses. Five NRSs reported results for AHT, of which four were meta-analysed (summary odds ratio [OR] 0.95, 95 % confidence intervals [CI] 0.80-1.13). Two studies assessed self-reported shaking (one cluster-RCT, OR 0.11, 95 % CI 0.02-0.53; one cohort study, OR 0.36, 95 % CI 0.20-0.64, not pooled). Meta-analyses of secondary outcomes demonstrated marginal improvements in parental response to inconsolable crying (summary mean difference 1.58, 95 % CI 0.11-3.06, on a 100-point scale) and weak evidence that interventions increased walking away from crying infants (summary incidence rate ratio 1.52, 95 % CI 0.94-2.45). No intervention effects were found in meta-analyses of parental mental wellbeing or other responses to crying.

INTERPRETATION

Low certainty evidence suggests that educational programmes for AHT prevention are not effective in preventing AHT. There is low to moderate certainty evidence that educational interventions have no effect or only marginally improve some parental responses to infant crying.

Abusive head injuries in infants: from founders to denialism and beyond

INTRODUCTION

Abusive head injuries is a major cause of severe morbidity and the main cause of mortality by head trauma in infants.

MATERIAL AND METHODS

Based on published data and their own clinical and medicolegal practice, the authors review briefly the historical roots and emergence of the concept of abusive head injuries (AHI), until the present scientific understanding of shaken baby syndrome (SBS) and Silverman syndrome. They then discuss the present epidemic of denialism and how this challenge to science should be seen as a stimulus to increase research and improve the accuracy of diagnosis and medical practice.

RESULTS

The denial of SBS is especially damaging because it undermines the possibilities of prevention and reparation for victims. The authors expand on AHI being part of a wider context of domestic violence and the prevention of child abuse being part of a broad and long-term endeavor to defend civilization values.

CONCLUSIONS

Prevention of AHI is a major challenge for the future. In the fields of science and prevention of child abuse, the input of pediatric neurosurgeons should not be underestimated.

Public policy and parent-child aggression: Considerations for reducing and preventing physical punishment and abuse

Parent-child physical aggression, including both physical punishment and abuse, remains a prevalent problem in the United States. In this paper, we briefly review the prevalence and harms of parent-child aggression and discuss changes in social norms and policies over the past several decades. Then, we discuss broad social policies influencing risk for parent-child physical aggression, policies relevant to reducing and preventing physical abuse, and policies relevant to reducing and preventing physical punishment. We close by considering future directions to strengthen research and evaluation and accelerate progress toward ending parent-child physical aggression.

Effects of Educational Interventions on Maternal Self-efficacy and Childhood Diarrhea: A Randomized Clinical Trial

OBJECTIVE

Diarrhea still causes high morbidity and mortality in children under five, requiring constant interventions. Thus, the study aims to evaluate the effects of educational technologies on maternal self-efficacy to prevent childhood diarrhea.

METHODS

Randomized clinical trial carried out in Fortaleza, Ceará, Brazil, with four randomized groups of mothers of children under 5 years of age, as follows: control group (n = 61), group A (booklet, n = 60), group B (video, n = 60), and group AB (booklet and video, n = 60). From June to October 2015, data collection was carried out in three moments (the first in person and the others by telephone monitoring).

RESULTS

All groups improved their self-efficacy after the intervention, with higher scores in the group AB (booklet and video). A statistically significant association was found between the occurrence of diarrhea and maternal self-efficacy in groups A (booklet) (p = 0.023) and AB (booklet and video) (p = 0.042) at the second moment of data collection. From the second moment to the third moment, the risk of diarrhea decreased in group A, from 12.8 to 1.3, and in group AB, from 8.5 to 1.1.

CONCLUSION

The technologies used, isolated or combined, were effective in improving maternal self-efficacy and decreasing the occurrence of childhood diarrhea; therefore, they can be used by nurses as health education tools.

The role of household composition of children diagnosed with abusive head trauma

BACKGROUND

To prevent abusive head trauma (AHT), many studies focus on understanding the risk factors. Few studies assess the role of household composition.

OBJECTIVE

To describe the household composition of children diagnosed with AHT and assess the relationships between patient and household characteristics, perpetration, and fatality.

PARTICIPANTS AND SETTING

Children admitted to a large pediatric hospital with AHT between January 1, 2010 and December 31, 2019.

METHODS

The diagnosis of AHT was made at initial hospitalization by a child abuse pediatrician with a multidisciplinary team review. The electronic medical records of identified patients were reviewed to identify demographic information, the number and ages of all of their siblings and the number and relationship to patients of all adults who were reported as being present at the time of AHT and therefore considered to be possible perpetrators. Descriptive statistics were used to characterize the sample. Comparisons were made using Fisher exact tests and Mann-Whitney tests.

RESULTS

Children with AHT who were under 12 months of age and had siblings in the home, particularly siblings under age 5, had greater odds of being injured by a biological parent. Children 12 months or older and children without siblings had greater odds of being injured by a boyfriend or girlfriend of their parent or guardian.

CONCLUSIONS

In cases of AHT, the possible perpetrator differed based on the presence of young siblings living in the home, which has important implications for AHT prevention.

Incidence of hospitalization for abusive head trauma in Chiba City, Japan

BACKGROUNDS

This study aimed to examine the incidence of abusive head trauma (AHT) admissions by calculating admission rates of AHT cases among infants <12 months old in a population-based sample in Chiba city, Chiba prefecture, Japan.

METHODS

We retrospectively examined medical records of infants admitted to all pediatric secondary and tertiary hospitals in Chiba city between 2011 and 2015. We collected 13 AHT cases, as assessed by hospital-based multidisciplinary child protection teams. One experienced pediatric radiologist and two pediatricians evaluated the case histories and computed tomography images of cases to evaluate them clinically as "strongly" or "moderately" suspected AHT.

RESULTS

The overall incidence per 100 000 person-years was 34.5 cases (95% confidence interval (CI): 18.4-59.1), of which 13.3 (95% CI: 4.3-31.0), were strongly suspected to be AHT and 21.3 (95% CI: 9.2-41.9) were moderately suspected. There were no statistical differences in computed tomography findings between severe and moderately suspected AHT.

CONCLUSIONS

The incidence of hospitalization of infants with AHT was similar to that reported in population-based studies in other countries.

Maternal Perceptions of Infant Behavior as a Potential Indicator of Parents or Infants in Need of Additional Support and Intervention

The goal of the present study is to examine the relationship between early infant behaviors, which can be easily reported by parents, with parent-infant bonding and maternal mental health. It has long been established that child characteristics and behaviors have a significant impact on parent well-being and how parents respond to their infants. Examining parent perceptions of challenging infant behaviors may help health professionals identify high risk infants in need of intervention and mothers in need of additional support. Mothers of 73 infants between the ages of 3.5 weeks and 6 months filled out questionnaires. Infant stomach issues were positively correlated with bonding issues, maternal anxiety and maternal depression. Infant crying issues were also positively correlated with bonding issues, maternal anxiety and maternal depression. Potential clinical and research applications of the instrument include early identification of caregivers in need of support and screening for further clinical assessment and care.

Epidemiology of Abusive Head Trauma Among Children in Saudi Arabia

BACKGROUND AND OBJECTIVES

To examine abusive head trauma (AHT) trends using data obtained from hospital-based child protection centers (CPCs) and the distribution of age in months among young children in Saudi Arabia.

METHODS

A retrospective study was conducted that includes data obtained from 58 hospital-based CPCs in all 13 regions of Saudi Arabia registered in the National Family Safety Registry from 2010 to 2020. AHT cases (n=106) were identified for inclusion in the registry by a daily review of the emergency department logbooks.

RESULTS

Over the 11-year period, there was a sharp increase in the number of cases, specifically after 2014, from seven cases per year in 2010 to 16 cases in 2020. AHT affects predominantly children aged 0-12 months (72.6%), followed by 13-24 months (17.9%), 25-36 months (3.8%), 37-48 months (3.8%), and 49-60 months (1.9%). Victims were characterized by a predominance of crying infants (23.6%), past history of abuse (13.2%), a child's chronic disease and disability (7.6%), and prematurity (2.8%).

CONCLUSION

Different training and educational programs need to be performed to raise awareness of AHT. Enacting the pediatrician's mandatory reporting law will improve the rate of reporting cases.

Outcome of abusive head trauma in children less than 2 years: A single center study from a middle-income country

BACKGROUND

Abusive head trauma (AHT) is a severe manifestation of physical abuse in young children. This study examines the outcome of AHT in children under 2 years and features associated with mortality and disability.

METHODS

Retrospective chart review of 72 children under 2 years diagnosed to have AHT between 2011 and 2018 at a tertiary teaching hospital in Malaysia. Demographic variables, clinical features, results of neuroimaging and their associations with outcome were explored.

RESULTS

The median age at presentation was 4 months, 78% were six months or younger and 68% were male. Two-thirds became unwell in the care of an alternative caregiver. Subdural hemorrhage was present in 98%. Mortality was 10%. Forty-nine survivors returned with median interval of 16 months (IQR 5-44 months) between discharge and last follow-up. At least 35% of 65 survivors were disabled with 29% having multiple disabilities. Multiple disabilities (61.1% versus 25.8%) and cognitive impairment (61.1% versus 22.6%) were significantly higher in children 3 years or older at last follow-up (p < 0.05). Signs of brainstem dysfunction at presentation, requirement for ventilation and hypoxic-ischemic injury on neuroimaging were associated with mortality. Needing ventilation, cerebral edema and neurological or visual impairment at discharge were associated with disability.

CONCLUSIONS

Outcomes of death or disability in 42% make prevention of AHT a public health priority. Survivors require long-term multi-disciplinary follow-up for coordination of rehabilitation and educational support. Prevention should be directed at improving resources and services to support families in the care of young infants under 6 months.

Preventing abusive head trauma: can educating parents reduce the incidence?

Abusive head trauma (AHT) is the most lethal form of child abuse; preventing AHT should be a national priority, but research into this area is woefully underfunded. Prevention programs have primarily focused on universal parent education during the neonatal period, a time when parents are a captive audience of the health care establishment whose focus is on the needs of their newborn infant, and who will soon be exposed to the frustration and anger of infant crying. Research has suggested a strong causal link between infant crying and AHT, and parents - particularly fathers and father figures - have been identified as the most common perpetrators of AHT. A number of studies have suggested that educating parents during the postnatal period about the normalcy of inconsolable infant crying and its evolution over the first several months of postnatal life improves parental knowledge about infant crying and a number of positive parenting behaviors, and decreases emergency room visits for crying. In 1998, we began a pilot program in Upstate New York near Buffalo that led to a 47% reduction in AHT incidence. Similar studies have demonstrated 35-75% reductions in incidence, which has led to enthusiasm for this approach to preventing AHT. We, as well as another group, have enacted statewide programs in Pennsylvania and North Carolina; unfortunately, these two large statewide replication trials failed to demonstrate any impact of such an intervention on AHT rates. Serial messages for parents, provided repeatedly over the period of greatest risk for AHT, might be another avenue of research.

Parental knowledge on infant crying and abusive head trauma and relevant shaking behaviors in China

BACKGROUND

This study aims to characterize the knowledge about infant crying and abusive head trauma (AHT), and shaking behaviors in parents of children in China, which are lacking currently.

METHODS

A cross-sectional survey was conducted in 2020. We collected information about the knowledge of the typical patterns of infant crying and AHT, and asked about beliefs of the effects of violent shaking on children's health, and shaking behavior among parents.

RESULTS

A total of 568 parents completed the questionnaire, and only 1.6 % of them answered all nine knowledge questions related to infant crying correctly. Overall, 42.6 % of participants reported they had heard about AHT, but only 17.1 % of the parents reported they knew enough about the dangers of infant shaking. About 45 % of the parents acknowledged that they had shaken their infants at least once. Parents who were from western region of China (OR = 3.860; 95 % CI = 1.871, 7.966; p < 0.001) and have felt very frustrated because of the baby's crying over half of the time (OR = 3.401; 95 % CI = 1.862, 6.211; p < 0.001) had the highest risk of shaking. Majority of the parents reported that they needed further information about infant soothing techniques, knowledge of prevention and treatment about AHT.

CONCLUSIONS

Majority of Chinese parents do not have enough knowledge about normal infant crying, nevertheless, most of them expressing needs in learning more. Community-wide advocating efforts aiming to educate parents on awareness and knowledge about AHT should be a health priority in China.

Community-Level Prevention of Childhood Maltreatment: Next Steps in a World with COVID-19

Maltreatment of children continues to be a major public health concern, with high social, economic and health burdens. Rates vary by a number of factors that can be categorized into different levels of the social ecology. Research and theory in this field point to the importance of community-level factors that can contribute to either risk or prevention of child maltreatment. The COVID-19 pandemic context creates additional risks and concerns related to child maltreatment and exacerbates risk factors that existed before: e.g., families and communities are in much worsened states of poverty, unemployment, and food insecurity; losses and grief are affecting mental health; and limitations and safety concerns are affecting in-person child protection work and more. Central to recovery from this pandemic will be the mobilization of community-level resources and the building back up of the social fabric that can support vulnerable children and caregivers. Key to this mobilization will be a better intersectional understanding of structural inequities in the child welfare system and in our communities. Efforts to dismantle structural biases and discrimination are critical to provide safety and support for families and vital for effective child maltreatment prevention. In this context, we discuss the state of the science of community-level prevention of childhood maltreatment, highlighting evidence-based community-level prevention programs and how these types of efforts may be impacted by the current COVID-19 global pandemic.

Is there an association between infantile colic and subdural hemorrhage?

We present the hypothesis that subdural hemorrhages during childbirth might be associated with so-called three-month colic, whereby an infant cries intensively and repeatedly during its first three months. A traditional interpretation is that this infantile crying is associated with nutrition and is accordingly "a gut issue", but this is probably not the whole explanation. It has also been suggested that infantile crying can trigger a caregiver to shake the baby to make it stop crying, thereby inflicting a subdural hemorrhage. A mechanism-based argument supporting our hypothesis would be that the bilateral film-thin subdural hemorrhage associated with a high percentage of deliveries might cause meningeal irritation and in some cases also symptoms as inconsolable crying. An epidemiological argument is that infantile crying is more frequent among first-born, male and premature babies; these categories have also an increased incidence of subdural hemorrhage. Moreover, preventive programs for managing infantile crying have had no effect on the incidence of alleged shaken baby cases. As infantile crying is currently considered unexplained, it is reasonable to explore the proposed hypothesis and strategies which refute or corroborate it. We suggest that a cohort study of premature, first born and male babies with and without infantile crying are examined with brain MRI scan soon after delivery with clinically and MRI follow up during 3-6 months.

Inequities in Pediatric Abusive Head Trauma According to Neighborhood Social and Material Deprivation: A Population-Level Study in British Columbia, Canada

OBJECTIVES

To explore the relationship between neighborhood social and material deprivation and the rates of abusive head trauma (AHT), and whether it differs according to sex, and following the implementation of the Period of PURPLE Crying (PURPLE) program.

METHOD

A cross-sectional study design was applied to data from children 0 to 24 months old with a confirmed AHT diagnosis between 2005 and 2017 in British Columbia. Dissemination area-based social and material deprivation scores were assigned to residential areas, where AHT cases were recorded. Poisson regression models tested the relationship between deprivation scores and AHT rates, adding sex and pre-post program implementation as interaction terms.

RESULTS

With each increase in material and social deprivation quintiles, AHT rates increased by 42% (95% CI [1.18, 1.72]) and 25% (95% CI [1.06, 1.51]), respectively, following a social gradient. AHT rate disparities between neighborhoods did not change following the PURPLE program implementation.

CONCLUSIONS

This study stresses the need to provide additional AHT prevention services proportionately to the levels of neighborhood disadvantage, in addition to universal AHT programs, to successfully protect all children.

Effectiveness of an Educational Video in Maternity Wards to Prevent Self-Reported Shaking and Smothering during the First Week of Age: A Cluster Randomized Controlled Trial

This study aimed to investigate whether watching an educational video on infant crying and the dangers of shaking and smothering within 1 week after delivery at maternity wards reduces self-reported shaking and smothering, at a 1-month health checkup. A cluster randomized controlled trial, stratified by area and hospital function, was employed in 45 obstetrics hospitals/clinics in Osaka Prefecture, Japan. In the intervention group, mothers watched an educational video on infant crying and the dangers of shaking and smothering an infant, within 1 week of age, during hospitalization at maternity wards, without blinding on group allocation. Control group received usual care. A total of 4722 (N = 2350 and 2372 for intervention and control group, respectively) mothers who delivered their babies (still birth and gestational age < 22 weeks were excluded) between October 1, 2014, and January 31 were recruited. Outcomes were self-reported shaking and smothering behaviors, knowledge on infant crying and shaking, and behaviors to cope with infant crying, assessed via a questionnaire at a 1-month health checkup. In all, 2718 (N = 1078 and 1640) responded to the questionnaire (response rate: 58.3%), and analytic sample size was 2655 (N = 1058 and 1597 for intervention and control group, respectively). Multilevel analysis was used to adjust for correlation within the cluster. Prevalence of shaking was significantly lower in the intervention group (0.19%) than in the control group (1.69%). Intention-to-treat analysis showed an 89% reduction in the reported prevalence of self-reported shaking (OR: 0.11, 95% CI: 0.02–0.53) due to watching the educational video. However, self-reported smothering behavior showed no significant reduction (OR: 0.66, 95% CI: 0.27–1.60). No side effects were reported. Watching an educational video on infant crying and the dangers of shaking and smothering within 1 week after delivery at maternity wards reduced self-reported shaking at 1 month of age. UMIN Clinical Trial Registry UMIN000015558.

Mapping global evidence on strategies and interventions in neurotrauma and road traffic collisions prevention: a scoping review

BACKGROUND

Neurotrauma is an important global health problem. The largest cause of neurotrauma worldwide is road traffic collisions (RTCs), particularly in low- and middle-income countries (LMICs). Neurotrauma and RTCs are preventable, and many preventative interventions have been implemented over the last decades, especially in high-income countries (HICs). However, it is uncertain if these strategies are applicable globally due to variations in environment, resources, population, culture and infrastructure. Given this issue, this scoping review aims to identify, quantify and describe the evidence on approaches in neurotrauma and RTCs prevention, and ascertain contextual factors that influence their implementation in LMICs and HICs.

METHODS

A systematic search was conducted using five electronic databases (MEDLINE, EMBASE, CINAHL, Global Health on EBSCO host, Cochrane Database of Systematic Reviews), grey literature databases, government and non-government websites, as well as bibliographic and citation searching of selected articles. The extracted data were presented using figures, tables, and accompanying narrative summaries. The results of this review were reported using the PRISMA Extension for Scoping Reviews (PRISMA-ScR).

RESULTS

A total of 411 publications met the inclusion criteria, including 349 primary studies and 62 reviews. More than 80% of the primary studies were from HICs and described all levels of neurotrauma prevention. Only 65 papers came from LMICs, which mostly described primary prevention, focussing on road safety. For the reviews, 41 papers (66.1%) reviewed primary, 18 tertiary (29.1%), and three secondary preventative approaches. Most of the primary papers in the reviews came from HICs (67.7%) with 5 reviews on only LMIC papers. Fifteen reviews (24.1%) included papers from both HICs and LMICs. Intervention settings ranged from nationwide to community-based but were not reported in 44 papers (10.8%), most of which were reviews. Contextual factors were described in 62 papers and varied depending on the interventions.

CONCLUSIONS

There is a large quantity of global evidence on strategies and interventions for neurotrauma and RTCs prevention. However, fewer papers were from LMICs, especially on secondary and tertiary prevention. More primary research needs to be done in these countries to determine what strategies and interventions exist and the applicability of HIC interventions in LMICs.

Abusive Head Trauma in Infants and Children

Abusive head trauma (AHT) remains a significant cause of morbidity and mortality in the pediatric population, especially in young infants. In the past decade, advancements in research have refined medical understanding of the epidemiological, clinical, biomechanical, and pathologic factors comprising the diagnosis, thereby enhancing clinical detection of a challenging diagnostic entity. Failure to recognize AHT and respond appropriately at any step in the process, from medical diagnosis to child protection and legal decision-making, can place children at risk. The American Academy of Pediatrics revises the 2009 policy statement on AHT to incorporate the growing body of knowledge on the topic. Although this statement incorporates some of that growing body of knowledge, it is not a comprehensive exposition of the science. This statement aims to provide pediatric practitioners with general guidance on a complex subject. The Academy recommends that pediatric practitioners remain vigilant for the signs and symptoms of AHT, conduct thorough medical evaluations, consult with pediatric medical subspecialists when necessary, and embrace the challenges and need for strong advocacy on the subject.

Effectiveness of using an educational video simulating the anatomical mechanism of shaking and smothering in a home-visit program to prevent self-reported infant abuse: A population-based quasi-experimental study in Japan

BACKGROUND

A video that simulates the anatomical mechanism of shaking the infant head, which may have a stronger impact on the viewer, and a tool to prevent self-reported smothering in response to crying, has never been investigated.

OBJECTIVE

To investigate whether watching an educational video at home visit at 2 months postpartum on infant crying and the dangers of shaking and smothering reduces self-reported shaking and smothering behaviors at 4 months postpartum.

METHOD

In a quasi-experimental study in A city in Japan, the video intervention was implemented at home visits by a midwife, public health nurse or trained volunteers when babies were 2 months old. At the 4-month health checkup, participants received a questionnaire about the video, self-reported shaking and smothering behaviors and other covariates. The impacts of watching the video and self-reported shaking or smothering were analyzed using multiple logistic regression.

RESULTS

In total, 5961 caregivers provided valid response for this study (valid response rate: 73.8 %). In the adjusted model, those who watched the video were 74 % less likely to shake their infants (odds ratio (OR): 0.36, 95 % confidence interval (CI): 0.21-0.64), 43 % were less likely to smother their infants (OR: 0.57, 95 % CI: 0.37-0.89), 52 % were less likely to shake or smother (OR: 0.48, 95 % CI: 0.33-0.69) their infants.

CONCLUSION

The educational video on infant crying and the dangers of shaking and smothering, with anatomical mechanism of shaking, may halve the risk of self-reported shaking and smothering at 4 months of age.

Advances and Future Directions of Diagnosis and Management of Pediatric Abusive Head Trauma: A Review of the Literature

Abusive head trauma (AHT) is broadly defined as injury of the skull and intracranial contents as a result of perpetrator-inflicted force and represents a persistent and significant disease burden in children under the age of 4 years. When compared to age-matched controls with typically single occurrence accidental traumatic brain injury (TBI), mortality after AHT is disproportionately high and likely attributable to key differences between injury phenotypes. This article aims to review the epidemiology of AHT, summarize the current state of AHT diagnosis, treatment, and prevention as well as areas for future directions of study. Despite neuroimaging advances and an evolved understanding of AHT, early identification remains a challenge for contemporary clinicians. As such, the reported incidence of 10–30 per 100,000 infants per year may be a considerable underestimate that has not significantly decreased over the past several decades despite social campaigns for public education such as “Never Shake a Baby.” This may reflect caregivers in crisis for whom education is not sufficient without support and intervention, or dangerous environments in which other family members are at risk in addition to the child. Acute management specific to AHT has not advanced beyond usual supportive care for childhood TBI, and prevention and early recognition remain crucial. Moreover, AHT is frequently excluded from studies of childhood TBI, which limits the precise translation of important brain injury research to this population. Repeated injury, antecedent abuse or neglect, delayed medical attention, and high rates of apnea and seizures on presentation are important variables to be considered. More research, including AHT inclusion in childhood TBI studies with comparisons to age-matched controls, and translational models with clinical fidelity are needed to better elucidate the pathophysiology of AHT and inform both clinical care and the development of targeted therapies. Clinical prediction rules, biomarkers, and imaging modalities hold promise, though these have largely been developed and validated in patients after clinically evident AHT has already occurred. Nevertheless, recognition of warning signs and intervention before irreversible harm occurs remains the current best strategy for medical professionals to protect vulnerable infants and toddlers.

The lifetime costs of pediatric abusive head trauma and a cost-effectiveness analysis of the Period of Purple crying program in British Columbia, Canada

BACKGROUND

Abusive head trauma (AHT) is a severe form of child abuse causing devastating outcomes for children and families, but its economic costs in Canada has yet to be determined. The Period of PURPLE crying program (PURPLE) is an AHT prevention program implemented in British Columbia for which success in reducing AHT events was recently reported.

OBJECTIVE

This study estimated the lifetime costs to society of incidental AHT events and compared the benefits and associated costs of AHT before and after the implementation of the PURPLE program.

PARTICIPANTS AND SETTING

Children aged 0-24 months old with a definite diagnosis of AHT between 2002 and 2014 in British Columbia were included in this study.

METHODS

An incidence-based cost-of-illness analysis, using the human capital approach was used to quantify the lifetime costs of AHT events according to their severity (least severe, severe and fatal). A cost-effectiveness analysis of the PURPLE program was conducted from both a societal and a health services' perspectives using decision tree models.

RESULTS

There were sixty-four AHT events between 2002-2014, resulting in a total cost of $354,359,080 to society. The costs associated with fatal, severe and least severe AHT averaged $7,147,548, $6,057,761 and $1,675,099, respectively. The investment of $5 per newborn through the PURPLE program resulted in a $273.52 and $14.49 per child cost avoidance by society and by the healthcare system.

CONCLUSIONS

This study provides evidence to policymakers and health practitioners that investing upstream in well-developed AHT prevention programs, such as PURPLE, not only promote child safety and health, but also translates into avoided costs to society.

Awareness of abusive head trauma in a German population-based sample: implications for prevention

BACKGROUND

Despite efforts to reduce the incidence of abusive head trauma (AHT), incidence rates remain high. One cause is that prevention programs mostly aim to educate mothers of newborns on AHT and infant crying. However, mothers commonly have already a high knowledge and constitute only a minority among identified AHT perpetrators. The hypothesis was that there are great differences in AHT awareness in different subgroups. To assess awareness of AHT, a population-based study was performed.

METHODS

A population-based representative sample of the German population aged >14 years (N = 2510) was assessed in a cross-sectional observational survey. The sample was selected in a random route approach between November 2017 and February 2018.

RESULTS

Overall knowledge of AHT was higher in women (67.9%) than in men (48.8%, p < 0.001). Female gender, having children, higher age, and level of education were predictors for the awareness of AHT. A majority of participants reported to have heard about AHT from the media.

CONCLUSIONS

Awareness of AHT differs significantly within the population. In groups at higher risk to perpetrate AHT, including men, young caregivers, and those with low educational level, awareness of AHT was low. These subgroups should be targeted by tailored education programs for prevention.

Incidence of nonaccidental head trauma in infants: a call to revisit prevention strategies

OBJECTIVE

Traumatic brain injury is a major sequela of nonaccidental trauma (NAT) that disproportionately affects young children and can have lasting sequelae. Considering the potentially devastating effects, many hospitals develop parent education programs to prevent NAT. Despite these efforts, NAT is still common in Western New York. The authors studied the incidence of NAT following the implementation of the Western New York Shaken Baby Syndrome Education Program in 1998.

METHODS

The authors performed a retrospective chart review of children admitted to our pediatric hospital between 1999 and 2016 with ICD-9-CM and ICD-10-CM codes for types of child abuse and intracranial hemorrhage. Data were also provided by the Safe Babies New York program, which tracks NAT in Western New York. Children with a diagnosis of abuse at 0-24 months old were included in the study. Children who suffered a genuine accidental trauma or those with insufficient corroborating evidence to support the NAT diagnosis were excluded.

RESULTS

A total of 107 children were included in the study. There was a statistically significant rise in both the incidence of NAT (p = 0.0086) and the incidence rate of NAT (p = 0.0235) during the study period. There was no significant difference in trendlines for annual NAT incidence between sexes (y-intercept p = 0.5270, slope p = 0.5263). When stratified by age and sex, each age group had a distinct and statistically significant incidence of NAT (y-intercept p = 0.0069, slope p = 0.0374).

CONCLUSIONS

Despite educational interventions targeted at preventing NAT, there is a significant rise in the trend of newly reported cases of NAT, indicating a great need for better injury prevention programming.

Epidemiology of abusive head trauma in West Virginia children <24 months: 2000-2010

BACKGROUND

Few states have published statewide epidemiology of abusive head trauma (AHT).

OBJECTIVE

To examine the statewide epidemiology of AHT in West Virginia (WV), with the primary objective of establishing AHT incidence for comparison to national data, and to use as a baseline for comparison to incidence post-implementation of a statewide AHT prevention program.

PARTICIPANTS AND SETTING

AHT cases in children less than 2 years old were identified from the 3 tertiary pediatric centers in WV.

METHODS

Cases were identified by using ICD-9 codes for initially identifying those with injuries which might be consistent with AHT, followed by medical record review to determine which of these met the criteria for inclusion as a case. Medical examiner data was used to find additional cases of AHT. Using the number of cases identified along with relevant census data, incidence of AHT was calculated.

RESULTS

There were 120 cases of AHT treated in WV hospitals from 2000 to 2010, 100 of which were WV residents. The incidence was 36.1/100,000 children <1 year of age and was 21.9 cases per 100,000 children <2 years of age. Incidence in infants increased during the latter years (2006-2010) of the study to 51.8/100,000 compared to the incidence during 2000-2005, which was 24.0/100,000 (p < .01).

CONCLUSIONS

Compared to US national, state and regional figures, the WV incidence of AHT was among the highest. In addition, the incidence of AHT increased significantly over the study period. Possible factors contributing to the rise in incidence are discussed.

Pediatric Traumatic Brain Injury and Associated Topics: An Overview of Abusive Head Trauma, Nonaccidental Trauma, and Sports Concussions

Pediatric traumatic brain injury (TBI) uniquely affects the pediatric population. Abusive head trauma (AHT) is a subset of severe pediatric TBI usually affecting children in the first year of life. AHT is a form of nonaccidental trauma. Sports-related TBI resulting in concussion is a milder form of TBI affecting older children. Current recommended perioperative management of AHT and sports concussions relies on general pediatric TBI guidelines. Research into more specific pediatric TBI screening and management goals is ongoing. This article reviews the epidemiology, mechanisms, clinical signs, and management of AHT and sports-related concussions.

Do data from child protective services and the police enhance modelling of perinatal risk for paediatric abusive head trauma? A retrospective case-control study

OBJECTIVES

First, to investigate whether there is a relationship between a family being known to child protective services or police at the time of birth and the risk of abusive head trauma (AHT, formerly known as shaken baby syndrome). Second, to investigate whether data from child protective services or police improve a predictive risk model derived from health records.

DESIGN

Retrospective case control study of child protective service and police records.

SETTING

Nine maternity hospitals.

PARTICIPANTS

142 consecutive cases of AHT admitted to a tertiary children's hospital from 1991 to 2010 and born in one of the nine participating maternity hospitals. 550 controls matched by the date and hospital of birth.

OUTCOME MEASURE

Abusive head trauma.

RESULTS

There is a relationship between families known to child protective services or police and the risk of AHT. Notification to child protective services: univariable OR 7.24 (95% CI 4.70 to 11.14). Involvement with youth justice: univariable OR 8.94 (95% CI 4.71 to 16.95). Police call-out for partner violence: univariable OR 3.85 (95% CI 2.51 to 5.91). Other violence offence: univariable OR 2.73 (95% CI 1.69 to 4.40). Drug offence: univariable OR 2.82 (95% CI 1.63 to 4.89). However, in multi-variable analysis with data from perinatal health records, notification to child protective services was the only one of these variables to remain in the final model (OR 4.84; 95% CI 2.61 to 8.97) and had little effect on overall predictive power. The area under the receiver operating characteristic curve was 89.5% (95% CI 86.6 to 92.5) using variables from health data alone and 90.9% (95% CI 88.0 to 93.7) when notification was added.

CONCLUSIONS

Family involvement with child protective services or police is associated with increased risk of AHT. However, accessing such data at the time of birth would add little predictive power to a risk model derived from routine health information.

Feasibility study of the calm baby gently program: An educational baby book intervention on safe practices related to infant crying

BACKGROUND

Abusive head trauma (AHT) is a preventable form of child abuse.

OBJECTIVE

This project used a mixed method design to assess the feasibility of the Calm Baby Gently educational baby book intervention for promoting safe practices related to infant crying in an effort to prevent AHT.

PARTICIPANTS AND SETTING

Three pediatric practices participated between June 2016 and January 2018, including 1045 caregivers who attended their infant's 2-month well-child visit.

METHODS

Pediatric providers gave the educational baby book to caregivers at the 1-month well-child visit. Caregivers completed a survey at the 2-month well-child visit on their use and satisfaction with the book and responses to infant crying. Thematic analysis of qualitative feedback was performed. Responses to infant crying were compared quantitatively between caregivers who had and had not read the book.

RESULTS

Of the 819 caregivers (78%) who received the book, 92% (754) read it, and 51% (421) had another caregiver read it. Caregivers considered the book approachable, understandable, validating, and helpful for improving knowledge and skills related to infant crying. The book was rated more helpful by caregivers of younger age, male gender, and non-white race. Controlling for age, gender, and race, caregivers who read the book were more confident (p = 0.033) and had more knowledge on how to respond appropriately to infant crying (p = 0.019) than caregivers who had not read it.

CONCLUSIONS

Calm Baby Gently is a feasible and well-received AHT prevention program. Randomized controlled trials are needed to better understand its impact on knowledge, behavior, and AHT rates.

Do we get the message through? Difficulties in the prevention of abusive head trauma

Many programs aim to prevent abusive head trauma throughout the USA, Europe, and in many other regions of the world. Most of these programs inform mothers shortly after delivery about the dangers of abusive head trauma. Effectiveness of these programs usually is measured by the increase of knowledge on abusive head trauma. Recent research showed, however that for effective primary prevention, a much broader approach might be necessary. But so far, there is no data that reports the knowledge on key messages on abusive head trauma in the general public as a baseline. We conducted a representative population-based survey on abusive head trauma knowledge in Germany. Whereas the dangers are generally well known, a majority might be ambivalent towards the recommendation to leave a crying infant alone for a few minutes when the caregiver becomes too stressed or frustrated. Furthermore, a majority prefers being informed on abusive head trauma before birth.Conclusion: Future preventive programs should focus on educating adolescents (potential baby sitters) and young adults when they do not yet have children of their own. What is known: • Most programs for primary prevention of abusive head trauma (AHT) focus on mothers shortly after delivery • There are no analyses so far of the quality of education programs in the general public, as educating mothers might not be sufficient to reduce incidence rates What is new: • Our study is the first population-based survey to measure the knowledge on AHT in a representative population sample and to provide the data base for targeted prevention programs. • The introduction of broader prevention programs might be necessary.

How Do Nurses Keep Children Safe From Abuse and Neglect, and Does it Make a Difference? A Scoping Review

OBJECTIVES

To explore the extent of child protection work performed by nurses and identify which interventions hold the strongest evidence for future practice.

DESIGN

This scoping review was guided by Arksey and O'Malley's framework for scoping reviews.

DATA SOURCES

Electronic databases (CINAHL, Medline, Scopus, Web of Science) and grey literature were searched in August 2017. Further studies were identified through manual literature searching.

RESULTS

Forty-one studies from seven countries met the inclusion criteria. The studies showed nurses keep children safe primarily through the prevention of abuse (n = 32), but also through detection of abuse (n = 1) and interventions to mitigate the effects of abuse (n = 8). Nurses' specific interventions most frequently involved post-natal home visiting (n = 20), parent education (n = 10) and assessment and care of children or adolescents following sexual abuse (n = 4). The main findings showed that although nurses did have positive impacts upon some measures of abuse and neglect, results were not consistent across studies. In addition, some studies used indirect measures of abuse and neglect, which may not impact children's experiences of abuse. It is difficult to extrapolate these findings to the broader nursing profession as literature did not accurately represent the range of ways that nurses keep children safe from abuse and neglect.

CONCLUSIONS

This review demonstrated nurses prevent, detect and respond to abuse and neglect in many ways. However, given mixed evidence and absence of some nurse interventions in the literature, further research is needed to represent the range of ways that nurses keep children safe and determine their effectiveness.

Lifetime Cost of Abusive Head Trauma at Ages 0-4, USA

This paper aims to estimate lifetime costs resulting from abusive head trauma (AHT) in the USA and the break-even effectiveness for prevention. A mathematical model incorporated data from Vital Statistics, the Healthcare Cost and Utilization Project Kids' Inpatient Database, and previous studies. Unit costs were derived from published sources. From society's perspective, discounted lifetime cost of an AHT averages $5.7 million (95% CI $3.2-9.2 million) for a death. It averages $2.6 million (95% CI $1.0-2.9 million) for a surviving AHT victim including $224,500 for medical care and related direct costs (2010 USD). The estimated 4824 incident AHT cases in 2010 had an estimated lifetime cost of $13.5 billion (95% CI $5.5-16.2 billion) including $257 million for medical care, $552 million for special education, $322 million for child protective services/criminal justice, $2.0 billion for lost work, and $10.3 billion for lost quality of life. Government sources paid an estimated $1.3 billion. Out-of-pocket benefits of existing prevention programming would exceed its costs if it prevents 2% of cases. When a child survives AHT, providers and caregivers can anticipate a lifetime of potentially costly and life-threatening care needs. Better effectiveness estimates are needed for both broad prevention messaging and intensive prevention targeting high-risk caregivers.

Simulation-based research to improve infant health outcomes: Using the infant simulator to prevent infant shaking

Simulation is a technique that creates a situation or environment to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain understanding of systems or human actions. We will first provide an introduction to simulation in healthcare and describe the two types of simulation-based research (SBR) in the pediatric population. We will then provide an overview of the use of SBR to improve health outcomes for infants in health care settings and to improve parent-child interactions using the infant simulator. Finally, we will discuss previous and future research using simulation to reduce morbidity and mortality from abusive head trauma, the most common cause of traumatic death in infancy.

Effectiveness of a Pediatric Abusive Head Trauma Prevention Program Among Spanish-Speaking Mothers

INTRODUCTION

This study aimed to evaluate participants' knowledge of and intent to share key messages of the Period of PURPLE Crying abusive head trauma prevention program among a majority Spanish-speaking population.

METHODS

This study was a retrospective review of a postintervention survey administered in the perinatal unit of a community birthing hospital. Surveys were administered to mothers of newborns by perinatal nurses as part of routine process evaluation prior to hospital discharge between May 30, 2014, and May 15, 2015.

RESULTS

A majority of participants (86.4%) answered all six knowledge questions correctly. Among participants who reported that the father or significant other was not present during the PURPLE education (44.1%), all (100%) reported intending to share the PURPLE information with their partners. The majority of participants (88.1%) intended to share the information with others who take care of their infants.

CONCLUSION

The PURPLE abusive head trauma prevention program demonstrated positive preliminary results in knowledge and intended behavior among a population of majority Spanish-speaking participants. These findings offer an important first step toward provision of effective universal abusive head trauma prevention among growing Spanish-speaking populations. Further evaluation is needed of acceptability, retention of messages, and postintervention behavior change among Spanish-speaking participants and nurses.

Potential Opportunities for Prevention or Earlier Diagnosis of Child Physical Abuse in the Inpatient Setting

OBJECTIVES

To compare rates of previous inpatient visits among children hospitalized with child physical abuse (CPA) with controls as well as between individual abuse types.

METHODS

In this study, we used the Pediatric Health Information System administrative database of 44 children's hospitals. Children <6 years of age hospitalized with CPA between January 1, 2011, and September 30, 2015, were identified by discharge codes and propensity matched to accidental injury controls. Rates for previous visit types were calculated per 10 000 months of life. χ2 and Poisson regression were used to compare proportions and rates.

RESULTS

There were 5425 children hospitalized for CPA. Of abuse and accident cases, 13.1% and 13.2% had a previous inpatient visit, respectively. At previous visits, abused children had higher rates of fractures (rate ratio [RR] = 3.0 times; P = .018), head injuries (RR = 3.5 times; P = .005), symptoms concerning for occult abusive head trauma (AHT) (eg, isolated vomiting, seizures, brief resolved unexplained events) (RR = 1.4 times; P = .054), and perinatal conditions (eg, prematurity) (RR = 1.3 times; P = .014) compared with controls. Head injuries and symptoms concerning for occult AHT also more frequently preceded cases of AHT compared with other types of abuse (both P < .001).

CONCLUSIONS

Infants hospitalized with perinatal-related conditions, symptoms concerning for occult AHT, and injuries are inpatient populations who may benefit from abuse prevention efforts and/or risk assessments. Head injuries and symptoms concerning for occult AHT (eg, isolated vomiting, seizures, and brief resolved unexplained events) may represent missed opportunities to diagnose AHT in the inpatient setting; however, this requires further study.

Assessment of Maternal Knowledge and Confidence About Abusive Head Trauma and Coping With Infant Crying Before and After Infant Safety Education in the Neonatal Intensive Care Unit

Infants with a history of perinatal illness are at higher risk for abusive head trauma (AHT). Crying is a common trigger for physical abuse, and education on coping with infant crying is an important component of AHT prevention. This study assesses the effects of education in the neonatal intensive care unit (NICU) on mothers' knowledge about AHT and infant crying, self-efficacy in applying the education to infant cares and providing the education to others, and the quality of AHT and infant crying education after discharge. Mothers received a standardized education program about AHT and infant crying and completed a preeducation survey, posteducation survey, and 4- to 5-month follow-up survey. Overall, there was a sustained increase in knowledge (P < .001) and confidence (P < .001). Mothers who received verbal education reported a higher increase in confidence (P = .03). Few received information from healthcare providers about crying (35%) and AHT (20%) after discharge. At follow-up survey, most felt highly confident in their ability to share information about AHT (97%) and calm their infant (95%). Most had shared the education with others (77%). Education on AHT and crying in the NICU can produce sustained increases in mothers' knowledge and confidence, but the effectiveness may be improved by addressing unique barriers to education in this population.

Epidemiology and Pattern of Traumatic Brain Injury in a Developing Country Regional Trauma Center

Objective

To determine the epidemiological aspects of patients with traumatic brain injury (TBI) in a regional trauma center.

Methods

A cross-sectional study was conducted on patients with TBI during 2013 to 2016 in a single center in Hamedan, central Iran. The distribution and relationships of TBI was assessed with gender, age, type of trauma, traumatic cause, exiting status and Length of Hospitalization (LOH). Data were analyzed by Stata V11 statistical software.

Results

In general, 9426 patients with TBI were enrolled in analyses. The mean ± SD age of patients was 29.70 (± 21.46) years. Multivariate logistic regression indicated that being male [OR: 1.29; 95% CI (2.92-4.73), P ≤0.001], 41-50 to 71-80 and 90+ years old' age groups (1.32<OR<3.12, 0.029<p≤0.001), having surgery [OR: 5.58; 95% CI (4.89-6.37), p≤0.001], and different types of trauma (p≤0.001) were significantly related to LOH. Moreover, odds ratio of mortality was 1.52 times greater in males than females (p≤0.001). As the age increases, the odds ratio of mortality was also rising. However, having surgery [OR: 3.72; 95% CI (2.92-4.73), p≤0.001], LOH >5 days [OR: 2.01; 95% CI (1.60-2.52), p≤0.001] and different types of trauma were significantly related to mortality.

Conclusion

TBI is one of the main causes of mortality and LOH of the young population. By providing preventive measures and a traumatic care system, the burden of trauma can be greatly reduced, the implementation of the trauma care system in Hamedan province is a necessity.

Perinatal Risk and Protective Factors for Pediatric Abusive Head Trauma: A Multicenter Case-Control Study

OBJECTIVE

To estimate associations between factors recorded in pregnancy and the first week of life and subsequent abusive head trauma.

STUDY DESIGN

Multicenter, retrospective case-control study of perinatal records from 142 cases of abusive head trauma and 550 controls, matched by date and hospital of birth from 1991 to 2010. Multiple logistic regression assessed the relationship between perinatal exposures and abusive head trauma.

RESULTS

The risk of abusive head trauma decreased with increasing maternal age (OR, 0.91 per year; 95% CI 0.85-0.97) and increasing gestational age at birth (OR 0.79 per week; 95% CI 0.69-0.91). Mothers of cases were more likely to be Māori (OR 4.61; 95% CI 1.98-10.78), to be single (OR 5.10; 95% CI 1.83-14.23), have recorded social concerns (OR 4.29; 95% CI 1.32-13.91), and have missing data for antenatal care, partner status, social concerns, and substance abuse (OR 13.53; 95% CI 2.39-76.47). Case mothers were more likely not to take supplements in pregnancy (OR 3.53; 95% CI 1.30-9.54), to have membrane rupture longer than 48 hours before delivery (OR 13.01; 95% CI 2.84-59.68), and to formula feed (OR for mixed breast and formula feeding 6.06; 95% CI 2.39-15.36) before postnatal discharge (median 3 days).

CONCLUSIONS

Factors associated with subsequent abusive head trauma can be identified from routine perinatal records. Targeted interventions initiated perinatally could possibly prevent some cases of abusive head trauma. However, any plans for targeted prevention strategies should consider not only those with identified risk factors but also those for which data are missing.

Effect of the Earned Income Tax Credit on Hospital Admissions for Pediatric Abusive Head Trauma, 1995-2013

OBJECTIVES

Policies that increase household income, such as the earned income tax credit (EITC), have shown reductions on risk factors for child maltreatment (ie, poverty, maternal stress, depression), but evidence is lacking on whether the EITC actually reduces child maltreatment. We examined whether states' EITCs are associated with state rates of hospital admissions for abusive head trauma among children aged <2 years.

METHODS

We conducted difference-in-difference analyses (ie, pre- and postdifferences in intervention vs control groups) of annual rates of states' hospital admissions attributed to abusive head trauma among children aged <2 years (ie, using aggregate data). We conducted analyses in 14 states with, and 13 states without, an EITC from 1995 to 2013, differentiating refundable EITCs (ie, tax filer gets money even if taxes are not owed) from nonrefundable EITCs (ie, tax filer gets credit only for any tax owed), controlling for state rates of child poverty, unemployment, high school graduation, and percentage of non-Latino white people.

RESULTS

A refundable EITC was associated with a decrease of 3.1 abusive head trauma admissions per 100 000 population in children aged <2 years after controlling for confounders ( P = .08), but a nonrefundable EITC was not associated with a decrease ( P = .49). Tax refunds ranged from $108 to $1014 and $165 to $1648 for a single parent working full-time at minimum wage with 1 child or 2 children, respectively.

CONCLUSIONS

Our findings with others suggest that policies such as the EITC that increase household income may prevent serious abusive head trauma.

Association of a Postnatal Parent Education Program for Abusive Head Trauma With Subsequent Pediatric Abusive Head Trauma Hospitalization Rates

IMPORTANCE

Studies suggest that a postnatal parental intervention may reduce the incidence of abusive head trauma (AHT) of infants and young children.

OBJECTIVE

To assess the effect of statewide universal AHT education for parents on AHT hospitalization rates in Pennsylvania and on parents' self-reported knowledge gains and parenting behaviors.

DESIGN, SETTING, AND PARTICIPANTS

Changes in AHT hospitalization rates in Pennsylvania before and during the intervention were compared with those in 5 other states lacking universal parental AHT education during the same period. Data were collected from maternity units and birthing centers throughout Pennsylvania from the parents of 1 593 834 infants born on these units from January 1, 2003, to December 31, 2013. Parental behavior and knowledge were assessed through immediate (n = 16 111) and 7-month postintervention (n = 146) parent surveys in a per protocol analysis of evaluable parents.

INTERVENTIONS

Parents read a brochure, viewed an 8-minute video about infant crying and AHT, asked questions of the nurse, and signed a commitment statement affirming their participation. Educational posters were displayed on each unit.

MAIN OUTCOMES AND MEASURES

Changes in AHT hospitalization rates before and during the intervention in Pennsylvania and 5 other states. Secondary outcomes included self-reported knowledge gains and changes in parenting practices.

RESULTS

A total of 1 180 291 parents (74.1%) of children ranging in age from 0 to 23 months signed a commitment statement. Incidence rate ratios for hospitalization for AHT increased in Pennsylvania from 24.1 (95% CI, 22.1-26.3) to 26.6 (95% CI, 24.9-28.4) per 100 000 children aged 0 to 23 months during the intervention period; changes in Pennsylvania were not significantly different from aggregate changes in the 5 other states, from 22.4 (95% CI, 21.2-23.6) to 22.0 (95% CI, 21.2-22.8) per 100 000 children aged 0 to 23 months. A total of 16 111 parents (21.5% men, 78.5% women) completed the postnatal survey. Despite an overall 74.1% adherence with the intervention, only 20.6% of parents saw the brochure and video and only 5.7% were exposed to the entire intervention. Among the respondents answering individual questions on the postnatal surveys, 10 958 mothers (91.0%) and 2950 fathers (88.6%) reported learning a lot about understanding infant crying as normal; 11 023 mothers (92.2%) and 2923 fathers (88.9%), calming their infant, 11 396 mothers (94.6%) and 3035 fathers (91.9%), calming themselves; 10 060 mothers (85.1%) and 2688 fathers (83.4%), selecting other infant caregivers; and 11 435 mothers (94.8%) and 3201 fathers (95.8%), that the information would decrease the likelihood of shaking an infant. Among the 143 respondents completing the 7-month survey, 109 (76.2%) reported remembering the information while their child was crying.

CONCLUSIONS AND RELEVANCE

This intervention was not associated with a reduction in pediatric AHT hospitalization rates but was associated with self-reported gains in parental knowledge that were retained for 7 months.

Association of adverse childhood experiences with shaking and smothering behaviors among Japanese caregivers

Shaking and smothering in response to infant crying are life-threatening child abuse. Parental childhood abuse history is known to be one of the most robust risk factors for abusing their offspring. In addition to childhood abuse history, other adverse childhood exposures (ACEs) need to be considered due to co-occurrence. However, few studies have investigated the impact of ACEs on caregivers shaking and smothering their infant. This study aims to investigate the association of ACEs with shaking and smothering among caregivers of infants in Japan. A questionnaire was administered to caregivers participating in a four-month health checkup between September 2013 and August 2014 in Chiba City, Japan, to assess their ACEs (parental death, parental divorce, mentally ill parents, witness of intimate partner violence, physical abuse, neglect, psychological abuse and economic hardship), and shaking and smothering toward their infants (N=4297). Logistic regression analysis was used to examine the cumulative and individual impacts of ACEs on shaking and smothering. Analyses were conducted in 2015. A total of 28.3% reported having experienced at least one ACE during their childhood. We found that only witness of IPV had a significant association with shaking of infant (OR=1.93, 95% CI: 1.03-3.61). The total number of ACEs was not associated with either shaking or smothering. Our findings suggest that shaking and smothering in response to crying can occur regardless of ACEs. Population-based strategies that target all caregivers to prevent shaking and smothering of infants are needed.