Effectiveness of educational materials designed to change knowledge and behaviors regarding crying and shaken-baby syndrome in mothers of newborns: a randomized, controlled trial

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.

Preventive interventions for perinatal mood and anxiety disorders: A review of selected programs

Perinatal mood and anxiety disorders (PMADs) have high prevalence rates and profound deleterious effects on birthing people, families, and society. Counseling interventions have been shown to be effective and carry minimal risk. We review here the protocols and clinical trial data of four preventive counseling interventions that are effective at preventing PMADs. We present the Mothers and Babies (MB) program, a cognitive-behavioral preventive intervention, and Reach Out, Stay Strong, Essentials for mothers of newborns (ROSE), an interpersonal psychotherapy preventive intervention. We also present Mindfulness-Based Cognitive Therapy for Perinatal Depression (MBCT- PD), a preventive intervention that combines a cognitive-behavioral and mindfulness-based approach, and Practical Resources for Effective Postpartum Parenting (PREPP), a parent-infant dyadic intervention with psychodynamic, cognitive-behavioral, mindfulness-based, and psychoeducational elements. We recommend that screening for risk of PMADs (not just current mood symptoms) and providing preventive interventions to those at risk should be included as part of standard obstetrics care.

Alarm or emotion? intranasal oxytocin helps determine information conveyed by dog barks for adult male human listeners

BACKGROUND

Barks play an important role in interspecific communication between dogs and humans, by allowing a reliable perception of the inner state of dogs for human listeners. However, there is growing concern in society regarding the nuisance that barking dogs cause to the surrounding inhabitants. We assumed that at least in part, this nuisance effect can be explained by particular communicative functions of dog barks. In this study we experimentally tested two separate hypotheses concerning how the content of dog barks could affect human listeners. According to the first hypothesis, barks that convey negative inner states, would especially cause stress in human listeners due to the process called interspecific empathy. Based on the second hypothesis, alarm-type dog barks cause particularly strong stress in the listener, by capitalizing on their specific acoustic makeup (high pitch, low tonality) that resembles to the parameters of a baby's cry. We tested 40 healthy, young adult males in a double-blind placebo controlled experiment, where participants received either intranasal oxytocin or placebo treatment. After an incubation period, they had to evaluate the (1) perceived emotions (happiness, fear and aggression), that specifically created dog bark sequences conveyed to them; and (2) score the annoyance level these dog barks elicited in them.

RESULTS

We found that oxytocin treatment had a sensitizing effect on the participants' reactions to negative valence emotions conveyed by dog barks, as they evaluated low fundamental frequency barks with higher aggression scores than the placebo-treated participants did. On the other hand, oxytocin treatment attenuated the annoyance that noisy (atonal) barks elicited from the participants.

CONCLUSIONS

Based on these results, we provide first-hand evidence that dog barks provide information to humans (which may also cause stress) in a dual way: through specific attention-grabbing functions and through emotional understanding.

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.

Mothers' Awareness Towards Infantile Colic in Saudi Arabia

Background Infantile colic is defined as severe pain in the abdominal region of a baby primarily due to gastrointestinal implications and is believed to self-resolve with time. Recently established Rome IV criteria of diagnosis state that infantile colic should be diagnosed if there are symptoms like excessive crying, irritability and fussiness. Hence, this study aimed to assess the level of maternal awareness towards infantile colic in Saudi Arabia and to explore the relationship between the level of awareness and different socio-demographic factors like age, gender, nationality, etc. Methodology A cross-sectional study was carried out in Saudi Arabia from February to May 2021. An online self-administered questionnaire via Google Forms was used as the primary data collection tool. The generated link was randomly shared on electronic social media platforms including Facebook, WhatsApp, Telegram, and Twitter. Results A total of 425 participants were finally enrolled in the study. One-third of the participants (n=141, 33.2%) were aged more than 40 years and 399 were married (93.9%). Out of a total of 20 points, the mean score of maternal awareness was found to be 13.6±2.5. One-third of the participants (n=143, 33.6%) thought that rocking or carrying the baby would soothe the colic symptoms. Further, 175 participants (41.2%) used pain-relieving drugs and 7.8% sang lullabies. A total of 346 (81.4%) usually got frustrated/exhausted due to excessive crying sessions of the baby. Additionally, those who had received guidelines, educational programs or awareness sessions about the management of colic symptoms in babies had a significant awareness level (P-value = 0.032), while those who had not received education had poorer awareness. Conclusion Nearly one-third of the participants had good knowledge about infantile colic. More than one-third of the participants had previously received educational programs or awareness sessions about the management of colic symptoms in babies. More than half of the participants stated that postnatal maternal depression can occur as a result of infantile colic thereby psychological conflicts occur regarding the maternal role and inconsistent interaction styles with babies. Age, nationality, and marital status did not have a significant effect on the awareness level of the participants.

A Scientometric Review of Infant Cry and Caregiver Responsiveness: Literature Trends and Research Gaps over 60 Years of Developmental Study

Infant cry is an adaptive signal of distress that elicits timely and mostly appropriate caring behaviors. Caregivers are typically able to decode the meaning of the cry and respond appropriately, but maladaptive caregiver responses are common and, in the worst cases, can lead to harmful events. To tackle the importance of studying cry patterns and caregivers' responses, this review aims to identify key documents and thematic trends in the literature as well as existing research gaps. To do so, we conducted a scientometric review of 723 documents downloaded from Scopus and performed a document co-citation analysis. The most impactful publication was authored by Barr in 1990, which describes typical developmental patterns of infant cry. Six major research thematic clusters emerged from the analysis of the literature. Clusters were renamed "Neonatal Pain Analyzer" (average year of publication = 2002), "Abusive Head Trauma" (average year of publication = 2007), "Oxytocin" (average year of publication = 2009), "Antecedents of Maternal Sensitivity" (average year of publication = 2010), "Neurobiology of Parental Responses" (average year of publication = 2011), and "Hormonal Changes & Cry Responsiveness" (average year of publication = 2016). Research clusters are discussed on the basis of a qualitative inspection of the manuscripts. Current trends in research focus on the neurobiology of caregiver responses and the identification of factors promoting maternal sensitivity. Recent studies have also developed evidence-based strategies for calming crying babies and preventing caregivers' maladaptive responses. From the clusters, two topics conspicuously call for future research: fathers' responsiveness to infant cry and the impact of caregiver relationship quality on cry responsiveness.

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.

Shaken Baby Syndrome (SBS) or Pediatric Abusive Head Trauma from Shaking: Guidelines for Interventions During the Perinatal Period from the French National College Of Midwives

Shaken baby syndrome is the most severe head injury in children. Shaking is an extremely violent gesture, often repeated. The children affected are generally less than a year old, in 2/3 of cases, less than 6 months old. More than 10% of them die, and more than three-quarters of the survivors have long-term effects. Prevention is therefore essential. When a parent (or any person) is strongly upset by an infant's uncalmable crying, the best thing for them to do is to lay the child down in a supine position in his or her bed, leave the room, and then ask for help.

A Parent Guidebook for Occupational Therapy Using Ayres Sensory Integration®

IMPORTANCE

Occupational therapy using Ayres Sensory Integration® (ASI) is an evidence-based intervention that includes parent education and participation to support outcomes. However, guidelines for this parent component have not been published.

OBJECTIVE

To obtain input from stakeholders on a revised guidebook for parent education during ASI intervention.

DESIGN

Cross-sectional survey design.

SETTING

Online surveys.

PARTICIPANTS

Experts in ASI, occupational therapy practitioners who use this approach, and parents of children with autism who received occupational therapy using this intervention.

OUTCOMES AND MEASURES

Surveys designed and vetted to obtain input on content and usability.

RESULTS

Experts rated the guidebook as consistent with ASI principles, practitioners rated it as clinically useful, and parents rated it as useful and clear.

CONCLUSIONS AND RELEVANCE

The parent guidebook for ASI is ready for further testing and use. What This Article Adds: This report adds knowledge translation and best practice strategies in parent education to the parent guidebook for ASI and provides evidence that it is acceptable by experts, parents, and clinicians.

Crying in the first 12 months of life: A systematic review and meta-analysis of cross-country parent-reported data and modeling of the "cry curve"

Crying is an ubiquitous communicative signal in infancy. This meta-analysis synthesizes data on parent-reported infant cry durations from 17 countries and 57 studies until infant age 12 months (N = 7580, 54% female from k = 44; majority White samples, where reported, k = 18), from studies before the end Sept. 2020. Most studies were conducted in the United States, the United Kingdom, and Canada (k = 32), and at the traditional cry "peak" (age 5-6 weeks), where the pooled estimate for cry and fuss duration was 126 mins (SD = 61), with high heterogeneity. Formal modeling of the meta-analytic data suggests that the duration of crying remains substantial in the first year of life, after an initial decline.

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.

Underestimating isolated bilateral hygroma as non-accidental head injury with dramatic consequences: a case presentation

OBJECTIVE

Abusive head injury (AHI) in infancy is associated with significantly worse outcomes compared to accidental traumatic brain injury. The decision-making of the diagnosis of AHI is challenging especially if the clinical signs are not presenting as a multifactorial pattern.

METHOD

We present a case of isolated bilateral hygroma in which this differential diagnosis of AHI was evaluated but primarily not seen as such leading subsequently to extensive secondary AHI with fatal brain injury.

RESULTS

The case of an 8-week-old infant with apparently isolated bilateral hygroma without any external signs of abuse and no retinal hemorrhages was interpreted in causative correlation to the perinatal complex course of delivery. At a second readmission of the case, severe brain injury with bilateral cortical hypoxia, subarachnoid and subdural hemorrhages, and skull and extremity fractures led to severe disability of the affected infant.

CONCLUSION

Any early suspicion of AHI with at least one factor possibly being associated with abusive trauma should be discussed in multidisciplinary team conferences to find the best strategy to protect the child. Beside clinical factors, social factors within the family household may additionally be evaluated to determine stress-related risk for traumatic child abuse. In general, prevention programs will be essential in future perspective.

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.

Development and validation of the infant crying and parent well-being screening tool

This article describes the development and validation of the infant crying and parent well-being (ICPW) screening tool, developed to provide an effective and efficient way of identifying families struggling with infant crying and soothing. Construct validity for the ICPW was assessed using survey data from 290 parents of infants. Scores on the ICPW were associated with parental depression, parenting stress, and low co-parent confidence. Parents with positive ICPW screens-indicating additional support is needed-were more likely to have high or clinical levels of parenting stress than parents with negative screens. Inconsolable and excessive infant crying negatively impacts the well-being of parents, and most importantly, is the primary trigger for infant abuse. The ICPW is a unique, efficient tool that allows providers to screen for families who may need additional support around infant crying and soothing.

Trends, Diagnoses, and Hospitalization Costs of Child Abuse and Neglect in the United States of America

We conducted a secondary analysis of the National Inpatient Sample (NIS) to examine child abuse and neglect hospitalization from 1998-2016. The NIS is the largest all-payer, inpatient care database in the United States and is maintained by the Health Care Utilization Project. Participants were youth 18 years and younger with discharged diagnoses of child abuse and neglect from hospitals. The rate of child abuse or neglect hospitalizations did not vary significantly over the study period (1998-2016), which on average was 6.9 per 100,000 children annually. Males (53.0%), infants (age < 1; 47.3%), and young children (age 1-3; 24.2%) comprised most of the child maltreatment cases. Physical abuse was the most frequent type of maltreatment leading to hospitalization. Government insurance was the most common payer source, accounting for 77.3% of all child maltreatment hospitalizations and costing 1.4 billion dollars from 2001-2016. Hospitalizations due to child abuse and neglect remain steady and are costly, averaging over $116 million per year. The burden on government sources suggests a high potential for return on investment in effective child abuse prevention strategies.

Implementation of iPads to Increase Compliance With Delivery of New Parent Education in the Mother-Baby Unit: Retrospective Study

BACKGROUND

Abusive head trauma (AHT) is a serious health problem affecting more than 3000 infants annually in the United States. The American Academy of Pediatrics and the Centers for Disease Control and Prevention (CDC) recommend that health care providers counsel new parents about the dangers of AHT. Previous studies demonstrate that parental education is effective at reducing AHT events. South Carolina law requires hospitals to offer all new parents with the opportunity to watch an educational video about AHT. This mandate is addressed in different ways at the several delivery centers within a large South Carolina health care system with a range of viewing methods utilized, from DVD players to mobile workstations to personal devices. Frequent technical barriers and workflow inefficiencies resulted in low rates of compliance with this mandate at several campuses. To improve compliance of parent viewing of this educational video, the health care system standardized video viewing protocol across all campuses by implementing the use of iPads for parental education. Existing literature suggests that patient education can be improved in the hospital setting by utilizing tablet computers, but our literature search identified a gap in research around the education of parents and caregivers during hospitalization for childbirth. We used the implementation of an iPad-based parental education delivery protocol to evaluate whether tablet computers can improve compliance with delivering new parent education in the hospital setting.

OBJECTIVE

The objective of this study was to evaluate whether the standardized use of iPads to deliver education in the mother-baby unit resulted in improved rates of parents' acceptance of the opportunity to view an educational video about AHT.

METHODS

We interviewed physicians and nurses to determine what previous protocols were in place to educate new parents before a standardized iPad-based protocol was implemented across 6 campuses of a large South Carolina health care system. A retrospective study was conducted by review of 5231 records from across the 6 campuses to determine the pre- and postintervention compliance rates of viewing the AHT educational video by parents in the mother-baby unit.

RESULTS

Compliance increased overall (P<.001) across sites from an average of 41.93% (SD 46.24) to 99.73% (SD 0.26) (φ=0.510). As much as 4 of 6 locations saw a significant increase in compliance rates after introducing the iPad intervention (P<.001). The remaining 2 locations that showed no significant difference (P>.05) had very high rates of preintervention compliance.

CONCLUSIONS

Following the implementation of a standardized iPad-based protocol to deliver new parent education, there was a significant improvement in the percentage of new parents who viewed an educational video about AHT in the mother-baby unit. Based on these results, other health care providers should consider iPads to be a feasible and effective method for delivering hospital-based education to families in the mother-baby unit.

How do expectant fathers respond to infant cry? Examining brain and behavioral responses and the moderating role of testosterone

Expectant parents’ responses to infant cry may indicate future risk and resiliency in the parent-child relationship. Most studies of parental reactivity to infant cry have focused on mothers, and few studies have focused on expectant fathers, although fathers make important contributions to parenting. Additionally, although different responses to infant cry (behavioral, psychological and neural) are hypothesized to track together, few studies have analyzed them concurrently. The current investigation aimed to address these gaps by characterizing multimodal responses to infant cry within expectant fathers and testing whether prenatal testosterone moderates these responses. Expectant fathers responded to infant cry vs frequency-matched white noise with increased activation in bilateral areas of the temporal lobe involved in processing speech sounds and social and emotional stimuli. Handgrip force, which has been used to measure parents’ reactivity to cry sounds in previous studies, did not differentiate cry from white noise within this sample. Expectant fathers with higher prenatal testosterone showed greater activation in the supramarginal gyrus, left occipital lobe and precuneus cortex to cry sounds. Expectant fathers appear to interpret and process infant cry as a meaningful speech sound and social cue, and testosterone may play a role in expectant fathers’ response to infant cry.

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.

Abusive head trauma: Canadian and global perspectives

Canada has come a long way since Dr. C. Henry Kempe first described battered-child syndrome in 1962. The year 1999 was crucial in Canada's battle against shaken baby syndrome/abusive head trauma (SBS/AHT), when the first national conference on the topic was held in Saskatoon. This was followed by the issuance of a national statement and multidisciplinary guidelines, recently updated in 2020. Incidence of AHT in Canada is similar to that found in population-based studies from Switzerland and New Zealand. The mainstay of prevention of AHT in Canada is education of parents and caregivers with respect to their response to infant crying. Population-based data for global incidence of AHT are lacking, largely because of social and cultural differences contributing to poor understanding of AHT as a medico-legal entity. India faces a distinct challenge in the battle against female feticide and infanticide.

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.

Preventing maternal mental health disorders in the context of poverty: pilot efficacy of a dyadic intervention

BACKGROUND

The United States Preventive Services Task Force recommends that clinicians provide or refer pregnant and postpartum women who are at an increased risk of perinatal depression to counseling interventions. However, this prevention goal requires effective interventions that reach women at risk of, but before, the development of a depressive disorder.

OBJECTIVE

We describe a pilot efficacy trial of a novel dyadic intervention to prevent common maternal mental health disorders, that is, Practical Resources for Effective Postpartum Parenting, in a sample of women at risk of maternal mental health disorders based on poverty status. We hypothesized that Practical Resources for Effective Postpartum Parenting compared with enhanced treatment as usual would reduce symptoms of maternal mental health disorders after birth.

STUDY DESIGN

A total of 60 pregnant women who were recruited from obstetrical practices at Columbia University Irving Medical Center were randomized to the Practical Resources for Effective Postpartum Parenting (n=30) or enhanced treatment as usual (n=30) intervention. The Edinburgh Postnatal Depression Scale, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, and Patient Health Questionnaire were used to compare maternal mood at 6 weeks, 10 weeks, and 16 weeks after delivery.

RESULTS

At 6 weeks after delivery, women randomized to Practical Resources for Effective Postpartum Parenting had lower mean Edinburgh Postnatal Depression scores (P=.018), lower mean Hamilton Depression scores (P<.001), and lower mean Hamilton Anxiety scores (P=.041); however, the incidence of postpartum mental disorders did not differ by treatment group.

CONCLUSION

The Practical Resources for Effective Postpartum Parenting, which is an intervention integrated within obstetrical care, improves subclinical symptomology for at-risk dyads at a crucial time in the early postpartum period; however, our study did not detect reductions in the incidence of postpartum mental disorders.

Implementation of an Abusive Head Trauma Prevention Program Through Interdisciplinary Collaboration: A Pilot Study

BACKGROUND

Shaken baby syndrome/abusive head trauma (SBS/AHT) is the leading cause of child abuse death. Our institution piloted an evidence-based educational program to increase nurse and caregiver knowledge about SBS/AHT.

METHODS

Nurses participated in a pretest survey, completed online implementation training, and then were given a posttest survey to determine the change in SBS/AHT knowledge. Once trained, nurses disseminated information to caregivers with children younger than 6 months. Caregivers (N = 87) watched an educational video, reviewed information in a booklet with a nurse, and participated in teach-back related to key points of the intervention in both a hospital and the community setting.

RESULTS

Prior to the education, nurses (n = 115) scored 8.03 out of 10.00 on the SBS/AHT assessment. Following the intervention, nurses (n = 120) scored 9.00 out of 10.00 on the assessment, t(233) = -6.61, p < .001. During education, caregivers (n = 69) were able to recall 8.55 out of 12 key educational components. In the community setting, caregivers (n = 18) worked together to recall 12 out of the 12 key components. Caregivers were most likely to recall ways to comfort their crying baby (94%) and why shaking a baby is dangerous (93%).

CONCLUSION

This pilot study significantly increased nurses' knowledge of SBS/AHT and provided education to caregivers about SBS/AHT.

Which Mothers Know That All Babies Cry? A Randomized Controlled Trial of a Child Abuse Prevention Program for Low-Income New Mothers

This study evaluated an intervention for low-income new mothers, half from Spanish-speaking homes, that provides education around infant crying and abusive head trauma (AHT). At enrollment, non-US-born mothers were less likely than US-born mothers to have heard of shaken baby syndrome (60% vs 89%, P ≤ .0001) or to know shaking babies could lead to brain damage or death (48% vs 80%, P < .0001). At follow-up, non-US-born intervention mothers had improved knowledge of the peak of crying (31% vs 4%, P = .009), improved knowledge that shaking a baby could lead to brain damage or death (36% vs 12%, P = .035), and identified more calming strategies for parenting stress compared with non-US-born control mothers (+0.8 [SD = 1.1] vs -0.4 [SD = 1.4]). This study identifies a gap in AHT knowledge at baseline of non-US-born mothers. These mothers had improved knowledge with intervention and are an important population for similar prevention efforts.

Association of Infertility Treatment with Perception of Infant Crying, Bonding Impairment and Abusive Behavior towards One's Infant: A Propensity-Score Matched Analysis

Background: Although previous qualitative studies suggested the link between infertility treatment and negative emotions towards infants, few empirical population-based studies have investigated the association of infertility treatment with the perception of infant crying, bonding impairment, and abusive behavior towards one’s infant. Methods: Women who participated in a four month health-checkup program in Aichi Prefecture, Japan (n = 6590) were asked to a complete a questionnaire that included infertility treatment history, perception of infant crying, maternal–infant bonding impairment assessed by the Mother to Infant Bonding Scale Japanese version, and abusive behavior towards one’s infant. Outcomes were dichotomized, and a conditional logistic regression was applied, using the propensity score match for infertility treatment exposure adjusted for known covariates. Results: A total of 690 participants (11.1%) reported infertility treatment history, and 625 cases were matched. We found that mothers with infertility treatment history were 1.36 times more likely to perceive a higher frequency of infant crying (95% confidence interval (CI):1.05–1.78), but no association with maternal–infant bonding impairment (odds ratio (OR): 1.18; 95% CI: 0.81–1.72) and abusive behavior towards the infant (OR: 0.82; 95% CI: 0.49–1.36). Conclusions: Infertility treatment may be associated with the perception of a higher frequency of infant crying, but it is not associated with bonding impairment and abusive behavior. Further longitudinal study is needed to replicate the findings.

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.

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.

Management of Subdural Hematohygromas in Abusive Head Trauma

BACKGROUND

The optimal management of nonacute subdural fluid collections in infantile abusive head trauma (AHT) remains controversial.

OBJECTIVE

To review the outcomes and costs of the various treatments for symptomatic subdural fluid collections in children with AHT at a single center.

METHODS

Our AHT database was queried to identify children requiring any intervention for hematohygromas. Demographic, hospital course, radiologic, cost, readmission, and follow-up information were collected.

RESULTS

From January 2009 to March 2018, the authors identified 318 children with AHT, of whom 210 (66%) had a subdural collection of any type (blood or cerebrospinal fluid). A total of 50 required some form of intervention specifically for chronic hematohygromas. The initial management consisted of transfontanelle percutaneous aspiration (n = 31), burr holes with (n = 12) or without (n = 3) external subdural drainage, and mini-craniotomy (n = 4). Of those who were initially managed with 1 or more needle aspiration, 23 (74%) required further intervention-12 subduroperitoneal shunts and 11 nonshunt procedures. No patient who underwent burr holes/external drainage required further intervention (n = 16). Overall, the average number of interventions needed in these 50 children for definitive treatment was 1.8 (range, 1-4). A total of 15 children ultimately required a subduroperitoneal shunt. Complications (infectious, hemorrhagic, and thrombotic) were significant and occurred in all treatment groups except burr holes without drainage (n = 3). The average hospital charge for the entire cohort was $166 300.25 (range, $19 126-$739 248).

CONCLUSION

Based on our experience to date, burr hole with controlled external subdural drainage is an effective and preferred treatment for traumatic hematohygromas; complications and need for additional intervention is low.

Abusive head trauma: evidence, obfuscation, and informed management

Abusive head trauma remains the major cause of serious head injury in infants and young children. A great deal of research has been undertaken to inform the recognition, evaluation, differential diagnosis, management, and legal interventions when children present with findings suggestive of inflicted injury. This paper reviews the evolution of current practices and controversies, both with respect to medical management and to etiological determination of the variable constellations of signs, symptoms, and radiological findings that characterize young injured children presenting for neurosurgical care.

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.

Who's Watching the Children? Caregiver Features Associated with Physical Child Abuse versus Accidental Injury

OBJECTIVE

To compare caregiver features and caregiving arrangements of children with physical abuse vs accidental injuries.

STUDY DESIGN

Data came from a prospective, observational, multicenter study investigating bruising and psychosocial characteristics of children younger than 4 years of age. Using logistic regression, we examined how abuse vs accidental injury and severity of injury were associated with caregiver sex, relation to the child, whether caregiving arrangements were different than usual at the time of injury, and length of the main caregiver's relationship with his/her partner.

RESULTS

Of 1615 patients, 24% were determined to have been physically abused. Abuse was more likely when a male caregiver was present (OR 3.31, 95% CI 2.38-4.62). When the male was the boyfriend of the mother (or another female caregiver), the odds of abuse were very high (OR 169.2, 95% CI 61.3-614.0). Severe or fatal injuries also were more likely when a male caregiver was present. In contrast, abuse was substantially less likely when a female caregiver was present (OR 0.25, 95% CI 0.17-0.37) with the exception of a female babysitter (OR 3.87, 95% CI 2.15-7.01). Caregiving arrangements that were different than usual and caregiver relationships <1 year were also associated with an increased risk of abuse.

CONCLUSIONS

We identified caregiver features associated with physical abuse. In clinical practice, questions regarding caregiver features may improve recognition of the abused child. This information may also inform future abuse prevention strategies.

Does maternal attachment to her infant mediate the link between perceptions of infant crying at 6 months and parenting stress at 24 months? A structural equation modelling approach

BACKGROUND

Parenting stress is influenced by many factors including maternal attachment and excessive infant crying, yet the nature of these relationships is not well understood. For example, excessive infant crying despite maternal soothing may impact maternal attachment to the child, leading to higher stress. This paper explored whether maternal perception of excessive infant crying at 6 months was associated with higher maternal parenting stress at 24 months, and whether maternal attachment mediated this relationship.

METHODS

All families, present at 24 months in a randomized controlled trial of a 5-year early intervention programme targeting school readiness skills in disadvantaged area of Ireland, were included. At 6 months, infant crying was assessed using a maternal reported measure of duration of infant crying, and maternal attachment to the infant was assessed using the Condon Maternal Attachment Scale. Parenting stress was assessed at 24 months using the childrearing stress subscale from the Parenting Stress Index. Structural equation modelling was used to explore the direct and indirect effects of maternal perceptions of excessive infant crying on parenting stress, controlling for infant, maternal, and environmental characteristics, and focusing on the mediating role of maternal attachment.

RESULTS

Reporting excessive infant crying at 6 months was associated with lower maternal attachment at 6 months, which led to higher parenting stress at 24 months. In addition, vulnerable adult attachment style, previous maternal mental health difficulties, low paternal education, paternal involvement with the child, and not being married were associated with higher parenting stress.

CONCLUSION

Findings suggest that the association between maternal perceptions of excessive crying at 6 months and later parenting stress may be mediated through maternal attachment to the infant. Interventions based on improving maternal attachment could be investigated to determine the effectiveness of supporting mothers with low attachment.

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.

Pediatric Abusive Head Trauma Prevention Initiatives: A Literature Review

Abusive head trauma (AHT) is a serious form of child maltreatment that needs to be prevented. The aim of this study was to summarize the main AHT prevention strategies described in literature, aiming to identify evidence of their efficiency, as well as strengths and limitations. International databases were reviewed from 2005 to 2015 using the key words Shaken Baby Syndrome or abusive head trauma or nonaccidental head trauma or abusive head injury or nonaccidental head injury and prevention. A total of 1,215 articles were found and 34 complete articles were selected for this study. Five initiatives with the main objective of reducing infant crying in the first months of life were found, three aimed at caregiver's emotional regulation and 12 aimed at raising parents and caregivers awareness on AHT. Among them, parental education about infant crying and risks of shaking a baby stands out for its empirical evidence.

Eight-year outcome of implementation of abusive head trauma prevention

Low incidence rates and economic recession have hampered interpretation of educational prevention efforts to reduce abusive head trauma (AHT). Our objective was to determine whether the British Columbia experience implementing a province-wide prevention program reduced AHT hospitalization rates. A 3-dose primary, universal education program (the Period of PURPLE Crying) was implemented through maternal and public health units and assessed by retrospective-prospective surveillance. With parents of all newborn infants born between January 2009 and December 2016 (n = 354,477), nurses discussed crying and shaking while delivering a booklet and DVD during maternity admission (dose 1). Public health nurses reinforced Talking Points by telephone and/or home visits post-discharge (dose 2) and community education was instituted annually (dose 3). During admission, program delivery occurred for 90% of mothers. Fathers were present 74.4% of the time. By 2-4 months, 70.9% of mothers and 50.5% of fathers watched the DVD and/or read the booklet. AHT admissions decreased for <12-month-olds from 10.6 (95% CI: 8.3-13.5) to 7.1 (95% CI: 4.8-10.5) or, for <24-month-olds, from 6.7 (95% CI: 5.4-8.3) to 4.4 (95% CI: 3.1-6.2) cases per 100,000 person-years. Relative risk of admission was 0.67 (95% CI: 0.42-1.07, P = 0.090) and 0.65 (95% CI: 0.43-0.99, P = 0.048) respectively. We conclude that the intervention was associated with a 35% reduction in infant AHT admissions that was significant for <24-month-olds. The results are encouraging that, despite a low initial incidence and economic recession, reductions in AHT may be achievable with a system-wide implementation of a comprehensive parental education prevention program.

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.

Infant colic: mechanisms and management

Infant colic is a commonly reported phenomenon of excessive crying in infancy with an enigmatic and distressing character. Despite its frequent occurrence, little agreement has been reached on the definition, pathogenesis or the optimal management strategy for infant colic. This Review aims to delineate the definitional entanglement with the Rome IV criteria, which were published in 2016, as the leading, most recent diagnostic criteria. Moreover, neurogenic, gastrointestinal, microbial and psychosocial factors that might contribute to the pathophysiology of infant colic are explored. This Review underlines that a comprehensive medical history and physical examination in the absence of alarm symptoms serve as guidance for the clinician to a positive diagnosis. It also highlights that an important aspect of the management of infant colic is parental education and reassurance. Management strategies, including behavioural, dietary, pharmacological and alternative interventions, are also discussed. Owing to a lack of large, high-quality randomized controlled trials, none of these therapies are strongly recommended. Finally, the behavioural and somatic sequelae of infant colic into childhood are summarized.

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.

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.

Systematic Review and Meta-Analysis: Fussing and Crying Durations and Prevalence of Colic in Infants

OBJECTIVE

To determine the mean duration of fussing and crying and prevalence of colic using modified Wessel criteria in infants in the first 3 months of life.

STUDY DESIGN

A systematic literature search was performed using the databases Medline, PsycINFO, and Embase. The major outcome measure was mean total fuss/cry duration during 24 hours at ages 1-2 weeks (11 samples), 3-4 weeks (6 samples), 5-6 weeks (28 samples), 8-9 weeks (9 samples), and 10-12 weeks (12 samples).

RESULTS

Of 5687 articles reviewed, 28 diary studies (33 samples) were suitable for inclusion in meta-analysis; these studies included 8690 infants. No statistical evidence for a universal crying peak at 6 weeks of age across studies was found. Rather, the mean fuss/cry duration across studies was stable at 117-133 minutes (SDs: 66-70) in the first 6 weeks and dropped to a mean of 68 minutes (SD: 46.2) by 10-12 weeks of age. Colic was much more frequent in the first 6 weeks (17%-25%) compared with 11% by 8-9 weeks of age and 0.6% by 10-12 weeks of age, according to modified Wessel criteria and lowest in Denmark and Japan.

CONCLUSIONS

The duration of fussing/crying drops significantly after 8-9 weeks of age, with colic as defined by modified Wessel criteria being rare in infants older than 9 weeks. Colic or excessive fuss/cry may be more accurately identified by defining fuss/cry above the 90th percentile in the chart provided based on the review.

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.

Association between maternal intimate partner violence victimization during pregnancy and maternal abusive behavior towards infants at 4 months of age in Japan

The purpose of this study was to investigate whether maternal intimate partner violence (IPV) victimization during pregnancy is associated with abusive behavior by the mother towards infants at 4 months of age. A population-based sample of 6590 mothers with 4-month-old infants participated in this study in Japan. Abusive behavior was assessed via questionnaire and defined as frequency of shaking and smothering during the preceding month. Both verbal and physical IPV during pregnancy were assessed retrospectively. Multiple logistic regression analysis was used, adjusting for types of IPV and potential covariates, specifically postpartum depression. Maternal exposure to verbal and physical IPV during pregnancy was reported by 10.9% and 1.2% of women, respectively. In the adjusted model, women exposed to verbal IPV alone were significantly more likely to abuse offspring (odds ratio: 1.59, 95% confidence interval: 1.17-2.16) while exposure to physical IPV did not have an additive effect for abusive behavior. Maternal victimization by verbal, but not physical IPV was associated with maternal abusive behavior towards their 4-month-old infant. Screening for verbal abuse during pregnancy might be an efficient approach to identify high-risk mothers of infant abuse.

The impact of an educational intervention on knowledge about infant crying and abusive head trauma

BACKGROUND

Infants follow a predictable trajectory of increased early crying. Frustration with crying is reported to be a trigger for abusive head trauma (AHT).

OBJECTIVE

To evaluate the impact of postpartum delivery of the educational program, the Period of PURPLE Crying (PURPLE), in a group of first-time mothers. The primary objective was to determine whether there was a change in knowledge about infant crying and shaking after exposure to PURPLE. Factors associated with change in knowledge were also examined.

METHOD

A total of 93 participants were recruited over a four-month period at a tertiary care hospital in Nova Scotia. Pre- and postintervention data were collected.

RESULTS

Knowledge about infant crying increased significantly after program delivery (P=0.001). Low baseline crying knowledge was a significant predictor of increased knowledge about infant crying (P≤0.01). There was an insignificant decrease in shaking knowledge (P=0.5), which may have been the consequence of high baseline knowledge.

CONCLUSION

An educational program for new parents appears to be warranted, especially with respect to improving knowledge about infant crying. This may have a positive benefit in AHT prevention. Additional studies are required to evaluate the impact of the program on other caregivers and on rates of AHT.

An evidence-based method for targeting an abusive head trauma prevention media campaign and its evaluation

BACKGROUND

A triple-dose abusive head trauma (AHT) prevention program (Period of PURPLE Crying) was implemented. The third dose consisted of an education media campaign. The study objectives were to describe the qualitative and spatial methods developed to target AHT prevention and to evaluate this campaign.

METHODS

A questionnaire on the level of importance of factors, rated on a 7-point Likert scale, was distributed to a panel of experts to determine the best advertising locations. Ranked factors were used to create weights for statistical modeling and mapping within a Geographic Information Systems to determine optimal ad locations. The media campaign was evaluated via a telephone survey of randomly selected households.

RESULTS

The survey found locations of new families, high population density, and high percentage of lone parents to be the most important factors for selecting billboard sites. Spatial analysis revealed six areas that ranked highest in our factors. Five billboards, four media posters, and six transit shelters were selected for our advertisements. A population-based telephone survey revealed that 23% of respondents knew the campaign. Nearly half (42%) heard the radio public service announcements, and 9% saw billboards.

CONCLUSION

Extending primary prevention efforts to the public helps to create a cultural change in the way inconsolable crying, the trigger for AHT, is viewed. With the use of ranked factors and Geographic Information Systems, geographic locations with high visibility and specific risk factors for AHT were identified for targeting the campaign, facilitating the likelihood that our message was reaching the population in greatest need.

PREPP: postpartum depression prevention through the mother-infant dyad

Most interventions to prevent postpartum depression (PPD) focus on the mother rather than the mother-infant dyad. As strong relationships between infant sleep and cry behavior and maternal postpartum mood have been demonstrated by previous research, interventions targeted at the dyad may reduce symptoms of PPD. The goal of the current study was to examine the effectiveness of Practical Resources for Effective Postpartum Parenting (PREPP). PREPP is a new PPD prevention protocol that aims to treat women at risk for PPD by promoting maternally mediated behavioral changes in their infants, while also including mother-focused skills. Results of this randomized control trial (RCT) (n = 54) indicate that this novel, brief intervention was well tolerated and effective in reducing maternal symptoms of anxiety and depression, particularly at 6 weeks postpartum. Additionally, this study found that infants of mothers enrolled in PREPP had fewer bouts of fussing and crying at 6 weeks postpartum than those infants whose mothers were in the Enhanced TAU group. These preliminary results indicate that PREPP has the potential to reduce the incidence of PPD in women at risk and to directly impact the developing mother-child relationship, the mother's view of her child, and child outcomes.