Collaboration alert!
Phoenix Children's Hospital and the Arizona Department of Health and Safety have posted a SBS awareness video created by PCH to the AzDHS website.
I haven't been able to listen to the audio yet, but the video looks good, it's about 7 minutes, and it includes an appearance by Luis Gonzalez, the father of triplets, who is a major league ballplayer (now for the Florida Marlins, then for the Arizona Diamondbacks...)
Also includes a simple, yet vivid demonstration of the different outcomes when an egg is dropped and when it's shaken
Wednesday, December 31, 2008
Monday, December 29, 2008
Science Daily reports on research that found, for high risk individuals, the greatest deterrent to driving while intoxicated is the perception - not the actual likelihood - of getting caught...
"Essentially, law enforcement needs to focus on perceptions; it is important that drivers perceive that they will be caught if they drive impaired," said Lilliard Richardson, professor in the MU Truman School of Public Affairs. "We found that high-risk drivers are less likely to drink and drive if they perceive they are likely to be stopped or arrested by police. However, the mere existence of laws designed to discourage people from drinking and driving does not impact high-risk drivers. The results provide support for the value of high-visibility enforcement campaigns. Public safety education and media efforts are important components of the overall strategy for reducing impaired driving."This suggests the importance of education and awareness efforts that target the higher-risk groups with information about the investigation and prosecution of those who inflict injuries.
Similar increases in abuse cases, different explanations
The Washington Post reports on a rise in the incidence of abuse and neglect in the DC area, and speculation that it is tied to the economic stresses on families:
About a month ago, Allison Jackson began to notice an increase in the number of children coming into the emergency room at Children's National Medical Center in the District with burns, broken bones, fractured skulls and injured stomachs. Puzzled, she called colleagues across the country, who told her that they, too, noticed an increase in child abuse cases.
"We are all questioning whether it's the economy and the stresses that come with a bad economy," said Jackson, who is the medical director of the hospital's Child and Adolescent Protection Center.
A similar rise in abuse cases is reported in Sweden (Sverige)...although the suggestion is that the increase there results from growing awareness and recognition.
Of note, the article indicates the Mio group [Mio-Gruppen] at Astrid Lindgren Hospital is working to increase awareness of Shaken Baby Syndrome with a project entitled "shaken baby".According to Felipe Estrada at Brå [Swedish National Council for Crime Prevention] the figures do not however indicate that child abuse is on the rise in Sweden but do indicate that there is greater transparency. "More cases are reported today than previously." Astrid Lindgren's Children's Hospital in Solna, outside of Stockholm, is working to develop concrete guidelines to help staff and ensure that more cases of child abuse are detected.
Tingberg observes such abuse is often a case of ignorance or frustration among parents who don't realise how little is needed to seriously injure their baby.And Montgomery County, Maryland is also noticing a rise in abuse, as described in this report from WTOP:
Despite the increase in reports of child abuse, death remains a very rare occurrence in Sweden, with seven cases per year, and is almost never connected to a history of abuse.
Karla Smith, a prosecutor in Montgomery County, thought that's what she was seeing when she noted the number of child abuse cases crossing her desk. She's Chief of the Family Violence Unit at the State's Attorney's Office.
But it was a recent trip to Children's Hospital that confirmed what she was thinking.
"And I ran into a couple of neurosurgeons and they were talking to me about the fact that they were seeing a significant increase in the number of cases of abusive head traumas, and that's what they refer to if we're talking about a shaken baby case or a child who's been shaken and thrown."
Sunday, December 28, 2008
Well, it being the season to look over the year past and compile lists, I visited PubMed.org to see what a search for "shaken baby" and 2008 would find.
Of 68 articles and letters in their database, I found the 26 (ranked in publication order) of interest:
1: J Emerg Med. 2008 Dec 10.
Retinal hemorrhages and shaken baby syndrome: An evidence-based review.
Togioka BM, Arnold MA, Bathurst MA, Ziegfeld SM, Nabaweesi R, Colombani PM, Chang DC, Abdullah F.
Center for Pediatric Surgical Trials and Outcomes Research, Division of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Background: Among the causes of non-accidental head injury (NAHI), shaken baby syndrome (SBS) is difficult to diagnose and is associated with retinal hemorrhages (RH). Description: To identify findings and patterns of RH specific to SBS, a PubMed search using the keywords "shaken baby syndrome" or "child abuse" and "retinal hemorrhage" was conducted; 66 articles met the inclusion criteria. The published data address the utility of RH in three categories: 1) in diagnosing SBS; 2) as correlated to intracranial pathology; and 3) in prognosticating SBS. The present review aimed to summarize studies in a way that facilitates clinical decision-making.
RESULTS: Studies found a 53-80% incidence of RH with abusive head injury and a 0-10% incidence with proven severe accidental trauma. RHs are found bilaterally 62.5-100% of the time in SBS cases, and flame-shaped hemorrhages are the most common. The incidence of RH from convulsions, chest compressions, forceful vomiting, and severe persistent coughing in the absence of another condition known to cause RH is 0.7%, 0-2.3%, 0%, and 0%, respectively.
CONCLUSION: SBS remains a difficult cause of NAHI to diagnose. Ophthalmologic examination can provide critical diagnostic and prognostic information in cases of suspected SBS. Child abuse should be highly suspect in children with RH and a parental explanation of accidental head injury, especially if the RHs are found to be bilateral, flame-shaped, or to extend through to all layers of the retina.
2: Graefes Arch Clin Exp Ophthalmol. 2008 Dec 4.
A finite element infant eye model to investigate retinal forces in shaken baby syndrome.
Hans SA, Bawab SY, Woodhouse ML.
Department of Mechanical Engineering, Old Dominion University, 238 Kaufman Hall, Norfolk, VA, 23529-0247, USA, shans001@odu.edu.
BACKGROUND: Shaken baby syndrome (SBS) is a form of abuse in which an infant, typically 6 months or less, is held and submitted to repeated acceleration-deceleration forces. One of the indicators of abuse is bilateral retinal hemorrhaging. A computational model of an infant eye, using the finite element method, is built in order to assess forces at the posterior retina for a shaking and an impact motions.
METHOD: The eye model is based on histological studies, diagrams, and materials from previous literature. Motions are applied to the model to simulate a four-cycle shaking motion in 1 second with maximum extension/flexion of the neck. The retinal forces of the shaking motion, at the posterior eye, are compared to an impact pulse (60G) simulating a fall for a total duration of 100 ms.
RESULTS: The shaking motion, for the first cycle, shows retinal force means at the posterior eye to be around 0.08 N sustained from the time range of 50 to 200 ms, into the shake, with a peak in excess of 0.2 N. The impulse, area under the curve, is 15 N-ms for 250 msec for the first cycle. The impact simulation reveals a mean retinal force around 0.025 N for a time range of 0 to 26 ms, with a peak force around 0.11 N. Moreover, the impulse for the impact simulation is 13 times lower than the shaking motion.
CONCLUSION: The results suggest that shaking alone may be enough to cause retinal hemorrhaging, as there are more sustained and higher forces in the posterior retina, compared to an impact due to a fall. This is in part due to the optic nerve causing more localized stresses in a shaking motion than an impact.
3: J Dev Behav Pediatr. 2008 Dec;29(6):508-11.
Getting the word out: advice on crying and colic in popular parenting magazines.
Catherine NL, Ko JJ, Barr RG.
Centre for Community Child Health Research, Child and Family Research Institute, Vancouver, BC, Canada.
The objective of this study is to determine whether advice in parenting magazines reflects current evidence-based understanding of early infant crying and colic, where (1) "colic" is the upper end of a spectrum of crying behavior reflective of normal infant development, and (2) physical abuse--in particular, shaken baby syndrome (SBS)--is a serious medical consequence of early crying. All available issues of 11 popular Canadian parenting magazines published between January 2000 and December 2004 were hand-searched and systematically reviewed. Fifty-one articles were found with information on: (1) causes of, (2) responses to, and/or (3) mention of SBS or abuse as a consequence of crying and/or colic. There were 105 specific causes suggested, but almost no agreement concerning the causes of crying and colic. Similarly, there were 231 specific responses to crying and colic mentioned, but little agreement among the suggested responses. For both crying and colic together, the consequence of abuse was mentioned only 7 times, and SBS only twice. Making the advice literature a truly helpful vehicle for parents concerning normal behavioral development and its consequences for their new infant seems to be a significant challenge. Arguably, this is an important shared responsibility of physicians, researchers, and journalists.
4: Child Abuse Negl. 2008 Nov;32(11):1017-25.
Secondary analysis of the "Love Me...Never Shake Me" SBS education program.
Deyo G, Skybo T, Carroll A.
College of Nursing, The Ohio State University, Columbus, OH, USA.
OBJECTIVE: Shaken baby syndrome (SBS) is preventable; however, an estimated 21-74 per 100,000 children worldwide are victims annually. This study examined the effectiveness of an SBS prevention program in the US.
METHODS: A descriptive, secondary analysis of the Prevent Child Abuse Ohio (PCAO) "Love Me...Never Shake Me" SBS education program database included 7,051 women who completed a commitment statement, pre and post-test, and follow-up survey.
RESULTS: Participants were mostly White (76%), had at least some college education (62%), were privately insured (62%), and lived with the father and infant (63%). Mothers knew of the dangers of shaking (96%) and recommended SBS education for all parents (98%) because they found it helpful (97%). Scores on the pre and post-tests were significantly different, but there was no difference based on education site or demographics. There was a significant increase in a pre/post-test item pertaining to infant crying. At follow-up, participants remembered postpartum SBS education (98%), but post-discharge did not receive SBS education from their primary care provider (62%). Most mothers practiced infant soothing techniques (79%) provided in the education; however, few women practiced self-coping techniques (36%) and accessed community support services (9%).
CONCLUSIONS: Postpartum SBS prevention education should continue. Development of SBS programs should result from these study findings focusing on education content and program evaluation.
PRACTICE IMPLICATIONS: Mothers report that shaken baby syndrome education is important for all parents and memorable at follow-up. Postpartum SBS education should continue because the hospital is the primary place they receive education. Mothers' report they less frequently receive education from healthcare sources post-discharge. Diligence of primary care providers to incorporate SBS prevention education in well child visits will increase parental exposure to this information. Education may need to place greater emphasis on infant crying and soothing, as well as parent support and self-coping techniques versus the dangers of shaking.
Shaken baby syndrome education program: nurses making a difference.
Smith KM, deGuehery KA.
Shaken Baby Syndrome Education Program, Kaleida Health Women and Children's Hospital of Buffalo, Buffalo, NY, USA. ksmith@kaleidahealth.org
This article describes the nursing role in the Upstate New York Shaken Baby Syndrome (SBS) Education Program, an effort to educate parents of all hospital-born infants in the eight-county region of Western New York about the dangers of violent infant shaking. This program has now been expanded to include hospitals in 17 counties in Upstate New York. The major intervention is an educational program administered by nurses. These nurses describe the challenges and opportunities they faced in implementing a large community health program.
Testing educational strategies for Shaken Baby Syndrome.
Bailey M, Gress T, Bolden D, Pfitzer L.
Marshall University School of Medicine, Department of Pediatrics, Huntington, USA.
Shaken Baby Syndrome (SBS) occurs from the violent shaking of an infant, which may lead to brain damage or death. The goal of this study was to assess educational methods used to teach new mothers about SBS.
METHODS: Forty six parents at a community hospital were selected and randomly divided into three groups. Group 1 received a short lesson about SBS. Group 2 received the lesson and watched a locally developed SBS video. Group 3 received the lesson and watched a true dramatization of SBS created by a national organization. Pre and post surveys were administered.
RESULTS: Study groups were similar in regard to age, marital status, socioeconomic status and education. Group 1 parents showed no differences in scoring. Group 2 parents showed a significant increase in defining SBS and what to do for persistent infant crying. Group 3 parents scored significantly higher in defining SBS. CONCLUSION: Both video presentations improved scoring on understanding SBS but only the local video presentation increased scores in the management of persistent infant crying.
7: Child Abuse Negl. 2008 Oct;32(10):949-57.
Intervention type matters in primary prevention of abusive head injury: event history analysis results.
Russell BS, Trudeau J, Britner PA.
Worcester State College, Department of Psychology, Worcester, MA 01602, USA.
PURPOSE: The current study sought to compare interventional materials intended to raise public awareness of the caregiving practices connected to Shaken Baby Syndrome (SBS). Two hundred and sixty four adults (mean age 32 years) were recruited for participation through convenience sampling at a large Northeastern university. Participants fell into two groups-those who regularly cared for children (46%) and those who did not (54%).
METHODS: SBS awareness was surveyed prior to an educational intervention and at three times points (2, 6, and 12 weeks post-intervention) longitudinally. Three intervention levels were used: Two different video conditions, each with an informational brochure, and the brochure-only condition. Survey responses were combined into five factor scores. Changes in factor score over time were modeled using event history analysis to predict the conditional probability of change in awareness as a discreet event.
RESULTS: The resulting models show consistent results for three of the five factors, predicting the highest likelihood of increased awareness for a teaching video intervention, followed by a testimonial video, and the lowest probability for increased awareness for the use of an intervention using only a brochure. Negative change, or decreased awareness, was not predicted by the type of intervention materials. Demographic variables were not significant predictors of either positive or negative change.
CONCLUSION: The results indicate that the addition of video materials, and in particular material focusing on teaching alternative behaviors, significantly increases the likelihood of positive changes in SBS awareness over interventions which use only a brochure.
IMPLICATIONS FOR PRACTICE OR RESEARCH: The present study uses a two by three design to describe levels of improved awareness of Shaken Baby Syndrome across two groups of participants (those who regularly care for children and those who do not) and type of educational material (a brochure versus two different videos each in combination with the brochure). Results show a differential effect for each intervention level, and indicate a need for careful selection of educational materials for intervention programs concerned with preventing SBS through public awareness.
8: Med Sci Law. 2008 Oct;48(4):346-9
Cervical soft tissue lesions in the shaken infant syndrome: a case report.
Porzionato A, Macchi V, Aprile A, De Caro R.
Section of Anatomy, Department of Human Anatomy and Physiology, University of Padova, Italy.
Cervical soft tissue lesions have rarely been described in the shaken baby syndrome; they include ruptures of intervertebral discs and haemorrhages in the ligamenta flava, and in the interspinal and sternocleidomastoid muscles. We present here the autopsy case of a 30-month old girl who suffered an assault with multiple injury mechanisms, i.e., beating, sexual abuse and shaking trauma. External examination of the neck did not reveal bruises or excoriations, but cervical dissection showed haemorrhagic infiltration of the clavicular head of the sternocleidomastoid muscle, carotid region, posterior musculature of the pharynx and oesophagus, and retro-pharyngeal/oesophageal spaces. These findings were ascribed to the repeated violent movements of shaking trauma. The case presented confirms the occurrence of cervical soft tissue lesions in the shaken baby syndrome and reports injuries which have not previously been described. In suspected cases of shaken baby syndrome, particular attention must be paid to the examination of cervical soft tissue structures.
9: Acta Neuropathol. 2008 Sep;116(3):317-29. Epub 2008 Mar 26.
Shaken baby syndrome: re-examination of diffuse axonal injury as cause of death.
Oehmichen M, Schleiss D, Pedal I, Saternus KS, Gerling I, Meissner C.
Institute of Legal Medicine, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany. moehmichen@gmx.de
The discussion surrounding shaken baby syndrome (SBS) arose from the lack of evidence implicating diffuse axonal injury (DAI) as a cause of death. It was assumed instead that injury to the cervical cord, medulla, and nerve roots played a causal role. The present pathomorphological study examines 18 selected infants (<1-year-old)>
10: Acta Paediatr. 2008 Jun;97(6):782-5
Shaken baby syndrome and a baby's cry.
Talvik I, Alexander RC, Talvik T.
Children's Clinic of Tartu University Hospital, Tartu, Estonia. inga.talvik@kliinikum.ee
The aim of this study was to investigate the relationship between crying of an infant and inflicted head injury by shaking and/or impact. During the period between January 1, 1997 and December 31, 2003, 26 cases of shaken baby syndrome (SBS) were identified in Estonia. The incidence of SBS was 28.7 per 100,000 children under 1 year of age during the whole study period. In this group there were four children from twin pairs: two twin boys and a girl from a twin pair and a boy from another twin pair. This represents 15.4% of the 26 cases. Twins in Estonia represent 2.12% of infant births. The mean age on admission was 3.9 months. According to outpatient records almost all parents (88.5%) in the study group (23/26) had contacted their family physicians and other specialists because of excessive crying or irritability of the baby prior to the admission to the hospital with SBS or death. We found that the time curve of crying was similar to the curve of highest incidence of cases of SBS except the crying curve began earlier.
CONCLUSION. Our data confirm that the families with twins are at additional risk for SBS and parent's complaints of excessive crying of their infants should be taken as signal that parents need to be carefully counselled.
Shaken baby syndrome: facts, education, and advocacy.
Lewin L.
Case Western Reserve University, Frances Payne Bolton School of Nursing, Cleveland, OH, USA. lcl7@case.edu
Natural animal shaking: a model for non-accidental head injury in children?
Serbanescu I, Brown SM, Ramsay D, Levin AV.
Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, Ontaria, Canada.
BACKGROUND: Non-accidental head injury (NAHI) is a form of child abuse where a perpetrator may violently subject an infant to repeated acceleration-deceleration forces with or without head impact, producing injuries including retinal haemorrhages in most cases. Animal models have included laboratory shaking of mice and rats, but only a small fraction develop retinal haemorrhages presumably due to the small eyes, which would require unattainable force levels to mimic that sustained by the infant eye. Animal models are also problematic due to ethical issues raised by subjecting even anaesthetized animals to abusive injury.
METHODS: We investigated a naturally occurring event, where three animal victims were shaken by a canine. The eyes were harvested and examined histologically. RESULTS: The victims' eyes showed no haemorrhage or retinoschisis.
CONCLUSIONS: Our model may not be a complete NAHI mimic. The discrepancies may ensue from anatomical and mechanical differences in the injury mechanism. Other models must be sought to further study this form of abusive eye injury.
Evaluating the epidemiology of inflicted traumatic brain injury in infants of U.S. military families.
Ryan MA, Lloyd DW, Conlin AM, Gumbs GR, Keenan HT.
Department of Defense Center for Deployment Health Research, Naval Health Research Center, San Diego, California 92106, USA. margaret.ryan@med.navy.mil
BACKGROUND: Evaluating the incidence of inflicted traumatic brain injuries (inflicted TBI) in young children, and encompassing shaken baby syndrome (SBS) and related injuries, is an epidemiologic challenge. Data available regarding military families in the U.S. may complement other national surveillance efforts.
METHODS: A protocol was developed to assess the epidemiology of inflicted TBI among infants of U.S. military families, integrating data from the Department of Defense Birth and Infant Health Registry, healthcare utilization databases, child abuse reporting systems, and military personnel databases. The in-progress protocol, and its inherent strengths and limitations, are described here.
DISCUSSION: The primary strengths of data from U.S. military families are related to the full characterization of the denominator, such that analyses are person-time and population based. Unique data are available to describe the full population of military parents, including occupational, geographic, and socioeconomic factors, as well as deployment-related potential stressors. The limitations of military data are similar to many other child abuse surveillance systems in that cases are underreported and not fully characterized. Linking abuse reports and medical utilization data to population data, however, will allow unique analyses of "probable" and "possible" cases of inflicted TBI in infants of military families.
CONCLUSIONS: Data from the U.S. military, when appropriately linked and analyzed, provide opportunities to evaluate important risk factors for inflicted TBI in infants. Although epidemiologic challenges may make incidence rates using military data noncomparable to rates using other data sources, multivariate analyses can evaluate critical and unique risk factors, as well as the effectiveness of prevention initiatives.
14: Am J Prev Med. 2008 Apr;34(4 Suppl):S134-9
Passive surveillance of shaken baby syndrome using hospital inpatient data.
Wirtz SJ, Trent RB.
Epidemiology and Prevention for Injury Control Branch, California Department of Public Health, Sacramento, California 95899-7377, USA. steve.wirtz@cdph.ca.gov
BACKGROUND: The conference from which these articles came addressed the question of public health surveillance for shaken baby syndrome (SBS) and explores one component of a comprehensive SBS surveillance system that would be relatively easy to implement and maintain: passive surveillance based on hospital inpatient data. Provisional exclusion and inclusion criteria are proposed for a two-level case definition of diagnosed SBS (strict definition) and cases presumed to be SBS (broad definition). The strict SBS definition is based on the single SBS code in the ICD-9-CM (995.55). The broader presumptive SBS definition is based on research studies that have identified a pattern of diagnostic codes often considered part of the clinical diagnosis of SBS.
RESULTS: Based on 2006 analyses, California inpatient data are presented for 1998-2004. The strict SBS definition identified 366 cases over the 7 years, whereas the broader definition captured nearly 1000 cases. Annual rates show little fluctuation from the overall rate of 5.1 for strict SBS and 14.0 for broad SBS (per 100,000 children aged
15: Am J Prev Med. 2008 Apr;34(4 Suppl):S126-33
Incidence and demography of non-accidental head injury in southeast Scotland from a national database.
Minns RA, Jones PA, Mok JY.
Department of Child Life and Health, University of Edinburgh, Edinburgh, Scotland, United Kingdom. Robert.Minns@ed.ac.uk
BACKGROUND: This study utilized an existing national database of cases of non-accidental head injury (NAHI; also called inflicted traumatic brain injury [inflicted TBI] and shaken baby syndrome [SBS]) in Scotland to report the incidence, confidence intervals, and demography of such cases in Southeast Scotland.
METHODS: This prospective population-based study was conducted from January 1998 to September 2006. Data from the Lothian region of Scotland, where there is known full ascertainment of infant head injuries, including NAHI, have been used to calculate the incidence rate for this region of Scotland, with government statistics providing the normal annual infant population as the denominator. A new Scottish Index of Multiple Deprivation (SIMD), which assesses a very focused area (data zone population size=750) and provides novel information about social demography for education, housing, employment, health, crime, income, and geographic accessibility to services, was applied to the identified cases of NAHI during this study period. RESULTS: The mean incidence of NAHI in southeast Scotland for 8.75 years was 33.8/100,000 infants per year. The cases of NAHI were mostly located in the lowest 1 (or 2) quintiles for all SIMD domains (education, housing, employment, health, crime, income), although they had good accessibility to medical and other community services.
CONCLUSIONS: The incidence rates from this prospective study for NAHI are considerably higher than other published UK surveys and are not considered to reflect a cluster effect. The perpetrators in this study fit a strongly skewed profile aggregating to the lowest socioeconomic groups in the community.
16: Am J Prev Med. 2008 Apr;34(4 Suppl):S116-9
What are we trying to measure? The problems of case ascertainment.
Reece RM.
Department of Pediatrics, Tufts University School of Medicine, Boston, Massachusetts 02556, USA. rmreecel@aol.com
To determine the incidence of a particular phenomenon, one has to know how that phenomenon is defined. The term "shaken baby syndrome" (SBS) came into general usage in the 1980s, followed by shaken impact syndrome (SIS), inflicted childhood neurotrauma, abusive head trauma (AHT), inflicted traumatic brain injury (inflicted TBI), non-accidental head injury (NAHI), and others. Several means of defining this clinical syndrome have been suggested. Keenan has proposed a research definition. Minns has offered a pure clinical definition, and Livingston and Childs suggest a definition that combines the clinical and radiologic features with the history of events leading to the condition. By using these definitions, eight articles describing SBS, published in the last 20 years, were analyzed for these characteristics. A definition of shaken baby syndrome reflecting the common themes in these clinical reports is offered.
The challenges of assessing the incidence of inflicted traumatic brain injury: a world perspective.
Runyan DK.
Department of Social Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7240, USA.
OBJECTIVE: Commentary on the methods available for ascertaining the incidence of inflicted traumatic brain injury (inflicted TBI) and the difficulties involved in defining and measuring this condition in young children.
DESIGN: Review of published and unpublished international data regarding parental shaking of infants compared to studies assessing incidence.
RESULTS: Review of parental report data reveal that the shaking of young children is a surprisingly common act in a wide variety of countries and cultures. While 2.6% of parents of children aged under 2 years in the U.S. report shaking their child as an act of "discipline," survey data from lesser-developed countries on four continents indicate that shaking, as a form of discipline, may be many times more common among infants in their countries and that the consequences, short of hospitalization or death, are inadequately studied. Methodologic challenges to epidemiologic work to develop better estimates are discussed.
CONCLUSIONS: These data highlight the challenges faced in ascertaining the epidemiology of inflicted TBI in young children. While there is scientific evidence that the shaking of young children can produce profound destruction of children's brains and lives, these data reveal that there are many other children who are shaken by their caregivers but escape the acute clinical presentation of "shaken baby syndrome" or for whom the injuries are not recognized as due to inflicted TBI. The impact of these private acts must be further studied as there may be other long-lasting and serious intracranial impacts that have not been characterized.
Epidemiology the major missing element in the global response to child maltreatment?
Butchart A.
Department of Injuries and Violence Prevention, Noncommunicable Diseases, and Mental Health, World Health Organization, Geneva, Switzerland. butcharta@who.int
Inflicted childhood neurotrauma.
Fiske EA, Hall JM.
Carson-Newman College, Jefferson City, Tennessee 37760, USA. efiske@cn.edu
In this article, we review literature related to inflicted childhood neurotrauma (ICN). We discuss the rationale for use of the term "ICN," rather than the more benign, commonly used "shaken baby syndrome." The change in language alters the discourse about a potentially lethal outcome or lifelong problem for survivors. A description of ICN is followed by a discussion of ethical parameters and obligations of those who care for infants and children and professionals who are sentinels to these events such as law enforcement officials, nurses, physicians, and social workers.
Infant brain subjected to oscillatory loading: material differentiation, properties, and interface conditions.
Couper Z, Albermani F.
School of Engineering, University of Queensland, Brisbane 4072, Australia. z.couper@uq.edu.au
Past research into brain injury biomechanics has focussed on short duration impulsive events as opposed to the oscillatory loadings associated with Shaken Baby Syndrome (SBS). A series of 2D finite element models of an axial slice of the infant head were created to provide qualitative information on the behaviour of the brain during shaking. The test series explored variations in subarachnoid cerebrospinal fluid (CSF) representation, brain matter stiffness, dissipation, and nonlinearity, and differentiation of brain matter type. A new method of CSF modelling based on Reynolds lubrication theory was included to provide a more realistic brain-CSF interaction. The results indicate that solid CSF representation for this load regime misrepresents the phase lag of displacement, and that the volume of subarachnoid CSF, and inclusion of thickness variations due to gyri, are important to the resultant behavior. Stress concentrations in the deep brain are reduced by fluid redistribution and gyral contact, while inclusion of the pia mater significantly reduces cortex contact strains. These results provide direction for future modelling of SBS.
Update on child maltreatment.
Newton AW, Vandeven AM.
Department of Pediatrics, Harvard Medical School, Child Protection Program, Children's Hospital, Child Protection Consultation Program, Massachusetts General Hospital, Boston, Massachusetts 02115, USA. alice.newton@childrens.harvard.edu
PURPOSE OF REVIEW: The authors discuss the significance of studies published over the previous year regarding assessment and treatment and prevention of child maltreatment, including physical and sexual abuse, inflicted traumatic brain injury, and child neglect.
RECENT FINDINGS: The evidence base for many forms of child abuse is growing. As clinicians begin to understand the factors which may increase child vulnerability to abuse, more sophisticated and focused prevention efforts are being implemented. In response to a very public reprimand by the General Medical Council of two child abuse pediatricians, which was felt by many to be unwarranted, the UK government re-emphasized its commitment to the protection of children. In the US, this well-publicized set of events has renewed the medical community's commitment to the recognition of child abuse pediatrics as a formal subspecialty. Several authors detail the short-term and long-term outcome of varying forms of abuse for children as they grow into adults, reinforcing the importance of community efforts to prevent abuse and support families during times of heightened stress such as the current war in Iraq.
SUMMARY: The short-term and long-term impact of child maltreatment is significant not only for individuals, but for families and communities where abuse is taking place. General pediatricians have an important role to play with families and in the community as advocates for the protection of children.
Comparative study of the cognitive sequelae of school-aged victims of Shaken Baby Syndrome.
Stipanicic A, Nolin P, Fortin G, Gobeil MF.
Department of Psychology, University of Quebec at Trois-Rivières, Child and Family Development Research Unit, Quebec, Canada.
OBJECTIVE: Shaken Baby Syndrome (SBS) is now recognized as being the main cause of severe traumatic brain injury in infancy. However, our understanding of the impact of this type of abuse on child development remains sketchy. The main objective of the current study was therefore to shed light on the cognitive dysfunctions that are particular to SBS victims once they are school-aged.
METHOD: A clinical group was formed of 11 children diagnosed with SBS who had been admitted between 1988 and 1999 to a tertiary pediatric hospital in Quebec, Canada. The children were matched for age, gender, socio-economic status, and family composition to 11 healthy Quebec children, who made up the control group. A battery of composite tests was developed to assess the children's main cognitive functions and was administered individually to the 22 children. A univariate t-test was used to compare the performances of the two groups.
RESULTS: The mean age of the children in the clinical and control groups at the time of the assessment was 87.64 months and 90.18 months, respectively. Pairing and birth data were equivalent for both groups. Significant weaknesses were noted in the clinical group for intelligence quotient (IQ), working memory, mental organization, alternation, and inhibition. These deficits seemed to have a greater impact on the verbal sphere of the children's mental functioning.
CONCLUSION: Primary results point to the anterior cerebral regions of the brain as the principal site of dysfunctions that persist years post-trauma. It is important to consider these results longitudinally, even in children apparently less extensively affected, since the frontal regions only reach maturity at the end of adolescence.
Traumatic axonal injury in the spinal cord evoked by traumatic brain injury.
Czeiter E, Pal J, Kovesdi E, Bukovics P, Luckl J, Doczi T, Buki A.
Department of Neurosurgery, University of Pécs, Pécs, Hungary.
Although it is well known that traumatic brain injury (TBI) evokes traumatic axonal injury (TAI) within the brain, TBI-induced axonal damage in the spinal cord (SC) has been less extensively investigated. Detection of such axonal injury in the spinal cord would further the complexity of TBI while also challenging some functional neurobehavioral endpoints frequently used to assess recovery in various models of TBI. To assess TAI in the spinal cord associated with TBI, we analyzed the craniocervical junction (CCJ), cervico-thoracic (CT), and thoraco-lumber (ThL) spinal cord in a rodent model of impact acceleration of TBI of varying severities. Rats were transcardially fixed with aldehydes at 2, 6, and 24 h post-injury (n = 36); each group included on sham-injured rodent. Semi-serial vibratome sections were reacted with antibodies targeting TAI via alteration in cytoskeletal integrity or impaired axonal transport. Consistent with previous observations in this model, the CCJ contained numerous injured axons. Immunoreactive, damaged axonal profiles were also detected as caudal, as the ThL spinal cord displayed morphological characteristics entirely consistent with those described in the brainstem and the CCJ. Quantitative analyses demonstrated that the occurrence and extent of TAI is positively associated with the impact/energy of injury and negatively with the distance from the brainstem. These observations show that TBI can evoke TAI in regions remote from the injury site, including the spinal cord itself. This finding is relevant to shaken baby syndrome as well as during the analysis of data in functional recovery in various models of TBI.
Epilepsy associated with shaken baby syndrome.
Bourgeois M, Di Rocco F, Garnett M, Charron B, Boddaert N, Soufflet C, Roujeau T, Zerah M, Sainte-Rose C, Plouin P, Renier D.
Department of Pediatric Neurosurgery, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015, Paris, France. marie.bourgeois@nck.aphp.fr
OBJECT: The shaken baby syndrome (SBS) is an important cause of developmental delay in infants. Epileptic seizures are a common feature of this syndrome. The aim if this study is to analyse the impact of the early and late seizures disorder.
MATERIALS AND METHODS: We have retrospectively reviewed the clinical and electrophysiological findings in a series of 404 children hospitalised with SBS.
RESULTS: In the acute phase, clinical epileptic seizures of various semiologies were found in 73% of the infants. Only 11% of the children had a normal EEG on admission. A poor outcome was found in 88% of the children in case of persisting EEG anomalies despite anti-epileptic treatment with 48% mortality in these patients. The development of refractory epilepsy was also associated with a poor outcome in this series. In fact 96% of the children with seizure recurrence had behavioural problems.
CONCLUSIONS: The early recognition and subsequent management of these seizures is vital to prevent further neurological injury. Delayed or recurrent epileptic seizures may occur with a different semiology to the seizures in the acute phase and are also associated with a poor prognosis.
25: J Perinat Neonatal Nurs. 2008 Jan-Mar;22(1):68-76
Shaken baby syndrome.
Altimier L.
Mercy Anderson Hospital, Cincinnati, Ohio 45255, USA. Laltimier@cinci.rr.com
Non-accidental head trauma in infants is the leading cause of infant death from injury. Clinical features that suggest head trauma (also known as shaken baby syndrome or shaken impact syndrome) include the triad consisting of retinal hemorrhage, subdural, and/or subarachnoid hemorrhage in an infant with little signs of external trauma. Abusive head injuries are among the most common causes of serious and lethal injuries in children. These injuries may result from impact or shaking or a combination of these mechanisms. These mechanisms cause the child's head to undergo acceleration/ deceleration movements, which may create inertial movement of the brain within the cranial compartment.
The nature of shaken baby syndrome injuries and the significance of a "Lucid Interval".
Talbert D.
Institute of Reproductive and Developmental Biology, Imperial College School of Medicine, Du Cane Road, London, England, United Kingdom. gq_zheng@sohu.com
BACKGROUND: The possibility of shaking an infant sufficiently violently to cause brain damage by head rotational acceleration remains controversial and the nature of the anticipated injuries poorly defined. Animal studies of whiplash injuries have revealed two modes of injury; subdural haemorrhage (SDH) and cortex surface injury (CSI). CSI can be induced without SDH with a suitable whiplash impulse, suggesting independent mechanisms. Experimental whiplash injury has been found to bring an immediate cessation of cerebral function (coma) with a threshold approximating to peak velocity (applied accelerationxapplied time). Tangential forces producing brain acceleration are transferred across the subarachnoid space by trabeculae. Their total cross-sectional area is much less than that of the arachnoid and pia surfaces, producing high stress concentrations where trabeculae bond with the pia mater.
HYPOTHESIS: That CSI occurs within the pia-glia formation when astrocytes linking the pia below trabeculae to the cortex fail under the high local stress concentrations. The pia may be locally pulled off the neural tissue, dragging neural tissue with it. Axons will be stretched or broken, thereby immediately disrupting interneuron communications (coma).
CONCLUSION: In contrast to such immediate mechanical injuries, chemical (e.g. hypoxic) insults take time to develop, described as a "lucid interval". Crying requires recognition of a noxious stimulus, and coordination of respiratory and vocal muscles, showing that the infant is not in a coma but in a lucid interval. Therefore, when crying can be heard on 999 or 911 tape recordings the initial event could not have been shaking.
Of 68 articles and letters in their database, I found the 26 (ranked in publication order) of interest:
1: J Emerg Med. 2008 Dec 10.
Retinal hemorrhages and shaken baby syndrome: An evidence-based review.
Togioka BM, Arnold MA, Bathurst MA, Ziegfeld SM, Nabaweesi R, Colombani PM, Chang DC, Abdullah F.
Center for Pediatric Surgical Trials and Outcomes Research, Division of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Background: Among the causes of non-accidental head injury (NAHI), shaken baby syndrome (SBS) is difficult to diagnose and is associated with retinal hemorrhages (RH). Description: To identify findings and patterns of RH specific to SBS, a PubMed search using the keywords "shaken baby syndrome" or "child abuse" and "retinal hemorrhage" was conducted; 66 articles met the inclusion criteria. The published data address the utility of RH in three categories: 1) in diagnosing SBS; 2) as correlated to intracranial pathology; and 3) in prognosticating SBS. The present review aimed to summarize studies in a way that facilitates clinical decision-making.
RESULTS: Studies found a 53-80% incidence of RH with abusive head injury and a 0-10% incidence with proven severe accidental trauma. RHs are found bilaterally 62.5-100% of the time in SBS cases, and flame-shaped hemorrhages are the most common. The incidence of RH from convulsions, chest compressions, forceful vomiting, and severe persistent coughing in the absence of another condition known to cause RH is 0.7%, 0-2.3%, 0%, and 0%, respectively.
CONCLUSION: SBS remains a difficult cause of NAHI to diagnose. Ophthalmologic examination can provide critical diagnostic and prognostic information in cases of suspected SBS. Child abuse should be highly suspect in children with RH and a parental explanation of accidental head injury, especially if the RHs are found to be bilateral, flame-shaped, or to extend through to all layers of the retina.
Related Articles
Postmortem orbital findings in shaken baby syndrome. [Am J Ophthalmol. 2006]
Correlation between retinal abnormalities and intracranial abnormalities in
the shaken baby syndrome. [Am J Ophthalmol. 2002]
Findings in older children with abusive head injury: does shaken-child syndrome exist? [Pediatrics. 2006]
Review Shaken baby syndrome. [Crit Care Nurs Q. 2000]
Review Shaken baby syndrome: identification, intervention, and prevention. [Clin Excell Nurse
Pract. 1999]
2: Graefes Arch Clin Exp Ophthalmol. 2008 Dec 4.
A finite element infant eye model to investigate retinal forces in shaken baby syndrome.
Hans SA, Bawab SY, Woodhouse ML.
Department of Mechanical Engineering, Old Dominion University, 238 Kaufman Hall, Norfolk, VA, 23529-0247, USA, shans001@odu.edu.
BACKGROUND: Shaken baby syndrome (SBS) is a form of abuse in which an infant, typically 6 months or less, is held and submitted to repeated acceleration-deceleration forces. One of the indicators of abuse is bilateral retinal hemorrhaging. A computational model of an infant eye, using the finite element method, is built in order to assess forces at the posterior retina for a shaking and an impact motions.
METHOD: The eye model is based on histological studies, diagrams, and materials from previous literature. Motions are applied to the model to simulate a four-cycle shaking motion in 1 second with maximum extension/flexion of the neck. The retinal forces of the shaking motion, at the posterior eye, are compared to an impact pulse (60G) simulating a fall for a total duration of 100 ms.
RESULTS: The shaking motion, for the first cycle, shows retinal force means at the posterior eye to be around 0.08 N sustained from the time range of 50 to 200 ms, into the shake, with a peak in excess of 0.2 N. The impulse, area under the curve, is 15 N-ms for 250 msec for the first cycle. The impact simulation reveals a mean retinal force around 0.025 N for a time range of 0 to 26 ms, with a peak force around 0.11 N. Moreover, the impulse for the impact simulation is 13 times lower than the shaking motion.
CONCLUSION: The results suggest that shaking alone may be enough to cause retinal hemorrhaging, as there are more sustained and higher forces in the posterior retina, compared to an impact due to a fall. This is in part due to the optic nerve causing more localized stresses in a shaking motion than an impact.
Related Articles
Can shaking alone cause fatal brain injury? A biomechanical assessment of the Duhaime shaken baby syndrome model. [Med Sci Law. 2003]
Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome. [Am J Ophthalmol. 2002]
Review Update on shaken baby syndrome: ophthalmology. [Curr Opin Ophthalmol. 2007] Review Shaken baby syndrome. [Postgrad Med J. 2002]
3: J Dev Behav Pediatr. 2008 Dec;29(6):508-11.
Getting the word out: advice on crying and colic in popular parenting magazines.
Catherine NL, Ko JJ, Barr RG.
Centre for Community Child Health Research, Child and Family Research Institute, Vancouver, BC, Canada.
The objective of this study is to determine whether advice in parenting magazines reflects current evidence-based understanding of early infant crying and colic, where (1) "colic" is the upper end of a spectrum of crying behavior reflective of normal infant development, and (2) physical abuse--in particular, shaken baby syndrome (SBS)--is a serious medical consequence of early crying. All available issues of 11 popular Canadian parenting magazines published between January 2000 and December 2004 were hand-searched and systematically reviewed. Fifty-one articles were found with information on: (1) causes of, (2) responses to, and/or (3) mention of SBS or abuse as a consequence of crying and/or colic. There were 105 specific causes suggested, but almost no agreement concerning the causes of crying and colic. Similarly, there were 231 specific responses to crying and colic mentioned, but little agreement among the suggested responses. For both crying and colic together, the consequence of abuse was mentioned only 7 times, and SBS only twice. Making the advice literature a truly helpful vehicle for parents concerning normal behavioral development and its consequences for their new infant seems to be a significant challenge. Arguably, this is an important shared responsibility of physicians, researchers, and journalists.
Related Articles
Age-related incidence curve of hospitalized Shaken Baby Syndrome cases: convergent evidence for crying as a trigger to shaking. [Child Abuse Negl. 2006]
Differential calming responses to sucrose taste in crying infants with and without colic. [Pediatrics. 1999]
ReviewInfantile colic. [Am Fam Physician. 2004]
Age-related incidence of publicly reported shaken baby syndrome cases: is crying a trigger for shaking? [J Dev Behav Pediatr. 2007]
4: Child Abuse Negl. 2008 Nov;32(11):1017-25.
Secondary analysis of the "Love Me...Never Shake Me" SBS education program.
Deyo G, Skybo T, Carroll A.
College of Nursing, The Ohio State University, Columbus, OH, USA.
OBJECTIVE: Shaken baby syndrome (SBS) is preventable; however, an estimated 21-74 per 100,000 children worldwide are victims annually. This study examined the effectiveness of an SBS prevention program in the US.
METHODS: A descriptive, secondary analysis of the Prevent Child Abuse Ohio (PCAO) "Love Me...Never Shake Me" SBS education program database included 7,051 women who completed a commitment statement, pre and post-test, and follow-up survey.
RESULTS: Participants were mostly White (76%), had at least some college education (62%), were privately insured (62%), and lived with the father and infant (63%). Mothers knew of the dangers of shaking (96%) and recommended SBS education for all parents (98%) because they found it helpful (97%). Scores on the pre and post-tests were significantly different, but there was no difference based on education site or demographics. There was a significant increase in a pre/post-test item pertaining to infant crying. At follow-up, participants remembered postpartum SBS education (98%), but post-discharge did not receive SBS education from their primary care provider (62%). Most mothers practiced infant soothing techniques (79%) provided in the education; however, few women practiced self-coping techniques (36%) and accessed community support services (9%).
CONCLUSIONS: Postpartum SBS prevention education should continue. Development of SBS programs should result from these study findings focusing on education content and program evaluation.
PRACTICE IMPLICATIONS: Mothers report that shaken baby syndrome education is important for all parents and memorable at follow-up. Postpartum SBS education should continue because the hospital is the primary place they receive education. Mothers' report they less frequently receive education from healthcare sources post-discharge. Diligence of primary care providers to incorporate SBS prevention education in well child visits will increase parental exposure to this information. Education may need to place greater emphasis on infant crying and soothing, as well as parent support and self-coping techniques versus the dangers of shaking.
5: MCN Am J Matern Child Nurs. 2008 Nov-Dec;33(6):371-5.Related Articles
Preventing abusive head trauma among infants and young
children: a hospital-based, parent education program. [Pediatrics. 2005]
Creating opportunities for parent empowerment: program effects on the mental
health/coping outcomes of critically ill young children and their mothers.
[Pediatrics. 2004]
Review Shaken baby syndrome: identification, intervention, and
prevention. [Clin Excell Nurse Pract. 1999]
Shaken baby syndrome education program: nurses making a difference.
Smith KM, deGuehery KA.
Shaken Baby Syndrome Education Program, Kaleida Health Women and Children's Hospital of Buffalo, Buffalo, NY, USA. ksmith@kaleidahealth.org
This article describes the nursing role in the Upstate New York Shaken Baby Syndrome (SBS) Education Program, an effort to educate parents of all hospital-born infants in the eight-county region of Western New York about the dangers of violent infant shaking. This program has now been expanded to include hospitals in 17 counties in Upstate New York. The major intervention is an educational program administered by nurses. These nurses describe the challenges and opportunities they faced in implementing a large community health program.
Related Articles6: W V Med J. 2008 Nov-Dec;104(6):22-3.
Preventing abusive head trauma among infants and young children: a hospital-based, parent education program. [Pediatrics. 2005]
Review Understanding shaken baby syndrome. [Adv Neonatal Care. 2004]
Review Shaken baby syndrome: identification, intervention, and prevention. [Clin Excell Nurse Pract. 1999]
Testing educational strategies for Shaken Baby Syndrome.
Bailey M, Gress T, Bolden D, Pfitzer L.
Marshall University School of Medicine, Department of Pediatrics, Huntington, USA.
Shaken Baby Syndrome (SBS) occurs from the violent shaking of an infant, which may lead to brain damage or death. The goal of this study was to assess educational methods used to teach new mothers about SBS.
METHODS: Forty six parents at a community hospital were selected and randomly divided into three groups. Group 1 received a short lesson about SBS. Group 2 received the lesson and watched a locally developed SBS video. Group 3 received the lesson and watched a true dramatization of SBS created by a national organization. Pre and post surveys were administered.
RESULTS: Study groups were similar in regard to age, marital status, socioeconomic status and education. Group 1 parents showed no differences in scoring. Group 2 parents showed a significant increase in defining SBS and what to do for persistent infant crying. Group 3 parents scored significantly higher in defining SBS. CONCLUSION: Both video presentations improved scoring on understanding SBS but only the local video presentation increased scores in the management of persistent infant crying.
Related Articles
Shaken baby syndrome and a baby's cry. [Acta Paediatr. 2008]
Age-related incidence curve of hospitalized Shaken Baby Syndrome cases: convergent evidence for crying as a trigger to shaking. [Child Abuse Negl. 2006]
Review Understanding shaken baby syndrome. [Adv Neonatal Care. 2004]
Review Shaken baby syndrome: identification, intervention, and prevention. [Clin Excell Nurse Pract. 1999]
7: Child Abuse Negl. 2008 Oct;32(10):949-57.
Intervention type matters in primary prevention of abusive head injury: event history analysis results.
Russell BS, Trudeau J, Britner PA.
Worcester State College, Department of Psychology, Worcester, MA 01602, USA.
PURPOSE: The current study sought to compare interventional materials intended to raise public awareness of the caregiving practices connected to Shaken Baby Syndrome (SBS). Two hundred and sixty four adults (mean age 32 years) were recruited for participation through convenience sampling at a large Northeastern university. Participants fell into two groups-those who regularly cared for children (46%) and those who did not (54%).
METHODS: SBS awareness was surveyed prior to an educational intervention and at three times points (2, 6, and 12 weeks post-intervention) longitudinally. Three intervention levels were used: Two different video conditions, each with an informational brochure, and the brochure-only condition. Survey responses were combined into five factor scores. Changes in factor score over time were modeled using event history analysis to predict the conditional probability of change in awareness as a discreet event.
RESULTS: The resulting models show consistent results for three of the five factors, predicting the highest likelihood of increased awareness for a teaching video intervention, followed by a testimonial video, and the lowest probability for increased awareness for the use of an intervention using only a brochure. Negative change, or decreased awareness, was not predicted by the type of intervention materials. Demographic variables were not significant predictors of either positive or negative change.
CONCLUSION: The results indicate that the addition of video materials, and in particular material focusing on teaching alternative behaviors, significantly increases the likelihood of positive changes in SBS awareness over interventions which use only a brochure.
IMPLICATIONS FOR PRACTICE OR RESEARCH: The present study uses a two by three design to describe levels of improved awareness of Shaken Baby Syndrome across two groups of participants (those who regularly care for children and those who do not) and type of educational material (a brochure versus two different videos each in combination with the brochure). Results show a differential effect for each intervention level, and indicate a need for careful selection of educational materials for intervention programs concerned with preventing SBS through public awareness.
Related Articles
A family-based approach to the prevention of depressive symptoms in children at risk: evidence of parental and child change. [Pediatrics. 2003]
Review Psychological and/or educational interventions for the prevention of depression in children and adolescents. [Cochrane Database Syst Rev. 2004]
8: Med Sci Law. 2008 Oct;48(4):346-9
Cervical soft tissue lesions in the shaken infant syndrome: a case report.
Porzionato A, Macchi V, Aprile A, De Caro R.
Section of Anatomy, Department of Human Anatomy and Physiology, University of Padova, Italy.
Cervical soft tissue lesions have rarely been described in the shaken baby syndrome; they include ruptures of intervertebral discs and haemorrhages in the ligamenta flava, and in the interspinal and sternocleidomastoid muscles. We present here the autopsy case of a 30-month old girl who suffered an assault with multiple injury mechanisms, i.e., beating, sexual abuse and shaking trauma. External examination of the neck did not reveal bruises or excoriations, but cervical dissection showed haemorrhagic infiltration of the clavicular head of the sternocleidomastoid muscle, carotid region, posterior musculature of the pharynx and oesophagus, and retro-pharyngeal/oesophageal spaces. These findings were ascribed to the repeated violent movements of shaking trauma. The case presented confirms the occurrence of cervical soft tissue lesions in the shaken baby syndrome and reports injuries which have not previously been described. In suspected cases of shaken baby syndrome, particular attention must be paid to the examination of cervical soft tissue structures.
Related Articles
Incidence of impact trauma with cranial injuries ascribed to shaking. [Am J Dis Child. 1990]
Optic nerve damage in shaken baby syndrome: detection by beta-amyloid precursor protein immunohistochemistry. [Arch Pathol Lab Med. 2000]
Review Anatomy of the shaken baby syndrome. [Anat Rec. 1998]
Review Fall or shaken: traumatic brain injury in children caused by falls or abuse at home - a review on biomechanics and diagnosis. [Neuropediatrics. 2005]
9: Acta Neuropathol. 2008 Sep;116(3):317-29. Epub 2008 Mar 26.
Shaken baby syndrome: re-examination of diffuse axonal injury as cause of death.
Oehmichen M, Schleiss D, Pedal I, Saternus KS, Gerling I, Meissner C.
Institute of Legal Medicine, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany. moehmichen@gmx.de
The discussion surrounding shaken baby syndrome (SBS) arose from the lack of evidence implicating diffuse axonal injury (DAI) as a cause of death. It was assumed instead that injury to the cervical cord, medulla, and nerve roots played a causal role. The present pathomorphological study examines 18 selected infants (<1-year-old)>
Related Articles
Postmortem orbital findings in shaken baby syndrome. [Am J Ophthalmol. 2006]
Axonal injury and the neuropathology of shaken baby syndrome. [Acta Neuropathol. 1998]
Findings in older children with abusive head injury: does shaken-child syndrome exist? [Pediatrics. 2006]
Review Shaken baby syndrome: the quest for evidence. [Dev Med Child Neurol. 2008]
Review Shaken baby syndrome. [Crit Care Nurs Q. 2000]
10: Acta Paediatr. 2008 Jun;97(6):782-5
Shaken baby syndrome and a baby's cry.
Talvik I, Alexander RC, Talvik T.
Children's Clinic of Tartu University Hospital, Tartu, Estonia. inga.talvik@kliinikum.ee
The aim of this study was to investigate the relationship between crying of an infant and inflicted head injury by shaking and/or impact. During the period between January 1, 1997 and December 31, 2003, 26 cases of shaken baby syndrome (SBS) were identified in Estonia. The incidence of SBS was 28.7 per 100,000 children under 1 year of age during the whole study period. In this group there were four children from twin pairs: two twin boys and a girl from a twin pair and a boy from another twin pair. This represents 15.4% of the 26 cases. Twins in Estonia represent 2.12% of infant births. The mean age on admission was 3.9 months. According to outpatient records almost all parents (88.5%) in the study group (23/26) had contacted their family physicians and other specialists because of excessive crying or irritability of the baby prior to the admission to the hospital with SBS or death. We found that the time curve of crying was similar to the curve of highest incidence of cases of SBS except the crying curve began earlier.
CONCLUSION. Our data confirm that the families with twins are at additional risk for SBS and parent's complaints of excessive crying of their infants should be taken as signal that parents need to be carefully counselled.
Related Articles11: Nurs Womens Health. 2008 Jun;12(3):235-9.
Age-related incidence curve of hospitalized Shaken Baby Syndrome cases: convergent evidence for crying as a trigger to shaking. [Child Abuse Negl. 2006]
Age-related incidence of publicly reported shaken baby syndrome cases: is crying a trigger for shaking? [J Dev Behav Pediatr. 2007] Inflicted traumatic brain injury (ITBI) or shaken baby syndrome (SBS) in Estonia. [Acta Paediatr. 2006]
Review Shaken baby syndrome education: a role for nurse practitioners working with families of small children. [J Pediatr Health Care. 2006]
Review Understanding shaken baby syndrome. [Adv Neonatal Care. 2004]
Shaken baby syndrome: facts, education, and advocacy.
Lewin L.
Case Western Reserve University, Frances Payne Bolton School of Nursing, Cleveland, OH, USA. lcl7@case.edu
Related Articles12: Eye. 2008 May;22(5):715-7. Epub 2008 Feb 8.
Review Shaken baby syndrome. [J Perinat Neonatal Nurs. 2008]
Shaken baby syndrome: assessment, intervention, & prevention. [J Psychosoc Nurs Ment Health Serv. 2004] ReviewShaken baby syndrome. [Crit Care Nurs Clin North Am. 2006] Myths and facts...About shaken baby syndrome. [Nursing. 2008]
Natural animal shaking: a model for non-accidental head injury in children?
Serbanescu I, Brown SM, Ramsay D, Levin AV.
Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, Ontaria, Canada.
BACKGROUND: Non-accidental head injury (NAHI) is a form of child abuse where a perpetrator may violently subject an infant to repeated acceleration-deceleration forces with or without head impact, producing injuries including retinal haemorrhages in most cases. Animal models have included laboratory shaking of mice and rats, but only a small fraction develop retinal haemorrhages presumably due to the small eyes, which would require unattainable force levels to mimic that sustained by the infant eye. Animal models are also problematic due to ethical issues raised by subjecting even anaesthetized animals to abusive injury.
METHODS: We investigated a naturally occurring event, where three animal victims were shaken by a canine. The eyes were harvested and examined histologically. RESULTS: The victims' eyes showed no haemorrhage or retinoschisis.
CONCLUSIONS: Our model may not be a complete NAHI mimic. The discrepancies may ensue from anatomical and mechanical differences in the injury mechanism. Other models must be sought to further study this form of abusive eye injury.
Related Articles13: Am J Prev Med. 2008 Apr;34(4 Suppl):S143-7
Postmortem orbital findings in shaken baby syndrome. [Am J Ophthalmol. 2006]
Findings in older children with abusive head injury: does shaken-child syndrome exist? [Pediatrics. 2006]
Perpetrator accounts in infant abusive head trauma brought about by a shaking event. [Child Abuse Negl. 2005]
Review Non-accidental head injury--the evidence. [Pediatr Radiol. 2008]
Evaluating the epidemiology of inflicted traumatic brain injury in infants of U.S. military families.
Ryan MA, Lloyd DW, Conlin AM, Gumbs GR, Keenan HT.
Department of Defense Center for Deployment Health Research, Naval Health Research Center, San Diego, California 92106, USA. margaret.ryan@med.navy.mil
BACKGROUND: Evaluating the incidence of inflicted traumatic brain injuries (inflicted TBI) in young children, and encompassing shaken baby syndrome (SBS) and related injuries, is an epidemiologic challenge. Data available regarding military families in the U.S. may complement other national surveillance efforts.
METHODS: A protocol was developed to assess the epidemiology of inflicted TBI among infants of U.S. military families, integrating data from the Department of Defense Birth and Infant Health Registry, healthcare utilization databases, child abuse reporting systems, and military personnel databases. The in-progress protocol, and its inherent strengths and limitations, are described here.
DISCUSSION: The primary strengths of data from U.S. military families are related to the full characterization of the denominator, such that analyses are person-time and population based. Unique data are available to describe the full population of military parents, including occupational, geographic, and socioeconomic factors, as well as deployment-related potential stressors. The limitations of military data are similar to many other child abuse surveillance systems in that cases are underreported and not fully characterized. Linking abuse reports and medical utilization data to population data, however, will allow unique analyses of "probable" and "possible" cases of inflicted TBI in infants of military families.
CONCLUSIONS: Data from the U.S. military, when appropriately linked and analyzed, provide opportunities to evaluate important risk factors for inflicted TBI in infants. Although epidemiologic challenges may make incidence rates using military data noncomparable to rates using other data sources, multivariate analyses can evaluate critical and unique risk factors, as well as the effectiveness of prevention initiatives.
Related Articles
Review The epidemiology of traumatic brain
injury: a review. [Epilepsia. 2003] Surveillance for traumatic brain injury deaths--United States, 1989-1998. [MMWR Surveill Summ. 2002]
14: Am J Prev Med. 2008 Apr;34(4 Suppl):S134-9
Passive surveillance of shaken baby syndrome using hospital inpatient data.
Wirtz SJ, Trent RB.
Epidemiology and Prevention for Injury Control Branch, California Department of Public Health, Sacramento, California 95899-7377, USA. steve.wirtz@cdph.ca.gov
BACKGROUND: The conference from which these articles came addressed the question of public health surveillance for shaken baby syndrome (SBS) and explores one component of a comprehensive SBS surveillance system that would be relatively easy to implement and maintain: passive surveillance based on hospital inpatient data. Provisional exclusion and inclusion criteria are proposed for a two-level case definition of diagnosed SBS (strict definition) and cases presumed to be SBS (broad definition). The strict SBS definition is based on the single SBS code in the ICD-9-CM (995.55). The broader presumptive SBS definition is based on research studies that have identified a pattern of diagnostic codes often considered part of the clinical diagnosis of SBS.
RESULTS: Based on 2006 analyses, California inpatient data are presented for 1998-2004. The strict SBS definition identified 366 cases over the 7 years, whereas the broader definition captured nearly 1000 cases. Annual rates show little fluctuation from the overall rate of 5.1 for strict SBS and 14.0 for broad SBS (per 100,000 children aged
Related Articles
Age-related incidence curve of hospitalized Shaken Baby
Syndrome cases: convergent evidence for crying as a trigger to shaking. [Child
Abuse Negl. 2006]
15: Am J Prev Med. 2008 Apr;34(4 Suppl):S126-33
Incidence and demography of non-accidental head injury in southeast Scotland from a national database.
Minns RA, Jones PA, Mok JY.
Department of Child Life and Health, University of Edinburgh, Edinburgh, Scotland, United Kingdom. Robert.Minns@ed.ac.uk
BACKGROUND: This study utilized an existing national database of cases of non-accidental head injury (NAHI; also called inflicted traumatic brain injury [inflicted TBI] and shaken baby syndrome [SBS]) in Scotland to report the incidence, confidence intervals, and demography of such cases in Southeast Scotland.
METHODS: This prospective population-based study was conducted from January 1998 to September 2006. Data from the Lothian region of Scotland, where there is known full ascertainment of infant head injuries, including NAHI, have been used to calculate the incidence rate for this region of Scotland, with government statistics providing the normal annual infant population as the denominator. A new Scottish Index of Multiple Deprivation (SIMD), which assesses a very focused area (data zone population size=750) and provides novel information about social demography for education, housing, employment, health, crime, income, and geographic accessibility to services, was applied to the identified cases of NAHI during this study period. RESULTS: The mean incidence of NAHI in southeast Scotland for 8.75 years was 33.8/100,000 infants per year. The cases of NAHI were mostly located in the lowest 1 (or 2) quintiles for all SIMD domains (education, housing, employment, health, crime, income), although they had good accessibility to medical and other community services.
CONCLUSIONS: The incidence rates from this prospective study for NAHI are considerably higher than other published UK surveys and are not considered to reflect a cluster effect. The perpetrators in this study fit a strongly skewed profile aggregating to the lowest socioeconomic groups in the community.
Related Articles
A retrospective epidemiological analysis of non-accidental
head injury in children in Scotland over a 15 year period. [Scott Med J. 1998]
Annual incidence of shaken impact syndrome in young children. [Lancet. 2000]
16: Am J Prev Med. 2008 Apr;34(4 Suppl):S116-9
What are we trying to measure? The problems of case ascertainment.
Reece RM.
Department of Pediatrics, Tufts University School of Medicine, Boston, Massachusetts 02556, USA. rmreecel@aol.com
To determine the incidence of a particular phenomenon, one has to know how that phenomenon is defined. The term "shaken baby syndrome" (SBS) came into general usage in the 1980s, followed by shaken impact syndrome (SIS), inflicted childhood neurotrauma, abusive head trauma (AHT), inflicted traumatic brain injury (inflicted TBI), non-accidental head injury (NAHI), and others. Several means of defining this clinical syndrome have been suggested. Keenan has proposed a research definition. Minns has offered a pure clinical definition, and Livingston and Childs suggest a definition that combines the clinical and radiologic features with the history of events leading to the condition. By using these definitions, eight articles describing SBS, published in the last 20 years, were analyzed for these characteristics. A definition of shaken baby syndrome reflecting the common themes in these clinical reports is offered.
Related Articles17: Am J Prev Med. 2008 Apr;34(4 Suppl):S112-5
Postmortem orbital findings in shaken baby syndrome. [Am J Ophthalmol. 2006]
The challenges of assessing the incidence of inflicted traumatic brain injury: a world perspective.
Runyan DK.
Department of Social Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7240, USA.
OBJECTIVE: Commentary on the methods available for ascertaining the incidence of inflicted traumatic brain injury (inflicted TBI) and the difficulties involved in defining and measuring this condition in young children.
DESIGN: Review of published and unpublished international data regarding parental shaking of infants compared to studies assessing incidence.
RESULTS: Review of parental report data reveal that the shaking of young children is a surprisingly common act in a wide variety of countries and cultures. While 2.6% of parents of children aged under 2 years in the U.S. report shaking their child as an act of "discipline," survey data from lesser-developed countries on four continents indicate that shaking, as a form of discipline, may be many times more common among infants in their countries and that the consequences, short of hospitalization or death, are inadequately studied. Methodologic challenges to epidemiologic work to develop better estimates are discussed.
CONCLUSIONS: These data highlight the challenges faced in ascertaining the epidemiology of inflicted TBI in young children. While there is scientific evidence that the shaking of young children can produce profound destruction of children's brains and lives, these data reveal that there are many other children who are shaken by their caregivers but escape the acute clinical presentation of "shaken baby syndrome" or for whom the injuries are not recognized as due to inflicted TBI. The impact of these private acts must be further studied as there may be other long-lasting and serious intracranial impacts that have not been characterized.
Related Articles18: Am J Prev Med. 2008 Apr;34(4 Suppl):S103-5
A population-based study of inflicted traumatic brain injury in young children. [JAMA. 2003]
Analysis of perpetrator admissions to inflicted traumatic brain injury in children. [Arch Pediatr Adolesc Med. 2004]
Review Biochemical markers of brain injury: could they be used as diagnostic adjuncts in cases of inflicted traumatic brain injury? [Child Abuse Negl. 2004]
Review Rehabilitation of persons with traumatic brain injury. [NIH Consens Statement. 1998]
Epidemiology the major missing element in the global response to child maltreatment?
Butchart A.
Department of Injuries and Violence Prevention, Noncommunicable Diseases, and Mental Health, World Health Organization, Geneva, Switzerland. butcharta@who.int
Related Articles19: ANS Adv Nurs Sci. 2008 Apr-Jun;31(2):E1-8
Review Update on child maltreatment with a special focus on shaken baby syndrome. [Curr Opin Pediatr. 2005]
How to recognize shaken baby syndrome (SBS). [J Okla State Med Assoc. 2004]
Shaken baby syndrome: assessment, intervention, & prevention. [J Psychosoc Nurs Ment Health Serv. 2004]
Review Update on child maltreatment. [Curr Opin Pediatr. 2008]
Inflicted childhood neurotrauma.
Fiske EA, Hall JM.
Carson-Newman College, Jefferson City, Tennessee 37760, USA. efiske@cn.edu
In this article, we review literature related to inflicted childhood neurotrauma (ICN). We discuss the rationale for use of the term "ICN," rather than the more benign, commonly used "shaken baby syndrome." The change in language alters the discourse about a potentially lethal outcome or lifelong problem for survivors. A description of ICN is followed by a discussion of ethical parameters and obligations of those who care for infants and children and professionals who are sentinels to these events such as law enforcement officials, nurses, physicians, and social workers.
Related Articles20: Biomech Model Mechanobiol. 2008 Apr;7(2):105-25. Epub 2007 Mar 2
Shaken baby syndrome: assessment, intervention, & prevention. [J Psychosoc Nurs Ment Health Serv. 2004]
Infant brain subjected to oscillatory loading: material differentiation, properties, and interface conditions.
Couper Z, Albermani F.
School of Engineering, University of Queensland, Brisbane 4072, Australia. z.couper@uq.edu.au
Past research into brain injury biomechanics has focussed on short duration impulsive events as opposed to the oscillatory loadings associated with Shaken Baby Syndrome (SBS). A series of 2D finite element models of an axial slice of the infant head were created to provide qualitative information on the behaviour of the brain during shaking. The test series explored variations in subarachnoid cerebrospinal fluid (CSF) representation, brain matter stiffness, dissipation, and nonlinearity, and differentiation of brain matter type. A new method of CSF modelling based on Reynolds lubrication theory was included to provide a more realistic brain-CSF interaction. The results indicate that solid CSF representation for this load regime misrepresents the phase lag of displacement, and that the volume of subarachnoid CSF, and inclusion of thickness variations due to gyri, are important to the resultant behavior. Stress concentrations in the deep brain are reduced by fluid redistribution and gyral contact, while inclusion of the pia mater significantly reduces cortex contact strains. These results provide direction for future modelling of SBS.
Related Articles21: Curr Opin Pediatr. 2008 Apr;20(2):205-12
Rigid-body modelling of shaken baby syndrome. [Proc Inst Mech Eng [H]. 2005]
Can shaking alone cause fatal brain injury? A biomechanical assessment of the Duhaime shaken baby syndrome model. [Med Sci Law. 2003]
Shaken baby syndrome: a biomechanics analysis of injury mechanisms. [Forensic Sci Int. 2005]
Review Case analysis of brain-injured admittedly shaken infants: 54 cases, 1969-2001 [Am J Forensic Med Pathol. 2005]
Update on child maltreatment.
Newton AW, Vandeven AM.
Department of Pediatrics, Harvard Medical School, Child Protection Program, Children's Hospital, Child Protection Consultation Program, Massachusetts General Hospital, Boston, Massachusetts 02115, USA. alice.newton@childrens.harvard.edu
PURPOSE OF REVIEW: The authors discuss the significance of studies published over the previous year regarding assessment and treatment and prevention of child maltreatment, including physical and sexual abuse, inflicted traumatic brain injury, and child neglect.
RECENT FINDINGS: The evidence base for many forms of child abuse is growing. As clinicians begin to understand the factors which may increase child vulnerability to abuse, more sophisticated and focused prevention efforts are being implemented. In response to a very public reprimand by the General Medical Council of two child abuse pediatricians, which was felt by many to be unwarranted, the UK government re-emphasized its commitment to the protection of children. In the US, this well-publicized set of events has renewed the medical community's commitment to the recognition of child abuse pediatrics as a formal subspecialty. Several authors detail the short-term and long-term outcome of varying forms of abuse for children as they grow into adults, reinforcing the importance of community efforts to prevent abuse and support families during times of heightened stress such as the current war in Iraq.
SUMMARY: The short-term and long-term impact of child maltreatment is significant not only for individuals, but for families and communities where abuse is taking place. General pediatricians have an important role to play with families and in the community as advocates for the protection of children.
Related Articles22: Child Abuse Negl. 2008 Mar;32(3):415-28
Review Update on child maltreatment. [Curr Opin Pediatr. 2007]
Review Update on child maltreatment with a special focus on shaken baby syndrome. [Curr Opin Pediatr. 2005]
Family pediatrics: report of the Task Force on the Family. [Pediatrics. 2003] Preventive health care, 2000 update: prevention of child maltreatment. [CMAJ. 2000] Review An update on child abuse and neglect. [Curr Opin Pediatr. 2004]
Comparative study of the cognitive sequelae of school-aged victims of Shaken Baby Syndrome.
Stipanicic A, Nolin P, Fortin G, Gobeil MF.
Department of Psychology, University of Quebec at Trois-Rivières, Child and Family Development Research Unit, Quebec, Canada.
OBJECTIVE: Shaken Baby Syndrome (SBS) is now recognized as being the main cause of severe traumatic brain injury in infancy. However, our understanding of the impact of this type of abuse on child development remains sketchy. The main objective of the current study was therefore to shed light on the cognitive dysfunctions that are particular to SBS victims once they are school-aged.
METHOD: A clinical group was formed of 11 children diagnosed with SBS who had been admitted between 1988 and 1999 to a tertiary pediatric hospital in Quebec, Canada. The children were matched for age, gender, socio-economic status, and family composition to 11 healthy Quebec children, who made up the control group. A battery of composite tests was developed to assess the children's main cognitive functions and was administered individually to the 22 children. A univariate t-test was used to compare the performances of the two groups.
RESULTS: The mean age of the children in the clinical and control groups at the time of the assessment was 87.64 months and 90.18 months, respectively. Pairing and birth data were equivalent for both groups. Significant weaknesses were noted in the clinical group for intelligence quotient (IQ), working memory, mental organization, alternation, and inhibition. These deficits seemed to have a greater impact on the verbal sphere of the children's mental functioning.
CONCLUSION: Primary results point to the anterior cerebral regions of the brain as the principal site of dysfunctions that persist years post-trauma. It is important to consider these results longitudinally, even in children apparently less extensively affected, since the frontal regions only reach maturity at the end of adolescence.
Related Articles23: J Neurotrauma. 2008 Mar;25(3):205-13
Medical and cognitive outcome in children with traumatic brain injury. [Can J Neurol Sci. 2004]
Late neurologic and cognitive sequelae of inflicted traumatic brain injury in infancy. [Pediatrics. 2005]
Shaken baby syndrome in Canada: clinical characteristics and outcomes of hospital cases. [CMAJ. 2003]
Traumatic axonal injury in the spinal cord evoked by traumatic brain injury.
Czeiter E, Pal J, Kovesdi E, Bukovics P, Luckl J, Doczi T, Buki A.
Department of Neurosurgery, University of Pécs, Pécs, Hungary.
Although it is well known that traumatic brain injury (TBI) evokes traumatic axonal injury (TAI) within the brain, TBI-induced axonal damage in the spinal cord (SC) has been less extensively investigated. Detection of such axonal injury in the spinal cord would further the complexity of TBI while also challenging some functional neurobehavioral endpoints frequently used to assess recovery in various models of TBI. To assess TAI in the spinal cord associated with TBI, we analyzed the craniocervical junction (CCJ), cervico-thoracic (CT), and thoraco-lumber (ThL) spinal cord in a rodent model of impact acceleration of TBI of varying severities. Rats were transcardially fixed with aldehydes at 2, 6, and 24 h post-injury (n = 36); each group included on sham-injured rodent. Semi-serial vibratome sections were reacted with antibodies targeting TAI via alteration in cytoskeletal integrity or impaired axonal transport. Consistent with previous observations in this model, the CCJ contained numerous injured axons. Immunoreactive, damaged axonal profiles were also detected as caudal, as the ThL spinal cord displayed morphological characteristics entirely consistent with those described in the brainstem and the CCJ. Quantitative analyses demonstrated that the occurrence and extent of TAI is positively associated with the impact/energy of injury and negatively with the distance from the brainstem. These observations show that TBI can evoke TAI in regions remote from the injury site, including the spinal cord itself. This finding is relevant to shaken baby syndrome as well as during the analysis of data in functional recovery in various models of TBI.
24: Childs Nerv Syst. 2008 Feb;24(2):169-72; discussion 173Related Articles
Impaired axonal transport and altered axolemmal permeability occur in distinct populations of damaged axons following traumatic brain injury. [Exp Neurol. 2004] Review All roads lead to disconnection?--Traumatic axonal injury revisited. [Acta Neurochir (Wien). 2006]
Epilepsy associated with shaken baby syndrome.
Bourgeois M, Di Rocco F, Garnett M, Charron B, Boddaert N, Soufflet C, Roujeau T, Zerah M, Sainte-Rose C, Plouin P, Renier D.
Department of Pediatric Neurosurgery, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015, Paris, France. marie.bourgeois@nck.aphp.fr
OBJECT: The shaken baby syndrome (SBS) is an important cause of developmental delay in infants. Epileptic seizures are a common feature of this syndrome. The aim if this study is to analyse the impact of the early and late seizures disorder.
MATERIALS AND METHODS: We have retrospectively reviewed the clinical and electrophysiological findings in a series of 404 children hospitalised with SBS.
RESULTS: In the acute phase, clinical epileptic seizures of various semiologies were found in 73% of the infants. Only 11% of the children had a normal EEG on admission. A poor outcome was found in 88% of the children in case of persisting EEG anomalies despite anti-epileptic treatment with 48% mortality in these patients. The development of refractory epilepsy was also associated with a poor outcome in this series. In fact 96% of the children with seizure recurrence had behavioural problems.
CONCLUSIONS: The early recognition and subsequent management of these seizures is vital to prevent further neurological injury. Delayed or recurrent epileptic seizures may occur with a different semiology to the seizures in the acute phase and are also associated with a poor prognosis.
25: J Perinat Neonatal Nurs. 2008 Jan-Mar;22(1):68-76
Shaken baby syndrome.
Altimier L.
Mercy Anderson Hospital, Cincinnati, Ohio 45255, USA. Laltimier@cinci.rr.com
Non-accidental head trauma in infants is the leading cause of infant death from injury. Clinical features that suggest head trauma (also known as shaken baby syndrome or shaken impact syndrome) include the triad consisting of retinal hemorrhage, subdural, and/or subarachnoid hemorrhage in an infant with little signs of external trauma. Abusive head injuries are among the most common causes of serious and lethal injuries in children. These injuries may result from impact or shaking or a combination of these mechanisms. These mechanisms cause the child's head to undergo acceleration/ deceleration movements, which may create inertial movement of the brain within the cranial compartment.
Related Articles26: Med Hypotheses. 2008;71(1):117-21. Epub 2008 Mar 25
Review Shaken baby syndrome. [Orthop Nurs. 2003]
Review Nonaccidental head trauma in infants. [Childs Nerv Syst. 2007]
Review Shaken baby syndrome education: a role for nurse practitioners working with families of small children. [J Pediatr Health Care. 2006]
Shaken baby syndrome: assessment, intervention, & prevention. [J Psychosoc Nurs Ment Health Serv. 2004]
The nature of shaken baby syndrome injuries and the significance of a "Lucid Interval".
Talbert D.
Institute of Reproductive and Developmental Biology, Imperial College School of Medicine, Du Cane Road, London, England, United Kingdom. gq_zheng@sohu.com
BACKGROUND: The possibility of shaking an infant sufficiently violently to cause brain damage by head rotational acceleration remains controversial and the nature of the anticipated injuries poorly defined. Animal studies of whiplash injuries have revealed two modes of injury; subdural haemorrhage (SDH) and cortex surface injury (CSI). CSI can be induced without SDH with a suitable whiplash impulse, suggesting independent mechanisms. Experimental whiplash injury has been found to bring an immediate cessation of cerebral function (coma) with a threshold approximating to peak velocity (applied accelerationxapplied time). Tangential forces producing brain acceleration are transferred across the subarachnoid space by trabeculae. Their total cross-sectional area is much less than that of the arachnoid and pia surfaces, producing high stress concentrations where trabeculae bond with the pia mater.
HYPOTHESIS: That CSI occurs within the pia-glia formation when astrocytes linking the pia below trabeculae to the cortex fail under the high local stress concentrations. The pia may be locally pulled off the neural tissue, dragging neural tissue with it. Axons will be stretched or broken, thereby immediately disrupting interneuron communications (coma).
CONCLUSION: In contrast to such immediate mechanical injuries, chemical (e.g. hypoxic) insults take time to develop, described as a "lucid interval". Crying requires recognition of a noxious stimulus, and coordination of respiratory and vocal muscles, showing that the infant is not in a coma but in a lucid interval. Therefore, when crying can be heard on 999 or 911 tape recordings the initial event could not have been shaking.
Related Articles
Review Shaken baby syndrome: the quest for evidence. [Dev Med Child Neurol. 2008] Review Shaken baby syndrome. [Postgrad Med J. 2002]
Review Shaken baby syndrome. [J Perinat Neonatal Nurs. 2008]
Saturday, December 27, 2008
Research published in the British Medical Journal suggests that heavy metal fans engage in "head-banging" behavior that risks self-inflicted brain injuries, and offers a biomechanical model to explain why...
There are obvious parallels with SBS.
As the authors note in the article:
A summary from Cosmos magazine:
There are obvious parallels with SBS.
As the authors note in the article:
Young people at heavy metal concerts often report being dazed and confused, possible symptoms of mild traumatic brain injury. Little formal injury research has been conducted on the world wide phenomenon of head banging, even though case reports indicate the inherent risks in this activity, especially in head and neck injury.The authors offer some tongue in cheek prescriptions for prevention - training programs before concerts, "personal protective gear" or substitution of music by Michael Bolton...
A summary from Cosmos magazine:
Head-banging a health hazard
Thursday, 18 December 2008Agence France-Presse
Headbanging hurts: Be careful of your range of motion when rocking along to metal music, or you could end up injured, new research says.
Credit: DarkLight Nocturnal Entertainment
PARIS: Head-banging to heavy metal music can be hazardous to your health, researchers have found.
In the first-ever study of its kind, published this week in the British Medical Journal, metal aficionados jerking their heads up and down to a fast and furious beat are found to be at risk of everything from whiplash to strokes.
Modelling the technique
Australian risk and safety researchers Declan Patton and Andrew McIntosh, from the University of New South Wales in Sydney, attended hard rock and heavy metal concerts to observe head-banging techniques.
They then worked up a biomechanical analysis, culminating in a "theoretical head-banging model".
In their offbeat study the pair said that thrashing about to the music may cause similar effects to whiplash.
Tuesday, December 23, 2008
Lest anyone doubt there is reason to support education and awareness about post-partum depression, consider this article from the UK...
What you can do: support the Melanie-Blocker Stokes Mothers Act when it's reintroduced in the next Congress. Here's Katstone with suggestions...
'Baby blues' mother killed her son weeks after he left care
By Andrew Levy
Last updated at 2:04 AM on 23rd December 2008
A mother suffering from post-natal depression killed her baby son just weeks after social services took him out of foster care and handed him back to her.
Joanne Mallinder, 37, considered putting Jack up for adoption and asked for him to be taken into care even before he was born.
However, she changed her mind after the birth and they were reunited a month later.
Eight weeks on, she shook three-month-old Jack so hard that he suffered massive, irreparable brain damage, a jury heard.
He died from his injuries in hospital 13 months later.
What you can do: support the Melanie-Blocker Stokes Mothers Act when it's reintroduced in the next Congress. Here's Katstone with suggestions...
Monday, December 22, 2008
There sure are a lot of brochures out there...
There are a lot of brochures out there that are intended to increase awareness of shaken baby syndrome. The US and Canada being the cross-cultural melting pots that they are, some aren't in English.
In addition to providing some links to non-English brochures and resource materials, I thought it would be interesting to (1) spotlight some of the sources and (2) see how many different languages I can find that have a term for SBS.
Sources and Resources
The Ontario Neurotrauma Foundation's SBS Prevention Project offers "comforting cards" in (deep breath) English, Arabic, Bengali, Chinese, Farsi, French, Greek, Hindu, Italian, Korean, Oji-Cree, Ojibwe, Polish, Portuguese, Punabi, Russian, Somali, Spanish, Tagalog, Tamil, Urdu (great job, guys!)
Alberta's Health In Action offers crying/SBS brochures in Mandarin Chinese, Traditional Chinese, Farsi, French, Hindi, Korean, Punjabi, Sanish, Urdu and Vietnamese
The Minnesota Department of Health offers a variety of SBS prevention materials, including crying cards in English, Spanish, Hmong and Somali
The New York State Department of Health offers a simple SBS brochure in English, Spanish, Chinese and Russian, as does the Office of Children and Family Services, which also offers one in Arabic.
L'Association Française de Parents de Bébé Secoué
So far, it seems Shaken Baby Syndrome translates into:
Polish - zespół dziecka potrząsanego
Spanish - el síndrome del bebé sacudido
French - le Syndrome du Bébé Secoué
Danish - ruskevold mod spædbørn
Estonian - Raputatud lapse sündroom
German - Schütteltrauma
Italian - Sindrome del bambino scosso
Finnish - Ravistellun vauvan oireyhtymä
Hebrew - name transliterates to "tismonet ha-tinuk ha-minu-ar" or תסמונת התינוק המנוער. (Thanks to Israel's National Council for the Child!)
Norwegian - Kraftig filleristingssyndrom (thanks to Arne Stray-Pedersen)
Arabic - متلازمة الطفل المهزوز
Korean
Japanese (sorry, I lack the appropriate character sets for Japanese and Korean)
If you have other languages to add, please leave a comment or email:SkipperVigil@yahoo.com
In addition to providing some links to non-English brochures and resource materials, I thought it would be interesting to (1) spotlight some of the sources and (2) see how many different languages I can find that have a term for SBS.
Sources and Resources
The Ontario Neurotrauma Foundation's SBS Prevention Project offers "comforting cards" in (deep breath) English, Arabic, Bengali, Chinese, Farsi, French, Greek, Hindu, Italian, Korean, Oji-Cree, Ojibwe, Polish, Portuguese, Punabi, Russian, Somali, Spanish, Tagalog, Tamil, Urdu (great job, guys!)
Alberta's Health In Action offers crying/SBS brochures in Mandarin Chinese, Traditional Chinese, Farsi, French, Hindi, Korean, Punjabi, Sanish, Urdu and Vietnamese
The Minnesota Department of Health offers a variety of SBS prevention materials, including crying cards in English, Spanish, Hmong and Somali
The New York State Department of Health offers a simple SBS brochure in English, Spanish, Chinese and Russian, as does the Office of Children and Family Services, which also offers one in Arabic.
L'Association Française de Parents de Bébé Secoué
So far, it seems Shaken Baby Syndrome translates into:
Polish - zespół dziecka potrząsanego
Spanish - el síndrome del bebé sacudido
French - le Syndrome du Bébé Secoué
Danish - ruskevold mod spædbørn
Estonian - Raputatud lapse sündroom
German - Schütteltrauma
Italian - Sindrome del bambino scosso
Finnish - Ravistellun vauvan oireyhtymä
Hebrew - name transliterates to "tismonet ha-tinuk ha-minu-ar" or תסמונת התינוק המנוער. (Thanks to Israel's National Council for the Child!)
Norwegian - Kraftig filleristingssyndrom (thanks to Arne Stray-Pedersen)
Arabic - متلازمة الطفل المهزوز
Korean
Japanese (sorry, I lack the appropriate character sets for Japanese and Korean)
If you have other languages to add, please leave a comment or email:SkipperVigil@yahoo.com
Sunday, December 21, 2008
Might there be a tiny duplication of effort in the SBS awareness effort?
A Google search for the terms ["shaken baby" brochure] returned 8100 hits.
I think it good news that only 103 of those references appear to contain the term "shake your baby" (presumably as in 'never shake your baby'), which I think is a frame of reference best avoided, but not so good that only 35 contain the term "protect your baby"...
We'll see how things progress...
BTW: It doesn't account for a host of variables that skew results, but looking at the Google News archive, it's a bit surprising that news coverage with the term "shaken baby" peaked in 1997, and now seems to have dropped down a bit to 1995 levels.
A Google search for the terms ["shaken baby" brochure] returned 8100 hits.
I think it good news that only 103 of those references appear to contain the term "shake your baby" (presumably as in 'never shake your baby'), which I think is a frame of reference best avoided, but not so good that only 35 contain the term "protect your baby"...
We'll see how things progress...
BTW: It doesn't account for a host of variables that skew results, but looking at the Google News archive, it's a bit surprising that news coverage with the term "shaken baby" peaked in 1997, and now seems to have dropped down a bit to 1995 levels.
Many brochures attribute the "cause" of Shaken Baby Syndrome to crying, as in this example.
Inconsolable crying is the most common precipitating factor, but the cause is the frustration of a caregiver unable to control the behavior of a crying baby and the stress that follows upon it.
Perceived control is an important social determinant of health. Scientific American reports on an update on the Whitehall study, which found that the lack of control an employee has over his work was far more predictive of premature death than the workload or responsibilities of the position.
The update details the mechanisms responsible for those consequences. I can readily imagine similar biological consequences result from the stress of dealing with the frustration of taking care of an infant with inconsolable crying, coupled with lack of sleep and the uncertainties all new parents face.
Hopefully, there will be more research on the interaction between infant behaviors, such as colic or inconsolable crying, and the stress and control behaviors that result in their caregivers. Not only should it result in better coping strategies, but a better understanding of the variables in caregivers and ways to effectively communicate those strategies and influence behavior.
Inconsolable crying is the most common precipitating factor, but the cause is the frustration of a caregiver unable to control the behavior of a crying baby and the stress that follows upon it.
Perceived control is an important social determinant of health. Scientific American reports on an update on the Whitehall study, which found that the lack of control an employee has over his work was far more predictive of premature death than the workload or responsibilities of the position.
The update details the mechanisms responsible for those consequences. I can readily imagine similar biological consequences result from the stress of dealing with the frustration of taking care of an infant with inconsolable crying, coupled with lack of sleep and the uncertainties all new parents face.
Hopefully, there will be more research on the interaction between infant behaviors, such as colic or inconsolable crying, and the stress and control behaviors that result in their caregivers. Not only should it result in better coping strategies, but a better understanding of the variables in caregivers and ways to effectively communicate those strategies and influence behavior.
In January researchers—following up with the Whitehall II study, begun in the 1980s—unveiled fresh details about the mechanisms underlying the now firmly established links among low job control, stress and high cardiovascular disease. They found that fully a third of an individual’s total risk for heart disease stemmed from stress-related unhealthy behaviors, such as poor diet, smoking and lack of exercise, as well as lifestyle-influenced conditions such as high blood pressure and blood glucose. The other two thirds of risk was attributable to direct biological wear and tear from living constantly in fight-or-flight mode.
The European Heart Journal published the findings online January 23.
Saturday, December 20, 2008
The Sarah Jane Brain Foundation has been taking some innovative and exciting steps to support research that will help children who suffer pediatric brain injuries.
Today, they announced the formation of a legal advisory board.
Today, they announced the formation of a legal advisory board.
The Sarah Jane Brain Foundation, a non-profit organization whose mission is to assist in the research of new developments for children suffering from pediatric acquired brain injury (PABI) and the rehabilitation of these children, today announced the formation of a Legal, Regulatory and Finance Committee of its National Advisory Board. This Legal Committee will join the other Members of the National Advisory Board on January 8-9 in New York City to participate in the first National Acquired Brain Injury (PABI) Conference and Dinner (see below invitation).
The goals of the Legal Committee will be to review all of the legal, regulatory and financial issues facing the millions of children and their families suffering from PABI and the critical issues to implement and fund the first-ever National PABI Plan (criminal justice, family law, special education, Medicaid/health insurance, estate planning, personal injury/tort law, intellectual property/personal privacy, medical and bioethics, and many more).
Friday, December 19, 2008
The Providentia blog notes some interesting research on the utility of educational materials in SBS awareness activities....
http://www.typepad.com/services/trackback/6a00d834523c1e69e2010535ef0d01970c
Dealing with Shaken Baby Syndrome
A study in the November 2008 issue of Child Abuse and Neglect examines the value of prevention measures designed to raise public awareness of the caregiving practices connected to Shaken Baby Syndrome (SBS).
A sample of 264 adults (mean age 32 years) were recruited for participation at a large Northeastern university. Participants fell into two groups-those who regularly cared for children 46% and those who did not 54% . The researchers surveyed SBS awareness in the subjects prior to an educational intervention and at three times points 2, 6, and 12 weeks post-intervention longitudinally. Three intervention levels were used: Two different video conditions, each with an informational brochure, and the brochure-only condition. Survey responses were combined into five factor scores.
Analysis of survey results showed show consistent results for three of the five factors, predicting the highest likelihood of increased awareness for a teaching video intervention, followed by a testimonial video, and the lowest probability for increased awareness for the use of an intervention using only a brochure. Negative change, or decreased awareness, was not predicted by the type of intervention materials. Demographic variables were not significant predictors of either positive or negative change.
The researchers concluded that the addition of video materials, and in particular material focusing on teaching alternative behaviors, significantly increases the likelihood of positive changes in SBS awareness over interventions which use only a brochure. These results indicate a need for careful selection of educational materials for intervention programs concerned with preventing SBS through public awareness.My comment:
An interesting study, but there's more to be learned.
By way of background, an educational video was part of a program developed by Dr. Mark Dias to educate new parents about Shaken Baby Syndrome in the Buffalo area. It started in 1998 and since local hospitals incorporated the education program, the incidence of inflicted head injuries has dropped by 50%.
The program is being extended statewide this year in New York (if the funds in the budget aren't cut), and ten other states have adopted legislation to require hospitals to offer new parents the opportunity to learn how to keep their child safe.
Three things of note:
- participation is voluntary, and the rate depends on how well the nurse educators "frame" the video: "preventing injury" works much better than "preventing child abuse"
- the video used in NY ("Portrait of Promise") includes two surviving children. Seeing the consequences in terms of a child with inflicted injury seems more memorable than seeing a tombstone.
- while it is quite successful overall in reducing injury, there are at least 5 reports I've seen where a father has reportedly been shown the video and still has inflicted injury. There are many possible explanations: he may just have signed the form; he may have been in the room when the video was shown, but not watched it; he may have watched it, but not "got" the message about being prepared to cope with frustration; or he may have ignored it (a variation on the "I'm a good driver so I don't need to use a seat belt" guy style).
It would a very useful thing if more research could be done on the male response to this educational effort in particular, and early childhood education in general (for instance, recognizing potential signs of ASD and the importance of early intervention).
Do all/many/some men just tune these efforts out? Are there better ways to engage those men? (it's not your driving I'm worried about, honey - it's those bad drivers you're always pointing out to me...)
PS. Is there any website that offers psychology students suggestions on real-world research topics that they could explore?
http://www.typepad.com/services/trackback/6a00d834523c1e69e2010535ef0d01970c
Thursday, December 18, 2008
The Health section of our local newspaper, the Middletown Record, has a good article today on preventing Shaken Baby Syndrome.
It was written by Dr. Robin Altman, chief of general pediatrics at Maria Fareri Children's Hospital at Westchester Medical Center and one of the principals of the Hudson Valley SBS Prevention Initiative.
For more info, visit www.worldclassmedicine.com/shakenbaby.
It was written by Dr. Robin Altman, chief of general pediatrics at Maria Fareri Children's Hospital at Westchester Medical Center and one of the principals of the Hudson Valley SBS Prevention Initiative.
For more info, visit www.worldclassmedicine.com/shakenbaby.
Tuesday, December 16, 2008
Time magazine gives some context to the recent Lancet study on the incidence of abuse, and the difficulty of getting accurate statistics...
Unfortunately, the article only mentions prevention in passing:
The Lancet has a series of articles on incidence and treatment of child abuse. There is one on injury prevention, and the abstract for this survey of prevention techniques sounds interesting:
Based on a review of research conducted on child abuse between 2000 and June of this year, researchers estimate that 4% to 16% of children are physically abused each year in high-income nations, including the United States, United Kingdom, Australia and Canada. As many as 15% are neglected, and up to 10% of girls and 5% of boys suffer severe sexual abuse; many more are victims of other sexual injury. Yet researchers say that as few as 1 in 10 of those instances of abuse are actually confirmed by social-service agencies — and that measuring the exact scope of the problem is nearly impossible.
The issue lies in the delicate nature of the crimes — and the consequences of intervention. Many cases of abuse are rife with potential for long-term harm of the child, whether or not the assault is reported. The decision to report is rarely clear-cut, says Theresa Costello, director of the National Resource Center for Child Protective Services, who was not involved with the new research. "Professionals want to advocate for their clients, but they also know the reality of the public child-welfare system," she says. "There is a natural professional dilemma when you see a kid and you think, 'I should make a report,' but you're not sure you want to subject that child to the system."
Indeed, the second study in the Lancet analysis, citing previous research, reveals that physicians reported only 6% of children's injury cases to protective services, even though they suspected the injury was a result of abuse 10% of the time. Further, researchers say that many more cases of maltreatment — particularly of sexual abuse — are never even suspected, and the victimized children never come forward to report the assaults.
"The official statistics agencies produce are conservative estimates of probably the lowest level of child maltreatment," says Dr. Cathy Spatz Widom, a psychology professor at John Jay College of Criminal Justice, who specializes in the long-term effects of child abuse and is a lead author on one of the Lancet studies.
Unfortunately, the article only mentions prevention in passing:
The ultimate goal is to prevent abuse in the first place, says Widom, and to protect the well-being of children who have been victimized. "It would be wrong to assume that all maltreated children are going to turn out to have all of these problems," she says.
The Lancet has a series of articles on incidence and treatment of child abuse. There is one on injury prevention, and the abstract for this survey of prevention techniques sounds interesting:
The Lancet, Early Online Publication, 3 December 2008
doi:10.1016/S0140-6736(08)61708-0
Interventions to prevent child maltreatment and associated impairment
Prof Harriet L MacMillan MD a , C Nadine Wathen PhD b, Prof Jane Barlow DPhil c, Prof David M Fergusson PhD d, Prof John M Leventhal MD e, Heather N Taussig PhD f
Summary
Although a broad range of programmes for prevention of child maltreatment exist, the effectiveness of most of the programmes is unknown.
Two specific home-visiting programmes—the Nurse—Family Partnership (best evidence) and Early Start—have been shown to prevent child maltreatment and associated outcomes such as injuries. One population-level parenting programme has shown benefits, but requires further assessment and replication. Additional in-hospital and clinic strategies show promise in preventing physical abuse and neglect.
However, whether school-based educational programmes prevent child sexual abuse is unknown, and there are currently no known approaches to prevent emotional abuse or exposure to intimate-partner violence. A specific parent-training programme has shown benefits in preventing recurrence of physical abuse; no intervention has yet been shown to be effective in preventing recurrence of neglect. A few interventions for neglected children and mother—child therapy for families with intimate-partner violence show promise in improving behavioural outcomes.
Cognitive-behavioural therapy for sexually abused children with symptoms of post-traumatic stress shows the best evidence for reduction in mental-health conditions. For maltreated children, foster care placement can lead to benefits compared with young people who remain at home or those who reunify from foster care; enhanced foster care shows benefits for children.
Future research should ensure that interventions are assessed in controlled trials, using actual outcomes of maltreatment and associated health measures.
One day's worth of SBS cases, from Google News (duplicates from Florida, but Montana, Ohio, California, Indiana...
Searching for shaking baby:
Searching for "shaken baby"
Searching for shaking baby:
Trial Begins For Man Accused of Shaking Baby to Death
WOKV, FL - 23 minutes ago
Prosecutor Brian Aull told the court that Vessey admitted shaking the girl because she was crying. "After saying that he didn't for an hour, ...
Murder Trial Begins For Dad Accused Of Killing Baby
News4Jax.com, FL - 59 minutes ago
Testimony began on Tuesday in the murder trial for a father who police said admitted to shaking his baby daughter because she was crying. ...
Trial begins for Jacksonville NAS sailor in baby's death
Florida Times-Union, FL - 5 hours ago
By Paul Pinkham Former Jacksonville Naval Air Station sailor David Vesey admitted shaking his 3-month-old daughter but not hard enough to kill her, ...
Euclid man to be sentenced for injuring infant girl
The Plain Dealer - cleveland.com, OH - 10 hours ago
Doctors said the injuries were caused by shaking or being struck with extreme force, prosecutor's spokesman Ryan Miday said. ...
Former Anderson man pleads guilty to killing his infant son
Record-Searchlight, CA - 12 hours ago
Copeland initially said that he did not remember shaking his infant son, although he later changed his statement and said he shook him "forward and back and ...
Mother guilty of harming infant
Cincinnati.com, OH - 17 hours ago
20, 2007, incident, trying to get the baby to stop crying. But when Carr noticed something wrong with her child after the shaking, she called 911. ...
Hospital Sees Record Number Of Shaken Baby Cases
WISN.com, WI - Dec 15, 2008
The experts say it's normal for a baby to cry 2 to 3 hours a day. Yet often, it's a parent's inability to deal with those cries that prompts the shaking, ...
Searching for "shaken baby"
Murder Trial Begins For Dad Accused Of Killing Baby
News4Jax.com, FL - 58 minutes ago
Doctors, who said they suspected the baby's injuries were consistent with shaken baby syndrome, called police. Detectives questioned both parents and ...
Shaken baby trial continues in Missoula
KPAX-TV, MT - 11 hours ago
Missoula County prosecutors will continue to present their case against a Missoula man accused of Felony Aggravated Assault on Tuesday. ...
Former Anderson man pleads guilty to killing his infant son
Record-Searchlight, CA - 12 hours ago
The baby died at Mercy Medical Center in Redding, and an autopsy showed several injuries consistent with "shaken baby syndrome," including damage to the ...
Case continues in death of infant
Greeley Tribune, Colorado - 19 hours ago
... Medical Center in Greeley, where hospital officials advised Greeley police the baby’s injuries were consistent with that of shaken baby syndrome. ...
Miles' original sentence upheld
The Banner-Graphic, IN - 22 hours ago
The baby was diagnosed with shaken baby syndrome, and was hospitalized for a time at Riley Children's Hospital in Indianapolis
In 2006, Wisconsin adopted legislation that required education in hospitals, child care centers and schools. 
Today's news from Wisconsin is not so good...
The question, of course, is (a) whether the educational requirements are being implemented at all, and, if they are, (b) are they being effectively implemented?
If you'e from Wisconsin, or know someone who's given birth there recently, let us know what's really happening in the hospitals and other locations where education is required...
Today's news from Wisconsin is not so good...
The question, of course, is (a) whether the educational requirements are being implemented at all, and, if they are, (b) are they being effectively implemented?
If you'e from Wisconsin, or know someone who's given birth there recently, let us know what's really happening in the hospitals and other locations where education is required...
Sunday, December 14, 2008
The New York Times discussed the prospects (somehow that word doesn't seem appropriate in this context) for Medicaid cuts in New York. Actually, they're coming, in New York and most other states. It might be more appropriate to say the article gives a view into the abyss.
The relevance to prevention? Hospitals do wonderful things, and aren't just bricks and mortar edifices, but they constitute a significant investment in physical and organizational structure. Eliminating the clutter of inefficient and unnecessary things on hand is always hard than reducing spending on prevention.
It's also harder when organized constituencies are involved. Hospital unions will have a say in employee cuts. And, as noted in the article, a lot of Medicaid costs result from long term care for the elderly.
Those on the losing side are likely to be women and children, who make up the bulk of the Medicaid population, but don't require the same level of services. Unfortunately, if we cut primary care and prevention services, we cut the opportunities to ensure things stay that way.
Simple education for parents can save a significant portion of Medicaid dollars now being spent by parents who bring children to emergency departments. Similar results resulted in West Virginia (see fn 14)
The relevance to prevention? Hospitals do wonderful things, and aren't just bricks and mortar edifices, but they constitute a significant investment in physical and organizational structure. Eliminating the clutter of inefficient and unnecessary things on hand is always hard than reducing spending on prevention.
It's also harder when organized constituencies are involved. Hospital unions will have a say in employee cuts. And, as noted in the article, a lot of Medicaid costs result from long term care for the elderly.
Those on the losing side are likely to be women and children, who make up the bulk of the Medicaid population, but don't require the same level of services. Unfortunately, if we cut primary care and prevention services, we cut the opportunities to ensure things stay that way.
Simple education for parents can save a significant portion of Medicaid dollars now being spent by parents who bring children to emergency departments. Similar results resulted in West Virginia (see fn 14)
New York State spends more on Medicaid than any other state, $2,283 per capita per year, twice the national average of $1,026, a state Health Department spokeswoman said.
Dr. Richard F. Daines, the state health commissioner, said the new budget would lay out a plan to pay more to primary care and clinic doctors, while shifting that money away from hospitals, which in theory would see fewer patients because of better preventive care.
At the health forum, Mr. Baker said, “It’s not about curtailing generosity, it’s about whether or not we’re getting real value for the money that we’re spending.”
Hospital executives say that they are not opposed to making that shift, but that cutting Medicaid is counterproductive if the goal is to promote primary care.
“There is a fundamental dilemma or contradiction here on the state level between their stated health care policy reform agenda, which is all about robust primary and preventive care and better disease management, and the inevitable outcome of these cuts,” Alan D. Aviles, president of the city’s Health and Hospitals Corporation, said. The corporation runs the city’s 11 public hospitals, which get about 65 percent of their income from Medicaid.
“I don’t know whether the executive proposal will find a way to balance those problems, or whether the deficit will be so overwhelming it’s going to trump everything else and it’s only going to be about cost-cutting,” Mr. Aviles said.
Saturday, December 13, 2008
In light of the "new evidence" claims that are making the rounds, the Per Cale blog has an interesting post on myths and cognitive biases
...It seems that myth denial with accurate information may actually reinforce the myth.And this interesting post by John Allen Paulos on three common cognitive biases
University of Michigan researcher Norman Schwarz had volunteers read a flier from the Centers for Disease Control about flu vaccination myths. Within 30 minutes of reading the flier, older adults recalled 28% of the false statements as being true. After 3 days, they thought 40% of the myths were factual.1Younger people did better at first, but three days later they made as many errors as older people did after 30 minutes. Most troubling was that people of all ages now felt that the source of their false beliefs was the respected CDC.1...So denying myths actually reinforces them to some extent.The experiments do not show that denials are completely useless; if that were true, everyone would believe the myths. But the mind's bias does affect many people, especially those who want to believe the myth for their own reasons, or those who are only peripherally interested and are less likely to invest the time and effort needed to firmly grasp the facts.
The research also highlights the disturbing reality that once an idea has been implanted in people's minds, it can be difficult to dislodge. Denials inherently require repeating the bad information, which may be one reason they can paradoxically reinforce it.
Shankar Vedantam. Persistence of Myths Could Alter Public Policy Approach.
Washington Post. September 4, 2007. Page A03.
http://www.washingtonpost.com/wp-dyn/content/article/2007/09/03/AR2007090300933_pf.html
A legislative update from the Brain Injury Association of America:
As the House and Senate Appropriation Committees are working on conference negotiations for FY09 funding bills, BIAA joined a sign-on letter for increased funding of TBI programs. The timeline for action is unclear, but it appears the Democratic leadership wants FY 2009 appropriations bills on the President’s desk shortly after his inauguration on Jan. 20th.BIAA also issued a Legislative Action Alert, urging supporters to contact their Congressional representatives and support increased funding for TBI programs.
BIAA also sent letters to newly elected Members of Congress explaining the massive national public health issue which brain injury represents and urging them to join the Congressional Brain Injury Task Force.
The Centers for Disease Control and Prevention released new prevalence estimates for traumatic brain injury (TBI) in the United States. Reflecting the use of more conservative methodology, the CDC determined that although the annual incidence estimate has not changed (1.4 million individuals), the annual prevalence estimate for long-term TBI-related disability has decreased (from 5.3 million individuals to 3.2 million individuals).
BIAA reminded advocates, clinicians, researchers, policymakers and the public that the 3.17 million people living in the U.S. with a long-term disability need and deserve ongoing specialized rehabilitation, lifelong neurological disease management and individualized services and supports in order to maximize their health, independence and happiness.”
And let's not forget that the cost of pediatric brain trauma injuries is substantial....
At the request of the VA, the Institute of Medicine issued a report on “The Long-Term Consequences of Traumatic Brain Injury.” The IOM review of the scientific literature details numerous health effects associated with mild, moderate, and severe closed TBI.
[It's free if you read it online]
Friday, December 12, 2008
Preterm births are rising, and the complications that are associated with them suggest that there is likely to be a lot of stress for the child and the family.
Child offers resources for parents of preemies...
There are lots of other issues, of course, but prevention education in the NICU seems prudent, especially on coping skills, and not just during the very difficult time in the NICU, but when parents and child leave the NICU for the world.
Kudos to the March of Dimes for the work they're doing to help bring attention to this issue...and to the fact that, as a whole, the US can do better
Child offers resources for parents of preemies...
There are lots of other issues, of course, but prevention education in the NICU seems prudent, especially on coping skills, and not just during the very difficult time in the NICU, but when parents and child leave the NICU for the world.
Kudos to the March of Dimes for the work they're doing to help bring attention to this issue...and to the fact that, as a whole, the US can do better
Heather Payne has an interesting blog on the British Medical Journal site.
Right now, it's discussing the consequences of another child protection failure.
One of the curious by-products are the comments it attracts from those who inhabit a different reality and posit theories about Vitamin K deficiencies.
I've a great deal of admiration for those who work in the world of child protection and aren't satisfied with things as they are. It's an extraordinary person who can sustain that effort...
Right now, it's discussing the consequences of another child protection failure.
One of the curious by-products are the comments it attracts from those who inhabit a different reality and posit theories about Vitamin K deficiencies.
I've a great deal of admiration for those who work in the world of child protection and aren't satisfied with things as they are. It's an extraordinary person who can sustain that effort...
Resource: Education Begins At Home 2008 House Hearing
Worth reading - the House Committe on Education and Labor, chaired by Rep. George Miller, held a hearing on the Education Begins At Home Act.
The House report reviews the evidence and finds good reason to support home visiting services.
What's not to like?
Funding won't be available until 2010 and, in a time when the President-elect is proposing to establish a Chief Technology Office for the federal government, there is absolutely no mention of using social media to effectively and efficiently reach new parents.
And while the SBS Prevention Act would provide $20 million for hospital based prevention education ($5 per birth), the EBAH was amended to reduce the funding for hospital based education to $1 million - for a broader hospital based education program.
Hospital based education is accessible to almost everyone, not just those states and regions that are fortunate enough to have a good home visiting program in place (and EBAH will only fund organizations in place for three years, which leaves some doubt as to how it will benefit states and communities without programs).
Perhaps we can persuade Congress to fund education now as an economic stimulus initiative: say $20 per birth for education about SIDS, SBS and colic. It might help hospitals offset, just a tiny bit, the coming wave of Medicaid cuts.
And reduce by 50% the amount of unreimbursed money that hospitals spend to treat the consequences of inflicted head injuries...
I wonder if the American Hospital Association has a blog search running....
The House report reviews the evidence and finds good reason to support home visiting services.
Research shows that these programs, which provide a variety of services ranging from pre-natal medical care to school readiness and family literacy programs, can help improve student achievement, reduce child abuse rates, improve early identification of developmental delays and disabilities, and improve access to health services.
What's not to like?
Funding won't be available until 2010 and, in a time when the President-elect is proposing to establish a Chief Technology Office for the federal government, there is absolutely no mention of using social media to effectively and efficiently reach new parents.
And while the SBS Prevention Act would provide $20 million for hospital based prevention education ($5 per birth), the EBAH was amended to reduce the funding for hospital based education to $1 million - for a broader hospital based education program.
Hospital based education is accessible to almost everyone, not just those states and regions that are fortunate enough to have a good home visiting program in place (and EBAH will only fund organizations in place for three years, which leaves some doubt as to how it will benefit states and communities without programs).
Perhaps we can persuade Congress to fund education now as an economic stimulus initiative: say $20 per birth for education about SIDS, SBS and colic. It might help hospitals offset, just a tiny bit, the coming wave of Medicaid cuts.
And reduce by 50% the amount of unreimbursed money that hospitals spend to treat the consequences of inflicted head injuries...
I wonder if the American Hospital Association has a blog search running....
Thursday, December 11, 2008
A biomechanical analysis finds that shaking can produce retinal hemorrhages
A finite element infant eye model to investigate retinal forces in shaken baby syndrome.
Steven Alex Hans, Sebastian Y Bawab, and Michael L Woodhouse
Graefes Arch Clin Exp Ophthalmol, December 4, 2008;
Department of Mechanical Engineering, Old Dominion University, 238 Kaufman Hall, Norfolk, VA, 23529-0247, USA, shans001@odu.edu.
BACKGROUND: Shaken baby syndrome (SBS) is a form of abuse in which an infant, typically 6 months or less, is held and submitted to repeated acceleration-deceleration forces. One of the indicators of abuse is bilateral retinal hemorrhaging. A computational model of an infant eye, using the finite element method, is built in order to assess forces at the posterior retina for a shaking and an impact motions.
METHOD: The eye model is based on histological studies, diagrams, and materials from previous literature. Motions are applied to the model to simulate a four-cycle shaking motion in 1 second with maximum extension/flexion of the neck. The retinal forces of the shaking motion, at the posterior eye, are compared to an impact pulse (60G) simulating a fall for a total duration of 100 ms.
RESULTS: The shaking motion, for the first cycle, shows retinal force means at the posterior eye to be around 0.08 N sustained from the time range of 50 to 200 ms, into the shake, with a peak in excess of 0.2 N. The impulse, area under the curve, is 15 N-ms for 250 msec for the first cycle. The impact simulation reveals a mean retinal force around 0.025 N for a time range of 0 to 26 ms, with a peak force around 0.11 N. Moreover, the impulse for the impact simulation is 13 times lower than the shaking motion.
CONCLUSION: The results suggest that shaking alone may be enough to cause retinal hemorrhaging, as there are more sustained and higher forces in the posterior retina, compared to an impact due to a fall. This is in part due to the optic nerve causing more localized stresses in a shaking motion than an impact.
It's time to start planning for Shaken Baby Syndrome Awareness Week 2009 (the third full week of April).
Three suggestions for things you can do:
- ask your federal, state and local representatives to adopt a resolution or proclamation recognizing SBS Awareness Week 2009, acknowledging the reason why we need awareness and prevention efforts, and thanking those hospitals, child care organizations, schools and other groups for their efforts to educate parents and caregivers about their opportunity to help protect children from injury.
As an example, South Carolina adopted this resolution
In 2008, Senator Chris Dodd and Congresswoman Nita Lowey sponsored SBS Awareness Week resolutions in the Senate and House.
- ask those representatives to visit a hospital, child care center or school to thank the educators
- write a letter to the editor of your local newspaper or email the editor of a blog or website that deals with parenting. Ask them to write a story, post a poll or tak other action to bring attention to SBS during SBS Week.
It works...
Three suggestions for things you can do:
- ask your federal, state and local representatives to adopt a resolution or proclamation recognizing SBS Awareness Week 2009, acknowledging the reason why we need awareness and prevention efforts, and thanking those hospitals, child care organizations, schools and other groups for their efforts to educate parents and caregivers about their opportunity to help protect children from injury.
As an example, South Carolina adopted this resolution
In 2008, Senator Chris Dodd and Congresswoman Nita Lowey sponsored SBS Awareness Week resolutions in the Senate and House.
- ask those representatives to visit a hospital, child care center or school to thank the educators
- write a letter to the editor of your local newspaper or email the editor of a blog or website that deals with parenting. Ask them to write a story, post a poll or tak other action to bring attention to SBS during SBS Week.
It works...
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