Prevention and Conseqences in Tampa Bay: Graham Warren

In Tampa Bay, Florida 10Connects.com [WTSP] has a great report on the impact of Shaken Baby Syndrome on one family, and about prevention efforts.

The video embedded in the story is compelling, and well worth watching... Link

Susan Martin-Warren is a mother who is going through it right now. She was happily married with two young sons when in 2005 she got a call that would change all of their lives forever.

"He explained that he had found Graham limp, not breathing, white." Her 3-month-old son was rushed to the hospital. "Graham had to go into surgery at 3 o'clock in the morning to actually remove the blood clot that they had identified on a cat scan that night."

After three hours of brain surgery, the prognosis wasn't good. Susan says doctors explained that due to the massive amount of brain damage he suffered, it was likely that Graham would wind up in a vegetative state. It would be five days later before Susan realized her own son was a victim of child abuse at the hands of her husband, Tom Warren.

Especially timely in light of this report about a sharp increase in inflicted injury in Florida: Link

The Department of Children and Families says crimes against babies are up drastically.

“I’ve have seen more shaken baby child deaths in the last four months than I saw in the first two years that I was here. Those are frightening statistics,” said DCF Secretary George Sheldon.

Connecticut: A Special Panel on SBS Prevention - April 16

What better fanfare could there be for Shaken Baby Syndrome Awareness Week?

On April 16th, the CT Children's Trust Fund hosts an excellent panel presentation on preventing Shaken Baby Syndrome with Senator Chris Dodd, Mark Dias, Ron Barr, Debbie Eappen and Darryl Gibbs.  Link to CTF announcement.

Shaken Baby Syndrome: WORKING TOGETHER. PREVENTING THE TRAGEDY

Join us for an inspiring and meaningful conversation about addressing this major problem.The forum will feature an incredible panel of experts and parents who have lost a child to shaken baby syndrome.

Dr. Mark Dias, the country’s preeminent expert in efforts to prevent shaken baby syndrome, neurosurgeon and professor at Pennsylvania State University

Dr. Ron Barr, highly regarded international scholar and author of the prevention program “Period of Purple Crying”

Debbie Eappen, mother of a son lost to Shaken Baby Syndrome and ophthalmologist

Darryl Gibbs, father of a daughter lost to Shaken Baby Syndrome and national parent advocate Introduction by

Marilyn Barr, founder and executive director, National Center on Shaken Baby Syndrome

Moderated by Anita Ford Saunders, principal of AFS Communications and host on CPTV

Thursday, April 16 
5:30 to 7:30 p.m. 
Light Supper and Forum 
Wadsworth Atheneum Museum of Art
600 Main Street, Hartford, CT 06103

Registration: $20 
To register: 
•Log on to www.cvent.com 
•Click on the RSVP for Eventtab at top of page 
•Enter event code: 62NQ724W5ZW

For information, call 860.418.8763.

With special thanks to Clear Channel, Inc, The CT Forum, Drs. John Leventhal and Kirsten Bechtel, Yale NH Hospital, Drs. Nina Livingston and Skip Berrien, CT Children's Medical Center and St. Francis Hospitals. Funding for the Forum provided by the Administration on Children and Families, HHS and private donors.

Failing Grades: States' Standards for Child Care Centers

The Early Ed Watch blog (thanks, New America Foundation) brings news of a report by the National Association of Child Care Resource and Referral Agencies on state efforts to monitor child care. Link to report.

The news is not good.

Who's watching who's watching the children? The federal government
leaves this task to the states. But states are failing to ensure that childcare
centers are safe, according to a report released today by the National Association
of Child Care Resource & Referral Agencies.

Parents assume that if a child care center has obtained a state license, it must meet some basic standards of child safety and personnel training. But in many places, the license means very little, said Linda K. Smith, NACCRRA's executive director.

"A license on a wall does not mean that a center has ever been inspected," Smith said. "This is inexcusable."

NACCRRA examined state regulations and oversight in 50 states plus the District of Columbia and the Department of Defense, which runs its own network of child-care centers. Each state was judged using a scorecard created by the association that gave states points for policies that address health, safety, and quality of childcare providers -- such as how frequently the facilities are inspected, whether caregivers must go through background checks, and whether directors have any training in child development.

The average score was an F. No state earned an A or B, and only one -- Washington, D.C. -- earned a C. The Department of Defense got the top score, with 131 of 150 possible points or a B grade. Unlike states, the military must comply with standards under the Military Child Care Act of 1989.

NACCRRA's breakdown of the states with the strongest and weakest standards in child care licensure (the Defense Department and District of Columbia were included):

Top 10: DoD, DC, OK, TN, MD, RI, NY, IL, FL, WA
Bottom 10: NM, AK, IA, MO, KS, CA, GA, NE, LA, ID

Good news - three of the largest birthplace states are in the top 10.

Bad news - California is in the bottom 10....

And here's a stat from NCCRRA's webpage that caught my eye...

Over 11 million children under age 5 spend an average of 36 hours a week in
non-parental care settings. Almost two-thirds of these children are in
center-based care.

Perspective: Happiness and Parenting - the daily tribulations matter

ScienceDaily offers an economist's view of how the social expectations of happiness run head first into the realities of parenting (the excerpt is edited a bit for brevity...)

Is Parenting A Joy Or A Trial?

University of York economist Nattavudh Powdthavee claims that the idea that parenting makes us happy is an illusion. Writing in the latest issue of The Psychologist, he offers an explanation to one of the most surprising conclusions of recent research into wellbeing -- that having children does not increase our level of happiness.

"Social scientists have found almost zero association between having children and happiness," he said. "In a recent study of British adults for example we found that parents and non-parents reported the same levels of life satisfaction. Other studies from Europe and the USA found that parents report significantly lower levels of satisfaction than people who haven't had children."

Dr Powdthavee argues that the belief that having children makes you happy is a focussing illusion. "To imagine what it's like being a mother or a father we're likely to focus more on the good things about being a parent than the bad things. This is mainly because we believe that the rare but meaningful experiences like a child's first smile or seeing them get married will give us massive and long-lasting increases in happiness.

"But in reality, we rarely think about these big experiences on a daily basis, simply because they do not occur to us every day.

Instead, parents spend much of their time attending to the very core processes of child care - problems at school, cooking and laundry - which are much more frequent but a lot less salient events. And it is these small but negative experiences that are more likely to impact on our day-to-day levels of happiness and life satisfaction."

Stimulating Research on Prevention

The Economic Stimulus Bill (American Recovery and Reinvestment Act of 2009) provided $1.1 billion for federal agencies to oversee studies on the merits of competing medical treatments. New York Times; Scientific American; Washington Post

"Injury prevention" doesn't readily come to mind as a medical treatment, does it?

But if "healthcare" is the maintenance of good health, what could be more central to maintaining health and well-being than preventing preventable illness?

Prevention education has been likened to a vaccination against shaken baby syndrome. The effectiveness of many medicines varies with individual and social factors, such as gender and race (as noted in this Wall Street Journal article). The effectiveness of education does as well.

So, why shouldn't healthcare dollars evaluate not just the efficiency and effectiveness of treatments for the consequences of disease and injury, but prevention education too?

The Institutes of Medicine will be recommending priorities for that research, and CDC invites suggestions from the public.

You're invited. Visit the IOM website and submit ideas by March 27, 2009.

Link: http://iom.edu/CMS/3809/63608.aspx?utm_medium=etmail&utm_source=Institute%20of%20Medicine&utm_campaign=CER+Priorities+Request+for+Input&utm_content=CER+Priorities+Stakeholders&utm_term=

Tiny URL for the link above (preview) - http://preview.tinyurl.com/cy5fzj

Perspective: Blaming the Messenger (or, in the case of the BBC, the Home Visitor)

Once, I liked listening to the BBC. Now, it's a mixed experience...

This BBC report on post-partum depression (one of the "Am I Normal?" series: link) is interesting in many respects.

Unfortunately, it opens by framing a "controversy" about post-partum depression screening.

The reporter starts with a point of view, "motherhood is being medicalized" (with a tip of the hat to journalistic objectivity, she asks it as a question) and then proceeds to demonstrate the controversy by sound bites from a slew of mothers with complaints about their experience of screening during home visiting, juxtaposed with an interview of a single doctor, who explains what the screening process intends to accomplish...

There is some unintended irony.

At one point the reporter tells us that mothers wanted more information about the post-birth delivery and support during that time, and at another point, muses that many of the events described in the Edinburgh Depression Scale would seem to experienced parents as "par for the course."

How exactly does a new parent understands what's "par" when they're playing on a course for the first time and there's no comparison of performance? Eventually, the interviews do provide insight: for example, a psychiatrist discusses the modern problem of parenting in social isolation.

It's unfortunate that much the focus of the report is on the consequences of labeling PPD an "illness": the reporter sometimes seems not to notice the points about the experience of motherhood that are made in some interviews.

Nonetheless, the interviews provide some interesting insights into the challenges parents face, and the conclusion is important: recognizing and accepting the fact that the expectations of motherhood do not always square with our individual experience of motherhood.

In other words, mothers - and families - need to know that not being normal at times is a normal part of motherhood.

Natasha Richardson

The tragic death of Natasha Richardson stirs memories.

Anyone who has ever watched the inexorable fading of the light that accompanies a traumatic brain injury knows what her family experienced.

There is abiding darkness, but perhaps there is also one tiny bit of silver lining to be found: many more people are now aware of the potential consequences that can follow a seemingly minor "insult" to the brain.

By coincidence, March is Brain Injury Awareness Month and this week is Brain Awareness Week

Education is important. Scientific American offered a neurosurgeon's explanation of possible causes and missed opportunities: getting quick medical attention for a developing trauma is critical - the "golden hour" of emergency medicine.

Because of this tragedy, more people now know that....

The tragic story, if confirmed, is a reminder that even minor blows to the head can lead to devastating bleeding that can cause strokes or otherwise damage brain tissue.

One possibility, sometimes called "talk and die" syndrome, is that the actress had delayed bleeding between her skull and her brain stem, which sits at the top of the spinal cord and regulates consciousness, breathing, and the heart and connects the brain to many of the body's sensory and motor nerves.

Another possibility is that there was a tear in the inner lining of her arteries, causing blood clots. To find out more about Richardson's potential injury, we spoke with neurosurgeon Keith Black, chairman of the Department of Neurosurgery at Cedars-Sinai Medical Center in Los Angeles.

Based on Richardson's symptoms, what kind of injury do you think she suffered?

The possibilities range from what we call an arterial dissection to a preexisting condition that might have been triggered by the event. An arterial dissection is where patients have a very mild injury tear the inner lining of20the arteries of the neck, either the carotid or vertebral arteries, and that can occur with even minor trauma that one may not believe to be significant. That tearing in the artery can cause clotting, which can set up a stroke (an interruption of the brain's blood supply caused by a blockage or a rupture of a blood vessel). If that clot is in the vertebral artery system, it can cause a stroke in the brain stem, which can be devastating.

The other possibility is delayed bleeding in the brain. That can be from either a tear in a vein or an artery in the brain tissue itself, and that can be either an epidural hematoma (between the skull and the dura, the membrane that surrounds the brain) or a subdural hematoma (between the dura and the brain).

Another possibility is that she had a condition that predisposed her to having a more catastrophic event. This could be an abnormality in how fast her blood clots after a bleed. Or if she's been on any aspirin, blood thinners, or, supplements like omega-3 fish oil, that can make things worse. The other thing one has to worry about is whether she had a vascular abnormality in the brain like an arteriovenous malformation (an abnormal connection between high-pressure arteries and low-pressure veins). If an AVM tears one can get a more significant bleed.

I think the two most likely conditions would either be the arterial dissection in the neck or the delayed bleeding within the brain itself.

What is "talk and die" syndrome?

That refers to the fact that we always worry about people with head injuries that don't show up immediately, which is why we like to observe people after a head injury for 24 hours. Generally when we talk about "talk and die" it's usually a delayed bleed like an epidural hematoma.

How would you assess a patient after a fall like this?

The most important test would be a CT scan (a 3D X-ray that can provide cross-section images of anatomical structures), which would tell you=2 0if there is bleeding in the brain itself. If there is bleeding, it would tell you if it needs to be relieved with surgery or with medication. It would also give you an indication if she's had a stroke, and whether she's had one of these arterial dissections that may be showering blood clots into the brain.

How would you treat her?

If there's bleeding in the brain, if it's causing pressure and if it's an area that's accessible, one may think about surgery to remove the blood clot. Usually, that's done on an emergent basis, and since we haven't heard reports that she's going undergoing surgery then that's probably not the scenario she's facing.

Another possibility is that the clot is in an area that you cannot safely operate on like the brain stem. That's because the structures of the brain are very compact in that area, and it's very risky to operate on. One may then try to manage the clot with medications (such as hypertension drugs like labetalol).

And an interesting article on Medical News points out an obvious lesson in prevention that isn't so obvious to many skiers - it's not that a helmet will always help, but if you're not wearing it, it can't help you...

The apparent lack of focused trauma in Richardson's case cast doubt on whether a helmet would have helped.

But a 2006 Norwegian study found that helmets reduced the rate of head injury among skiers and snowboarders by 60%, regardless of skill level. (See: Helmets Endorsed for Skiers and Snowboarders of All Skills)

Although Richardson may have suffered a freak injury that a helmet could not prevent, injury prevention groups and specialists emphasized that skiers, bicyclists, and others at risk for head injuries should always wear helmets.

Resource: Bibilography on Grief After Infant Death

The Association of SIDS and Infant Mortality Programs (ASIP) and the National Fetal and Infant Mortality Review Program have updated their bibliography on grief and bereavement following pregnancy loss and perinatal and infant death.   The bibliography was prepared by ASIP member, Dr Jodi Shaefer, PhD, RN and reviewed by Dr. Joan Arnold, Ph.D, RN, also an ASIP member.   It now includes an annotated summary of articles and is available at: http://www.acog.com/departments/nfimr/bereavementLiterature3-07.pdf

The Economy and Shaken Baby Syndrome: Massachusetts

From the Boston Globe and WPRI in Providence, one more report that economic stresses are increasing the need for SBS prevention efforts... Link - Illinois ; Link - New York

Shaken baby syndrome cases rising
Economic stress on parents could be to blame
Bruce Morin Published : Thursday, 19 Mar 2009, 7:41 AM EDT

WPRI) - In Massachusetts, shaken baby syndrome cases are on the rise. Experts feel that economic stress on parents could be to be blame.
In the last three months, Children's Hospital Boston and Massachusetts General Hospital have seen nine infants with shaken baby syndrome. According to the Boston Globe, there were only four cases in the same period last year.
Research has linked increased economic stress within families to increased child abuse. Dr. Alice Newton, medical director of Children's protection team says that in the recent cases, parents had either been laid off or faced other financial hardships.

The Globe reports on concerns that funding for the SBS prevention initiative in Massachusetts may be at risk:

The [Children's Trust Fund] plans to brief legislators today on the latest figures and on its prevention efforts.

There is some concern, Bartley said, that the program might not continue to receive its annual $350,000 allocation because the money is no longer listed separately in the state budget.

Broader public education about how to avoid shaken baby syndrome is still badly needed, said Alison Goodwin, spokeswoman for the Department of Children and Families, because it can be very hard to predict which infants are most at risk. She said the majority of cases do not involve clients of the agency, which works with families that have been the subject of previous abuse or neglect reports.

Parents who are "at risk" may need more education and parenting support resources, but sustained funding is needed for education that offers every new parent the opportunity to learn how they can help protect their child from injury.

New parents are "born" every day, and they need to learn good parenting skills, just like they learned reading, writing and arithmetic. Once a child learns to read, schools don't stop teaching reading, do they?....

Prematurity and Coping

Prematurity.org has an interesting article on the consequences of premature birth.

It suggests that the SBS prevention community and organizations which provide support to parents of premature infants have reason to collaborate on prevention education.

Of note:

Having established the difficulties of maternal bonding for parents of infants born premature who are separated for extended periods, it should also be noted that following discharge these infants place enormous demands on their parents. Studies that have followed premature dyads shortly after discharge are numerous, and have noted substantial differences in the premature infant as a social partner regardless of mother's emotionality.

For example, where behavioural and social differences between premature and term infants are reported, premature infants are found to be less responsive, to show less positive affect (Field, 1979), and to be less initiating and more irritable (Goldberg & DiVitto, 2002; Cox, Hopkins & Hans, 2000). These findings lead Field (1979) and others (Mangelsdorf, Plukett, Dedrick, Berlin, Meisels, McHale, & Dichtellmiller, 1996) to conceptualise the premature infant as having a relatively high threshold to social stimulation coupled with a low tolerance for behavioural stimulation.

That is, premature infants are less socially responsive and harder to soothe.

Prevention: Learning About The Teachable Moment

Birth is considered a "teachable moment."

The best teachable moments seem to (1) increase perceptions of personal risk and outcome expectancies, (2) prompt strong affective or emotional responses, and (3) redefine self-concept or social role. PubMed Abstract; Link to article and cite list

They involve change and invoke emotions, heightening our desire to learn.

ScienceDaily reports on brain research study that suggests our neural learning infrastructure is more responsive when confronted with unexpected information.

As one of the researchers put it:

Similar to an economic theory, where efficient markets respond to unexpected events and expected events have no effect, we found that the dopaminergic system of the human brain seems to be wired in a similar rational manner -- tuned to learn whenever anything unexpected happens but not when things are predictable...

The study was looking at reward-based learning, which seems to occur when dopaminergic neurons, which drive a larger basal ganglia circuit, are activated in response to unexpected rewards and depressed after the unexpected omission of reward. As they put it, a "lucky" win seems to be retained better than a probable loss.

In that model, by responding to unexpected financial rewards, those cells encode information that seems to help participants maximize reward in the probabilistic learning task.

It's interesting to consider how that model might transfer to the post-natal experience. In the absence of information about appropriate behavior, parent and child are engaged in probabilistic reward-based learning: baby cries, parent responds and both behaviors are modified depending on the outcome.

It's also interesting to consider how that learning might be affected in parent/child dyads where one or both have dopamine disorders. Dopamine seems to been involved in many events important in the first year:

[d]opamine has many functions in the brain, including important roles in behavior and cognition, motor activity, motivation and reward, inhibition of prolactin production (involved in lactation), sleep, mood, attention, and learning. Link to Wikipedia

Animal studies have found that "mild" brain insult at birth (one minute anoxia) can "cause long term changes in dopamine-mediated behavior in both guinea pig and rat, two species spanning the level of human brain maturity at birth." Links to Abstract and PDF of article; another study finding links between birth insult and dopamine disorders Abstract

Opportunity 10: What to Expect...

Having heard Penelope Leach talking about her new book recently, and finding myself in a Barnes & Noble store with a few minutes to spare, I perused the baby literature.

The AAP mentions it three times, Penelope and Dr. Sears mention is once, but I was disappointed to find no mention of it in "What to Expect the First Year".

It, of course, is shaken baby syndrome.

What to Expect has an extensive section on crying and colic, but no mention of shaking or inflicted injury other than an allusion to scary feelings and unspecified child abuse. Not very helpful in developing a coping plan...

The lack of information about shaking, frustration and coping is really disappointing because the discussion about crying and coping with colic behavior is pretty good.

Baby literature tends to produce strong feeling for and against, but we've owned most of the What to Expect series and I think they're generally pretty useful resources...

It makes me wonder if the author, Heidi Murkoff, shares Oprah's phobia (from all accounts, Oprah's window has been completely opaque to overtures from the SBS community to discuss SBS: give the diverse nature of topics that are covered on her show, feel free to speculate among yourselves about why abuse would be excluded).

PS. Link to a sample AAP brochure on crying and colic, with education about the danger of shaking...

Sometimes It Isn't "An Accident"...

...and it isn't understandable.  

In Ohio, the father of Camyrn Wilson, a two month old boy,  admitted shaking his son because he was jealous of the attention that his wife was paying to the child. He was sentenced to 15 years to life...

Akron Beacon Journal and another ABJ article

Cleveland Plain Dealer

Schools: Education for Babysitters, Mount Venon, Ohio

Kudos to these high school students in Mt Vernon, Ohio.  

The Mount Vernon News reports on an education program Lynn Tullos, Alicia Williams and Brittany Hopkins, officers of the Family, Career and Community Leaders of America, put together for seventh-grade students - 71% of those students care for other children.

Imagine if every high school had a group of students who did this...

The high school trio visited the youngsters to give some safety tips for baby sitters and to inform them of the dangers of shaken baby syndrome. Tullos said seventh-grade is not too early to teach about such topics, because a class survey showed 71 percent of the seventh-graders have watched children by themselves, mostly caring for siblings after school.

Knowing where to access emergency numbers and first aid supplies are two of the most important things a baby sitter should know, the FCCLA team said. Members discussed what to do in case of a fire or choking incident, and talked about how to safely prepare meals while tending a youngster. They distributed sample “safety cards” to record important baby-sitting information such as contact numbers, allergies and safe outdoor meeting place in case of a fire, and gave each seventh-grader a mini first aid kit complete with Band-Aids and antibiotic cream.

It's not the first time a FCCLA chapter has sponsored an event to increase awareness of Shaken Baby Syndrome: senior Megan Akavickas and the chapter at DC Everest High School in Wisconsin sponsored a bowl-a-thon in December, and donated the proceeds to the National Center on Shaken Baby Syndrome.

Judges: Different Time Zones

Searching Google News yesterday, these news headlines appeared next to each other.

Mother receives 16 months in prison for shaking baby
Mail Tribune - ‎Mar 7, 2009 By Sanne Specht
A White City woman charged nearly two years ago with shaking and injuring her 1-month-old son was sentenced Friday in Jackson County Circuit

Women gets 20 years for child abuse
Greeley Tribune - ‎Mar 7, 2009‎
Medical reports and police investigation into the baby’s injuries concluded that the baby’s symptoms were consistent with shaken baby syndrome, according to ...

It's not a good thing when the justice system begins to reminds you of a roulette wheel...

Canada: Bad News from Alberta Foster Care

The Edmonton Sun reports that a child in foster care was suspected to have inflicted head injuries, and the prognosis is not good.

The story includes on an exchange of views in the provincial legislature about the safety of the province's foster care program. It's probably not a good sign that the person in charge seems to consider this as a matter of routine: "Whenever we have a serious incident like this we always do a special case review...”

Hopefully, the inquiry will look into the circumstances that led to the injury and make some recommendations for change. One obvious question to ask is whether foster caregivers who care for infants have received training about the causes, consequences and prevention of SBS in young children and how they can cope...

It's not the first time this has happened in foster care, but effective recommendations for prevention training could be the beginning of the end.

Alberta has some excellent SBS education resources (Health in Action coordinates the Alberta SBS Prevention Campaign) , but they won't help if the caregivers don't get some effective training.

Alberta baby seriously injured in government care
NDP says foster home over-crowded
By Jim Macdonald, THE CANADIAN PRESS

EDMONTON — Police are investigating after a baby in foster care was seriously injured Monday in a quiet community just east of Calgary.
Children’s Services Minister Janice Tarchuk confirmed in the legislature Thursday that the 14-month-old boy was gravely injured while in the province’s care.
“We do have a small boy that is in our care that has been taken to hospital with serious injuries,” Tarchuk later told reporters.

However, New Democrat Rachel Notley got a tip and told the legislature Thursday that she’d heard the baby’s injuries were life-threatening.
She also said a reliable source said the boy was in an over-crowded foster home.
“Will the minister admit that this very recent tragedy occurred in a government-approved foster home that had been allowed to exceed the maximum number of children in care?” Notley asked Tarchuk in assembly.
The minister would not confirm the overcrowding. But Tarchuk said this incident will be reviewed.
“Whenever we have a serious incident like this we always do a special case review,” she said. “I think at this point, we’ll let the police proceed with their investigation.”
Notley said her “third-hand” source told her the baby had been shaken to the point of being seriously injured and at one point the infant had been placed in life support.
Notley said this incident raises serious questions about the state of foster care in Alberta given that a young boy died just two years ago after being abused while in care.
In early 2007, a three-year-old Edmonton boy died while in foster care and the foster mom was later convicted of manslaughter.
“And we knew it was because there were too many kids in that foster home,” said Notley, who challenged the minister on a government review into the toddler’s death.
“The recommendations were made a year ago and they should have acted on them by now,” said Notley. “It’s unforgivable.”
“They’re studying while people are dying and that’s all we’ll ever get from this minister,” she said. “That’s why we need a public inquiry run by someone who doesn’t answer to this minister.”
Tarchuk said she could not speak about any of the specific details of the case. But she said the province’s review of foster care was very extensive and found the system in good shape.
The recommended changes, which will be fully implement by summer, include six-month interim licences for new foster parents and tighter controls on how many children are allowed in each home, she said.
But Notley slammed the review, saying it appeared to have been orchestrated by the government as a public relations exercise.
“We’ve had nothing but smoke-and-mirror type reviews that were staffed by hand-picked, government-friendly officials,” she said. “It is time for us to look into how we are treating our children in care and to get it right.”
“We can’t afford to have kids who are in our care dying and being injured. It’s outrageous.”

Good News Iowa: Governor Signs SBS Prevention Legislation

(photo courtesy IowaPolitics.com via Flickr)

Iowa Governor Chet Culver signed SBS prevention legislation into law today.

Congratulations to the folks in Iowa who advocated for this legislation, and to the legislators and governor for their quick action in adopting this important protection into law.

DES MOINES, Iowa -- Gov. Chet Culver said Thursday that a new law is just the beginning of efforts to end shaken baby syndrome cases in Iowa.

The new law will establish a statewide program to educate parents and caregivers.

Culver and his wife Mari were joined by a group of advocates for children and those against child abuse as the governor signed the new bill into law.

The law now requires the Iowa Department of Public Health to establish an initiative to teach new parents and daycare provider's techniques for dealing with anger and frustration.

Culver said it's the first step in educating about the dangers of shaken baby syndrome.

"From 1997 to 2005, shaken baby syndrome was the cause of 47 of 112 homicides of infants. It was the leading cause of death of these children," said Culver.

Officials said because shaken baby syndrome cases are 100 percent preventable, the law also would make more resources available to parents to give them the tools they need to care for their children in a positive environment.

Science: Fraying Maternal Instincts

Will the recession result in better mothers?

Science Daily reports on research findings that

The trend to move miles away from hometowns and family for work is leaving many women feeling ‘ignorant and ill-equipped’ to cope with pregnancy and childbirth.

According to a University of Warwick study of motherhood, many women do not have the support and advice they need when they have a baby because they live too far from close family.
* * *
The study also showed many women felt unprepared to care for their child and that motherhood was not instinctive. They agreed that they felt a natural instinct to care for their child, but had no idea how to go about it.

The collapse of the housing market and rising unemployment are reducing the mobility of the workforce. Perhaps one unanticipated mitigation will be an increase in the ability of new parents to draw upon traditional social support networks...

Good News: SBS Prevention Education, Vancouver

An encouraging report on SBS education for new parents: a study in the March edition of the Canadian Medical Association Journal found the PURPLE campaign materials increased parental awareness of crying behaviors and "walk aways."

Educational materials for new mothers may prevent shaken baby syndrome, CMAJ study shows (Eureka)

Educational materials on how to deal with crying newborns lead to increased knowledge about infant crying and behaviours that are important to preventing shaken baby syndrome, found two new studies being published online March 2 in CMAJ and Pediatrics.

The CMAJ study involved 1279 mothers in a randomized controlled trial in Greater Vancouver, BC, Canada. Half were provided materials from the Period of PURPLE Crying program and the other half received materials with parent safety tips and sleeping position guidelines. Materials were delivered by public health nurses during routine visits within 2 weeks of birth.

Mothers who received the PURPLE materials scored 5% higher in knowledge about crying compared with mothers who received the control materials. They walked away 1.7 times more frequently from inconsolable infant crying, and were 13% more likely to warn about the danger of shaking infants and to share advice about walking away if frustrated.

The PURPLE materials indicate that the following behaviours are normal but frustrating for parents and suggest coping mechanisms:

Peak pattern, where crying increases, peaks during the second month, then declines
Unexpected timing of prolonged crying
Resistance to soothing
Pain-like look on the face
Long crying bouts
Evening and late afternoon clustering

To help caregivers deal with a crying infant, PURPLE suggests:
* calming responses (carry, comfort, walk and talk)
* put the baby down in a safe place, then walk away to calm yourself
* NEVER shake a crying baby

The researchers suggest that additional communication could result in increased awareness about the dangers of shaken baby syndrome. In this study, the nurses did not know which materials they were delivering. "The intervention may have had stronger effects if the nurses had reinforced the messages, or if the messages were reinforced by multiple exposures through prenatal, maternity and postnatal health care providers, media and community support organizations," write Dr. Ronald Barr and coauthors.

"These findings complement the small number of reports that have reported that practical and contextually relevant materials presented to parents before or shortly after birth can change knowledge and behaviours and perhaps reduce the incidence of shaken baby syndrome," conclude the authors.

It's interesting that the authors conclude that greater impact might result if the nurses giving the information were not "blinded" to the materials being distributed. That seems to tie in with the results previously reported in the Montreal study:

However, there was no doubt as to the relevance of the nurses' participation; the majority (94%) of parents agreed that simply receiving the information cards without the nurses' participation would have been insufficient.

I thought it was good … It wouldn't have been right to say, okay, take the cards and read them, and that's that … I found we weren't left on our own, so there was no risk that we would not read the cards.

Also of note:

1. while the conclusions of the study seem to be couched in terms of mothers who "received" the materials, at one point it is noted that higher effects were observed among mothers who had watched the DVD or read the materials.

That seems to fit with previous research and reinforces the importance of: (1) video education materials; (2) prevention models that do more than just deliver education materials to new parents; and (3) the focus provided by hospital-based education (the study delivered materials by home visits after birth).

2. the study reported that there was already a high awareness of the danger of shaking babies in both study groups. It would be interesting to find out how representative that awareness is across a spectrum of communities in the US and Canada, and whether there is any effect on behavior following high-profile events like the recent maternity tourist incident in Vancouver.

3. the control group got an info set about safe sleep practices, with no mention of whether that information was also given to the intervention group.

It would be interesting to analyze the effect of getting both sets when an "injury prevention" frame is applied to the materials (and to find out whether parents respond differently to "delivery" of "injury prevention" (SIDS) and "child abuse prevention" (SBS) materials.

Even though the Back to Sleep campaign is 15 years old, it's still important to inform new parents. When California evaluated the effectiveness of the First Five materials provided to new parents, one result they found was a significant increase in awareness of safe sleep practices.

UPDATE: Link to abstract for a companion study in the March edition of Pediatrics:

RESULTS. The mean infant crying knowledge score was greater in the intervention group (69.5) compared with controls (63.3). Mean shaking knowledge was greater for intervention subjects (84.8) compared with controls (83.5). For reported maternal behavioral responses to crying generally, responses to unsoothable crying, and for self-talk responses, mean scores for intervention mothers were similar to those for controls. For the behaviors of information sharing, more intervention mothers reported sharing information about walking away if frustrated and the dangers of shaking, but there was little difference in sharing information about infant crying. Intervention mothers also reported increased infant distress. 

Child Abuse: The Persistence of Consequences

Not Exactly Rocket Science blogged on a study showing the persistent effects child abuse can have on the brain of survivors. It's a cogent explanation of the science, and worth reading....

Together, McGowan's results paint a very suggestive picture that links child abuse to later illness and death. Abuse leads to epigenetic changes that modify genes including NR3C1. These changes, especially those involving methyl groups, are very stable and they could slash the gene's activity for a very long time, potentially even for life. With the gene not working properly in many cells, the body can't produce enough glucocorticoid receptor.

As a result, the HPA trinity can't turn itself down properly and is constantly on high-alert. The body behaves as if it were stressed, even when nothing stressful is happening. The result is a higher risk of anxiety, depression and suicide. McGowan admits that this the whole picture is still speculative, but the individual steps make sense in the light of his results.