Prevention of shaken baby syndrome: Never shake a baby

Abstract

Shaken baby syndrome (SBS) represents injuries to the head, skeleton and eyes of a young child and is the leading cause of fatal or life-threatening child abuse. SBS is preventable. The dangers and consequences of shaking a baby are not well appreciated by the general public. Simple educational programs and community nursing support programs have been shown to be helpful. Inadequate physician training and knowledge in child maltreatment have also been identified as problems. This article outlines the evidence for interventions in the prevention of SBS and recommendations for health care providers and educators.

Shaken Baby Syndrome (SBS) is a name given to a group of physical findings that are believed to result from the forceful shaking of a child, with or without direct impact to the head. The names shaken-impact syndrome and whiplash shaken infant syndrome have also been used to describe the same constellation of injuries. Whichever name is used, the findings represent inflicted traumatic brain injury in a young child. The injuries seen in SBS may include: subdural hematomas, subarachnoid hemorrhages, retinal hemorrhages, rib fractures that are typically posterior, long bone fractures that are typically metaphyseal, bruises, lacerations or other fractures due to impact.

SBS occurs most frequently in infants, although it can occur in older children. Infants are particularly at risk because of poor head control (due to relatively large head size and weight and relative weakness of neck muscles). Unique features of the immature brain are also contributing factors. When significant rotational acceleration-deceleration forces are applied, as in shaking, the brain is susceptible to shearing of the bridging veins in the subdural space, diffuse axonal injury, contusion and edema (1).

The circumstances surrounding these events are not well understood but the injuries frequently occur in a tragic moment involving a crying baby and a frustrated caregiver. Feeding, diapering and toileting difficulties may also be triggers associated with shaking. Many victims of SBS die (15% to 27%) or suffer serious neurological consequences (more than 30%) (2–4). However, SBS is preventable.

This article focuses on the epidemiology of SBS in Canada and its prevention through education to the public, promotion of physician awareness and targeted community interventions.

EPIDEMIOLOGY

Almost all (95%) fatal or life-threatening child abuse injuries are due to inflicted head trauma (5,6). In the United States, 17% of deaths in a paediatric intensive care unit were attributed to child abuse with head trauma (7). In a prospective population-based study, the estimated incidence of severe or fatal brain injury among infants was 30 per 100,000 (8).

Recent Canadian data revealed that 2.1% of children in Canada are the subjects of child maltreatment investigations and 45% of these are confirmed to have suffered maltreatment (9). Between 1988 and 1998 in 11 Canadian paediatric tertiary care hospitals, 364 children were diagnosed with SBS (10). The median age was 4.6 months, but infants as young as seven days and children as old as four years were identified. The outcomes were devastating, with death occurring in 69 children (19%), neurological injury occurring in 162 children (55%) and visual impairment occurring in 192 children (65%). Only 22% of the surviving children showed no signs of impairment at the time of discharge. The perpetrator was identified in 66% of cases and was most commonly the biological father (50%), stepfather or other male partner (20%), or biological mother (12%) (10).

PREVENTION

Public education

Widely targeted programs that educate the public regarding the dangers of shaking babies have been recommended for over 30 years (11). In 2001, Health Canada, the Canadian Paediatric Society and partners, published the Joint Statement on SBS (12). Included in this statement is the recommendation to “provide the general public and targeted audiences not just with the caution regarding shaking a baby but with guidance for coping with the demands of a baby.” It also cautioned against letting “inexperienced caregivers, those who have difficulty controlling their anger and those with any resentment toward an infant look after a baby, even for a short time.”

Several studies have demonstrated that between 25% and 50% of college students, high school students, adults, pregnant and parenting teens, and female inmates, are unaware of the dangers of shaking a baby (13–16).

Unrealistic expectations of children’s behaviour are associated with child abuse and the lack of alternative approaches to managing children’s behaviour is a factor associated with physical punishment (15–18). Parent education cards on such topics as constant crying, feeding problems, temper tantrums and toilet training, developed to contain information on appropriate expectations of children and nonviolent approaches to behaviour management have demonstrated effectiveness in changing parents’ knowledge and reported behaviour (13,19). The distribution of these cards in physician offices resulted in 50% fewer parents choosing slapping or spanking as a behaviour management approach (13).

The prevention of inflicted head injury has been targeted with information cards as part of a “Don’t Shake the Baby” project for new parents. While in-hospital, following delivery, mothers were given an information card outlining the dangers of shaking and suggestions for dealing with a crying infant. Response postcards were received from 21% of participating parents with 75% stating that the information card was helpful, 46% indicating that they were “not as likely to shake my baby now” and 90% responding that other parents should read the card (19).

These studies suggest that pamphlets given out in physician offices or hospitals are read by parents and can change their knowledge and attitudes. It is hoped that this would also result in a change in their behaviour.

Physician awareness

Physicians have a responsibility to identify and protect children at risk for abuse. The combination of less than optimal physician training in child maltreatment and the nonspecific presentation of head injuries in infants makes this task particularly difficult.

Inadequate physician knowledge in child maltreatment has been well documented. A recent study of Canadian paediatric residency programs demonstrated that only three programs required residents to complete any clinical training in child protection (20). Almost half of the residents indicated that they had seen five or fewer cases of abuse or neglect, two-thirds had never contacted a child welfare agency, and 85% of graduating residents felt that they required further training (20). These results are in agreement with studies of American paediatric residents, American paediatric emergency fellows and Canadian psychiatry residents (21–24).

The likelihood of reporting maltreatment among practicing physicians is related to the amount of training they have received in this field (25) and scores on tests of knowledge of maltreatment are positively correlated with residents’ reports of exposure to child abuse instruction in their training programs (21).

The signs of inflicted head trauma in infants are often nonspecific and can be difficult to recognize. They include seizures, decreased level of consciousness, respiratory distress, irritability, lethargy, vomiting and apnea.

In a retrospective study of inflicted head trauma in children less than three years of age, the diagnosis was missed by physicians in 31% of patients at the time of initial presentation (26). In a group of asymptomatic but high-risk children less than two years of age admitted to hospital for investigation of physical abuse, 37% had head injuries on imaging studies despite normal neurological examinations (27). Of 364 cases of SBS seen in Canadian paediatric centres, 40% had no sign of external injury (10). Physicians must maintain a high index of suspicion to make the correct diagnosis.

Community interventions

Community-based public health initiatives have been proposed as a means to provide prevention of child maltreatment in general, prevention within targeted high-risk groups and prevention of recidivism in families with a history of child abuse. Comprehensive evidence-based reviews on this topic were published in 1994 and 2000 (28,29). The most commonly studied intervention was home visitation by nurses in the perinatal and early childhood periods. It was demonstrated that extended home visitation programs can prevent child physical abuse and neglect among poor, adolescent or single parents (30). The 1994 review arrived at the same conclusion but cautioned that the effectiveness of this type of program for the general population was unclear (28).

More recently, frequent home visits by nurses from the prenatal period until the child’s second birthday have been shown to prevent child maltreatment, reduce childhood injuries, and reduce the number of health care encounters among disadvantaged primipara mothers (29,31). The evidence for this intervention was of sufficient quality that it was recommended as part of the periodic health examination as a grade A recommendation.

SUMMARY

SBS represents a constellation of injuries to the brain, eyes and skeletal system that results from forceful shaking with or without impact to the head of a young child. The consequences can be grave. Inflicted head injury or SBS is the leading cause of death due to child maltreatment. In order to protect children, we must make parents and caregivers aware of the dangers of shaking. We must also support them in using safe approaches to the challenges of infant and child care.

Twenty-five per cent to 50% of populations studied are unaware of the risks of shaking a baby. The delivery of simply worded information cards on the dangers of shaking and alternatives to dealing with a crying infant have been shown to change parental knowledge and understanding of appropriate child behaviour management techniques. Nurse home visitation programs, conducted between the prenatal period and the age of two, have shown to decrease rates of maltreatment in certain populations. Physicians are expected to detect and manage cases of child maltreatment, yet they often have inadequate training in this field. This needs to be improved.

Recommendations

1. Routinely provide “Never Shake the Baby” counselling to all expectant and new parents.

2. Provide written information on ways to deal with a crying infant to all expectant and new parents and provide counselling on choosing appropriate alternate caregivers.

3. Physicians should inform themselves on child behaviour management approaches and should use anticipatory guidance with parents to discuss these at health maintenance visits.

4. Require educational programs on “Never Shake the Baby” to be provided to all prospective caregivers by supporting the inclusion of such programming in high school curriculae, parenting programs, babysitting classes, prenatal classes and to the general population.

5. Refer all first-time mothers who are single, teenagers or of low socioeconomic status for frequent home visits from a public health nurse, and support the use of such a program for up to two years.

6. Ensure that all health care workers are familiar with the signs and symptoms of SBS.

7. Require education administrators to include child maltreatment as a topic of core content in the training of paediatricians, family physicians and medical students.

Handouts for parents on the dangers of shaking and strategies for dealing with a crying infant are available at: <www.caringforkids.cps.ca/babies/SBS.htm>; in Paediatrics & Child Health 2001;6(9):668-9 (English), 678–679 (French); and as a pamphlet or video from the Canadian Paediatric Society (<www.cps.ca> or 613-526-9397).