When soothing succeeds: Simulating a risk for repeated shaking in abusive head trauma in infants.

PURPOSE: To investigate the observation that perpetrators of abusive head trauma engage in repeated shakings because shaking "works" to quiet the infant. METHODS: Sixty first-time parent couples individually cared for a programmable model infant in two consecutive 7-min trials. After six minutes of consolable followed by inconsolable crying, parents selected one of three soothing techniques. For trial one, parents were randomized to a "Successful" or "Failed" Soothing Condition. Whether the soothing technique was repeated after trial two was determined by the study investigators. Parents rated their frustration after each trial. RESULTS: As hypothesized, parents were more likely to repeat a soothing technique that "worked" in trial one. Compared to fathers, mothers reported more frustration when soothing failed. CONCLUSIONS: That caregivers were more likely to repeat a successful soothing technique converges with perpetrator confessions that crying cessation after shaking may be a reason why shaking is used repeatedly in response to crying.

Repeated mild shaking of neonates induces transient cerebral microhemorrhages and anxiety-related behavior in adult rats.

Growing evidence suggests that neonatal cerebral microhemorrhages (MHs) are implicated in neuropsychiatric diseases in adults. Although animal studies have identified the progression of the underlying mechanisms of MHs, few studies have investigated the histopathology and behavioral outcomes. In this study, we created an experimental rat model of MHs using a new experimental device for repeated mild shaking brain injury (SBI) in the neonatal period and examined temporal changes in MHs using susceptibility weighted imaging (SWI) and iron histochemistry. SWI demonstrated transient MHs in the gray matter of the cerebral cortex and hippocampus in injured rats. Iron histochemical staining demonstrated leakage of iron and iron-positive cells surrounding MHs. This staining pattern lasted for a long time and continued after disappearance of hemorrhagic signals on SWI. These data suggested the presence of iron-associated gray matter injury after MHs. In the open field test, these injured rats showed anxiety-related behavior as adults. This model may be useful for exploring the underlying mechanisms of changes that occur after MHs and the behavioral outcomes of repeated mild SBI in early development.

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

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

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

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

Extended follow-up of neurological, cognitive, behavioral and academic outcomes after severe abusive head trauma.

Studies about long-term outcome following abusive head trauma (AHT) are scarce. The aims of this study were to report long-term neurological, cognitive, behavioral and academic outcomes, ongoing treatments and/or rehabilitation, several years after AHT diagnosis, and factors associated with outcome. In this retrospective study, all patients admitted to a single rehabilitation unit following AHT between 1996 and 2005, with subsequent follow-up exceeding 3 years, were included. Medical files were reviewed and a medical interview was performed with parents on the phone when possible. The primary outcome measure was the Glasgow Outcome Scale (GOS). Forty-seven children (out of 66) met the inclusion criteria (mean age at injury 5.7 months; SD=3.2). After a median length of follow-up of 8 years (range 3.7-12), only seven children (15%) had "good outcome" (normal life - GOS I) and 19 children (40%) presented with severe neurological impairment (GOS III and IV). Children sustained epilepsy (38%), motor deficits (45%), visual deficit (45%), sleep disorders (17%), language abnormalities (49%), attention deficits (79%) and behavioral disorders (53%). Most children (83%) had ongoing rehabilitation. Only 30% followed a normal curriculum, whereas 30% required special education services. Children with better overall outcome (GOS I and II) had significantly higher educated mothers than those with worse outcomes (GOS III and IV): graduation from high school 59% and 21% respectively (p=0.006). This study highlights the high rate of severe sequelae and health care needs several years post-AHT, and emphasizes the need for extended follow-up of medical, cognitive and academic outcomes.

Assessment of parental awareness of the shaken baby syndrome in Ireland.

UNLABELLED: Shaken baby syndrome (SBS) results in cerebral trauma. Creating awareness through education may improve parental response to a distressed infant. We aim to assess current parental understanding of SBS and identify knowledge gaps. A prospective assessment was carried out in two independent maternity hospitals (National Maternity Hospital (NMH) and Midland Regional Hospital (MRH)) over a 4-month period. Multi-dimensional questionnaires were distributed to parents (n = 233) and results were assessed anonymously. Statistical analysis was performed using SPSS21 software. Two hundred thirty-three participants were included: n = 114 (NMH), n = 119 (MRH). Fifty-four percent (n = 62, NMH) and 50 % (n = 60, MRH) had never heard of SBS. Of those who had, media was the commonest source: 94 % (47/50) NMH; 86 % (47/59) MRH. Less than 1 % of participants obtained information through a health care provider. Nearly all respondents wanted further information, regardless of whether they had prior knowledge (100 % (NMH); 99.2 % (MRH)). Participants wanted information delivered via a midwife (51 % (58/114) NMH; 45 % (54/119) MRH), with reading material (61 % (69/114) NMH; 59 % (70/119) MRH), during pre-natal period (50 % (57/114) NMH; 65 % (77/119) MRH). Importantly, parents of Irish origin were more likely to have heard of SBS compared to those of non-Irish origin (p = 0.026 (NMH), p = 0.020 (MRH)). CONCLUSION: Half of all participants had no prior knowledge of SBS, with majority expressing interest in learning more. Therefore, a national "Don't Shake" campaign is evolving. WHAT IS KNOWN: • Studies have shown that educating parents regarding shaken baby syndrome (SBS) may result in a more safe and appropriate response to infant crying [ 3 ]. • In Ireland, there is no such education provided to parents in maternity hospitals. What is New: • Just over half of our participants had not heard of SBS, and we have identified parental perceptions of SBS, and parents preferred method of anti-SBS education delivery. • This research will act as a launching platform for an anti-SBS campaign in Ireland.

Evaluation of Period of PURPLE Crying, an abusive head trauma prevention program.

The Period of PURPLE Crying program is used to educate parents and caregivers about normal infant crying and the dangers of infant shaking. We evaluated nurse-led, hospital-based implementation of the program using a nonexperimental, posttest-only design. New mothers rated the program as useful, and the program was effective in teaching mothers about normal infant crying, the dangers of infant shaking, and soothing and coping techniques. The findings support the feasibility and need for broad dissemination of the program.

Preventing abusive head trauma resulting from a failure of normal interaction between infants and their caregivers.

Head trauma from abuse, including shaken baby syndrome, is a devastating and potentially lethal form of infant physical abuse first recognized in the early 1970s. What has been less recognized is the role of the early increase in crying in otherwise normal infants in the first few months of life as a trigger for the abuse. In part, this is because infant crying, especially prolonged unsoothable crying, has been interpreted clinically as something wrong with the infant, the infant's caregiver, or the interactions between them. Here, we review an alternative developmental interpretation, namely, that the early increase in crying is a typical behavioral development in normal infants and usually does not reflect anything wrong or abnormal. We also review evidence indicating that this normal crying pattern is the most common trigger for abusive head trauma (AHT). Together, these findings point to a conceptualization of AHT as the consequence of a failure in an otherwise common, iterative, and developmentally normal infant-caregiver interaction. They also imply that there is a window of opportunity for prevention of AHT, and potentially other forms of infant abuse, through a public health primary universal prevention strategy aimed at changing knowledge and behaviors of caregivers and society in general concerning normal development of infants and the significance of early increased infant crying. If effective, there may be important implications for prevention of infant abuse nationally and internationally.

Child abuse.

Child abuse can have a long-lasting and devastating effect on the growth and development of infants, children, and adolescents. Studies of abused and neglected children indicate that they have a higher rate of delayed intellectual development, poor school performance, aggressive behaviors, and social and relationship deficits compared with nonmaltreated children. Early recognition and appropriate treatment is one of the most important factors in preventing further child abuse and maltreatment. Every practitioner should be educated on the signs and symptoms of child abuse. The referral to child protective services is a necessity for the future well-being of the child.

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

BACKGROUND: Infant crying is an important precipitant for shaken-infant syndrome. OBJECTIVE. To determine if parent education materials (The Period of PURPLE Crying [PURPLE]) change maternal knowledge and behavior relevant to infant shaking. METHODS: This study was a randomized, controlled trial conducted in prenatal classes, maternity wards, and pediatric practices. There were 1374 mothers of newborns randomly assigned to the PURPLE intervention and 1364 mothers to the control group. Primary outcomes were measured by telephone 2 months after delivery. These included 2 knowledge scales about crying and the dangers of shaking; 3 scales about behavioral responses to crying generally and to unsoothable crying, and caregiver self-talk in response to unsoothable crying; and 3 questions concerning the behaviors of sharing of information with others about crying, walking away if frustrated, and the dangers of shaking. 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. CONCLUSIONS: Use of the PURPLE education materials seem to lead to higher scores in knowledge about early infant crying and the dangers of shaking, and in sharing of information behaviors considered to be important for the prevention of shaking.

Getting the word out: advice on crying and colic in popular parenting magazines.

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.

Outcome following subdural haemorrhages in infancy.

Subdural haemorrhages (SDH) are associated with significant neurodisability in affected individuals. The incidence of SDH in infants is between 12 and 25 cases per 100,000 children and most detected SDH are due to physical abuse. In the infant brain, SDH are caused by tearing of the bridging veins in the subdural space and may result in significant brain injury. The challenge of assessing outcome in infants with SDH is evaluating whether SDH or other accompanying brain insults are instrumental in the neurodevelopmental outcome.

A review of social factors in the investigation and assessment of non-accidental head injury to children.

Investigation and assessment work in non-accidental head injury cases is complex and challenging. This article discusses briefly the professional systems involved and the conditions necessary for effective practice. It then reviews briefly the literature on social factors in serious and fatal child abuse in order to provide a context for discussion of recent UK studies of non-accidental head injuries/shaken baby syndrome. The findings on social factors are compared and areas for further research are suggested. The article then considers how best to use the existing knowledge base about these cases within assessment frameworks currently in use and considers issues in presenting assessment conclusions to decision-makers.

Pharmacologic treatment of cognitive deficits and hypersexuality due to "shaken-baby syndrome".

OBJECTIVE: To describe the clinical effects of amantadine and propranolol in an agitated pediatric patient with cognitive deficits, hyperactivity, and hypersexualism secondary to "shaken-baby syndrome." BACKGROUND: Patients with shaken-baby syndrome can present with cognitive and behavioral impairments. CASE: A 9-year-old girl presented with cognitive impairments secondary to shaken-baby syndrome at 3 weeks of age. She was receiving many medications, including dextroamphetamine, methylphenidate, and clonidine, that were not effective in improving her cognitive status or decreasing her hypersexuality. She was weaned from stimulants and clonidine and prescribed amantadine 100 mg bid with improvement of attention, concentration, and cognition, although hypersexuality remained. She was then started on propranolol 10 mg tid and a gradual increase to 40 mg tid with amelioration of hypersexuality and hyperactivity and no unwanted effects noted. Self-weaning of propranolol was associated with the return of hypersexuality. The combination of amantadine and propranolol led to improvement of cognition and behavior, especially intellectual functioning and appropriate socialization with peers, respectively. CONCLUSION: Cognitive deficits and hypersexuality with hyperactive features due to shaken-baby syndrome may respond to the drug regimen of amantadine and propranolol.