Prevention of Abusive Head Trauma in Infants

Medicine and Health Rhode Island, Dec 2003 by Barron, Christine C

"We are living through the greatest time in history in terms of material prosperity, but it will be a commentary on our times and our individual and collective lives if we do nothing about these horrors known as child abuse. Here, in the greatest county in the world, I ask you- How can we honestly proclaim ourselves the stewards of our time if we allow this to go on?" - News Commentator Tom Brokaw.

In the United States, an estimated 4 children die each day as a result of abuse and neglect.1

Abusive head trauma (AHT) is the most common cause of morbidity and mortality in physically abused infants, with a peak incidence at 6 months of age.2-3

AHT encompasses inflicted central nervous system (CNS) injuries, including mechanisms of both shaking and impact, commonly referred to as Shaken Baby Syndrome (SBS). The classic findings include: subdural hemorrhages, retinal hemorrhages, and fractures of long bones or ribs. Victims have presenting signs and symptoms along a continuum ranging from decreased responsiveness, irritability, and lethargy to convulsions, unresponsiveness and death. Survivors have serious neurological consequences.4,5,6

John Caffey first described AHT as long bone fractures and subdural hematomas.7 This concept was further developed with descriptions of shaking mechanisms by Guthkelch and Caffey.8,9 Since that time there has been continued debate over whether shaking alone or shaking with impact is required to generate the forces causing the lesions seen in AHT. Published reports support both therories.10-15

Because the outcomes for victims remain poor,16,17 the quest is to identify preventive strategies. Ray Helfer and C. Henry Kempe stated, "For many, the most exciting and encouraging aspect of this total problem lies in the area of prevention."18

Prevention efforts are defined within three categories, primary, secondary and tertiary. Primary prevention refers to approaches applied to the general population, without targeting a particular high-risk group. Secondary prevention includes those programs directed toward people considered high risk for a particular condition. Tertiary prevention efforts are implemented after a condition has been identified, and is synonymous with treatment. The goal of a tertiary program is to prevent recurrence or other negative consequences. These definitions are discrete; most actual prevention plans traverse these definitions. Support for primary and secondary prevention has been stronger due to the limited success of strategies implemented once maltreatment has occurred.19

Dr. John Caffey recommended primary prevention through a massive public educational program on the dangers of shaking. Three obstacles impeded the momentum to implement prevention programs for AHT. First, experts disagreed initially on the importance of educating the public about the dangers of shaking: many professionals believed that the dangers of shaking were common knowledge. Studies completed between 1982 and 1990 refuted this theory. These studies demonstrated that a significant percentage (25-50%) of adolescents and adults did not know that shaking was dangerous. These findings strongly supporting a general awareness prevention strategy.20-23 Second, shaking was often precipitated by inconsolable crying combined with caretakers' impulsivity; in short, it was not a premeditated plan. Thirdly, most other prevention strategies were aimed at populations with certain risk factors. Although there are clearly certain risk factors for AHT, including poverty and social stressors, 24,25 race and socioeconomic class do not skew the incidence of AHT. Despite these initial obstacles, prevention strategies have prevailed as the current focus for AHT. This prevention focus has recently been supported by the American Academy of Pediatrics (AAP), with recommendations to devote resources to the prevention of AHT.26

Several prevention programs have been shown to prevent the occurrence of devastating and often fatal cases of AHT. Although not specifically designed as a prevention strategy, the establishment of Child Fatality Review Teams has benefited prevention efforts. These teams have improved multidisciplinary communication, death scene investigations, fatality classification and creation of preventative recommendations.27,28

A cornerstone of many prevention programs is the education of medical professionals to recognize the signs and symptoms of inflicted head injury, to avoid misdiagnosis and further injuries. Diagnosing child victims of AHT can be difficult due to the variation in presenting symptoms. In 1999, Jenny published a review in which 31% (54/173) of child victims were evaluated by physicians who did not recognize the diagnosis of AHT. Fifteen children (27.8%) were re-injured after the missed diagnosis, and four of those children died. These cases represent missed AHT diagnosis and missed opportunities for tertiary prevention interventions.29

Many documented primary prevention strategies include education for parents of newborns. Showers conducted an educational campaign in 1989, providing educational information to parents. The parents concluded that the campaign was worthwhile, 30 but due to lack of funding, further data were not collected to evaluate efficacy.