Infant abusive head trauma: Incidence, outcomes and awareness

Abstract

Background:
Abusive head trauma of infants is a significant cause of morbidity and mortality. The incidence in Australia has been estimated at 29.6 cases of abusive head trauma for which hospital admission is required per 100 000 infants aged 0-24 months and under per year; more frequent than low speed runovers, drowning and childhood neoplasms.

Objective:
This article provides a review of the significant incidence and outcomes of abusive head trauma and seeks to raise awareness of the potential of evidence based interventions to reduce infant injury and its consequences in the community.

Discussion:
An evidence based program, the Period of PURPLE Crying®, has been shown to reduce infant injury. An evaluation of the suitability of program materials for different cultural groups in Australia needs to be assessed. Such a scoping project is proposed as a necessary prerequisite to a pilot clinical intervention.

Full text

PROFESSIONAL
Infant abusive head trauma
Incidence, outcomes and awareness
which provides information to family and carers
and web based training and support for providers.
Evaluating the cultural appropriateness of this
intervention for the rural and remote Australian
context is overdue and necessary before its
clinical use.
The problem
Abusive head trauma is a common cause of
mortality and morbidity in infants.2 The incidence
of AHT in Australia is comparable to overseas
studies. A recent study into the incidence of AHT
in Queensland found 29.6 cases of AHT for which
hospital admission was required per 100 000
infants aged 0–24 months and under per year.1
A population based study in the United Kingdom
found that the incidence of subdural haemorrhage
due to child abuse was 10.1 cases annually per
100 000 children under the age of 2 years,5 and
25–30 cases per 100 000 presentations per year
in Edinburgh, Scotland.2 In the United States,
between 1200–1400 children may be injured
or killed by shaking every year.6 More recent
incidence studies in the USA have suggested rates
of AHT occurrence are approximately 10 times
higher than that of the most common childhood
leukaemia.1
The consequences of AHT are significant. In
80% of cases severe morbidity is present, which
includes intellectual impairment, behavioural
disorders and impaired motor and cognitive skills.7
Enduring cognitive limitations due to AHT include
problems with IQ, mental organisation, memory,
alternation, inhibition and verbal processing.8 The
level of long term impairment seen in children
who have experienced AHT in infancy has been
demonstrated to be significantly higher than
that found in children who have experienced an
accidental head injury during infancy.1 The high
morbidity and incidence of AHT has financial
implications for the healthcare system. Lifetime
costs for brain injury have been estimated to be
The term ‘abusive head trauma’ (AHT)
encompasses both shaking and impact
related brain and head injuries in
infants and children aged up to 2 years.1
Prevention and intervention research for
AHT has not been prioritised in Australia,
despite the high cost and lifelong
morbidity for survivors and the growing
international evidence of the low cost of
effective prevention and intervention.2
Addressing the AHT injury toll is a core clinical
responsibility for primary care providers, who are
in the best position within the current Australian
health system to provide population-wide
pre-injury interventions. This article describes
the incidence and aetiology of AHT and hopes
to raise awareness of the problem. The most
evidence based intervention for AHT prevention
is the Period of PURPLE Crying® program,2–4
Background
Abusive head trauma of infants is a significant cause of morbidity and mortality.
The incidence in Australia has been estimated at 29.6 cases of abusive head
trauma for which hospital admission is required per 100 000 infants aged 0–24
months and under per year; more frequent than low speed runovers, drowning
and childhood neoplasms.
Objective
This article provides a review of the significant incidence and outcomes of
abusive head trauma and seeks to raise awareness of the potential of evidence
based interventions to reduce infant injury and its consequences in the
community.
Discussion
An evidence based program, the Period of PURPLE Crying®, has been shown
to reduce infant injury. An evaluation of the suitability of program materials
for different cultural groups in Australia needs to be assessed. Such a scoping
project is proposed as a necessary prerequisite to a pilot clinical intervention.
Keywords
child abuse; craniocerebral trauma; infant
William Liley
Anne Stephens
Melissa Kaltner
Sarah Larkins
Richard C Franklin
Komla Tsey
Rebecca Stewart
Simon Stewart
Reprinted from AUSTRALIAN FAMILY PHYSICIAN VOL. 41, NO. 10, OCTOBER 2012
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Infant abusive head trauma – incidence, outcomes and awarenessPROFESSIONAL
efficacy, with reductions in AHT incidence of
up to 50%.4 Barr additionally postulates that
programs which increase awareness of crying
norms also decrease general childhood physical
assault incidence alongside AHT.4
There have been several locally designed,
urban based prevention efforts in Australia: at
the Westmead Hospital in Sydney, New South
Wales; the Royal Women’s and Children’s
Hospital in Adelaide, South Australia;20 and in
Ipswich in southeast Queensland.1 To date, the
evaluations of these local Australian programs
have not been published nor implemented
within the rural/remote context.
The Period of PURPLE Crying® (Table 1)
informs prevention initiatives at the Westmead
Children’s Hospital.1 This intervention has been
implemented across North America and was
referenced in The Royal Australian College
of General Practitioners continuing education
program for GPs regarding early infant care.21
prevention strategies for children under 5 years
of age.17–19
There is a compelling need to educate and
train primary care professionals, including
doctors, early childhood educators, health
workers, nurses and midwives, in order to
decrease the number of preventable cases
of AHT. There is also a need for continued
monitoring of AHT. Wirtz and Trent14 call for a
comprehensive surveillance system to identify
high risk areas or groups for intervention and to
monitor trends over time.
Prevention programs
Research suggests that AHT is preventable.2,3
Barr4 asserts that prevention programs delivered
to birthing parents have been shown to
decrease AHT incidence and increase parental
awareness of the dangers of shaking and
physically harming their baby. Carer education
based prevention programs have shown strong
$2.5 million per moderate case and $4.8 million
per severe case, with annual treatment costs
varying from $8800 to over $280 000.9
Incidence studies in Queensland established
that occurrence of AHT was more frequent
than that of low speed runovers, drowning and
childhood neoplasms in Australian children
during age incidence peaks.1 The frequency of
infant AHT in Queensland, and the long term
sequelae and costs to the healthcare system
underline the need to implement and evaluate
AHT prevention programs in Queensland
settings.
Recognition of the problem
Research has identified numerous factors
relating to the infant, family and perpetrator
that appear to be associated with an increased
risk of AHT.1 Epidemiological research suggests
that preventive efforts should engage male
carers alongside female carers, as males are
reported to be more frequent perpetrators of
AHT than females.10 There is a correlation
between the peak of infant crying and
subsequent incidence of AHT.11 A three-
component model of AHT aetiology, whereby
infant factors, carer factors and situational
factors interact and lead to the occurrence of
AHT, has been suggested and is outlined in
Figure 1.
While AHT injuries carry lifelong disability,
diagnosis remains contentious.12 This is
due in part to the nonspecific symptoms of
head injury; there is wide variability in the
clinical presentation, ranging from nonspecific
symptoms such as vomiting, to coma or
death.13 This suggests a high rate of missed
cases. Carers’ attempts to conceal instances
of child assault1,14 also increase the risk of
misdiagnosis. In a large number of cases, the
history provided by the carer is either ‘no’
history or that of a short fall from a bed, couch,
counter or other item of household furniture.6
According to Chadwick,15 the probability of
receiving a life-threatening head injury as a
result from a fall of less than 1.3 m is remote,
with the outcome of short falls most commonly
benign.15,16 Despite it being possible to
differentiate abusive head injury from accidental
head injury or disease,16 AHT does not feature
in Queensland and Australian national injury
Figure 1. Aetiology of abusive head trauma
Adapted from Kaltner, 20101
Infant factors
Age associated development, encompassing:
• physiologicalrisk
• crying
• separationanxiety
Abusive head trauma
Situational factors
• Familysocioeconomicstatus
• Stressfulsituationsincludingmilitaryinvolvement,
natural disaster
• Isolation
• Twinstatus
• Pregnancydifficulties
Carer factors
• Understandingofnormalcryingpatternsininfantsand
the dangers of shaking
• Frustrationtolerance
• Ageandcarerexperience
• Substancemisuse
• Psychopathology
• Jealousyofinfant’srelationshipwithothercarers
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PROFESSIONALInfant abusive head trauma – incidence, outcomes and awareness
Melissa Kaltner BPsych(Hons), PhD,
is Allied Health Research Coordinator
(Research Fellow), Darling Downs Health
Service District (Queensland Health),
Queensland
Sarah Larkins MBBS, BMedSc, MPH&TM,
PhD, FRACGP, FARGP, is Associate
Professor, General Practice and Rural
Medicine, Health of Underserved
Populations Research Group, School of
Medicine and Dentistry, James Cook
University, Townsville, Queensland
Richard C Franklin BSc, MSocSc, PhD, is
Associate Professor, Injury Prevention and
Safety Promotion, Anton Breinl Centre
for Public Health and Tropical Medicine
and Rehabilitation Sciences, Townsville,
Queensland
Komla Tsey BA, PhD, is Professor & Tropical
Leader (Education for Social Sustainability),
The Cairns Institute and School of
Education, James Cook University, Cairns,
Queensland
Rebecca Stewart MBBS, FRACGP, MClinEd,
is a medical trainer, Tropical Medical
Training, Townsville and Senior Lecturer,
Department of General Practice and
Rural Medicine, James Cook University,
Townsville, Queensland
Simon Stewart BSW, PGCertChProtPrac,
MSocPol, is team leader, Department of
Child Safety, Townsville, Queensland.
Conflict of interest: none declared.
References
1. Kaltner M. Abusive head trauma: incidence
and associated factors in Queensland [PhD
thesis]. Brisbane: University of Queensland,
2010.
2. Reece RM, Dias MS, Barr M, Russell SB,
Barr RG, Runyan DK. White paper. Shaken
baby syndrome/abusive head trauma pre-
vention. 2010. Available at http://dontshake.
Community and expert engagement is
essential to ensure that any AHT prevention
interventions are appropriate to the
Australian context. A more widespread
program is urgently required in Australia
to begin to address this issue, to raise
awareness, enhance early parenting skills
where needed, and to reduce the burden of
injury caused by AHT.
Authors
William Liley MBBS, BPhty, DipEdSt(counsel),
Integrated Women’s Health Unit, Cairns Base
Hospital, Queensland. william.liley@gmail.com
Anne Stephens BA, BEd(GE), PhD, is Senior
Researcher, The Cairns Institute, James Cook
University, Cairns, Queensland
Building the quality of
services and evidence base
in rural and remote Australia:
a strategy for change
There is a paucity in the current literature in
Australia, particularly for rural and remote
regions, regarding effective interventions to
decrease infant AHT. We propose that an initial
scoping project to examine the Period of PURPLE
Crying® program and its suitability for the rural
and remote Australian context is a necessary
first step before conducting implementation
and clinical trials. A statewide epidemiological
data analysis found that children of Aboriginal
and Torres Strait Islander descent are over
represented in AHT cases in Queensland and
are up to three times more likely to experience
an incidence of severe AHT compared to infants
from the wider Australian community.1 While
this might reflect systematic data deficits and
reporting bias, this documented occurrence in
Aboriginal and Torres Strait Islander populations
adds to the imperative for a culturally sensitive
intervention program.
In this initial scoping project, primary care
and local specialists will be interviewed to
evaluate the cultural appropriateness of the
intervention in its current form for possible
use in a local trial in northern Queensland.
Table 1. A snapshot of the Period of PURPLE Crying® program
The Period of PURPLE Crying® program is an evidence based approach to infant
AHTprevention.Iteducatescarersandserviceproviderstounderstandthe
frustrating features of crying in normal infants, which can lead to shaking or abuse
The program includes an 11-page booklet, 10-minute DVD and website resources for
parents and care providers of new infants (Figure 2). The materials are presented to
parents/carers before leaving the maternity setting (or very early in the infant’s life),
by allied health workers, midwives, GPs or maternity physicians. The intervention is
supported by internet based training and resources
The validated materials are designed to be accessible, available to services at low
cost (USD2.00 per package), and intended to be given to every family with every
birth. The materials present people from diverse ethnic backgrounds and are
presented in plain English and in up to 10 languages
Randomised controlled trials in the United States and Canada in 2003–07 with over
4400 parents in a range of medical settings, including hospitals, pre-natal classes and
home nurse visits, concluded that the program can significantly alter the knowledge
and change the behaviour of carers; evaluation is ongoing
The program is implemented in over 800 hospitals and organisations in 49 states of
theUSAandinCanada,JapanandAustralia
Source National Centre on Shaken Baby Syndrome, 2011
Figure 2. Period of PURPLE Crying® Intervention materials
Reproduced from Barr, 201111
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Infant abusive head trauma – incidence, outcomes and awarenessPROFESSIONAL
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