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International collaboration on prevention of
shaken baby syndrome – an ongoing
project/intervention
Sue Foley
1,3
, Zsuzsanna Kova
´
cs
5
, Jenny Rose
1
, Robyn Lamb
1
, Fran Tolliday
2
,
Martine Simons-Coghill
1
, Amanda Stephens
2,4
,Do
´
ra Scheiber
5
, Andrea Toma
5
,
Katalin Asbo
´
th
5
, Tama
´
s Kassai
6
, Helen Agathonos
7
, Nahara R. L. Lopes
8
,
Lu
´
cia C. A. Williams
8
, Figen Sahin
9
, Aysin Tasar
10
, Terry Sarten
1
1
The Children’s Hospital at Westmead,
2
Western Sydney Local Health District,
3
The University of Technology,
4
The University of Sydney, Sydney, Australia,
5
National Institute of Child Health, Hungary,
6
National Institute of
Traumatology and Emergency, Budapest, Hungary,
7
Society for the Prevention of Cruelty to Children (ELIZA),
Greece,
8
Universidade Federal de Sa
˜
o Carlos, Sa
˜
o Paulo, Brazil,
9
Gazi University Faculty of Medicine,
Department of Pediatrics,
10
Ankara Research and Education Hospital, Department of Pediat rics, Ankara, Turkey
Caring for young infants can be stressful. Non-accidental brain or head injury (shaken baby syndrome) is a
result of parental stress, and a lack of knowledge of how to respond to a crying infant and the dangers of
shaking a child. This article demonstrates the value of international collaboration in projects to prevent child
maltreatment. It includes reports of prevention of shaken baby syndrome programmes in Australia,
Hungary, Greece, Brazil and Turkey.
Keywords: Shaken baby syndrome (SBS), Prevention, International collaboration
Introduction
Shaken baby syndrome (SBS), also described as non-
accidental brain injury (NABI), is a special form of
child abuse caused by vigorously shaking an infant,
often in anger, to make it stop crying or whining. It
includes impact injuries and additional musculo-
skeletal injuries. SBS commonly presents with sub-
dural and/or subarachnoid haemorrhages, retinal
haemorrhages and brain damage from oedema,
bleeding, stroke, axonal injury and hypoxic-ischaemic
injury. Whiplash-like shaking results in significant
acceleration/deceleration force. It is thought that this
causes subdural haemorrhages by tearing the dural
bridging veins, and retinal haemorrhages by causing
vitreoretinal traction. The incidents occur mostly in
infants under 1 year of age. In the worst cases, the
violent shaking causes death. It may result in severe
and permanent brain injury, spinal-cord injuries,
retinal haemorrhages and rib fractures.
1–4
The out-
come is often devastating with 15–38% of children
dying of their injuries, more than one-third having
serious neurological sequelae, and two-thirds having
visual impairment. Survivors often require long-term
multidisciplinary medical care and special education.
SBS and its impact on child well-being is causing
international concern.
4
In most instances, the crying of an infant or toddler
triggers the event. Rarely, similar symptoms are
caused by unintentional actions such as tossing the
infant to make him or her laugh, or by road traffic
accidents. Inflicted brain injury has a poor prognosis.
The safety of vulnera ble children is best achieved
through prevention by educating professionals, par-
ents and carers,
5,6
and, to this end, efforts to prevent
SBS have been initiated in many countries.
7
The experience of projects in four countries that
have collaborated in the Western Sydney, Australia
initiative is presented.
Western Sydney, Australia
The Shaken Baby Prevention Project in Western
Sydney, known as ‘Shaking Your Baby is Just Not
the Deal’, began in late 2001.
8
The project team has
developed a short animated film, posters, pamphlets
and postcards to support parent and carer education.
Although the staff are mostly public health employ-
ees, funds for the project were provided by KidsWest,
a children’s charity (www.kidswest.org.au). The
organization continues to be a partner in the project,
Correspondence to: Z Kovacs, National Institute of Child Health,
Budapest, Hungary. Email: drkovacszsuzsa@freemail.hu
ß
W. S. Maney & Son Ltd 2013
DOI 10.1179/2046905513Y.0000000093
Paediatrics and International Child Health 2013 VOL.33 NO.4 233
which is essential when public health funding for
prevention is so unpredictable.
Western Sydney is multi-lingual and multi-cultural.
The project sought informal assistance with translat-
ing and reviewing the film script from the
International Society for Prevention of Child Abuse
and Neglect (ISPCAN) members. A request for
assistance was posted on the website (listserv) and
the international partnerships in the prevention
process began at this time. Subsequently, a master
copy of the film on DVD and master versions of
associated resources were provided to international
colleagues who were encouraged to develop their own
local and culturally appropriate projects.
The film and information sheets were formally
trialled in the Children’s Hospital at Westmead
(CHW) and the nearby Westmead Hospital in
Western Sydney. The trial demonstrated that the
resources were very acceptable to parents. Appro-
ximately 90% of respondents remembered the key
message that shaking is dangerous, 78% reported that
they sought assistance with their crying infant in the
3 months after being shown the film. For examples of
participants’ comments, see Appendix 1.
Consultation and feedback with staff and parents
identified implementation options to further develop
associated educational strategies such as postcards
and new posters. Local colleagues were also con-
sulted in order to ascertain the best way to
disseminate the information. CHW provides acute
and ongoing medical, rehabilitative, psychiatric and
psycho-social care for injured SBS infants. The
contributing psycho-social elements in the infant’s
family and community were the key elements
addressed in this prevention programme.
Many student social workers contributed to the
project’s development and to the action research. One
of these research projects found that 30% of staff in
several hospital and community health settings did
not know that shaking an infant was dangerous.
Ongoing education of all staff interacting with
parents and carers is essential. The project also
discovered that the extent to which the Australian
community at large is educated in the dangers and
prevention of SBS is very patchy.
From National Project to International
Collaboration
The translated Australian film was first presented
internationally in Estonia in 2004. It has subsequently
been trialled as an interactive and collaborative project,
encouraging local teams to develop their own transla-
tions and strategies for education in prevention.
9
Briefly, the key elements of the project’s education
in prevention are: increasing parental knowledge of
safe ways in which to respond to a crying infant,
providing easily understood information about the
dangers of shaking an infant, and confirming that
parents and carers should ask for help if they are
worried about their infant’s crying. These compo-
nents are particularly important for parents of infants
who are hard to settle.
10
Hungary
In 2003, the first survey of child maltreatment and
death was conducted by UNICEF in member
countries of the Organisation for Economic Co-
operation and Development (OECD). The study
showed that, in these countries, about 3500 children
under the age of 15 years die every year from abuse
and maltreatment. Hungary was then ranked as the
sixth worst performing country, and, over a 5-year
period, 113 children were killed either by abuse or
neglect.
11
Almost 50% of these children were ,1 year
of age. Around 200,000 children, equal to 10% of the
whole child population, are registered by the Social
Welfare System as being ‘at risk’. Most of these
endangered children have severe social problems.
Every year, more than 3000 children suffer from
physical abuse, more than 6000 from emotional
abuse, and nearly 300 from sexual abuse; over
15,000 children are physically neglected and over
13,000 are emotionally neglected.
12
An unknown number of cases remain unidentified,
but the figure is estimated to be 1:25. Unde rlying
causes are economic, social, and related to a lcohol
abus e, but cultural perceptions are also relevant. A
study found that 80% of participating parents
believed that corporal punishment is acceptable in
raising children.
13
The problem of child abuse and
neglect has become a very important focus for the
National Institute of Child Health in Buda pest. In
2004, a protocol was published for doctors and
health visit ors and an educational DVD was devel-
oped. This has been followed by interdi sciplinary
seminars for doctors, health visitors , nurses, social
workers, teachers and university students through-
out the country. According to the data, half of the
fatal cases were ,1 year of age and 70% of them
died as a res ult of infanticide. There were no exact
data on how many children a year are killed or
injured by SBS, so it was decided to focus on this
aspect, including using the translated Australian
educational material.
14
Six conferences were organized and the programme
included:
N
Early mother/child attachment disorders, post-partum
depression;
N
SBS as a special form of child abuse;
N
SBS cases in the accident and emergency department.
N
The role of health visitors in preventing SBS.
Media involvement in this programme has led to
widespread dissemination of the information and has
Foley et al. Prevention of shaken baby syndrome
234 Paediatrics and International Child Health 2013 VOL.33 NO.4
resulted in the involvement of all the paediatric
departments and hospitals in the country. The first
Hungarian website on child abuse was launched, with
one subpage on SBS. The translated animated film
can be watched on this webpage (www.gyermekban
talmazas.hu) and associated written material
accessed.
While the impact of this programme has not yet
been formally evaluated, it is hoped that a significant
step has been taken towards preventing SBS in
Hungary.
Brazil
Shaken baby syndrome is not very well known in
Brazil. A recent literature review found only one
published study on this topic in Brazil,
15
and it
reported an alarming fact: of 142 health professionals
interviewed, 97% did not know what SBS was, and
60.8% reported that they had shaken a child.
16
A North American study investigated the use of
disciplinary strategies in different countries, including
Brazil. In the Brazilian sample, 813 mothers were
interviewed and 10% reported that in the week before
the study they had shaken their children aged
,2years.
17
These studies provide evidence of a
possible lack of knowledge of the occurrence and
severity of SBS in Brazil, highlighting the need to
raise awareness in the population at large. In 2009, a
partnership was established between The Western
Sydney Shaken Baby Prevention Project at West-
mead and the Laboratory for Violence Analysis and
Prevention (LAPREV) of Universidade Federal de
Sa˜o Carlos (UFSCar) in Sa˜o Carlos, Brazil, the
Center for Integrated Studies of Childhood and
Adolescence Health (CEIIAS) of Rio de Janeiro,
the Zero to Six Institute in Sa˜o Paulo, and the Special
Interest Group in Child and Adolescent Telemedicine
University Network (RUTH), resulting in three
versions of the translated and adapted ‘Responding
to a Crying Baby’ video: one in Spanish, one in
Portuguese and one in Brazilian Portuguese. The
pamphlet was translated into Portuguese.
In 2011, LAPREV began a research project which
aimed to evaluate the effectiveness of these materials
in raising parental awareness of SBS.
18
The study
included 82 new mothers, seven fathers of newborns
and one pregnant woman in a maternity ward. They
were divided into three experimental groups. The first
group (‘experimental video’ group), watched the
‘Responding to a Crying Baby’ video, the second
group (‘pamphlet’ group) read the pamphlet about
SBS, and the third group (‘control video’ group)
watched a video about child safety which did not
address SBS. The participants completed the ‘Crying
Baby Questionnaire’ and the ‘Shaken Baby Syndrome
Awareness Assessment’ before intervention (pre-test),
immediately after intervention (post-test) and
6 months after intervention (follow-up).
The pamphlet group showed a significant increase in
knowledge of the consequences of shaking an infant
and of strategies to adopt when a baby is crying
inconsolably or the parents are getting frustrated. In
addition, on follow-up, only the pamphlet group
reported leaving an infant for a while in order to deal
with the crying. So, there was an increase of knowledge
and a change in parental behaviour.
The experimental video group demonstrated a
significant increase in awareness of the average
number of hours a day of infant crying. These results
indicate that SBS material seems to be effective in
changing parental knowledge of this type of child
maltreatment and can be used in prevention pro-
grammes and campaigns.
Following this study, a new research project was
undertaken in 2013. It aims to develop a Brazilian
instrument to measure awareness of SBS amongst
parents and caregivers and to train health providers
at Basic Health Units in its prevention. In parallel to
the studies, LAPREV also held lectures and work-
shops for health and educational professionals of
some municipalities in the state of Sa˜o Paulo,
sensitizing a larger number of them to the importance
of preventing SBS.
Greece
In Greece, the initiative to participate in the Shaken
Baby Project was taken by the Society for the
Prevention of Cruelty to Children: Eliza (SPCC), a
small, non-governmental organization which, since
its founding in 2009, has been increasingly involved in
innovative approaches to preventing child maltreat-
ment at primary, secondary and tertiary levels
(www.eliza.org.gr).
The Shaken Baby Project targeted parents of
young children and health and education profes-
sionals. The project was incorporated into a 2-year
campaign on prevention of child abuse implemented
by the SPCC during 2011–2012.
The Shaken Baby Project has included the follow-
ing stages:
N
Stage 1: A detailed study of the literature and the SBS
prevention educative material from Australia;
N
Stage 2: The creation of a training package;
N
Stage 3: The dissemination of information to health-
and early childhood education professionals;
N
Stage 4: Electronic access to parents of young
children through Babyzone (www.babyzone.gr) and
facebook.
N
Stage 5: After posting the SBS video on Babyzone
(www.babyzone.gr), a 5-week research project which
asked mothers about their experiences related to risk
factors for SBS and their coping mechanisms;
N
Stage 6: Outreach to parents in maternity and
paediatric hospitals.
Foley et al. Prevention of shaken baby syndrome
Paediatrics and International Child Health 2013
VOL.33 NO.4 235
See Appendix 2 for further details of these stages.
Seven large private hospitals with maternity and
paediatric clinics were co ntacted within the pro-
gramme’s collaboration with the Intelligent M edia
Agency, which operates health information pro-
grammes in hospitals through television sets placed
in public areas. Patients, visitors and staff have access
to this information all day. The SBS video was shown
twice a day for 12 months, reaching an estimated
420,000 viewers monthly.
Collaboration in this international prevention
project has been a great opportunity for the SPCC
to be involv ed in a cross-cultural exercise in parenting
and prevention of child abuse. A small NGO in
Greece brought to public attention a problem which
is neglected even within the medical community to
which it is most relevant.
The collaboration also provided an opportunity for
dialogue with other professions so that a multi-
sectorial and multi-disciplinary response would be
seen as essential. Furthermore, the SBS package in its
various usages ope ned a new perspective on the
causes of a wide spectrum of problems of later
childhood often associated with neglect, and showed
that early recognition of a family’s difficulties and a
parent’s failure to care properly for an infant can
prevent an escalating spiral of violence before it is too
late to treat.
One of the most valuable aspects of the approach
was the provision of options for parents. In Greece,
the medicalization of children’s simple, everyday
behaviour or ‘simple problems’ tends to lead to
procedures which are often unnecessary, costly and
anxiety-provoking for parents, especially young
parents of a first child.
Feedback was requested from the different groups
reached, and optional contact through a helpline
directly to the programme co-ordinator or to
Intelligent Media was offered. Early childhood
professionals were mainly interested in acquiring
more information on implementing the programme
with parents as well as places for referral of cases
needing support. Among the hospital population
with access to the SBS video for a year, only five
contacts were made to Intelligent Media for more
information, and none to the helpline.
This finding may have various interpretations in
a society which traditionally solves problems within
the family or community and associates helplines
with severe social problems requiring legal interven-
tion. In contrast, a happy event at a maternity or
paediatric hospital, such as a pregnancy, birth or a
resolved paediatric problem, when there is the support
of close relatives, does not seem to cause the kind of
anxiety that might interfere with a positive primary
relationships between mother and child or create other
predisposing factors which could lead to SBS. Another
reason for limited feedback from hospitals may be that
all seven hospitals where the SBS video could be
shown were private, thus excluding socially and
economically deprived populations who cannot afford
services and could be characterized as more ‘vulner-
able’. Nevertheless, it should be noted that the various
public insurance schemes do cover all or part of
private hospital fees, thus allowing families a choice.
The application of an SBS prevention programme with
a different methodology to public hospitals and health
centres for populations of low socio-economic status
may enrich the above preliminary data.
A limitation of the Greek project was that it did
not provide for pre-/post-testing and so changes of
attitude and behaviour could not be evaluated.
Turkey
Although awareness of child abuse and neglect
(CAN) is increasing among professionals and com-
munities at large, SBS, a special form of CAN, is a
very recent concern in Turkey. Families are not aware
that shaking an infant can be harmful.
A recent study which investigated Turkish parents’
knowledge of and attitudes towards SBS reported
that 50.3% of parents had no idea that shaking an
infant might be harmful and 24% thought that
shaking an infant would not be harmful.
19
SBS is
not readily diagnosed by medical professionals. To
our knowledge, there are only a few case reports of
SBS in Turkey.
20–22
One multi-centre study retro-
spectively reviewed 345 infants wi th subdural or sub-
arachnoid bleeding, lethargy, coma, skull fracture or
retinal haemorrhage: 22% of injuries were inflicted
but only three of the 345 were diagnosed as SBS
during their hospital stay.
23
Because there were no prevention programmes in
Turkey in 2009, a member of the Turkish team
contacted the Western Sydney team through
ISPCAN listserv – a members’ e-mail group through
which members can post ideas and requests. This
team generously offered their material and it was
translated for use in Turkey. A study was undertaken
to evaluate the effectiveness of the training in Turkey.
A secondary aim of the study was to discover the
most effective time at which to train mothers. This
information was impor tant in order to determine the
best way to progress towards wi despread, country-
wide implementation.
The study was undertaken in 2010 in two different
hospitals, a univers ity and a state hospital in Ankara.
A total of 545 mothers of full-term, healthy infants
were included in the study. To evaluate the effect of
timing of training, they were divided into three
groups according to when training was given:
Group 1 mothers were trained within the first
Foley et al. Prevention of shaken baby syndrome
236 Paediatrics and International Child Health 2013 VOL.33 NO.4
48 hours of birth, before discharge from hospital
(217, 39.8%); Group 2 mothers were trained during
their infant’s first well-child visit 3–7 days after birth
(235, 43.1%); and Group 3 mothers were trained in
the Obstetrics Department during their last check-up
visit (93, 17.1%).
To evaluate the effe ct of training on knowledge of
SBS, all mothers were tested before and after training,
and it was found that training was useful in all three
groups. Within each group, post-test scores increased
statistically significantly compared with pre-test scores:
5.0 (2.2) and 6.4 (1.7) in the pre- and post-tests,
respectively (P50.001). There was no statistically
significant difference between the groups in the pre-
test score whereas, in the post-test, the Group 1 score
was significantly lower than those of the other two
groups (P50.001). This was interesting because most
of the relevant prevention programmes suggest that
training should be given in the post-partum period
before discharge from hospital. The study observed
that mothers in the immediate post-partum period
(Group 1) were reluctant to watch the video or listen to
the trainers because of their pain or problems with the
infant.
In conclusion, this study demonstrated that mate-
rial from the Australian project was useful for
mothers in Turkey also. The study was presented at
the ISPCAN Asian Regional Conference in Delhi in
2011 and at the multi-national symposium of the
ISPCAN XIXth International Congress on Child
Abuse and Neglect in Istanbul in 2012.
24
At the
National Congress of Social Paediatrics in November
2012, Dr Sahin of the Turkish team gave a lecture on
prevention of SBS and during her presentation the
translated Western Sydney video was shown. This
generated significant interest in the material and in its
wider implementation. The team is now trying to
extend the prevention programme through collabora-
tion with different univers ity hospitals. The ultimate
goal is to initiate a nationa l prevention programme.
The projects in Australia, Hungary, Brazil, Greece
and Turkey demonstrate the value of international
collaboration in educating professionals, parents and
carers in the dangers of shaking infants and the
importance of safe care of crying infants. All of the
collaborating countries recognized the importance of
educating professionals and parents to ensure that
infants, the most vulnerable members of our com-
munities, receive appropriate and safe care.
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Appendix 1: Participants’ Comments
Examples of the participants’ comments about the
materials as reported in the Australian study include:
Foley et al. Prevention of shaken baby syndrome
Paediatrics and International Child Health 2013
VOL.33 NO.4 237
N
It (the DVD film) helps if baby is crying and we are
anxious and home alone.
N
It was useful with information about handling the
baby. I told our family that shaking the baby was
harmful.
N
I did not realize that shaking was so bad.
N
Shaking a baby causes serious problems. I learnt what
to do when the baby cries such as feed the baby first,
play with them, take them out for a walk, call the
helpline and they may settle.
N
When you are managing a baby and all they do is
screaming, in the back of your head you know not to
shake them.
N
My husband knew what to do if the baby was crying;
not to become panicky.
Appendix 2: Further Details of the
Implementation Stages of the Greece
Project
Stage 1: A detailed study of the literature as well as a
study of the SBS educating material from Australia.
Stage 2: A collaborative relationship was estab-
lished with the Arrow advertising agency in Athens
(www.arrow.gr) for the production of resource
material. The training package produced included
the following: (i) translation of the leaflet in to Greek
following a pilot study undertaken with professionals
and parents of young children, (ii) translation of the
video in to Greek, with minor changes, (iii) a video
for professionals, (iv) an information leaflet devel-
oped for professionals to assist them in using the
project material, and (v) an accompanying letter
signed by the President of the Executive Board of
Foundation ELIZA and the scientific co-ordinator of
the Shaken Baby Project.
Stage 3: Information was disseminated to health
professionals and multi-disciplinary conference atten-
dees. Members of professional societies involved in
child care and early childhood education were
contacted by email and notices were published in
professional journals and parent journals.
Stage 4: A collaborative relationship was established
with the media agency, Intelligent Media (www.intelli-
gentmedia.g r), specializing in the dissemination of
informationonhealthissuestoparentsofyoung
children (www.babyzone.gr). This included the follow-
ing: (i) a profile of Foundation ELIZA – Against Child
Abuse,(ii)amailingofShakenBabyto13,000members
of Babyzone, through their electronic Newsletter, and
(iii) a profile of the project on Facebook.
Stage 5: A 5-week project took place following the
posting of the SBS video on Babyzone. In the section
‘Mothers Respond’, mothers were asked to answer
the following questions: ‘The last time your baby was
crying persistently, how did you respond? How did
your child stop crying? What did you find was useful?
Did you find the video useful?’ Parents were asked to
share their experiences so that other parents could see
what was helpful. Responses were received from
150 mothers with infants under 1 year of age. Thei r
replies varied, but most were in accordance with the
contents of the leaflet.
Stage 5: The film was shown twice a day to a
hospital population of about 420,000 people per
month in six hospitals in Athens and one in Larissa,
which included mothers in maternity units, parents
and relatives in paediatric units, visitors to outpatient
departments and hospital staff of all levels.
Foley et al. Prevention of shaken baby syndrome
238 Paediatrics and International Child Health 2013 VOL.33 NO.4