Characteristics and associations of ocular and non-ocular manifestations of shaken baby syndrome.

OBJECTIVES: Shaken baby syndrome (SBS), a subset of abusive head trauma, results from non-accidental, violent head shaking. Most survivors suffer permanent neurological sequelae. Accurate diagnosis is imperative and remains challenging. The purpose of this study is to describe ocular injuries and associated neurotrauma in suspected SBS. METHODS: We retrospectively surveyed the National Trauma Data Bank 2008-2014 for patients ≤ 3 years old admitted for suspected SBS. Statistical analysis was performed with SPSS software. Significance was set at p < 0.05. RESULTS: Three hundred forty-seven (13.9%) of 2495 patients who were ≤ 3 years old were admitted with abusive head trauma and ocular injuries which resulted from suspected SBS. Most were < 1 year old (87.9%) and male (54.2%). Common eye injuries were retinal hemorrhages (30.5%), eye/adnexa contusion (14.7%), and retinal edema (10.7%). Common neurotrauma were subdural (75.5%), subarachnoid (23.9%), and intracerebral hemorrhage (ICH) (10.4%). Mean (SD) Injury Severity Score was severe, 20.2 (8.2), and Glasgow Coma Score was moderate, 9.2 (12.8). The mortality rate was 16.7%. Retinal hemorrhages were not significantly associated with one type of neurotrauma over others. Ocular/adnexa contusion (OR 4.06; p < 0.001) and commotio retinae/Berlin's edema (OR 5.27; p < 0.001) had the greatest association with ICH than other neurotrauma. Optic neuropathy (OR 21.33; p < 0.001) and ICH (OR 3.34; p < 0.001) had the highest associated with mortality. CONCLUSIONS: Our study supports previous studies showing that retinal and subdural hemorrhages were the most common ocular injury and neurotrauma in SBS, respectively. However, we did not find a significant propensity for their concurrence. Commotio retinae/Berlin's edema was significantly associated with both intracerebral and subdural hemorrhages.

[Brain injury following child maltreatment syndrome in newborns and young children. Shaken baby syndrome]. / Cherepno-mozgovaya travma v strukture sindroma zhestokogo obrashcheniya s det'mi u mladentsev i detei rannego vozrasta. Sindrom tryaski mladentsa.

BACKGROUND: Shaken baby syndrome is widely discussed in the literature. This syndrome is considered as a variant of child maltreatment syndrome. In the English-language literature, there are data on high incidence of this syndrome and difficult diagnosis. There are no such diagnosis in the Russian and reports devoted to this issue. OBJECTIVE: To assess the incidence and nature of injuries following child maltreatment/shaken baby syndrome in infants and young children. MATERIAL AND METHODS: We analyzed case records of 3668 patients aged 1-36 month between 2017 and 2021 with injury/suspected traumatic brain injury (TBI). Mild TBI was in 47.2% of patients, moderate and severe - in 56.8% of patients. Twenty-eight children admitted with GCS score 3-8. CT was performed in case of risk factors for intracranial injuries (1703 patients). Abnormalities were found in 71.6% of cases. Sixty-four children required surgical treatment. Overall mortality rate was 0.7%. RESULTS: Accidental trauma was found in 3664 cases. We verified child maltreatment/shaken baby syndrome in only 4 (0.1%) cases. At the alleged moment of injury, there were male persons (cohabitant or guardian) with the child that is consistent with literature data. In all 4 cases, we observed severe combined TBI. In one case, brain damage was regarded as a result of chronic trauma. Indeed, MRI diagnosed thrombosis of bridging veins along convexital parts of the frontal, parietal and occipital lobes. There were GOS grade I in 2 patients (death), grade III in 1 patient (severe disability) and grade IV in 1 patient (recovery). CONCLUSION: Child maltreatment/shaken baby syndrome is less common among infants and young children in the Russian Federation. This may be due to national, cultural and religious traditions. Indeed, infants and children under 3 years of age are cared for by female persons. The mechanism of injury (shaking) leads to typical multiple injuries involving various organs and systems. These damages require multidisciplinary approach to diagnosis and treatment. MRI-confirmed thrombosis of bridging veins may be an additional diagnostic sign indicating the mechanism of injury.

Abusive head trauma in small children - a single-centre experience in Finland.

Shaken baby syndrome (SBS) is a challenging condition from both a medical and legal perspective. The path of the patients differs significantly from those with noninflicted traumas. While treating these cases, it is essential that all history, information and treatment are comprehensively documented. This article describes the investigations and interventions necessary as soon as SBS is suspected. The Oulu University Hospital protocol for suspected child abuse is described. Authors also give an overview of the SBS path in Finland from the police and prosecution's point of view.

Confessed versus denied inflicted head injuries in infants: similarities and differences.

BACKGROUND AND PURPOSE: Abusive head injuries (AHI), and in particular shaken baby syndrome (SBS), are common causes of mortality and morbidity in infants. Although SBS is a well-established entity, based on clinical experience and experimental data, and confirmed by the perpetrators' confessions, a growing number of publications challenge the diagnostic criteria, and even the validity of the perpetrators' confession. We decided to study AHI in infants and compare cases with and without confession. MATERIAL AND METHODS: We collected prospectively all cases of infantile traumatic head injuries hospitalized in our institution between 2001 and 2021. From this database, we selected victims of AHI, comparing cases for which the perpetrator confessed during police inquiry ("confession" group) versus cases without confession ("denial" group). RESULTS: We studied 350 cases of AHI in infants; 137 of these (39.1%) were confessed. We found no statistically significant difference between the two groups regarding the child's previous history, as well as the personality and previous history of the caretakers. However, the "confession" group showed significantly more severe clinical presentation, cerebral lesions, retinal hemorrhages, and a more pejorative outcome. CONCLUSIONS: We conclude that the diagnosis of AHI was confirmed by the confession in a large number of cases, indicating that the diagnostic criteria of AHI are robust. We also found that denial, although possibly sincere, was likely ill-founded, and that the perpetrators' decision to confess or deny was markedly influenced by the severity of the inflicted lesions.

Abusive head trauma: Canadian and global perspectives.

Canada has come a long way since Dr. C. Henry Kempe first described battered-child syndrome in 1962. The year 1999 was crucial in Canada's battle against shaken baby syndrome/abusive head trauma (SBS/AHT), when the first national conference on the topic was held in Saskatoon. This was followed by the issuance of a national statement and multidisciplinary guidelines, recently updated in 2020. Incidence of AHT in Canada is similar to that found in population-based studies from Switzerland and New Zealand. The mainstay of prevention of AHT in Canada is education of parents and caregivers with respect to their response to infant crying. Population-based data for global incidence of AHT are lacking, largely because of social and cultural differences contributing to poor understanding of AHT as a medico-legal entity. India faces a distinct challenge in the battle against female feticide and infanticide.

Preventing abusive head trauma: can educating parents reduce the incidence?

Abusive head trauma (AHT) is the most lethal form of child abuse; preventing AHT should be a national priority, but research into this area is woefully underfunded. Prevention programs have primarily focused on universal parent education during the neonatal period, a time when parents are a captive audience of the health care establishment whose focus is on the needs of their newborn infant, and who will soon be exposed to the frustration and anger of infant crying. Research has suggested a strong causal link between infant crying and AHT, and parents - particularly fathers and father figures - have been identified as the most common perpetrators of AHT. A number of studies have suggested that educating parents during the postnatal period about the normalcy of inconsolable infant crying and its evolution over the first several months of postnatal life improves parental knowledge about infant crying and a number of positive parenting behaviors, and decreases emergency room visits for crying. In 1998, we began a pilot program in Upstate New York near Buffalo that led to a 47% reduction in AHT incidence. Similar studies have demonstrated 35-75% reductions in incidence, which has led to enthusiasm for this approach to preventing AHT. We, as well as another group, have enacted statewide programs in Pennsylvania and North Carolina; unfortunately, these two large statewide replication trials failed to demonstrate any impact of such an intervention on AHT rates. Serial messages for parents, provided repeatedly over the period of greatest risk for AHT, might be another avenue of research.

Infant abuse diagnosis associated with abusive head trauma criteria: incidence increase due to overdiagnosis?

Background: The hypothesis of this study is that the diagnosis of infant abuse is associated with criteria for shaken baby syndrome (SBS)/abusive head trauma (AHT), and that that changes in incidence of abuse diagnosis in infants may be due to increased awareness of SBS/AHT criteria. Methods: This was a population-based register study. Setting: Register study using the Swedish Patient Register, Medical Birth Register, and Cause of Death Register. The diagnosis of infant abuse was based on the International Classification of Diseases, 9th and 10th revision. Participants: All children born in Sweden during 1987-2014 with a follow-up until 1 year of age (N = 2 868 933). SBS/AHT criteria: subdural haemorrhage, cerebral contusion, skull fracture, convulsions, retinal haemorrhage, fractures rib and long bones. Outcomes: Incidence, rate ratios, aetiologic fractions and Probit regression analysis. Results: Diagnosis of infant abuse was strongly associated with SBS/AHT criteria, but not risk exposure as region, foreign-born mother, being born preterm, multiple birth and small for gestational age. The incidence of infant abuse has increased tenfold in Sweden since the 1990s and has doubled since 2008, from 12.0 per 100 000 infants during 1997-2007 to 26.5/100 000 during 2008-2014, with pronounced regional disparities. Conclusions: Diagnosis of infant abuse is related to SBS/AHT criteria. The increase in incidence coincides with increased medical preparedness to make a diagnosis of SBS/AHT. Hidden statistics and a real increase in abuse are less plausible. Whether the increase is due to overdiagnosis cannot be answered with certainty, but the possibility raises ethical and medico-legal concerns.

Self-Reported Prevalence and Risk Factors for Shaking and Smothering Among Mothers of 4-Month-Old Infants in Japan.

BACKGROUND: To estimate the prevalence of shaking and smothering and to determine risk factors in a population-based sample of mothers with 4-month-old infants in Japan. METHODS: We administered a questionnaire to women who participated in a 4-month health checkup program in Aichi Prefecture, Japan (n = 6487; valid response rate, 66.8%), and assessed frequency of shaking and smothering during the past 1 month, as well as maternal, infant, and familial characteristics. Associations of shaking, smothering, and either shaking or smothering with possible risk factors were analyzed using multiple logistic regression. RESULTS: Self-reported prevalence of shaking, smothering, and either shaking or smothering at least once during the past month was 3.9% (95% confidence interval [CI], 3.5%-4.4%), 2.7% (95% CI, 2.3%-3.1%), and 5.4% (95% CI, 4.9%-6.0%) respectively. Several different risk factors were found for shaking and smothering. Risk factors for either shaking or smothering were age 34 years or younger (especially 24 years or younger), age 40 years or older, full-time working, later attendance at 4-months health checkup, primiparity, living in a detached house, living on the 2nd floor or higher (especially on the 10th floor or higher), economic adversity, perceived excessive crying, and postpartum depression. Protective factors against infant abuse were living in a four-room house and having a larger number of people to consult with. CONCLUSIONS: Self-reported prevalences of shaking and smothering among mothers in Japan were similar to prevalences reported in western countries. These finding may be useful for identifying mothers at increased risk of shaking and smothering their infants.

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.

Analysis of national empirical data on the characteristics and trends of injury among Taiwan's victims of hospitalized child abuse between 1997 and 2009.

OBJECTIVE: To investigate the characteristics and trends of injury among hospitalized child abuse children younger than 18 years between 1997 and 2009. METHODS: We selected hospitalized child abuse cases from the Taiwan's National Health Insurance (NHI) Database in accordance with ICD-9-CM 995.5x or E967.x. RESULTS: There were 1,212 victims of hospitalized child abuse during the research period, including 735 boys and 477 girls. The victims were most frequently inflicted by the father or stepfather, and the most common injury was intracranial damage; besides, the victims most commonly sought treatment in medical centers. Infants younger than 1 year accounted for the highest percentage of hospitalized victims. Although there were no apparent trends in the overall hospitalization rate of the child abuse victims over the 13-year period, the rate of abuse among girls increased gradually over the years. CONCLUSIONS: The medical staff in hospitals should provide appropriate treatment to the victims and contact relevant organizations to intervene; moreover, government agencies should formulate effective control measures to develop a safe growth environment for children.

Educational paper: Abusive Head Trauma part I. Clinical aspects.

UNLABELLED: Abusive Head Trauma (AHT) refers to the combination of findings formerly described as shaken baby syndrome. Although these findings can be caused by shaking, it has become clear that in many cases there may have been impact trauma as well. Therefore a less specific term has been adopted by the American Academy of Pediatrics. AHT is a relatively common cause of childhood neurotrauma with an estimated incidence of 14-40 cases per 100,000 children under the age of 1 year. About 15-23% of these children die within hours or days after the incident. Studies among AHT survivors demonstrate that approximately one-third of the children are severely disabled, one-third of them are moderately disabled and one-third have no or only mild symptoms. Other publications suggest that neurological problems can occur after a symptom-free interval and that half of these children have IQs below the 10th percentile. Clinical findings are depending on the definitions used, but AHT should be considered in all children with neurological signs and symptoms especially if no or only mild trauma is described. Subdural haematomas are the most reported finding. The only feature that has been identified discriminating AHT from accidental injury is apnoea. CONCLUSION: AHT should be approached with a structured approach, as in any other (potentially lethal) disease. The clinician can only establish this diagnosis if he/she has knowledge of the signs and symptoms of AHT, risk factors, the differential diagnosis and which additional investigations to perform, the more so since parents seldom will describe the true state of affairs spontaneously.

Parental awareness, knowledge, and attitude about shaken baby syndrome in Riyadh, Saudi Arabia: a cross-sectional study.

Introduction: shaken baby syndrome (SBS) is an abusive head trauma inflicted on infants and young children. Injuries induced by shaking can result in death or permanent neurologic disability. It is difficult to know the exact number of SBS cases per year because many cases of SBS are not reported and/or never receive a diagnosis. From a public health perspective, creating greater awareness about SBS is important. Previous studies have revealed poor awareness and knowledge about shaken baby syndrome. In this study our aims to investigate the awareness, knowledge level, and attitude regarding shaken baby syndrome and to highlight the sources and factors associated with SBS knowledge among parents of the pediatric population in Riyadh, Saudi Arabia. Methods: a cross-sectional study was conducted between January 2021 and September 2021. A validated electronic questionnaire was distributed among parents of the pediatric population in Riyadh, Saudi Arabia using the convenient random sampling method; SPSS version 22 was used to analyze the collected data. Results: the study involved 577 participants; 59.8% were mothers and 96.5% were Saudis. A total of 32.1% had previously heard about SBS. The overall knowledge mean score was low (2.95 + 1.74), and attitude was positive among 82.5% of the participants. The factors significantly associated with knowledge level were gender, marital status, and occupation. Conclusion: the participants had poor knowledge and awareness about SBS, but, despite that, they expressed a positive attitude toward learning more about it. This should prompt health authorities to increase efforts to improve public awareness and knowledge about SBS.

Ophthalmological lesions in shaken baby syndrome: A retrospective analysis of 133 consecutive cases (1992-2018).

INTRODUCTION: Shaken Baby Syndrome (SBS) is a non-accidental head trauma in which shaking causes cranio-cerebral lesions. Shaking can lead to ophthalmologic lesions such as retinal hemorrhage (RH). The aim of the present study was to compare our long-term results in to the literature data. PATIENTS AND METHODS: This study was a single-center retrospective descriptive analysis of 133 consecutive SBS cases (1992-2018). Only seniors in ophthalmology were authorized to perform these examinations. We studied type of lesion (retinal, intra-vitreal, papilledema), location (uni- or bi-lateral), and correlation with gender and age. Infants with a traumatic context without suspicion of child abuse were excluded. RESULTS: Mean age at diagnosis was 131days (range, 14days-10months). Boys accounted for 72.2% of the population. The prevalence of ophthalmologic lesions was 70.3%. 94.4% were RH; intra-vitreous hemorrhage (6.7%) and papilledema (11.1%) were less frequent. Lesions were bilateral in 81.1% of cases. Retinal lesions were classified in terms of location. Macular involvement was diagnosed in 8.2% of cases. 18.8% of retinal lesions could not be classified because of lack of precision in the ophthalmology report. The prevalence of ophthalmic lesions was higher for children aged over 6months: 80%. CONCLUSION: This series highlighted a high rate of ophthalmic lesions in SBS, with a high rate of bilateral involvement. RH was the most frequent lesion. RH in a context of subdural hematoma is a strong argument in favor of SBS. The forensic implications are that rigorous ophthalmologic examination by a senior practitioner is mandatory.

Transfer of knowledge to diagnose infant abuse and its incidence - a time-series analysis from Sweden.

AIM: To analyse the transfer of knowledge on how to detect physical abuse, especially shaken baby syndrome/abusive head trauma (SBS/AHT), and its association to trends in infant abuse diagnoses (maltreatment and assault). METHODS: Design: retrospective population-based and quasi-experimental. SETTING: Sweden 1987-2019. PATIENTS: Children below age 1 year, selected from the National Patient Register (n = 1150). Exposures: Literature search for transfer of knowledge by diffusion, dissemination and implementation, and whether supportive or disruptive of the SBS/AHT paradigm. MAIN OUTCOME MEASURE: Abuse diagnoses (maltreatment or assault). ANALYSES: Incidence rate, incidence rate ratio (IRR). RESULTS: The overall incidence rate of abuse was 32.23 per 100,000 during the years 1987-2019. It was rather stable 1987-2000. The SBS diagnosis was introduced in the late 1990s. A comprehensive increase of transfer of knowledge on physical abuse, specifically on SBS/AHT and dangers of shaking, took place from 2002 and onward through diffusion, dissemination and implementation. Maltreatment diagnoses, but not assault diagnosis, increased steeply during 2002-2007, peaking in 2008-2013 [IRR 1.63 (95% confidence interval 1.34-1.98)]. Transfer of disruptive knowledge on SBS/AHT during the period 2014-2019 was associated with a decline in maltreatment diagnoses [IRR 0.84 (95% confidence interval 0.71-0.99)]. CONCLUSION: An increase in maltreatment diagnoses was associated with transfer of supportive knowledge of the SBS/AHT paradigm, while a decline occurred toward the end of the study period, which might indicate a burgeoning de-implementation process.

External Hydrocephalus as a Cause of Infant Subdural Hematoma: Epidemiological and Radiological Investigations of Infants Suspected of Being Abused.

BACKGROUND: Acute subdural hematoma (ASDH) and chronic subdural hematoma (CSDH) in infants have been regarded as highly specific for abuse. Other causes of CSDH have not been investigated in a large population. PURPOSE: The purpose of this study was to investigate to what extent external hydrocephalus is present in infants with ASDH and CSDH undergoing evaluation for abuse. MATERIAL AND METHODS: Eighty-five infants suspected of being abused, with ASDH (n = 16) or CSDH (n = 69), were reviewed regarding age, risk factor profiles, craniocortical width (CCW), sinocortical width (SCW), frontal interhemispheric width (IHW), subarachnoid space width (SSW), and head circumference (HC). In infants with unilateral subdural hematoma (SDH), correlations between contralateral SSW and ipsilateral CCW and SDH width were investigated. RESULTS: Infants with CSDH had significantly lower mortality, were more often premature and male, and had significantly higher CCW, SCW, IHW, and SSW than infants with ASDH (P < 0.05). Ipsilateral CCW (R = 0.92, P < 0.001) and SDH width (R = 0.81, P < 0.01) correlated with contralateral SSW. Increased HC was more prevalent in infants with CSDH (71%) than in infants with ASDH (14%) (P < 0.01). Forty-two infants, all with CSDH, had at least one of CCW, SCW, or IHW ≥95th percentile. Twenty infants, all with CSDH, had CCW, SCW, and IHW >5 mm, in addition to increased HC. CONCLUSION: A substantial proportion of infants with CSDH who had been suspected of being abused had findings suggesting external hydrocephalus.

Ocular Injuries in Pediatric Patients Admitted With Abusive Head Trauma.

BACKGROUND: Pediatric abusive head trauma (AHT) refers to head injury from intentional blunt force or violent shaking in children aged five years or less. We sought to evaluate the epidemiology of ocular injuries in AHT. METHODS: This retrospective analysis of the National Trauma Data Bank (2008 to 2014) identified children aged five years or less with AHT and ocular injuries using ICD-9-CM codes. Demographic data, types of ocular and nonocular/head injuries, geographic location, length of hospital admission, injury severity, and Glasgow Coma scores were tabulated and analyzed. RESULTS: A total of 10,545 children were admitted with AHT, and 2550 (24.2%) had associated ocular injuries; 58.7% were female. The mean age was 0.5 (±1.0) years. Most (85.7%) were aged one year or less. Common ocular injuries included contusion of eye/adnexa (73.7%) and retinal edema (59.3%), and common head injuries were subdural hemorrhage (SDH) (72.8%) and subarachnoid hemorrhage (22.9%). Retinal hemorrhages occurred in 5.3%. About 42.8% of children had injury severity scores greater than 24 (very severe), and the mortality rate was 19.2%. Children aged one year or less had the greatest odds of retinal hemorrhages (odds ratio [OR] = 2.44; P = 0.008) and SDH (OR = 1.55; P < 0.001), and the two- to three-year-old group had the greatest odds of contusions (OR = 1.68; P = 0.001), intracerebral hemorrhages (OR = 1.55; P = 0.002), and mortality (OR = 1.78; P < 0.001). For all ages, SDH occurred most frequently with retinal edema compared with other ocular injuries (OR = 2.25; P < 0.001). CONCLUSIONS AND RELEVANCE: Ocular injuries varied with age and were variably associated with nonocular injury. The youngest group was most frequently affected; however, the two- to three-year-old group was most likely to succumb to injuries.

Shaken baby syndrome and a triple-dose strategy for its prevention.

OBJECTIVES: Inflicted traumatic brain injury associated with Shaken Baby Syndrome (SBS) is a leading cause of injury mortality and morbidity in infants. A triple-dose SBS prevention program was implemented with the aim to reduce the incidence of SBS. The objectives of this study were to describe the epidemiology of SBS, the triple-dose prevention program, and its evaluation. METHODS: Descriptive and spatial epidemiologic profiles of SBS cases treated at Children's Hospital, London Health Sciences Centre, from 1991 to 2010 were created. Dose 1 (in-hospital education): pre-post impact evaluation of registered nurse training, with a questionnaire developed to assess parents' satisfaction with the program. Dose 2 (public health home visits): process evaluation of additional education given to new parents. Dose 3 (media campaign): a questionnaire developed to rate the importance of factors on a 7-point Likert scale. These factors were used to create weights for statistical modeling and mapping within a geographic information system to target prevention ads. RESULTS: Forty-three percent of severe infant injuries were intentional. A total of 54 SBS cases were identified. The mean age was 6.7 months (standard deviation, 10.9 months), with 61% of infant males. The mean Injury Severity Score was 26.3 (standard deviation, 5.5) with a 19% mortality rate. Registered nurses learned new information on crying patterns and SBS, with a 47% increase in knowledge posttraining (p < 0.001). Over 10,000 parents were educated in-hospital, a 93% education compliance rate. Nearly all parents (93%) rated the program as useful, citing "what to do when the crying becomes frustrating" as the most important message. Only 6% of families needed to be educated during home visits. Locations of families with a new baby, high population density, and percentage of lone parents were found to be the most important factors for selecting media sites. The spatial analysis revealed six areas needed to be targeted for ad locations. CONCLUSIONS: SBS is a devastating intentional injury that often results in poor outcomes for the child. Implementing a triple-dose prevention program that provides education on crying patterns, coping strategies, and the dangers of shaking is key to SBS prevention. The program increased knowledge. Parents rated the program as useful. The media campaign allowed us to extend the primary prevention beyond new parents to help create a cultural change in the way crying, the primary trigger for SBS, is viewed. Targeting our intervention increased the likelihood that our message was reaching the population in greatest need.

Subdural hematomas and emergency management in infancy and childhood: a single institution's experience.

OBJECTIVE: We aimed to identify the incidence, clinical features, management, and outcome of subdural hematomas (SHs) in infancy and childhood. METHODS: Twenty-one children younger than 11 years with SH were analyzed. Clinical features and possible child abuse were considered in each case. RESULTS: Eight children experienced minor injuries due to hitting of solid items on their head. Five of these children also had coagulation disorders. Three of the children suffered from child abuse, only one of the children had head trauma due to car accident. Nine of the patients experienced SH due to fall down. Nine patients have acute SH, 7 had subacute SH, 4 had chronic SH, and 1 had acute and subacute SH together. Clinical presentation varied greatly. Most of them presented with vomiting and seizure. The outcome patterns were different among the patients. Deep coma on admission was associated with an unfavorable outcome. CONCLUSIONS: Subdural hematoma is common in infancy and childhood and carries a poor prognosis. Most of the cases are due to head trauma, coagulation disorders, and child abuse. We believe that clinical investigation of such children should be carried out in a multidisciplinary approach with the collaboration of pediatricians, social workers, and neurosurgeons.