Shaken baby syndrome intervention reduces calls to nurse advice line, not head trauma rates

A program to prevent abusive head trauma (AHT), also known as shaken baby syndrome, was associated with a decline in calls to a nurse advice line but not with a significant change in AHT rates in North Carolina, according to an article published online by JAMA Pediatrics.

AHT is a rare, but severe, form of child maltreatment with severe consequences that can include death or long-term neurological, development and cognitive issues. Infant crying is the most significant trigger of AHT.

Adam J. Zolotor, M.D., Dr.P.H., of the University of North Carolina, Chapel Hill, and coauthors describe the AHT prevention program, the Period of PURPLE Crying, which was delivered to 88 percent of the parents of newborns (n=405,060) in North Carolina from June 2009 through September 2012. The intervention, which was developed by the National Center on Shaken Baby Syndrome, teaches parents about normal infant crying. The intervention included education provided by a nurse, a DVD and a booklet, with messages reinforced by primary care physicians and through a media campaign.

The authors measured changes to the number of after-hours calls to a nurse advice line for infant crying before and after the intervention was implemented. They also analyzed AHT rates over time in North Carolina and in five comparison states.

The authors report that two years after the intervention was implemented, parental telephone calls to the nurse advice line declined by 20 percent for children younger than 3 months and by 12 percent for children 3 to 12 months.

However, there was no significant effect on North Carolina's state-level AHT rates. North Carolina had average AHT rates of 34.01 per 100,000 person-years before the intervention and 36.04 after the intervention, according to the results. The comparison states had average AHT rates of 33.22 per 100,000 person-years before the intervention and 33.41 after the intervention.

Limitations of the study include that while 88 percent of parents of newborns received the AHT prevention education, it is unknown if those people not exposed to the intervention were at highest risk for AHT. Also, the authors do not know whether perpetrators of AHT were exposed to the program. "It may be that the intervention was ineffective, the study was underpowered, the follow-up was too brief or a decrease in cases may have been obscured by unmeasured confounding. Future research should use the most robust methods available to establish a causal relationship between prevention programs and AHT," the study concludes.

Editorial: Challenges in Prevention of Abusive Head Trauma

In a related editorial, Joanne N. Wood, M.D., M.S.H.P., of The Children's Hospital of Pennsylvania, Philadelphia, writes: "The negative findings from this large, rigorous evaluation study by Zolotor et al raise questions about the effectiveness of AHT prevention programs and highlight the challenges in AHT prevention. ... We have made progress in understanding AHT prevention, but we still have much to learn. As Zolotor et al conclude, the high costs of AHT to children, families and society demand that we must not give up."