Dr. Harvey Karp, a pediatrian and author of "The Happiest Baby On The Block" discusses his work relating to Shaken Baby Syndrome and models of care of infants and children and means for caregivers to better cope during periods of a baby's prolonged crying. Listen to the podcast here.
A crying baby and a momentary loss of control by a frustrated parent or caregivercan end in the death of the baby or life-long permanent and severe neurological damage.
Shaken Baby Syndrome (SBS) kills or seriously injures many newborns and infants annually. According to state data resources, San Francisco documented about 60 SBS incidents annually in recent years, yet amazingly there is no SBS prevention program in the City.
The increasing incidence of infant victims of Shaken Baby Syndrome (SBS) is a tragedy for the child, the family and the community. Shaken Baby Syndrome is a collection of signs and symptoms resulting from violently shaking an infant or child. This momentary loss of control by the caregiver can lead either to the death of the baby or to life-long permanent and severe neurological damage. The injuries may include diffuse brain injury, bleeding in or around the brain, bleeding in the retina of the eyes and multiple fractures of the ribs, arms and legs. Victims can be left with blindness, profound motor and cognitive retardation, and seizures. This preventable outcome occurs in families of all socioeconomic levels and is typically a consequence of the violent shaking of an infant by an exasperated caregiver following a period of the baby’s prolonged crying.
The San Francisco Shaken Baby Syndrome (SBS) Prevention Work Group formed in May 2005 when pediatricians and health department workers in San Francisco noted an increase in the number of Shaken Baby Syndrome cases in San Francisco. In their appeal to try to "do something" to address the issue, they convened a small group of interested professionals. The SBS Prevention Work Group’s members are representatives from all five delivery hospitals (California Pacific Medical Center, Kaiser, St. Luke’s, San Francisco General Hospital, UCSF), the SF Child Abuse Council, San Francisco Department of Public Health (SFDPH) Maternal and Child Health, Public Health Nursing, Child Health and Disability Prevention Program (CHDP), WIC, Blue Cross and San Francisco Health Plan. SFDPH’s Maternal and Child Health has provided a leadership role in the SBS Prevention Work Group as part of an overall strategy of child abuse prevention.
Although the San Francisco Department of Human Services’ Foster Care reports an increase in SBS, it is difficult to locate accurate data. SBS is often misdiagnosed or suspected, but not confirmed. There are problems with death certificate and hospitalization data. The death certificates do not have a specific code for “Shaken Baby Syndrome” as a cause of death. Hospitals do have a code for “Shaken Baby Syndrome,” but the numbers are quite conservative, as only confirmed cases are counted. In addition, hospital data does not include deaths or injuries outside of the hospital. Also, many children who are shaken do not come to medical attention; thus, the severe injuries that are counted in the data are likely just the tip of the iceberg. For the last four years of hospital data collected by the State, using very conservative definitions, the rate of SBS for San Francisco was 8.81/100,000, well above the State average of 5.52/100,000. Further, among injury deaths, the leading cause of death for infants in the State of California is homicide. SBS is a significant proportion of those homicides. Prospective population-based studies estimate the incidence of serious or fatal abusive head trauma to be between 17 and 25 per 100,000. A population-based anonymous survey of parents suggests that there are about 150 undetected shaken babies for every infant who sustains an injury as a result of shaking.
Around the same time that the SBS Prevention Work Group began meeting, a study was published demonstrating an effective model for SBS prevention, Dr. Mark S. Dias’ “Preventing Abusive Head Trauma Among Infants and Young Children: A Hospital-Based, Parent Education Program”, published April 4, 2005 in Pediatrics. This study outlines an educational intervention performed by nursing staff with all new mothers, mothers’ partners and/or families of newborns before they were discharged from the hospital. This intervention reduced the incidence of Shaken Baby Syndrome by about 50%. This study found that use of a separate educational piece on Shaken Baby Syndrome played a significant role in the reducing the incidence of SBS. This set the intervention apart, giving weight over the numerous patient education pieces received by mothers when they are discharged from the hospital.
The SBS Work Group surveyed all five delivery hospitals in San Francisco and found that none are providing targeted Shaken Baby Syndrome prevention health education to the mothers, the mother’s partners and/or families of the newborns. The SBS Prevention Work Group’s goal is to educate parents and thus reduce the incidence of SBS in San Francisco. The Dias study results were so compelling that the SBS Prevention Work Group has as its core objective the replication of a similar intervention in all five hospitals. This evidence-based project would standardize a community-wide child abuse prevention intervention for every baby born in San Francisco.
The SBS Prevention Work Group proposes a hospital-based parent education intervention based on the Dias study. This County-wide intervention entails hospital nursing staff providing SBS prevention education to new mothers, mother’s partners and/or families of the 13,000 babies born in San Francisco hospitals each year. Nursing staff will utilize a variety of culturally appropriate, multi-lingual health education materials that will be developed by the project (e.g., brochures, videos, and magnets.) The intervention includes nursing staff reviewing information about Shaken Baby Syndrome, crying babies, how to calm a crying baby, what to do if the baby doesn’t stop crying, and San Francisco’s TALKLine, a 24 hour parental stress hotline. The mothers and caregivers will be encouraged to tell anyone who provides care for their baby about SBS and its prevention.
The bottom line is that SBS results from an out-of-control, uninformed caregiver. It is child abuse.
This program proposes to educate all parents and caregivers of newborns in the most basic child abuse prevention strategies. The information provided will be targeted to the parents and caregivers of the newborns, but the basic child abuse prevention messages will remain true regardless of the child’s age.
SBS prevention training for obstetrical and pediatric providers, governmental and community-based agencies
The delivery hospital intervention will not cover the entire at-risk population of children. Some San Francisco residents give birth at out-of-county hospitals, and families with infants and small children move into San Francisco. These families and caregivers will also need SBS prevention education. In addition, there are many newborn caregivers who are not present at the birthing hospital (relatives, neighbors, teenage babysitters, friends, childcare providers) who need to hear the SBS prevention message via community-based agencies or health care providers.
The training component of this program will provide SBS prevention training for obstetrical and pediatric providers, governmental and community-based agencies to reach those who did not receive the educational intervention in a San Francisco delivery hospital. These staff will in turn be able to provide the SBS message to their clients.
A public awareness campaign will be planned, implemented, and evaluated to inform the general public, who would not necessarily be informed at the delivery hospital, but who may be responsible for caring for a newborn or small child. The campaign strategies will include development of public awareness posters and ads for newspapers and buses. The entire community must be made aware of the risks of shaking a baby and prevention techniques.
The San Francisco Shaken Baby Syndrome Prevention Project has made significant strides this past year in developing our program including hiring a part time training coordinator through a collaboration with the UCSF National Center of Excellence in Women’s Health, and developing training and health education materials. We have implemented the project at three of the hospitals in San Francisco including SFGH, UCSF and CPMC and have trained 216 nurses and 42 staff members from Talk Line and various family resource centers.
As you will see below, we have accomplished a great deal of work in part from the tremendous amount of in-kind work that has been done by the SBS Prevention Work Group members and through the funds raised. Below is a list of organizations that provided in-kind support:
San Francisco Department of Public Health (SFDPH), Maternal, Child, Adolescent Health (MCAH)
San Francisco General Hospital (SFGH), Inpatient Pediatrics
California Pacific Medical Center (CPMC)
San Francisco Child Abuse Prevention Center (SFCAPC)
Foster Care/Universal Home Visiting Program
SFDPH Public Health Nursing
UCSF Children’s Hospital
SFGH Midwifery Services
Maxine Hall Health Center
UCSF National Center of Excellence in Women’s Health
UCSF, Pediatric Critical Care
SFDPH, Child Health & Disability Prevention
SFGH Women’s Health Center
Anthem Blue Cross
St Lukes Medical Center, Pediatrics
We have worked hard to raise funds to support the SBS prevention project activities and are continually fundraising to achieve full implementation of the entire proposed SBS project. To date, we have received financial commitment from:
UCSF National Center of Excellence in Women’s Health
Kaiser Permanente Foundation
The San Francisco Foundation
Mount Zion Health Fund
California Pacific Medical Center
First Five of San Francisco
Health Education and Training Materials
After extensive research on other national SBS prevention projects, our training curriculum and PowerPoint presentation have been developed and tailored to meet the unique needs of each delivery hospital. The training entails providing: 1) Basic Information on Shaken Baby Syndrome, 2) Overview of City-Wide Educational Intervention and 3) Hospital Role in Project. The training provides detailed information on how the educational intervention will take place at each hospital including where SBS education will be documented, where brochures will be stored and information on the study component of the project.
Thanks to all our SBS work group members in-kind support, we have finalized the English, Spanish, and Chinese brochures. These materials were reviewed not only by health professionals at the five delivery hospitals, but have received input from parents, and community advocates.
In addition, we have finalized the message for patient and nurse incentives. We have chosen a duck magnet and a three sided pen for the incentives.
As of December 2008, 218 nurses from SFGH, UCSF and CPMC and 42 staff members from Talk Line and various family resources throughout San Francisco have been trained. The resource centers and agencies include: Portola Family Connections, Asian Perinatal Advocates Family Support Services, South of Market Child Care, Edgewood Center for Children and Families – Kinstart Program, Department of Public Health Childcare Health Project, Visitation Valley Community Center, Excelsior Family Connection, and the Instituto Familiar de la Raza.
As we train the 500 nurses at the five delivery hospitals, we will continue to raise funds so we are able to implement the second tier of the SBS project.
For more information on our project or if you are interested in donating, or providing in-kind support, please contact:
Joanna Laffey, MPH
Training Coordinator – SF Shaken Baby Syndrome Prevention Project
UCSF National Center of Excellence in Women’s Health
(650) 991-2747 Telephone
(650) 991-2748 Fax