A statewide intervention in Pennsylvania failed to significantly reduce hospitalization rates for abusive head trauma (AHT) among infants ages 0 to 23 months, researchers reported.
Published online in JAMA Pediatrics, the study found that the incidence rate ratios for AHT hospitalizations in Pennsylvania increased from 24.1 (95% CI 22.1 to 26.3) before the intervention to 26.6 (95% CI 24.9 to 28.4) after the intervention per 100,000 children.
Additionally, there was no improvement in Pennsylvania compared with five other states without such measures (22.4; 95% CI 21.2 to 23.6 versus 22.0; 95% CI 21.2 to 22.8) per 100,000 children, reported Mark Dias, MD, of Penn State Children's Hospital, and colleagues.
However, the researchers noted that the Pennsylvania Shaken Baby Syndrome Prevention Program did yield self-reported gains in parental knowledge that were retained for 7 months.
The results were similar to those of a hospital-based parental education program in North Carolina, yet contradicted the conclusions of smaller studies in Upstate and Downstate New York.
In an accompanying editorial, John M. Leventhal, MD, medical director of the Yale-New Haven Children's Hospital Child Abuse Program of Yale School of Medicine in Connecticut, and colleagues wrote that "despite these efforts, the incidence of AHT during the intervention was higher than before the intervention and not different than the incidence in five other states where universal educational programs about AHT were not available."
The editorial noted that a lack of a control group made it difficult to determine whether the intervention really was not successful, but suggested that confounders, "such as the most recent economic recession," may have substantially minimized the effects.
For the study, Dias and colleagues evaluated the effectiveness of the program compared with five other states without universal parental AHT education during the same period.
The intervention was completed by 1,180,291 parents during the postpartum hospital stay at maternity units and birthing centers from Jan. 1, 2003, to Dec. 31, 2013. All participants were asked to read a brochure, watch an 8-minute video on the dangers of shaking an infant ("Portrait of Promise"), and sign the commitment statement, and were encouraged to ask questions of the nurse.
Parental behavior and knowledge were assessed through immediate (n=16,111) and 7-month post-intervention (n=146) parent surveys in a per-protocol analysis of evaluable parents.
The researchers found that despite a high adherence to the intervention (74.1%), just 20.6% of participants saw the brochure and video and just 5.7% were exposed to the entire intervention.
Among parents who answered individual questions on the postnatal surveys, 10,958 mothers (91.0%) and 2,950 fathers (88.6%) reported learning a lot about understanding infant crying as normal; 11,023 mothers (92.2%) and 2,923 fathers (88.9%) learned about calming their infant; and 11,396 mothers (94.6%) and 3,035 fathers (91.9%) learned about calming themselves.
Additionally, 10,060 mothers (85.1%) and 2,688 fathers (83.4%) reported learning how to choose infant caregivers and 11,435 mothers (94.8%) and 3,201 fathers (95.8%) reported learning how to decrease the likelihood of shaking an infant.
Among the 143 respondents who completed the 7-month survey, 109 (76.2%) reported remembering the information while their child was crying.
Dias and colleagues noted that while the results were "certainly disappointing," they were not dissuaded from continuing their efforts to reduce AHT.
They proposed alternative ideas to support families during this critical period, including: supplementing the information repeatedly to parents over time (e.g., with serial text messages); combining such information with family and community supports (e.g., home visitation for high-risk families); and providing policies such as paid family leave.
Leventhal and colleagues agreed that there is work to be done: "An educational intervention on the postpartum floor may not be the right kind of intervention ... even if the intervention is an effective one, it may have been unsuccessful because it did not reach the intended audience."
The editorial made several suggestions for modifying and strengthening AHT interventions:
- Provide the same educational intervention in a systematic, consistent manner from multiple, diverse sources
- Educate parents on how to manage their own feelings of frustration and anger
- Encourage legislation that increases the reach of paid parental leave
- Employ home visitors to deliver information
- Reach and actively engage male caregivers
Study limitations cited by the researchers included the lack of contemporaneous groups, as well as the potential for both selection bias and recall bias.
Dias and some of the other co-authors reported receiving salary support from grants from the Centers for Disease Control and Prevention and the Pennsylvania Department of Health, and Dias and one other coauthor reported receiving compensation for expert witness testimony in cases of abusive head trauma.
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