Child Abuse & Neglect 38 (2014) 1914–1922
Contents lists available at ScienceDirect
Child Abuse & Neglect
Parents’ behavior in response to infant crying: Abusive head trauma education Hina Simonnet a,e , Anne Laurent-Vannier a , Wenlun Yuan b , Marie Hully a , Sakil Valimahomed a , Malek Bourennane d , Mathilde Chevignard a,c,∗ a Physical Medicine and Rehabilitation Department for Children with Acquired Neurological Injury, Saint Maurice Hospitals, Saint Maurice, France b Centre de recherche en Epidémiologie et Santé des Populations U1018 Inserm, Paul Brousse Hospitals, Villejuif, France c Sorbonne Universités, UPMC Univ Paris 06, Inserm, CNRS, LIB, F-7013, Paris, France d Maternity Department, Saint Maurice Hospitals, Saint Maurice, France e Paediatric Neurology Department, Necker Enfants Malades Hospital, Paris, France
a r t i c l e
i n f o
Article history: Received 14 March 2014 Received in revised form 27 May 2014 Accepted 3 June 2014 Available online 17 July 2014 Keywords: Shaken baby syndrome Abusive head trauma Non-accidental head injury Primary prevention Crying
a b s t r a c t Abusive head trauma (AHT) is still too common, and probably underestimated. It is the leading cause of death from child abuse. Crying is thought to contribute to the act of shaking. Objectives of this study were to (a) assess parents’ knowledge about infant crying, their ability to manage crying, and their knowledge about AHT; and (b) assess the feasibility and the impact of a simple educational intervention about crying and AHT with parents shortly after their child’s birth. A short questionnaire was completed orally by the parents of 190 consecutive newborns in a maternity hospital at day 2 of life. Then, during the routine examination of the child, the pediatrician gave parents a short talk about infant crying and AHT, and a pamphlet. Finally, parents were contacted by phone at 6 weeks for the postintervention questionnaire assessing their knowledge about crying and AHT. Among 202 consecutive births, parents of 190 children were included (266 parents; 70% mothers) over a 1-month period and answered the pre-intervention questionnaire. The intervention was feasible and easy to provide. Twenty-seven percent of mothers and 36% of fathers had never heard of AHT. At 6 weeks, 183 parents (68% of the sample; 80% mothers) answered the postintervention questionnaire. Parents’ knowledge improved significantly post-intervention. Parents found the intervention acceptable and useful. Health care professionals such as pediatricians or nurses could easily provide this brief talk to all parents during systematic newborn examination. © 2014 Elsevier Ltd. All rights reserved.
Introduction Abusive head trauma (AHT) is caused by violent shaking, with or without impact. Outcome of AHT is severe, with a high death rate (15%–38%; Committee on Child Abuse and Nelgect, 2001; King, MacKay, & Sirnick, 2003; Ward, Bennett, & King, 2004) and severe long-term disabilities in more than 50% of children, including neurological, motor, visual, cognitive, and behavioral impairments (Barlow, Thomson, Johnson, & Minns, 2005; Chevignard & Lind, 2014; Laurent-Vannier, Toure,
Abbreviations: AHT, abusive head trauma; SBS, shaken baby syndrome. ∗ Corresponding author address: Service de Rééducation des pathologies neurologiques acquises de l’enfant, Hôpitaux de Saint Maurice, 14 rue du Val d’Osne 94410 Saint Maurice, France. http://dx.doi.org/10.1016/j.chiabu.2014.06.002 0145-2134/© 2014 Elsevier Ltd. All rights reserved.
H. Simonnet et al. / Child Abuse & Neglect 38 (2014) 1914–1922
1915
Table 1 Baseline socio-demographic characteristics of the sample [mean ± SD; n (%)]. Mean ± SD or n (%) Mothers (n = 186) Age, years First child Education level High school Fathers (n = 80) Age, years Education level High school Newborns (n = 190) Gestation age at birth (weeks) Weight (g) Apgar score at 1 min
30.9 ± 5.2 90 (48.4%) 25 (13.4%) 81 (44%) 79 (43.5%) 33.5 ± 6.3 11 (13.7%) 42 (52.5%) 27 (33.7%) 39.1 ± 1.4 3,259.5 ± 473.8 9.8 ± 1.1
Vieux, Brugel, & Chevignard, 2009). Its incidence, although probably underestimated (Carbaugh, 2004), has been reported to be 15–30 per 100,000 infants under 1 year of age (Hobbs, Childs, Wynne, Livingston, & Seal, 2005; Keenan, Runyan, Marshall, Nocera, & Merten, 2004). Crying is the most important factor triggering the act of shaking (Barr, Trent, & Cross, 2006; Lee, Barr, Catherine, & Wicks, 2007), promoted by anger and poor self-control (Fortin, Goulet, & Lampron, 2005). In normal infants, duration of daily crying can reach 4–5 h a day and it increases to a peak pattern around 6–8 weeks, prior to decreasing and stabilizing at 3 months (Barr et al., 2006). It seems that the perpetrator of the act of shaking is most often the father (King et al., 2003; Starling, Holden, & Jenny, 1995), and this act is repeated in more than half of cases (Adamsbaum, Grabar, Mejean, & Rey-Salmon, 2010), although one single episode of shaking has also been reported to be sufficient to cause serious lesions in almost half of cases (Adamsbaum et al., 2010). The act of shaking is violent (Adamsbaum et al., 2010; Committee on Child Abuse and Nelgect, 2001). About 25%–50% of parents do not know about the deleterious consequences of shaking (Showers & Johnson, 1985). Several prevention programs have been developed since the “Don’t shake a baby” campaign (Showers, 1992). These programs have been developed primarily in North America and usually include a variety of materials such as videos, brochures, or cards. Unfortunately, it has been difficult to include fathers in programs. Also, few studies have assessed parents’ knowledge pre- and post-intervention. The objectives of the present study were two-fold: (a) to assess parents’ knowledge about infant crying and their ability to manage it, as well as their knowledge about AHT; and (b) to assess the feasibility and the impact of a short and simple educational intervention shortly after the child’s birth, in the hope that parents would understand and apply this knowledge to their care of the child. Method Participants French-speaking parents of all newborns consecutively born at the Saint Maurice Maternity Hospital in France (2,200 births per year) between December 20, 2010, and January 20, 2011, were approached and offered the opportunity to participate in the study. Procedure The study was approved by the local ethics committee and all participants provided written informed consent. First, participants were interviewed at day 2 of life by a medical team member of the Physical Medicine and Rehabilitation Department. Fathers were included as often as possible. Demographic information (Table 1) was collected, such as parental age and education, and mother’s number of children. Information about the newborn, such as gender, term birth, birth weight, and Apgar score was also collected. Parents were asked for responses to questions on a short multiple-choice questionnaire (Table 2). They were asked questions about infant crying, AHT, other dangerous situations in comparison with AHT, and how they would manage if the baby was crying in an unbearable way. Then, during the routine examination of the newborn, at day 2 or 3 of life (always after the pre-intervention questionnaire had been completed), the Maternity Department pediatrician gave both parents a short informative talk of approximately three minutes about crying and AHT (Fig. 1), and provided them with a pamphlet on AHT developed in 2005 for a Paris regional campaign by the Francilien Resource Center for Brain Injury (http://www.france-traumatisme-cranien.fr/
1916
H. Simonnet et al. / Child Abuse & Neglect 38 (2014) 1914–1922
Table 2 Correct responses (in italic) to pre- and post-intervention questionnaires and comparison between both questionnaires. Mothers Pre-intervention questionnaire (n = 186) n (%) Questions in pre-intervention questionnaire Have you ever heard about Abusive Head Trauma? (If yes, how?) Yes Would you have the possibility to call someone if you got too nervous? (If yes, who?) Yes Questions in both questionnaires Do you think it is normal that a baby may cry for 2 h a day? Yes Do you think it is possible to shake a baby while playing with him/her? No Do you think shaking a baby is more dangerous than a spanking? Yes Do you think shaking a baby is more dangerous than a fall from the changing table? Yes Your baby is crying and you feel nervous, what do you do? Leave the baby in his/her bed Questions in post-intervention questionnaire Do you remember an intervention was given to you about AHT and infant crying? Yes Can shaking a baby lead to death or permanent disability? Yes Can only one occurrence of shaking be sufficient to create lesions? Yes Do you think this intervention was useful? Yes Have you already used this intervention? (If yes, in which circumstances?) Yes Would you recommend this intervention to be provided to all new parents? Yes Would you like to get more information? Yes Did you read the brochure? Yes
Fathers Post-intervention questionnaire (n = 147) n (%)
Pre-intervention questionnaire (n = 80) n (%)
Post-intervention questionnaire (n = 36) n (%)
136 (73)
–
52 (64)
–
165 (89)
–
68 (85)
–
136 (73)
125 (85)*
57 (71)
32 (90)
60 (32)
24 (16)*
28 (35)
5 (14)
168 (90)
140 (95)
67 (84)
36 (100)
43 (23)
102 (69)*
16 (20)
26 (72)
56 (30)
100 (68)*
22 (28)
27 (75)
–
147 (100)
–
36 (100)
–
145 (99)
–
36 (100)
–
138 (94)
–
35 (97)
–
144 (99)
–
36 (100)
–
73 (50)
–
23 (64)
–
146 (100)
–
35 (98)
–
28 (19)
–
9 (26)
–
131 (89)
–
23 (66)
p values were calculated using the McNemar test: *p < 0.001.
upload/mediatheque/plaquette-crftc-2005.pdf). The oral information was specifically developed for the purpose of the study; it was made of very short, slogan-like sentences, meant to be easily remembered. During the study period, other posters about AHT prevention were withdrawn and the maternity staff members were asked not to provide other information to parents on AHT so as to allow for the evaluation of the educational information that was the subject of the present study. Six weeks later, fathers and mothers were contacted separately by phone and asked to answer a questionnaire, including questions from the first interview and questions about their satisfaction and the usefulness of the information provided during the intervention (Table 2). Parents were considered lost to post-intervention follow-up if they did not answer at least three telephone calls and one telephone message. Statistical Analysis Demographic and newborn data were computed as means or percentages. We first analyzed answers to the preintervention questionnaire, using percentages of yes/no answers, to assess parents’ knowledge of crying and AHT. When several choices were possible, the wrong answers were pooled and the number of correct answers was recorded and considered in subsequent analyses. To assess the effect of the intervention on parents’ knowledge, answers of the questions present in both pre- and postintervention questionnaires were compared with a 2 McNemar test. In order to have an overview of parents’ knowledge
H. Simonnet et al. / Child Abuse & Neglect 38 (2014) 1914–1922
1917
1) Babies cry A baby may cry during 2 hours a day and this is normal. It does not necessarily mean that your child is ill or that you do not care for him/her correctly. 2) The Abusive Head Injury exists Exasperating crying of a baby can lead some adults who can’t stand it any longer, to shake him/her. This is called the Abusive Head Injury or Shaken Baby Syndrome. 3) Shaking a baby can kill him/her or lead to severe lifelong impairments Shaking a baby can be more dangerous than a fall or a spanking. Shaking has nothing to do with a game. Playing with a baby is not shaking him/her. 4) Once may be enough, consequences can be lifelong 5) If your baby is crying, you should check that: - he/she is not hungry - he/she does not need to have his/her nappy changed - he/she does not have fever, that he/she is not too covered If despite this, the baby still cries and you feel you cannot put up with it any longer: - First of all, leave the baby on his/her back in his/her bed and leave the room - Call someone you know and you can ask advice from - Most importantly, do not shake him/her Fig. 1. Short informative talk given by the pediatrician about crying and abusive head trauma (AHT)
pre- and post-intervention, we built a knowledge score, using the answers (Table 2– questions in both questionnaires). This score ranged from 0 (no right answers) to 5 (all right answers). To assess parents’ knowledge improvement score, we used the difference between post- and pre-intervention knowledge score values. To analyze factors influencing parents’ pre- and post-intervention knowledge (education, first time mother/multipara, age), analyses of variance (ANOVA) were performed. For this latter test, parents were divided into two age groups divided at the median age of the study sample. The association between parents’ demographic characteristics and their pre-intervention knowledge score, post-intervention knowledge score, and knowledge improvement score, was studied using multiple linear regression models. Models were adjusted according to parents’ age, education level, and whether this was the mother’s first child. For these models, we used data from individuals with no missing data for all covariates. We used a significant level with an ˛ < 0.05. Analyses were performed with SAS version 9.3 (SAS Institute, Inc, Cary, NC, USA). Results Sample Two hundred and two babies were born during the inclusion period, and the parents of 190 babies (94%) participated in the study. Reasons for non-participation were “we know enough about AHT” and/or “don’t want to be bothered at home in 6 weeks.” For six babies, parents did not speak French; one baby and one mother were transferred to another hospital for medical reasons. Two hundred and sixty six parents (mothers n = 186, fathers n = 80) answered the pre-intervention questionnaire, and 183 parents answered the post-intervention questionnaire (mothers n = 147, fathers n = 36) at 6 weeks post-intervention (mean babies’ age = 6.4 weeks; SD = 0.8). Although the demographic characteristics of fathers who did not answer the post-intervention questionnaire were similar to those who stayed in the study, the mothers for whom this was their first child were less likely than other mothers to refuse the post-intervention questionnaire (15% and 27%, respectively; p = .02). Parents’ demographic characteristics are presented in Table 1. Over 80% of parents had at least graduated from high school. Most babies (all but two) were born at full-term of pregnancy. Mothers, rather than fathers, received the educational intervention in a higher percentage of families (70% and 30%, respectively). Pre-intervention Questionnaire Overall, 27% of mothers and 36% of fathers had never heard of AHT. Those who knew about AHT had primarily heard about it through television or other media (Fig. 2). Twenty-seven percent of mothers and 29% of fathers did not know that a normal child may cry up to 2 h a day (Table 2). About one-third of the parents believed one could shake a baby by simply playing with him/her. More than half of the parents thought that shaking is dangerous and most of them rated shaking as more dangerous than a spanking; however, only around 20% believed that shaking a baby is more dangerous than a fall from the changing table. When asked what they
1918
H. Simonnet et al. / Child Abuse & Neglect 38 (2014) 1914–1922
Fig. 2. (A) Responses to the question “How did you hear about AHT?” (B) Responses to the question “Your baby is crying and you feel nervous, what do you do?” In the pre-intervention (B1) and the post-intervention (B2) questionnaires.
would do if the child had been crying, and they could not stand it any longer, only 30% of mothers and 28% of fathers said they would put the baby in his/her bed, whereas 32% of fathers and 28% of mothers said they would keep the baby in their arms (Fig. 2). Most parents (89% of mothers and 85% of fathers) reported they could call someone if they needed help. Overall, the mean pre-intervention knowledge score for parents who answered both questionnaires (Table 3) was 2.88 ± 1.11 and 2.64 ± 1.2 for mothers and fathers respectively, the difference between fathers and mothers was not significant. Mothers for whom this was their first child had significantly lower scores than other mothers (Table 3). No other association between the demographic characteristics of mothers or fathers with their questionnaire scores was found. Post-questionnaire Information Nearly all parents reported that shaking a baby could kill him/her or lead to permanent impairment and that shaking only once was enough to cause severe injuries. Almost all parents found this information useful and thought that it should be provided to all new parents. Most of them suggested that this information should be provided at the maternity unit (47% of mothers, 43% of fathers), but also at antenatal classes (25% of mothers, 24% of fathers), or repeated in both these settings (7% of mothers, 12% of fathers) but not during the first visit to the pediatrician or general practitioner (less than 1% of mothers, 2% of fathers) because it was too late following birth. The majority of parents (64% of fathers, 50% of mothers) reported having used the information provided, mostly during infant crying (91% of fathers, 81% of mothers). Most parents (81% of mothers, 74% of fathers) were satisfied with the amount of information provided at the hospital and did not report the need for more detailed information. A majority of parents reported having read the brochure given by the pediatrician (89% of mothers, 66% of fathers). Overall, the post-intervention knowledge score was 4.01 ± 0.94 for mothers and 4.22 ± 0.72 for fathers. Comparison Between Pre- and Post-intervention Questionnaires Answers Considering mothers’ answers, there were significant differences for four questions out of five with a significantly higher number of correct answers to these questions in the post-intervention than in the pre-intervention questionnaire (Table 2). As the number of fathers participating to the post-intervention questionnaire was low, the McNemar test was not applicable. The knowledge improvement score was higher for fathers (1.58 ± 1.3) than for mothers (1.19 ± 1.15; Table 3). For mothers, the knowledge improvement score was significantly higher when the baby was their first child than when they had other children. This association remained significant after adjustment for all covariates. Among fathers, no association was found.
H. Simonnet et al. / Child Abuse & Neglect 38 (2014) 1914–1922
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Table 3 Knowledge scores before and after intervention and improvement scores by demographic information. Pre-intervention knowledge score n = 147 Mean (sd) Mothers Educational level High school Siblings (1 or more vs 0) Yes No Age 18-31 31–45 Total/mean knowledge score
Post-intervention knowledge score n = 147 p
Mean (sd)
Mean (sd)
p
0.19
3.68 (1.05) 4.98 (0.95) 4.13 (0.88)
0.17
1.21 (1.65) 1.18 (1.08) 1.20 (1.04)
0.99
3.11 (1.15) 2.67 (3.11)
0.01*
4.00 (1.04) 4.18 (0.81)
0.24
0.86 (1.15) 1.47 (1.08)
Contents lists available at ScienceDirect
Child Abuse & Neglect
Parents’ behavior in response to infant crying: Abusive head trauma education Hina Simonnet a,e , Anne Laurent-Vannier a , Wenlun Yuan b , Marie Hully a , Sakil Valimahomed a , Malek Bourennane d , Mathilde Chevignard a,c,∗ a Physical Medicine and Rehabilitation Department for Children with Acquired Neurological Injury, Saint Maurice Hospitals, Saint Maurice, France b Centre de recherche en Epidémiologie et Santé des Populations U1018 Inserm, Paul Brousse Hospitals, Villejuif, France c Sorbonne Universités, UPMC Univ Paris 06, Inserm, CNRS, LIB, F-7013, Paris, France d Maternity Department, Saint Maurice Hospitals, Saint Maurice, France e Paediatric Neurology Department, Necker Enfants Malades Hospital, Paris, France
a r t i c l e
i n f o
Article history: Received 14 March 2014 Received in revised form 27 May 2014 Accepted 3 June 2014 Available online 17 July 2014 Keywords: Shaken baby syndrome Abusive head trauma Non-accidental head injury Primary prevention Crying
a b s t r a c t Abusive head trauma (AHT) is still too common, and probably underestimated. It is the leading cause of death from child abuse. Crying is thought to contribute to the act of shaking. Objectives of this study were to (a) assess parents’ knowledge about infant crying, their ability to manage crying, and their knowledge about AHT; and (b) assess the feasibility and the impact of a simple educational intervention about crying and AHT with parents shortly after their child’s birth. A short questionnaire was completed orally by the parents of 190 consecutive newborns in a maternity hospital at day 2 of life. Then, during the routine examination of the child, the pediatrician gave parents a short talk about infant crying and AHT, and a pamphlet. Finally, parents were contacted by phone at 6 weeks for the postintervention questionnaire assessing their knowledge about crying and AHT. Among 202 consecutive births, parents of 190 children were included (266 parents; 70% mothers) over a 1-month period and answered the pre-intervention questionnaire. The intervention was feasible and easy to provide. Twenty-seven percent of mothers and 36% of fathers had never heard of AHT. At 6 weeks, 183 parents (68% of the sample; 80% mothers) answered the postintervention questionnaire. Parents’ knowledge improved significantly post-intervention. Parents found the intervention acceptable and useful. Health care professionals such as pediatricians or nurses could easily provide this brief talk to all parents during systematic newborn examination. © 2014 Elsevier Ltd. All rights reserved.
Introduction Abusive head trauma (AHT) is caused by violent shaking, with or without impact. Outcome of AHT is severe, with a high death rate (15%–38%; Committee on Child Abuse and Nelgect, 2001; King, MacKay, & Sirnick, 2003; Ward, Bennett, & King, 2004) and severe long-term disabilities in more than 50% of children, including neurological, motor, visual, cognitive, and behavioral impairments (Barlow, Thomson, Johnson, & Minns, 2005; Chevignard & Lind, 2014; Laurent-Vannier, Toure,
Abbreviations: AHT, abusive head trauma; SBS, shaken baby syndrome. ∗ Corresponding author address: Service de Rééducation des pathologies neurologiques acquises de l’enfant, Hôpitaux de Saint Maurice, 14 rue du Val d’Osne 94410 Saint Maurice, France. http://dx.doi.org/10.1016/j.chiabu.2014.06.002 0145-2134/© 2014 Elsevier Ltd. All rights reserved.
H. Simonnet et al. / Child Abuse & Neglect 38 (2014) 1914–1922
1915
Table 1 Baseline socio-demographic characteristics of the sample [mean ± SD; n (%)]. Mean ± SD or n (%) Mothers (n = 186) Age, years First child Education level High school Fathers (n = 80) Age, years Education level High school Newborns (n = 190) Gestation age at birth (weeks) Weight (g) Apgar score at 1 min
30.9 ± 5.2 90 (48.4%) 25 (13.4%) 81 (44%) 79 (43.5%) 33.5 ± 6.3 11 (13.7%) 42 (52.5%) 27 (33.7%) 39.1 ± 1.4 3,259.5 ± 473.8 9.8 ± 1.1
Vieux, Brugel, & Chevignard, 2009). Its incidence, although probably underestimated (Carbaugh, 2004), has been reported to be 15–30 per 100,000 infants under 1 year of age (Hobbs, Childs, Wynne, Livingston, & Seal, 2005; Keenan, Runyan, Marshall, Nocera, & Merten, 2004). Crying is the most important factor triggering the act of shaking (Barr, Trent, & Cross, 2006; Lee, Barr, Catherine, & Wicks, 2007), promoted by anger and poor self-control (Fortin, Goulet, & Lampron, 2005). In normal infants, duration of daily crying can reach 4–5 h a day and it increases to a peak pattern around 6–8 weeks, prior to decreasing and stabilizing at 3 months (Barr et al., 2006). It seems that the perpetrator of the act of shaking is most often the father (King et al., 2003; Starling, Holden, & Jenny, 1995), and this act is repeated in more than half of cases (Adamsbaum, Grabar, Mejean, & Rey-Salmon, 2010), although one single episode of shaking has also been reported to be sufficient to cause serious lesions in almost half of cases (Adamsbaum et al., 2010). The act of shaking is violent (Adamsbaum et al., 2010; Committee on Child Abuse and Nelgect, 2001). About 25%–50% of parents do not know about the deleterious consequences of shaking (Showers & Johnson, 1985). Several prevention programs have been developed since the “Don’t shake a baby” campaign (Showers, 1992). These programs have been developed primarily in North America and usually include a variety of materials such as videos, brochures, or cards. Unfortunately, it has been difficult to include fathers in programs. Also, few studies have assessed parents’ knowledge pre- and post-intervention. The objectives of the present study were two-fold: (a) to assess parents’ knowledge about infant crying and their ability to manage it, as well as their knowledge about AHT; and (b) to assess the feasibility and the impact of a short and simple educational intervention shortly after the child’s birth, in the hope that parents would understand and apply this knowledge to their care of the child. Method Participants French-speaking parents of all newborns consecutively born at the Saint Maurice Maternity Hospital in France (2,200 births per year) between December 20, 2010, and January 20, 2011, were approached and offered the opportunity to participate in the study. Procedure The study was approved by the local ethics committee and all participants provided written informed consent. First, participants were interviewed at day 2 of life by a medical team member of the Physical Medicine and Rehabilitation Department. Fathers were included as often as possible. Demographic information (Table 1) was collected, such as parental age and education, and mother’s number of children. Information about the newborn, such as gender, term birth, birth weight, and Apgar score was also collected. Parents were asked for responses to questions on a short multiple-choice questionnaire (Table 2). They were asked questions about infant crying, AHT, other dangerous situations in comparison with AHT, and how they would manage if the baby was crying in an unbearable way. Then, during the routine examination of the newborn, at day 2 or 3 of life (always after the pre-intervention questionnaire had been completed), the Maternity Department pediatrician gave both parents a short informative talk of approximately three minutes about crying and AHT (Fig. 1), and provided them with a pamphlet on AHT developed in 2005 for a Paris regional campaign by the Francilien Resource Center for Brain Injury (http://www.france-traumatisme-cranien.fr/
1916
H. Simonnet et al. / Child Abuse & Neglect 38 (2014) 1914–1922
Table 2 Correct responses (in italic) to pre- and post-intervention questionnaires and comparison between both questionnaires. Mothers Pre-intervention questionnaire (n = 186) n (%) Questions in pre-intervention questionnaire Have you ever heard about Abusive Head Trauma? (If yes, how?) Yes Would you have the possibility to call someone if you got too nervous? (If yes, who?) Yes Questions in both questionnaires Do you think it is normal that a baby may cry for 2 h a day? Yes Do you think it is possible to shake a baby while playing with him/her? No Do you think shaking a baby is more dangerous than a spanking? Yes Do you think shaking a baby is more dangerous than a fall from the changing table? Yes Your baby is crying and you feel nervous, what do you do? Leave the baby in his/her bed Questions in post-intervention questionnaire Do you remember an intervention was given to you about AHT and infant crying? Yes Can shaking a baby lead to death or permanent disability? Yes Can only one occurrence of shaking be sufficient to create lesions? Yes Do you think this intervention was useful? Yes Have you already used this intervention? (If yes, in which circumstances?) Yes Would you recommend this intervention to be provided to all new parents? Yes Would you like to get more information? Yes Did you read the brochure? Yes
Fathers Post-intervention questionnaire (n = 147) n (%)
Pre-intervention questionnaire (n = 80) n (%)
Post-intervention questionnaire (n = 36) n (%)
136 (73)
–
52 (64)
–
165 (89)
–
68 (85)
–
136 (73)
125 (85)*
57 (71)
32 (90)
60 (32)
24 (16)*
28 (35)
5 (14)
168 (90)
140 (95)
67 (84)
36 (100)
43 (23)
102 (69)*
16 (20)
26 (72)
56 (30)
100 (68)*
22 (28)
27 (75)
–
147 (100)
–
36 (100)
–
145 (99)
–
36 (100)
–
138 (94)
–
35 (97)
–
144 (99)
–
36 (100)
–
73 (50)
–
23 (64)
–
146 (100)
–
35 (98)
–
28 (19)
–
9 (26)
–
131 (89)
–
23 (66)
p values were calculated using the McNemar test: *p < 0.001.
upload/mediatheque/plaquette-crftc-2005.pdf). The oral information was specifically developed for the purpose of the study; it was made of very short, slogan-like sentences, meant to be easily remembered. During the study period, other posters about AHT prevention were withdrawn and the maternity staff members were asked not to provide other information to parents on AHT so as to allow for the evaluation of the educational information that was the subject of the present study. Six weeks later, fathers and mothers were contacted separately by phone and asked to answer a questionnaire, including questions from the first interview and questions about their satisfaction and the usefulness of the information provided during the intervention (Table 2). Parents were considered lost to post-intervention follow-up if they did not answer at least three telephone calls and one telephone message. Statistical Analysis Demographic and newborn data were computed as means or percentages. We first analyzed answers to the preintervention questionnaire, using percentages of yes/no answers, to assess parents’ knowledge of crying and AHT. When several choices were possible, the wrong answers were pooled and the number of correct answers was recorded and considered in subsequent analyses. To assess the effect of the intervention on parents’ knowledge, answers of the questions present in both pre- and postintervention questionnaires were compared with a 2 McNemar test. In order to have an overview of parents’ knowledge
H. Simonnet et al. / Child Abuse & Neglect 38 (2014) 1914–1922
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1) Babies cry A baby may cry during 2 hours a day and this is normal. It does not necessarily mean that your child is ill or that you do not care for him/her correctly. 2) The Abusive Head Injury exists Exasperating crying of a baby can lead some adults who can’t stand it any longer, to shake him/her. This is called the Abusive Head Injury or Shaken Baby Syndrome. 3) Shaking a baby can kill him/her or lead to severe lifelong impairments Shaking a baby can be more dangerous than a fall or a spanking. Shaking has nothing to do with a game. Playing with a baby is not shaking him/her. 4) Once may be enough, consequences can be lifelong 5) If your baby is crying, you should check that: - he/she is not hungry - he/she does not need to have his/her nappy changed - he/she does not have fever, that he/she is not too covered If despite this, the baby still cries and you feel you cannot put up with it any longer: - First of all, leave the baby on his/her back in his/her bed and leave the room - Call someone you know and you can ask advice from - Most importantly, do not shake him/her Fig. 1. Short informative talk given by the pediatrician about crying and abusive head trauma (AHT)
pre- and post-intervention, we built a knowledge score, using the answers (Table 2– questions in both questionnaires). This score ranged from 0 (no right answers) to 5 (all right answers). To assess parents’ knowledge improvement score, we used the difference between post- and pre-intervention knowledge score values. To analyze factors influencing parents’ pre- and post-intervention knowledge (education, first time mother/multipara, age), analyses of variance (ANOVA) were performed. For this latter test, parents were divided into two age groups divided at the median age of the study sample. The association between parents’ demographic characteristics and their pre-intervention knowledge score, post-intervention knowledge score, and knowledge improvement score, was studied using multiple linear regression models. Models were adjusted according to parents’ age, education level, and whether this was the mother’s first child. For these models, we used data from individuals with no missing data for all covariates. We used a significant level with an ˛ < 0.05. Analyses were performed with SAS version 9.3 (SAS Institute, Inc, Cary, NC, USA). Results Sample Two hundred and two babies were born during the inclusion period, and the parents of 190 babies (94%) participated in the study. Reasons for non-participation were “we know enough about AHT” and/or “don’t want to be bothered at home in 6 weeks.” For six babies, parents did not speak French; one baby and one mother were transferred to another hospital for medical reasons. Two hundred and sixty six parents (mothers n = 186, fathers n = 80) answered the pre-intervention questionnaire, and 183 parents answered the post-intervention questionnaire (mothers n = 147, fathers n = 36) at 6 weeks post-intervention (mean babies’ age = 6.4 weeks; SD = 0.8). Although the demographic characteristics of fathers who did not answer the post-intervention questionnaire were similar to those who stayed in the study, the mothers for whom this was their first child were less likely than other mothers to refuse the post-intervention questionnaire (15% and 27%, respectively; p = .02). Parents’ demographic characteristics are presented in Table 1. Over 80% of parents had at least graduated from high school. Most babies (all but two) were born at full-term of pregnancy. Mothers, rather than fathers, received the educational intervention in a higher percentage of families (70% and 30%, respectively). Pre-intervention Questionnaire Overall, 27% of mothers and 36% of fathers had never heard of AHT. Those who knew about AHT had primarily heard about it through television or other media (Fig. 2). Twenty-seven percent of mothers and 29% of fathers did not know that a normal child may cry up to 2 h a day (Table 2). About one-third of the parents believed one could shake a baby by simply playing with him/her. More than half of the parents thought that shaking is dangerous and most of them rated shaking as more dangerous than a spanking; however, only around 20% believed that shaking a baby is more dangerous than a fall from the changing table. When asked what they
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Fig. 2. (A) Responses to the question “How did you hear about AHT?” (B) Responses to the question “Your baby is crying and you feel nervous, what do you do?” In the pre-intervention (B1) and the post-intervention (B2) questionnaires.
would do if the child had been crying, and they could not stand it any longer, only 30% of mothers and 28% of fathers said they would put the baby in his/her bed, whereas 32% of fathers and 28% of mothers said they would keep the baby in their arms (Fig. 2). Most parents (89% of mothers and 85% of fathers) reported they could call someone if they needed help. Overall, the mean pre-intervention knowledge score for parents who answered both questionnaires (Table 3) was 2.88 ± 1.11 and 2.64 ± 1.2 for mothers and fathers respectively, the difference between fathers and mothers was not significant. Mothers for whom this was their first child had significantly lower scores than other mothers (Table 3). No other association between the demographic characteristics of mothers or fathers with their questionnaire scores was found. Post-questionnaire Information Nearly all parents reported that shaking a baby could kill him/her or lead to permanent impairment and that shaking only once was enough to cause severe injuries. Almost all parents found this information useful and thought that it should be provided to all new parents. Most of them suggested that this information should be provided at the maternity unit (47% of mothers, 43% of fathers), but also at antenatal classes (25% of mothers, 24% of fathers), or repeated in both these settings (7% of mothers, 12% of fathers) but not during the first visit to the pediatrician or general practitioner (less than 1% of mothers, 2% of fathers) because it was too late following birth. The majority of parents (64% of fathers, 50% of mothers) reported having used the information provided, mostly during infant crying (91% of fathers, 81% of mothers). Most parents (81% of mothers, 74% of fathers) were satisfied with the amount of information provided at the hospital and did not report the need for more detailed information. A majority of parents reported having read the brochure given by the pediatrician (89% of mothers, 66% of fathers). Overall, the post-intervention knowledge score was 4.01 ± 0.94 for mothers and 4.22 ± 0.72 for fathers. Comparison Between Pre- and Post-intervention Questionnaires Answers Considering mothers’ answers, there were significant differences for four questions out of five with a significantly higher number of correct answers to these questions in the post-intervention than in the pre-intervention questionnaire (Table 2). As the number of fathers participating to the post-intervention questionnaire was low, the McNemar test was not applicable. The knowledge improvement score was higher for fathers (1.58 ± 1.3) than for mothers (1.19 ± 1.15; Table 3). For mothers, the knowledge improvement score was significantly higher when the baby was their first child than when they had other children. This association remained significant after adjustment for all covariates. Among fathers, no association was found.
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Table 3 Knowledge scores before and after intervention and improvement scores by demographic information. Pre-intervention knowledge score n = 147 Mean (sd) Mothers Educational level High school Siblings (1 or more vs 0) Yes No Age 18-31 31–45 Total/mean knowledge score
Post-intervention knowledge score n = 147 p
Mean (sd)
Mean (sd)
p
0.19
3.68 (1.05) 4.98 (0.95) 4.13 (0.88)
0.17
1.21 (1.65) 1.18 (1.08) 1.20 (1.04)
0.99
3.11 (1.15) 2.67 (3.11)
0.01*
4.00 (1.04) 4.18 (0.81)
0.24
0.86 (1.15) 1.47 (1.08)
