Abusive head trauma in infants and why we CAN afford to prevent it

Abusive head trauma (AHT) is a well-recognized and severe form of child abuse. Commonly referred to as ‘shaken baby syndrome’ (SBS), in recent years it has come to be named using less mechanism-specific terminology such as AHT. Between 2005 and 2008, 220 cases of AHT were reported in Canada (1). However, this likely underestimates the true scope of the problem because many abused infants brought for medical care are incorrectly diagnosed (2,3). In an effort to prevent AHT, the identification of infants ‘most at risk’ has been attempted, and evidence-based prevention programs such as the Period of PURPLE Crying are being implemented. The purpose of the current commentary is to present economic data that support the implementation of such a program for all new caregivers. Typically, an infant with AHT is brought to medical attention because of nonspecific symptoms such as irritability, vomiting or fever after a diagnostic workup reveals physical and imaging findings that have resulted from violent shaking and/or impact (4). Characteristic injuries include intracranial hemorrhage, retinal hemorrhages, brain injury and skeletal fractures. External evidence of trauma may be absent (4). In a recently reported series of Canadian AHT cases, the median age at presentation was five months, with 75% of children involved being younger than one year of age. Of the confirmed cases, 93% were hospitalized and slightly more than one-half required admission to an intensive care unit. Of those who survived, 55% had ongoing neurological injury and 65% experienced visual impairment at the time of discharge (3). These findings are consistent with knowledge that AHT has the highest trauma severity index of paediatric intensive care unit admissions (3). In addition to costs associated with the acute admission, survivors of AHT are likely to require expensive long-term multidisciplinary paediatric care, specialized education, adaptive housing or rehabilitative services (5). Additional ‘system’ costs are also incurred because of involvement of child welfare authorities, law enforcement or the judiciary. These costs and the ongoing cost to the health care system can be prohibitive, with lifetime care for a brain-injured infant estimated to be nearly US$14 million per child (6). In addition to the human costs, the financial costs of AHT are clearly undeniable. This led us to consider the following questions: “Do strategies for prevention of AHT exist?” and “What is the cost of prevention?” The current literature suggests that infant, caregiver and environmental characteristics all contribute to the level of risk (3,7). Infant characteristics that increase risk include prematurity, developmental delay and feeding difficulties (1). By highlighting the overlap of the age-specific incidence curve of AHT hospitalizations and the normal early infant crying curve, Barr et al (8,9) suggest that infant crying (a normal and expected behaviour) is the most common stimulus for AHT. Similarly, Lee et al (10) examined 591 cases of infant shaking and found that crying was reported as a specific stimulus in 166 of those cases. Based on these empirical data, the Period of PURPLE Crying, an evidence-based prevention program, was designed by the National Center on Shaken Baby Syndrome (11). ‘PURPLE’ crying stands for Peak pattern, Unexpected onset of crying bouts, Resistance to soothing, Pain-like facial grimace, Long crying bouts, and Evening clusters. This program was designed to educate new caregivers about the normal patterns of infant crying, to anticipate this potentially frustrating behaviour, and how to safely respond to a crying infant. New parents are provided with an 11-page colour booklet and a 10 min DVD, which they are encouraged to share with others. Data regarding the efficacy of this program are beginning to emerge. Recently, Barr et al (9,12) reported that in two separate randomized, controlled trials, mothers who received the PURPLE program material had greater mean scores for knowledge about infant crying and the dangers of shaking. The caregivers also reported that they shared information about inconsolable crying, walking away when frustrated, and the dangers of shaking with other caregivers (9,12). Perhaps, most importantly and directly applicable to AHT prevention, mothers who received the PURPLE material were 1.7 times more likely to utilize appropriate walk-away behaviours in response to inconsolable infant crying (9). This information supports the notion that by decreasing misunderstandings about the regular patterns of infant crying, administration of the PURPLE program potentially results in curtailed caregiver frustration and a reduction in AHT. The PURPLE program can also increase caregiver understanding of the dangers of shaking, and encourage appropriate and safe behavioural responses. A preliminary economic analysis of the costs associated with the initial hospitalization for newly diagnosed cases of AHT was conducted. Our hypothesis was that the direct costs of a hospital admission for AHT would exceed the cost of implementing a prevention program, such as the Period of PURPLE Crying, for an entire year to all new caregivers at our institution – the IWK Health Centre in Halifax, Nova Scotia. We reviewed nine recently admitted patients who were diagnosed with AHT as established by a multidisciplinary child protection team. Salaries of the health care workers involved, the costs of supplies used and procedures ordered, including laboratory fees, were calculated based on each patient’s length of stay in hospital. The median cost of an acute AHT admission was $12,962.30 (range $2,592.46 to $47,005.88). These costs did not account for building overhead (eg, electricity, water, etc) and general administration (eg, payroll, human resources, information technology, public relations, etc). More importantly, they did not take into account the cost of any readmissions or follow-up services. The cost of purchasing the Period of PURPLE Crying material ranges from $2.12 to $3.70 per package, depending on the number of packages purchased (11). This cost does not include shipping and handling, nor does it account for the time required to train staff and present the PURPLE program material to new parents. At our institution, approximately 4814 births occur annually, of which approximately 1800 are to primigravida mothers. The cost of providing the PURPLE program to all first-time parents at our institution would equal approximately $3,800 per year, not including the costs of training and delivery. Based on these data, the median cost of the initial hospitalization for one infant with AHT is more than three times the cost of providing the PURPLE program to all new parents for a full year at our institution. Available population-based data suggest that between two and four cases of AHT are recognized in our institution annually (1,3). If program delivery prevents even one AHT event per year, representing a 25% to 50% decrease in incidence, not only will the costs of implementation have been fully recovered, but more importantly, negative outcomes (both short and long term) for infants, their families and society will have been avoided. These data support the implementation of a prevention program for AHT as a potential cost-neutral or cost-saving undertaking for individual hospitals and governments. Limitations of the present economic study include its small size and that data from only one institution were analyzed. In addition, other ‘system’ costs of AHT, such as those incurred by child welfare authorities, the judiciary and law enforcement, were not captured. However, we argue that if included, these costs would only serve to increase the discrepancy between the cost of an AHT event and the cost of prevention. Evidence suggests that assaults on infants are precipitated by a crying infant and perpetrated by a caregiver who is unaware of a safe behavioural response (8). By implementing the PURPLE program, we can educate new caregivers about infant crying, the dangers of shaking, and the appropriate response to this predictable and normal infant behaviour. Ultimately, education may lead to caregivers being better equipped to handle a crying infant. Long-term epidemiological data regarding reduction in the incidence of AHT after implementation of the PURPLE program are not yet available. Importantly, even in the absence of this information, governments both in the United States and Canada are beginning to recognize the potential value and need for this type of initiative; the PURPLE program has been rolled out jurisdiction-wide in North Carolina, Utah, Kansas, British Columbia and certain parts of Ontario (11). We recognize that additional research on the long-term outcome of prevention programs, including factors such as the most effective windows, mode of delivery and most important populations to target, is needed. However, given the clear human and economic burden of AHT, and the apparent favourable economics of prevention being cost-neutral or cost-saving, we pose the following question to policy makers, hospital administrators and public health agencies: “How can we NOT afford to introduce an effective strategy to prevent AHT?”

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