Abusive head trauma & ICON – advice & resources for all

Abusive head trauma is a preventable and severe form of physical child abuse.

Trauma may result from shaking an infant by their shoulders, arms, or legs; or from impact (with or without shaking) caused by throwing or hitting a child. The resulting whiplash effect can cause  fractures or result in bleeding in the infant’s brain.

Nearly all victims of abusive head trauma suffer serious health consequences and at least one of every four babies who are violently shaken dies from this form of child maltreatment. Babies (newborn to 4 months) are at greatest risk of injury from shaking.  Inconsolable crying is a primary trigger for shaking a baby.

Playful interaction with an infant, such as bouncing the baby on the lap or tossing the baby up in the air, won’t cause the injuries associated with abusive head trauma. Instead, these injuries often happen when someone shakes the baby out of frustration or anger.

You should never shake a baby under any circumstances. Shaking a baby is a serious and deliberate form of abuse.

Call 999 right away if you believe that your baby or another baby is a victim of abusive head trauma. This is a life-threatening condition that requires immediate medical treatment.

ICON programme

ICON is a programme aimed at helping parents and carers with young babies to cope with infant crying.

Most babies start to cry more frequently at about two weeks of age, with crying becoming more frequent and longer lasting during the next few weeks and reaching a peak at six to eight weeks. The ICON programme offers the support to let parents and carers know that this behaviour is completely normal and that they are not alone in dealing with this situation. It is completely natural for babies to cry and it is important to remember that this will stop. After approximately eight weeks babies start to cry less and less each week.

ICON provides the important messages below on how to cope with a crying baby:

IInfant crying is normal and it will stop

CComfort methods can sometimes soothe the baby and the crying will stop.

O – It is OK to walk away, if you have checked the baby is safe and the crying is getting you. After a few minutes when you are feeling calm, go back and check on the baby.

NNever, ever shake or hurt a baby; it can cause lasting brain damage or death.

Find out more about this programme on the ICON website at iconcope.org

What are the symptoms of abusive head trauma?

Symptoms of abusive head trauma may include:

  • difficulty staying awake
  • body tremors
  • trouble breathing
  • poor eating
  • vomiting
  • discolored skin
  • seizures
  • coma
  • paralysis.

Babies have soft brains and weak neck muscles, so often have difficulty supporting their heads. They also have delicate blood vessels. Head trauma or shaking a baby or young child can cause their brain to repeatedly hit the inside of the skull, causing bruising in the brain, bleeding in the brain, and brain swelling. Other injuries may include broken bones as well as damage to the baby’s eyes, spine, and neck.

People may shake or hit an infant out of frustration or anger, often because the child won’t stop crying. Although this does eventually make the baby stop crying, it is usually because the trauma has damaged their brain.

How common is abusive head trauma?

Abusive head trauma affects around 24 of every 100,000 babies admitted to hospital each year.  Research suggests 1 in 9 mothers may have shaken their baby and up to 2 in 9 have felt like doing so at some point.

Who shakes babies and why?
Research tells us that:

  • 70% of perpetrators are males – fathers/male surrogates (Kesler et al 2008; Altman et al 2010)
  • this occurs in every socio-economic group
  • care givers lose control and shake – baby stops crying
  • there is a demonstrable relationship between the normal peak of crying and babies subject to abusive head trauma (Barr et al 2006)
  • the is a greater likelihood of occurrence in the 1st month of a baby’s life
    • with a peak at 6 weeks during the 2nd month
    • and a decrease during the 3rd to 5th months.

Triggers
Crying is considered the main trigger for shaking a baby:

  • peak of crying is 6-8 weeks of age
  • the child’s parents or their mother’s partner are responsible for abusive head trauma in 75% of cases
  • the majority of perpetrators are male
  • the most at risk groups are:
    • male babies
    • aged below 6 months
    • of low birth weight
    • babies who require regular contact with health professionals.

The Crying Curve – as illustrated at iconcope.org/parentsadvice – shows that babies start to cry more frequently from around 2 weeks of age.  Parents should be reassured that infant crying is normal and it will stop!

How is abusive head trauma diagnosed?

To make a diagnosis, a doctor will look for three conditions that often indicate abusive head trauma. These are:

  • encephalopathy, or brain swelling
  • subdural hemorrhage, or bleeding in the brain
  • retinal hemorrhage, or bleeding in a part of the eye called the retina.

The doctor will order a variety of tests to check for signs of brain damage and to help confirm the diagnosis. These tests may include:

  • MRI scan, which uses powerful magnets and radio waves to produce detailed images of the brain
  • CT scan, which creates clear, cross-sectional images of the brain
  • skeletal X-ray, which reveals spine, rib, and skull fractures
  • ophthalmic exam, which checks for eye injuries and bleeding in the eyes.

Before confirming abusive head trauma, the doctor will order a blood test to rule out other potential causes. Some symptoms of abusive head trauma are similar to those of other conditions. These include bleeding disorders and certain genetic disorders. The blood test will determine whether or not another condition is causing a child’s symptoms.

Can abusive head trauma be treated?

There is no medication to treat abusive head trauma. In severe cases, surgery may be required to treat bleeding in the brain. This may involve placement of a shunt, or thin tube, to relieve pressure or to drain excess blood and fluid. Eye surgery may also be needed to remove any blood before it permanently affects vision.

The outlook for children with abusive head trauma
Irreversible brain damage from abusive head trauma can occur in a matter of seconds. Many babies experience complications, including:

  • permanent vision loss (partial or total)
  • hearing loss
  • seizure disorders
  • development delays
  • intellectual disabilities
  • cerebral palsy, a disorder that affects muscle coordination and speech.

Providing support for parents and carers

Abusive head trauma is preventable. Parents or carers can avoid harming their baby by not shaking them under any circumstances. It is common to become frustrated when a baby will not stop crying. At some point most parents or carers will need reassurance, from their family or a practitioner, that crying is a normal behaviour in infants, and shaking is never the right response.

It is important to support parents or carers to find ways to relieve their stress when their child cries for extended periods of time. Suggest they call a family member or friend for support when they feel them self losing control.

There are also some hospital-based programmes that teach carers how to respond when infants cry and how to manage the stress of parenting.

Parents should also make sure their family members  and anyone who may care for their child are aware of the dangers of abusive head trauma.

Find more information and resources at iconcope.org/parentsadvice – parents should be reassured that infant crying is normal and it will stop!

Soothing a crying baby – support for parents

All babies cry, and some cry a lot. Crying is your baby’s way of telling you they need comfort and care.

Sometimes it’s easy to work out what they want, and sometimes it isn’t. The most common reasons for crying are:

  • hunger
  • a dirty or wet nappy
  • tiredness
  • wanting a cuddle
  • wind
  • being too hot or too cold
  • boredom
  • over stimulation.

There may be times of the day when your baby tends to cry a lot and can’t be comforted. Early evening is the most common time for this to happen. This can be hard for you, as it’s often the time when you’re most tired and least able to cope.

The amount babies cry tends to peak at about seven weeks, then gradually tail off.

Try some of the following ways to calm and comfort your baby. Some may work better than others:

  • if you are breastfeeding, let your baby suckle at your breast
  • if you are bottle feeding, give your baby a dummy; sterilise dummies as you would bottles
    • to avoid tooth decay, don’t dip them in anything sweet
    • some babies use their thumb instead
  • some older babies like to use a bit of cloth or a blanket as a comforter
  • hold your baby or put them in a sling so they are close to you; move about gently, sway and dance, talk to them and sing
  • rock your baby backwards and forwards in the pram, or go out for a walk or a drive
    • lots of babies like to sleep in cars, even if they wake up again when you stop, at least you’ll have had a break
  • find something for them to listen to or look at, this could be music on the radio, a CD, a rattle, or a mobile above the cot
  • try stroking your baby’s back firmly and rhythmically, holding them against you or lying face downwards on your lap
  • undress your baby and massage them gently and firmly, avoid using any oils or lotions until your baby is at least a month old
    • talk soothingly as you do it and keep the room warm enough, some health centres and clinics run baby massage courses – ask your midwife or health visitor
  • try a warm bath, this calms some babies instantly, but makes others cry even more
  • sometimes too much rocking and singing can keep your baby awake, you might find lying them down after a feed will help.

Getting help with a crying baby
You can talk to family, a friend, your health visitor or GP, or look for local community resources that support parents and care givers.

Contact the Cry-sis helpline on 08451 228 669, open 9am to 10pm, 7 days a week (you will be charged for your call.)  Cry-sis can put you in touch with other parents who have been in the same situation.

You can also visit the Cry-sis website for information on coping with crying babies at www.cry-sis.org.uk/help-with-crying-babies

If you decide to talk to your health visitor or GP, it can help to keep a record of how often and when your baby cries.

For example, this might be after every feed or during the evening. This can help your health visitor or GP to work out if there is a particular cause for the crying.

Keeping a record can also help you identify the times when you need extra support. You could think about possible changes to your routine.

There may be times when you’re so tired and angry you feel like you can’t take any more. This happens to a lot of parents, so don’t be ashamed to ask for help.

If you don’t have anyone who can take care of your baby for a short time and the crying is making you stressed, put your baby in their cot or pram, make sure they’re safe, close the door, go into another room and try to calm yourself down.

Set a time limit – for example, 10 minutes – then go back.

If possible plan ahead, some tips for new parents include:

  • make some arrangements for regular safe babysitting and get some rest
  • have a ‘back-up’ plan for calling in reliable help when your baby’s crying seems impossible to deal with
  • talk to friends, family or a health professional about your situation – you are not alone in this
  • know your care giver – never leave your child with someone you don’t know well and trust, or someone who has violent reactions or lacks maturity someone who is unused to caring for children.

Find more information and resources at iconcope.org/parentsadvice.

If your baby cries constantly

There are several reasons that can cause a baby to cry excessively. It can be exhausting if you have tried everything and nothing seems to comfort your baby.

Crying during feeds
Some babies cry and seem unsettled around the time of a feed. If you’re breastfeeding, you may find that improving your baby’s positioning and attachment helps them settle. You can go to a breastfeeding drop-in and ask for help, or talk to your health visitor.

It may be that something you’re eating or drinking is affecting your baby. If you think this is happening, try keeping a diary of what you eat and when the crying happens. If you see any patterns, talk to your health visitor.

Crying during feeds can sometimes be a symptom of reflux, a common condition where babies bring back milk after feeds. Speak to your health visitor or GP for more information and advice.

Colic
Excessive crying could be a sign that your baby has colic. Everyone agrees that colic exists, but nobody knows what causes it.

Some doctors think it’s a kind of stomach cramp. The crying sounds miserable and distressed, and stops for a moment or two, then starts up again, which suggests it could be caused by waves of stomach pain.

The crying can go on for some hours. There may be little you can do except try to comfort your baby and wait for the crying to pass.

For tips on coping with colic visit the NHS website at www.nhs.uk/conditions/colic

Illness
If your baby is crying constantly and you can’t console or distract them, or the cry doesn’t sound like their normal cry, it can be a sign they are ill.

Or they may be ill if they are crying and have other symptoms, such as a high temperature. If this is the case, contact your health visitor or GP.

Get medical attention as soon as you can if your baby:

  • has much drier nappies than usual
  • has a high temperature, but their hands and feet feel cold
  • has a fit (seizure or convulsion)
  • has blue, mottled, ashen (grey) or very pale skin
  • breathes rapidly or makes a throaty noise while breathing, or seems to be working hard to breathe, perhaps sucking in their stomach under their rib cage
  • has a spotty purple-red rash anywhere on the body – this could be a sign of meningitis.

For more information about signs of serious illness visit the NHS website at www.nhs.uk/spotting-signs-serious-illness

If you think there is something wrong, always trust your instincts.

During the day, Monday to Friday, contact your GP surgery. At evenings and weekends call NHS 111 or your GP’s out-of-hours number.

Advice and resources for practitioners to share

All practitioners can play a key role in reinforcing prevention through helping people understand the dangers of violently shaking a baby, the risk factors and the triggers for it, and ways to lessen the load on stressed out parents and caregivers.

ICON programme
ICON is an evidence based programme consisting of a series of brief ‘touch point’ interventions that reinforce the simple message making up the ICON acronym.

Find more information and resources, including videos to share, at iconcope.org/for-professionals/

Hampshire Safeguarding Children Partnership has led the roll-out of the ICON programme – find more information and resources on their website at www.hampshirescp.org.uk/toolkits/abusive-head-trauma/

The Derbyshire LSCB and Public Health Wales websites host a short video: Shaking your baby is just not the deal – which gives parents and carers practical tips about how to respond when their baby cries for long periods of time, doesn’t sleep or settle. The video originates from work undertaken over the last ten years by an Australian multi-disciplinary project team from The Children’s Hospital at Westmead, Sydney, New South Wales.

A ‘don’t shake your baby’ leaflet is also available and is designed to be printed out for parents.

Find these resources on the Derbyshire LSCB website at www.derbyshirescb.org.uk/unborn-child-babies-or-toddlers and with subtitles on the Public Health Wales website at www.wales.nhs.uk

Preventing shaken baby syndrome‘ is a guide for health departments and community-based organisations and be downloaded from the Ipswich & East Suffolk CCG website at www.ipswichandeastsuffolkccg.nhs.uk/Preventing_SBS (PDF)

Other useful resources available include:

Information relating to abusive head trauma from Serious Case Reviews (SCRs) has been compiled by the NSPCC and Knowledge and Information for the RCPCH and can be found on the RCPCH website at www.rcpch.ac.uk/briefings-serious-case-reviews-scrs-child-protection.

Research and practitioner resources

Bruising in babies
Bruising in babies who are not rolling or crawling is unusual. National and local serious case reviews have identified the need for heightened concern about any bruising in a baby who is not independently mobile. It is important that any suspected bruising is fully assessed even if the parents feel they are able to give a reason for it.

This protocol must be followed in all situations where an actual or suspected bruise is noted in an infant who is not independently mobile.

Read our Bruising / Marks in Non Mobile Infants – guidance for practitioners for more detailed information and a link to the GMSP procedures.

Winston Churchill Fellowship Report
The aim of this Fellowship was to explore international programmes relating to the prevention of child maltreatment, with a particular focus on Abusive Head Trauma in infants; and to gain an understanding about the wider context of the delivery of care and the systems and processes in which they are provided and commissioned. Specific outputs include the development of a UK based primary prevention programme.

The Fellowship report includes the observation and study of the programmes visited and the dedicated professionals who lead and research them. A critical analysis of the applicability of the different programmes within the UK health and social care context is considered alongside the evidence base underpinning prevention of Abusive Head Trauma and helping parents and caregivers cope with crying.

The ICON founder, Dr Suzanne Smith PhD, consolidated the programme study and research with a visit to USA and Canada in 2016 (courtesy of the Winston Churchill Memorial Trust Travel Fellowship) to see the prevention programmes in action and to understand more about what makes such programmes a success.

The executive summary of the report can be downloaded from the ICON website at iconcope.org/for-professionals

The full report Abusive Head Trauma: The Case For Prevention can be downloaded from the WCMT website at www.wcmt.org.uk/abusive-head-trauma-case-prevention

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