INJURY PREVENTION

HANDLE WITH CARE: PREVENTING ABUSIVE HEAD TRAUMA Authors: Debra Samaha, MPH, RN, Susan Barnard, MS, RN, APRN, CCRN, and Anna Maria Valdez, PhD, RN, CEN, CFRN, CNE, C-NPT, Lebanon and Nashua, NH, Minneapolis, MN Section Editor: Anna Maria Valdez, PhD, RN, CEN, CFRN, CNE, C-NPT

Earn Up to 8.0 CE Hours. See page 367. hild abuse continues to be a serious public health concern that affects millions of children around the world. 1 There were nearly 4 million cases of child maltreatment reported during 2013 in the United States alone. 2 Sadly, these alarming numbers do not tell the whole story. Sedlak et al. 3 estimated that child abuse is significantly under-reported, with only one third of children who experience abuse being identified and referred to child protective services for intervention. Emergency nurses are in a unique position to be able to identify child abuse or children who are at risk of abuse. Chang et al. 4 reported that 1 in every 10 children treated in the emergency department has experienced child abuse, and in many cases, the signs and symptoms of abuse may not be overtly obvious. 5 In addition, at-risk children may visit the emergency department before abuse begins, which creates an opportunity for emergency nurses to intervene by providing parental support, referrals, and education to prevent abuse. Emergency nurses must be educated on the subtle signs and symptoms of abusive head trauma (AHT) and knowledgeable about risk factors for abuse so that they can intervene early to prevent initial or continuing abuse.

C

Abusive Head Trauma

Of the millions of children who are maltreated each year, 18% sustain physical abuse, with the age range of birth to 1 year having the highest rate of victimization. 2 AHT, also known as Debra Samaha, Member, New Hampshire Chapter, is Program Director, Injury Prevention Center, Children's Hospital at Dartmouth-Hitchcock, Lebanon, NH. Susan Barnard, Member, New Hampshire Chapter, is Trauma/Stroke Program Coordinator, St Joseph Hospital, Nashua, NH. Anna Maria Valdez, Member, San Francisco Chapter, is Faculty, School of Nursing, Walden University, Minneapolis, MN. For correspondence, write: Anna Maria Valdez, PhD, RN, CEN, CFRN, CNE, C-NPT; E-mail: [email protected]. J Emerg Nurs 2015;41:350-2. Available online 22 April 2015 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.03.005

350

JOURNAL OF EMERGENCY NURSING

shaken baby syndrome, is the leading cause of preventable child abuse death in the United States. 6 According to Parks et al., 7 “estimates of the incidence of abusive head trauma vary, but most range from 20 to 30 cases per 100,000 children under one year of age.” Approximately 20% of affected infants will die as a result of their injuries from AHT, and nearly two thirds of infants and children who survive will have significant disability, 7 which may include permanent neurologic disability, static encephalopathy, mental retardation, cerebral palsy, cortical blindness, seizure disorders, and learning disabilities. 8 Primary Prevention Strategies: Period of PURPLE Crying

AHT commonly occurs in infants from birth to 1 year; however, there have been cases of AHT identified in children up to age 5 years. 7 According to Parks et al., 7 “the peak incidence and rapid decrease with age are thought to be related to episodes of prolonged, inconsolable, and unpredictable periods of crying that are developmentally normal for infants.” Emergency nurses can provide primary prevention for AHT by using the Period of PURPLE Crying program (National Center on Shaken Baby Syndrome, Farmington, UT). This evidence-based program is designed to educate parents about normal infant crying patterns, how to respond to the crying, and the dangers of shaking infants and children. 9 The Period of PURPLE Crying program is a 3-dose primary prevention program: Dose 1 is administered in birthing units of hospitals by nurses; dose 2 is administered as reinforcement in the pediatrician’s office or emergency department by home visitors, visiting nurses, or other supporters of families with infants; and dose 3 is a public awareness campaign to help affect the way infant crying is viewed within society. 10 PURPLE is an acronym used to describe the characteristics of the increased period of crying that most babies experience starting at about 2 weeks, peaking at about 2 months, and usually ending by about 4 to 5 months. The P stands for the “peak of crying” because the baby may cry more each week. The U stands for “unexpected” because the crying may come and go regardless of what the parent does. The R

VOLUME 41 • ISSUE 4

July 2015

Samaha et al/INJURY PREVENTION

stands for “resists soothing,” and the P represents “pain-like face.” The L is for “long lasting” because crying can last as long as 5 hours a day, and the E stands for “evening” because the baby may cry more in the late afternoon or evening. The word period means that there is a beginning and an end and therefore is a “period of time” in the infant’s life. 10 Information about how to implement the Period of PURPLE Crying program can be found at www.dontshake.org. Educational resources for parents on the Period of PURPLE Crying program can be accessed online at http://purplecrying.info/.

Secondary Prevention Strategies: Early Detection of Abuse

It is estimated that between 2% and 10% of children who are seen in the emergency department have experienced either abuse or neglect. 11 In a study of 44 children who died of child abuse, Leetch and Woolridge 11 found that 19% of the children had been treated in the emergency department within 1 month of their deaths; however, they were not identified as being abused or at risk of abuse at the time of the initial visit. Emergency nurses need to be knowledgeable in the recognition of sentinel injuries, which can appear minor on presentation, to intervene before serious abuse injuries occur. Sheets et al. 12 defined a sentinel injury as “a previous injury reported in the medical history that was suspicious for abuse because the infant could not cruise, or the explanation was implausible.” This may include minor injuries such as “frenulum tears or bruising in precruising infants (infants unable to pull to a stand and walk while holding onto something),” which may be the first clue to abuse. Leetch and Woolridge 11 identified several strategies for use in the emergency department to identify children at risk of abuse or continued abuse. Nurses in the emergency department can use the 6 B’s and the TEN-4 clinical decision rules to identify children who have been abused. The 6 B’s represent findings that are indicative of abuse: bruises, breaks, bonks (head injury), burns, bites, and baby blues. 12 The TEN-4 rule refers to the body region (thorax, ears, neck), and the number 4 is an age indicator. Any bruises on the torso (including genitals), ears, or neck in a child aged younger than 4 years or any bruising in a child aged younger than 4 months should trigger consideration of abuse. 13 Emergency nurses need to be especially vigilant in identifying infants and small children who have experienced AHT because they are often too young to verbalize complaints and may present with nonspecific symptoms such as fussiness, poor feeding, vomiting, irritability, or lethargy. 12 A thorough history focusing on the history of the event, as well as the behavior of the child after the event,

July 2015

VOLUME 41 • ISSUE 4

and the child’s medical and developmental histories are critical pieces of the ED assessment. Early identification of children who have experienced abuse is a vital secondary prevention strategy. Conclusion

Emergency nurses will continue to be on the front lines of identifying child abuse. Pediatric trauma services and emergency care providers are often the “final gatekeeper before an abused case becomes a fatality.” 4 Primary prevention strategies such as the Period of PURPLE Crying program can be used to reduce the risk of AHT in children under 1 year of age. In addition, emergency nurses can prevent severe abuse or negative outcomes from AHT by carefully evaluating children for subtle signs and symptoms of abuse. Emergency nurses must understand that AHT may present with relatively minor injuries and nonspecific symptoms. Health care providers in the emergency setting have an important role in the identification of abuse and prevention of further abuse. As the National Center on Shaken Baby Syndrome says, “Believe all babies can be safe from harm . . . We do!” 10

REFERENCES 1. Merrick MT, Latzman NE. Child maltreatment: a public health overview and prevention considerations. Online J Issues Nurs. 2014;9(1). Accessed February 8, 2015. 2. US Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child maltreatment, Washington, DC: Government Printing Office; 2013. http://www.acf.hhs.gov/sites/default/ files/cb/cm2013.pdf. Published 2013 Accessed February 8, 2015. 3. Sedlak AJ, Mettenburg J, Basena M, et al. Fourth national incidence study of child abuse and neglect (NIS-4): report to Congress, executive summary. Washington, DC: US Department of Health and Human Services, Administration for Children and Families. http://www.acf.hhs.gov/sites/ default/files/opre/nis4_report_exec_summ_pdf_jan2010.pdf. Accessed January 11, 2015. 4. Chang D, Knight V, Ziegfield S, Haider A, Warfield D, Paidas C. The tip of the iceberg for child abuse: the critical role of pediatric trauma service and its registry. J Trauma. 2004;57(6):1189-1198. 5. Sanders-Jordan K, Moore-Nadler M. Children at risk for maltreatment. Identification and intervention in the emergency department. Adv Emerg Nurs J. 2014;36(1):97-106. 6. Centers for Disease Control and Prevention. Preventing shaken baby syndrome. A guide for health departments and community based organizations. http://www.cdc.gov/Concussion/pdf/Preventing_SBS_508-a. pdf. Accessed January 10, 2015. 7. Parks SE, Annest JL, Hill HA, Karch DL. Pediatric Abusive Head Trauma: Recommended Definitions for Public Health Surveillance and Research, Atlanta, GA: Centers for Disease Control and Prevention; 2012.

WWW.JENONLINE.ORG

351

INJURY PREVENTION/Samaha et al

8. Christian CW, Block R. Abusive head trauma in infants and children. Pediatrics. 2009;123(5):1409-1411. http://pediatrics.aapublications.org/ content/123/5/1409.full.html. Accessed February 8, 2015.

12. Sheets LK, Leach ME, Koszewski IJ, Lessmeier BS, Nugent M, Simpson P. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics. 2013;131(4):701-707.

9. Barr RG, Barr M, Fujiwara T, Conway J, Catherine N, Brant R. Do educational materials change knowledge and behavior about crying and shaken baby syndrome? A randomized controlled trial. CMAJ. 2009;180(7):727-733.

13. Pierce MC, Kaczor K, Aldridge S, et al. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics. 2010;125(1):67-74.

10. National Center on Shaken Baby Syndrome. PURPLE program. http:// www.dontshake.org/purpleprogram. Accessed February 28, 2015. 11. Leetch AN, Woolridge D. Emergency department evaluation of child abuse. Emerg Med Clin North Am. 2013;31(3):853-873.

352

JOURNAL OF EMERGENCY NURSING

Submissions to this column are encouraged and may be sent to Anna Maria Valdez, PhD, RN, CEN, CFRN, CNE, C-NPT [email protected]

VOLUME 41 • ISSUE 4

July 2015

Handle With Care: Preventing Abusive Head Trauma.

Handle With Care: Preventing Abusive Head Trauma. - PDF Download Free
114KB Sizes 0 Downloads 8 Views