1. Shaken Baby Syndrome (SBS) Prevention for high school students
Discussion
Today we are going to discuss shaken baby syndrome prevention. In 2006, a Wisconsin state law was passed requiring people to learn about Shaken Baby Syndrome and how to prevent it. High school students were chosen as one of the groups who must learn this information. Other groups are middle school students, new parents, and child care providers.
How many of you have participated in Shaken Baby Syndrome Prevention training in the past?
(Show of hands.)
When did you participate?
Possible responses:
In middle school.
During babysitting classes.
In a class to train to become a child care assistant or provider.
I work/ volunteer at a child care center.
Soon after the birth of their child or the child of a family member or friend.
Why do you think all high school students are required to participate in Shaken Baby Syndrome prevention training even though some of you have learned about SBS in the past?
We are older now and understand more about SBS and how to prevent it.
We need to be reminded.
Some of us have our own children.
We baby sit for our family or friends.
It is an important topic that is in the news and we should know what is happening around us.
Many of us will be parents in the near future.
Some of us are child care providers or want to be a child care provider some day.
Some of us will be nurses, home visitors, teachers, social workers, etc. and we will come in contact with young children and their parents who need to know this information.

2. Let’s see what we know so far
Pre test
Provide students with a copy of the pre test. Ask them to answer the questions as best they can. Allow approximately 5 to 10 minutes for the activity.
After the students complete the pre test, you make discuss their responses or you may ask them to keep their test in front of them so that they can add notes as they participate in the class.
Note: The post test is identical to the pre test. You may want to print them back-to-back.
Let’s see what we know so far

3. All babies cry Crying is normal. Babies cry for many reasons.
ALL babies will have times when they CANNOT stop crying.
Narrative
We are going to begin by discussing crying.
All babies cry and it can be an irritating sound. This is nature’s way of making sure infants get their needs met so they can survive. If crying was a pleasant sound it would be easy to ignore.
Babies are completely dependant on their caregivers for survival.
It is normal for babies to cry and babies will cry for many reasons. A baby might cry to let you know he or she is hungry or thirsty, needs a diaper change, needs to be cuddled, doesn’t feel well, or is sleepy. A baby might cry to release tension.
In addition, you can expect there to be times when a baby can’t stop crying.
A baby’s crying can be very upsetting. It is important for you to understand what to expect in terms of infant crying, and to plan in advance for how you will handle crying.
Along with using this information for yourself, if a parent or other caregiver asks you about a baby’s crying, you can share what you learn in this session.

4. What is colic? “Colic” suggests intestinal distress
Is something medically wrong with the baby?
Is the baby in pain?
Does “infant colic” simply refer to a baby that cries a lot?
Narrative
The main symptom of colic is a lot of intense crying.
In medical terms, the word “colic” suggests intestinal distress or discomfort. The term suggests that a physical problem is causing the baby to cry. It is not known for sure what causes colic. It has never been shown that infants who cry a lot have something physically wrong with them.
Is a baby, like the one in the picture, in pain? When a baby draws up his legs, contorts his face, and screams, he certainly looks like he is in pain. Research that compared colicky infants to normal infants did not find any differences in terms of heart rate or the level of a stress hormone that indicates pain.
It is now believed that just as there is a range for normal weight or height for babies, there is a range of normal crying. The majority of infants who are labeled as “colicky” are not suffering a medical condition, they are simply normal infants who are fussy or cry more than most.

5. The amount of normal infant crying
Changes over time
Varies among normally-developing babies
Narrative
A great deal of research has been done about infant crying to find out what can be considered normal.
This diagram shows what is called the “crying curve.” It shows that crying normally starts to increase at about 2 weeks of age, peaks in intensity during the second month, and has decreased a lot by the fourth or fifth month of life.
Studies have found that the pattern and timing of infant crying is similar in many different circumstances, including:
Colicky or fussy babies – which we will discuss in more detail later.
Premature babies – their crying peaks about 6 weeks after their full term due date.
Other cultures – with different caregiving styles, (even other mammals).
Although the pattern and timing of crying is similar in different circumstances, there can be big differences in how much normal infants cry. As shown in the diagram, the average amount of crying is between 1 to 2 hours at the peak of crying, but some infants will cry less and some will cry more. The main point is that they all are normally developing infants.
Adapted from the NCSBS and Ronald G. Barr, MDCM

6. The period of PURPLE crying
Peak pattern
Unpredictable
Resistant to soothing
Pain-like face
Long bouts
Evening cry
Narrative
Dr. Ronald Barr, an expert on infant crying, refers to the stage of increased crying as the “period of purple crying.” His research has found that crying in the first months of life has the following characteristics:
It has a peak pattern. As mentioned, crying starts to increase around 2 weeks, peaks in the second month, and gradually decreases after that.
It is unpredictable. Crying can start and stop unexpectedly for no apparent reason.
It is resistant to soothing. Crying continues despite efforts to soothe the baby, even among babies with the very best parenting.
The baby tends to have a pain-like face when crying. Healthy, crying infants can look like they are in pain even if they are not.
There are long bouts of crying that can go on for one to two hours and longer.
Crying occurs more in the afternoon and evening.
Discussion
If this is a description of normal crying, how does colic fit in?
Response:
The answer is, “colic is normal crying”. Babies who are described as having colic are just at the upper end of the crying curve.
From the NCSBS and Ronald G. Barr, MDCM

7. Same baby ─ same day Narrative
These pictures show the same baby on the same day. In fact these two pictures were taken just a few hours apart. This baby is healthy and normal in both pictures.
Babies cry for many reasons and there are many different things you can try to do to calm a baby.
But what if your ideas don’t work and you can’t get a baby to stop crying?
When a baby or child can’t stop crying it is normal to feel frustrated.
Although you might not be able to calm the baby, it is important that YOU stay calm.

8. The crying game Activity: Crying game For this activity you will need:
a flip chart with two columns: Possibilities and Solutions
an audio clip of a crying baby
external speakers for your laptop
(or copy the audio of the crying baby to a CD and play it using a CD player)
the “Infant Crying Key” trainer resource
Note:
When you click, the photo of the crying baby on the right will get larger. If you click to enlarge the photo after you turn on the audio, that click will turn off the audio and you will need to restart the audio.
To turn on the audio clip, click on the yellow speaker icon above the pink block with the speaker symbol in the right hand corner. To pause the audio, click again on the yellow speaker icon.
Explain the following to the students
They need to figure out what this baby is trying to tell them.
You want them to make a list that has two columns. The left column will have the heading POSSIBIILITIES, the right column will have the heading SOLUTIONS.
Under the POSSIBILITIES column, they will list the reasons that babies might cry and under the SOLUTIONS column, they will list the things one could do to try to soothe a baby.
Record the possibilities and solutions in pairs. For example, left column: dirty diaper, right column: check/change diaper; left column: sick, right column: check temperature.
Depending on the size of the group you can either have participants take turns writing possibility/solution pairs on the flip chart or you can ask participants to call out their ideas and you write them on the paper.
While they make the list, you will play the audio of a crying baby. The crying will continue until someone thinks of the “right” answer that only you know.
Make sure everyone understands how to play the game before you begin.
Once you are ready to begin, click the mouse or press the enter button to enlarge the picture of the baby crying. Then click on the yellow audio icon to start crying baby audio clip. It is important that the sound be loud. The audio will stop after 5 minutes; you can restart it by re-clicking on the speaker icon.
While the audio is playing, encourage participants to come up with their own ideas for possibilities and solutions. If necessary use the “Infant Crying Key” to give them ideas.

9. Soothing an irritable baby
Feed baby slowly and burp baby often.
Make baby as comfortable as possible, for example, check temperature and diaper.
Provide gentle motion or relaxing sound.
Is baby hungry? Thirsty? Bored? Anxious? Sleepy?
Understand that all babies have times when they cannot stop crying.
Narrative or discussion
Review the information on the slide. Ask students for additional ways to soothe a baby if time allows. Record their responses on the flip chart.
When you are caring for a young child, it is always important to have the information you need about the child. This information could include normal child development, parenting skills, and ways to calm a child.
When caring for someone else’s child, it is important to talk to the parent about these things. For example, does the baby need a “nook” to go to sleep or does the baby fall asleep best if she is put down in her crib?

10. Difficult developmental phases
Night crying
Separation anxiety
Exploratory behavior
Negativism
Loss of appetite
Toilet training
Narrative
Just like crying, all young children will go through other developmental phases that can be challenging for parents and other caretakers. Two of the most important things to remember about these phases are:
They are completely normal and are signs that the child is developing as expected.
With the right support from you and other adults in the child’s life, the child will pass through the stages in a relatively short period of time.
Night crying often beginning at about 7 to 8 months of age. This can appear in a child who was sleeping well before, and is the result of a parent or caregiver always rocking or nursing baby to sleep in the first months of life. If you begin to put the baby to bed at a regular time and in a quiet location, the baby will soon learn to put herself to sleep.
Most young children experience separation anxiety when they are separated from a loved one. This stage usually occurs at about 6 months of age and can last up to 3 years of age. To hepl the child through this phase, offer reassurance, not punishment. It may also help to rehearse separations by playing peek-a-boo or hide and seek.
Toddlers are naturally curious, and will explore their surroundings to satisfy this curiosity. This is normal exploratory behavior. It is important to understand the child’s need to explore and learn about his environment and to provide a safe place for the child to meet his needs.
Children between the ages of 1 to 3 years of age will display acts of negativism. They may refuse to go to bed or take a bath. This phase is normal and is important to the child’s development of self-determinism. Do not punish the child for this type of behavior. Give some independence by only making rules that are necessary and by giving the child choices.
Between 18 months and 3 years of age, many children lose their appetite to some degree. Adults should keep in mind that this phase is normal, and they should not try to force feed the child. Most toddlers eat less than when they were babies because they are not growing as fast.
Children may refuse toilet training if they are not ready, or if the training is approached too forcefully. Don’t punish for accidents; instead, be supportive, sympathetic, and kind.

11. Narrative
A tired, frustrated caregiver and a crying baby can be a deadly combination leading a parent or other caregiver to shake a baby in a moment of frustration.
Situations like these can lead to Shaken Baby Syndrome.
A tired, frustrated caregiver and a crying baby can be a deadly combination leading a parent or other caregiver to shake a baby in a moment of frustration.

12. Elijah’s Story
Video
Inform the students that the video that they will see is a true story. It is a story about what can happen to a baby and to his whole family if he is shaken.
Note
Elijah’s Story runs for approximately 18 minutes.

13. Shaken Baby Syndrome (SBS) What is it?
SBS is a medical term used to describe the injuries that can result if a baby is violently shaken.
Violent shaking is one of the most devastating forms of child abuse.
Narrative
Shaken Baby Syndrome is a term used to describe the serious injuries that can result if a baby is violently shaken.
Violent shaking causes a baby’s head to whip back and forth. This motion can cause blood vessels in the brain and eyes to tear and bleed.
Compared to adults and older children, babies have fragile and undeveloped brains. Babies’ heads are heavy and their neck muscles are weak; this is why their heads require support whenever you pick them up or carry them. Half of SBS victims are less than 6 months old.
Older babies and young children are also at high risk because their skulls are further developed, and their soft spot is fused closed. If the baby’s brain is bruised by shaking, there is no way for the skull to expand to allow for the swelling.
Older children have been shaken and seriously harmed up to the age of 6. Children with developmental disabilities are at high risk for SBS longer than normally developing children.

14. Head movement during shaking
Narrative
These photos of a doll show how an infant’s head moves when violently shaken. Notice how far forward and backward the head moves. The weight of the infant’s head, weak neck muscles and the size difference between the adult and the infant all contribute to the effect.
The shaking has its most serious effects on the brain because different parts of the brain move at different speeds in different directions. This can cause tearing or shearing of the different layers of the brain resulting in damage to the brain cells.
Activity
For this activity you will need:.
An egg in a clear, plastic, covered bowl with a small amount of room at the top for air OR a covered, plastic bowl of jello.
A timer that can measure seconds.
Discuss some of the falling accidents that occur with babies. Include falling from a couch, a bed or a changing table. Use the slide to demonstrate the dramatic movement of the infant’s head during shaking vs the relatively minor movement during a fall.
Explain that the egg in the bowl represents the baby’s brain inside of the skull. The plastic bowl is the hard skull. The egg is the delicate brain tissue. When an infant is born, there is space between the skull and the brain so that the brain isn’t damaged during the birthing process, and that’s what the air space within the bowl represents. The large skull also allows room for the baby’s brain to grow.
Recruit a student volunteer. Ask the student to shake the egg as hard as s/he can for 2 seconds, then 5 seconds, then 10 seconds. Compare the egg prior to shaking to the egg after each subsequent period of shaking. Discuss how the consistency of the egg has changed and how it is impossible to get the egg back to its original form.

15. Brain movement inside the skull
Narrative
This is a diagram of how an infant’s brain moves inside her head when she is shaken.
The shaking has its most serious effects on the brain because different parts of the brain move at different speeds and in different directions. The brain not only moves back and forth but it also moves from side to side. The brain inside the skull moves faster than the skull much like the egg moved inside the hard bowl. This can cause tearing of the different layers of the brain resulting in damage to the brain cells.
The most common injuries of SBS are:
bleeding in the space between the brain and the skull
swelling of the brain
bleeding in the retinas in the back of the eyes

16. Signs that a baby has been shaken
Broken bones
Unusual crying
Sleepiness
Pale or bluish skin
Vomiting or refusing
to eat
Not breathing
Unconscious
Narrative
When a baby is shaken, the most serious effect is on the brain, but sometimes bones in the ribs, arms or legs will also be broken. Many babies have injuries to their brains without having broken bones. Sometimes there will be bruising to the baby’s head but most often there won’t be any external signs that the baby was shaken. Most of the damage will be to the baby’s brain.
Other signs that a baby has been shaken are:
Crying that sounds different from the baby’s usual cry, often a high pitched cry, or crying at times that the baby is usually calm
Sleepiness when the baby is usually awake
Vomiting or refusing to eat
Pale or bluish skin
Not breathing or having a hard time breathing
Unconsciousness
In most cases there won’t be external signs on the head that the infant was shaken. Please remember that these are important signs to watch for in an infant, but they do not necessarily mean that the baby has been shaken. Even Doctors often have a hard time diagnosing SBS. Other illnesses can also cause many of these symptoms. If you notice any of these signs or anything else that seems unusual, don’t be afraid to seek medical help and report what you have observed.

17. What are the long term results?
Even with prompt medical attention 1 of 4 infants dies.
Those who survive may have lifelong medical conditions:
Narrative
Shaking a baby can have extremely serious results.
About one of every four victims of Shaken Baby Syndrome dies.
Many babies who do survivor have life-long disabilities such as:
Blindness
Paralysis
Deafness
Complications from broken bones
Learning disabilities
Coordination problems
Developmental challenges, or
Seizures
Even babies who seem okay when they are released from the hospital may have problems later on, such as learning and attention difficulty in school.
Blindness
Paralysis
Deafness
Learning disabilities
Coordination problems
Developmental disabilities
Seizures

18. Risk factors for being a victim
Age
Gender
Greater demands for care, for example illness, pre-maturity, or other special needs of some kind
Narrative
Some babies and children are at greater risk for shaking than others. The primary risk factors are:
Age: More than half of SBS victims are under 6 months of age.
Gender: Sixty percent of victims are boys. It is unknown why this is the case.
Greater demands for care: Anything that makes an infant more difficult to care for, either temporarily or permanently, could make the infant more vulnerable to abuse.
For example, pre-term infants are generally more sensitive, harder to console, and may be less responsive to caregivers.
Illness, short-term such as an ear infection or chronic such as a developmental disability, can also make an infant more irritable and difficult to care for.

19. Who would shake a baby? Anyone, but some people are more at risk:
Late teens and early 20s
Males
Inexperience with babies
People with other risk factors – drug and alcohol use, mental illness, high stress, lack of self-control
Discussion
When you think of the kind of person who would shake a baby, who do you think of?
Do you think people who shake babies plan to injure the child or do you think they loose control?
Do you think that most people who shake babies or young children have warm feelings or love the baby?
The statistics show that perpetrators can be any age, male or female, any ethnic or racial group, poor or wealthy, but there are some factors that put people at higher risk for shaking a child. Those factors are:
Young people in their late teens or early 20s
Males
People who have little experience with babies
Individuals who abuse drugs or alcohol
People who are experiencing mental illness
When an individual is under high stress, they are more likely to lose control and harm a child
People who have not developed the skills to control their anger

20. Rate the Risk Calculator
Activity
Rate the Risk Calculator
For this activity you will need:
A line drawn along the front of the room marked off from 1 through 10.
The following scenarios copied, cut and distributed to the class
Divide the class into 10 groups or ask for volunteers from the class to represent the highlighted names in the scenarios. Provide each group with a scenario to read and discuss. Identify the line on the floor as the Rate the Risk calculator. The students’ goal is to rate the risk that the person(s) listed first in the scenario will violently shake the person(s) listed second in the scenario. Give the students 5 minutes for discussion, then request that they place themselves along the Rate the Risk calculator based on where they think the risk of shaking falls within the range.
Ask each volunteer to read their scenario and describe why then chose to Rate the Risk as they did. Ask the class whether they agree or disagree.
When they have completed the discussion, inform the class that all but one of the scenarios is based on an actual case of Shaken Baby Syndrome. Ask them which scenario is the exception (Kelly and LeRoy / Celia).
Next, ask each group to problem solve ways that the situation in their scenario could be improved for the family to decrease the risk of shaking. If they are having trouble identifying solutions, encourage them to think about ways for the caretaker(s) to get additional education on how to care for young children and how to obtain supports within their family or throughout the community. With the changes or supports in place, ask the groups to move to the number on the Rate the Risk Calculator that corresponds after the support is in place.
Complete the exercise by having the students visually identify how the risks of SBS have been reduced by the changes they have put in place.

21. The families - - - - Provide each group with a scenario: Beth / Shane
Beth is a 35-year-old mother who provides child care in her home. She has 2 children of her own, ages 4 and 3. Prior to becoming a mother, she worked full-time as a teacher in a child care center. Along with her won children, she also cares for another 4 year-old and Shane, a 6 month old boy.
Kelly and LeRoy / Celia
Kelly and LeRoy are the parents of 3 month old, Celia. They live with LeRoy’s parents. Kelly attends high school full time and brings Celia to a child care center at the school. LeRoy attends an alternate school setting and also works part time. LeRoy’s parents watch Celia for 2 hours each evening to give Kelly and LeRoy time to do homework, be together, see friends, or just rest. LeRoy and Celia attend a new father’s playgroup every Wednesday evening.
Kyle / Haley
Kyle, age 25, lives with his girlfriend, Stacy, and her 14 month old daughter, Haley. Kyle works full time during the day. Stacy has taken a night job so that Kyle can watch Haley while she works. Most nights, Kyle has a few friends over for drinks and playing cards.
Leah / Veronica
Leah is the 21 year old mother of Nathan, age 2 and Veronica, age 2 months. Just before Veronica was born, Leah, her husband and son moved in with her husband’s parents in another city. Leah is having a hard time sleeping and misses her friends and family. Her husband and his parents often care for Nathan but leave her alone with Veronica.
George and Lisa / Mark and Michael
George and Lisa are the parents of 6 month old twins, Mark and Michael. The twins were born prematurely. Mark is doing well but Michael requires oxygen through a breathing tube and needs to be fed every 2 hours. Mark is beginning to crawl around the house and get into things he can reach. He also cries to demand attention. Michael cries frequently, especially if he doesn’t eat and sleep on schedule.
Joyce / Sydney
Joyce is the 55 year old grandmother of 4 month old Sydney. Joyce was laid off from her job 6 months ago. She is having problems paying her bills and can’t find another job. She began babysitting for Sydney at age 6 weeks when her mother returned to work.
Rachel / Ella
Rachel, age 16, and her 3 month old daughter, Ella, live with Rachel’s parents. Rachel recently returned to high school. Her parents watch Ella while she is in school but have made it clear that Ella is Rachel’s responsibility at all other times.
Todd / Jenny
Tina and Scott, both age 34, have 5 children. Todd, age 14, is the oldest. Jenny, age 9 months is the youngest. Todd is often left in charge of his 4 brothers and sisters.

22. Remember the Rule of 10
Lay the baby on his back in his crib or another safe place.
Stay feet or more away.
Slowly count to or take deep breaths to calm yourself down.
After minutes, check on the baby
Repeat if necessary.
If you still feel stressed, call someone for help.
Narrative
If you are feeling frustrated with an infant or a young child, it is important to recognize your feelings and get some distance between you and the child. The Rule of 10 works well with babies, but it also works well with other young children. Read the information on the slide to the students. Ask if there are questions. Remind the students that crying is not always a sign of illness or danger and that a baby can be safe for a short period of time even though he is crying. Students may want to discuss ways to assure that a toddler is safe. Main points are that the child can’t fall, can’t reach things that could harm him and is safe from other children. 10 10 10 10

23. It’s okay to ask for help
Someone who can come over right away and help like a family member or friend
The baby’s doctor, or nurse helpline
Local community resources
Have the phone numbers of people who can help when the crying is too much.
Narrative
Not only is it OK to ask for help, sometimes it is the very best thing to do.
Before you begin to care for a child, either your own baby or the baby of a family member or friend, make sure that you are prepared by having a plan for who you can call for help if you need it. This could be a family member, a friend, or a resource in the community.
Note
Before the session, you may want to prepare a list of local resources and contact numbers to share with the students. These could include nurse help lines, family resource centers, and local support groups.

24. My pledge This hand will never harm a baby Pass the message on
Activity
Pledge cards to distribute to students
I’m going to ask each of you to recommit to the pledge that you made in middle school:
This hand will never harm a baby. If you agree, please sign your pledge card.
On the back of the card is the Rule of 10. Keep this card in a place where you can find it to remind yourself of your commitment to keeping babies and young children safe from Shaken Baby Syndrome.
Post test
Ask students to complete the post test. (The post test is the same as the pre test and will be printed on the back side.)
When they have completed the test, read off the answers. Ask students to grade their own tests or to grade the test of a classmate. Have them record the number correct on the bottom of each test.
Have students raise their hand if they got more responses correct on the second test. If time allows, facilitate a discussion on how they will use the information they have learned.
Pass the message on

25. This material was developed by the SBS Prevention K12 curriculum team
Susan Abbey – Children’s Trust Fund
Pamela Anderson – Middleton School District
Anne Haverland – Oshkosh School District
Nancy Graese – CESA 11
Nancy Merwin – Cuba City School District
Sue Mokler – Ripon School District
Wendi Schreiter – Wisconsin Shaken Baby Association
Copyright © Children’s Trust Fund of Wisconsin