PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

MS. NINGOLLEIMA.TENSUBAM FIRST YEAR M. SC. NURSING CHILD HEALTH NURSING YEAR 2010-2012

PADMASHREE COLLEGE OF NURSING GURUKRUPA LAYOUT, NAGARBHAVI BENGALURU-560072

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BENGALURU, KARNATAKA

PERFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1.

NAME OF THE CANDIDATE AND ADDRESS

MS. NINGOLLEIMA. TENSUBAM M. SC. NURSING 1ST YEAR PADMASHREE COLLEGE OF

NURSING,GURUKRUPA NAGARBHAVI, BENGALURU 560072 2. NAME OF THE INSTITUTE

LAYOUT

Padmashree College Of Nursing Bangalore 1st Year M. Sc. Nursing Child Health Nursing 3/04/10.

3.

COURSE OF THE STUDY AND SUBJECT

4.

DATE OF ADMISSION

5.

TITLE OF THE STUDY

Effectiveness of Planned Teaching Programme (PTP) on Knowledge and Attitude regarding Shaken Baby

Syndrome Among Caregivers of Infants in Selected Urban Area, Bengaluru.

6. BRIEF RESUME OF THE INTENDED WORK 6.1 INTRODUCTION

It only takes 30 seconds to change your babys life forever. Never shake your baby. Physical abuse is the leading cause of serious head injury in infants. Although physical abuse in the past has been a diagnosis of exclusion, data regarding the nature and frequency of head trauma consistently support the need for a presumption of child abuse when a child younger than 1 year has suffered an intracranial injury1. Head injuries are the leading cause of traumatic death and the leading cause of child abuse fatalities. Homicide is the leading cause of injury-related deaths in infants younger than four years. Serious injuries in infants, particularly those that result in death, are rarely accidental unless there is another clear explanation, such as trauma from a motor vehicle crash. when uncomplicated documented that 80% of deaths from head trauma in infants and children younger than two years were the result of nonaccidental trauma. shaken baby syndrome is unlikely to be an isolated event. Evidence of prior child abuse is common2. Shaken baby syndrome is a serious and clearly definable form of child abuse. It results from extreme rotational cranial acceleration induced by violent shaking or shaking/impact, which would be easily recognizable by others as dangerous. At the incidence and demography of non-accidental head injury in a prospective population-based study in pediatric units in Scotland during 199899. Shaken baby syndrome occurs with an annual incidence of 24.6 per 100,000 children under one year (95%)3. The immediate and long-term outcomes of head injury caused by shaken baby syndrome are worse than head injuries from other causes. At least one of

every four victims die, and > 50% have some type of residual neurological or visual impairment, or both. In 2000 approximately 1200 children died of neglect or abuse; 44% were infants < 1 year of age. The majority of deaths related to head injuries in children < 2 years old were a result of non-accidental trauma. The National Center on Shaken Baby Syndrome reported that > 500 shaken baby syndrome cases, either fatal or nonfatal, occurred in the U.S., the District of Columbia,1994-1998. The response rate in this study was only 42% (46 out of 113 surveys) and only 46% of the respondents reported survivors of shaken baby syndrome. Since cases with less serious injuries may not receive medical attention, or may go undetected, and no central shaken baby syndrome reporting registry is available, the actual incidence of shaken baby syndrome is unknown and likely underestimated4.

In the United States, more than 1,000 babies a year are given a diagnosis of shaken baby syndrome. And since the early 1990s, many hundreds of people mothers, fathers and babysitters have been imprisoned on suspicion of murder by shaking. The diagnosis is so rooted in the public consciousness that, this year, the Senate unanimously declared the third week of April National Shaken Baby Syndrome Awareness Week5.

Recent Canadian data on children hospitalized for Shaken Baby Syndrome show that 19% died, 59% had neurological, visual impairment and/or other health effects and only 22% appeared well at discharge. Recent data indicate that babies who appear well at discharge may show evidence of cognitive or behavioral difficulties later on, possibly by school age6. When someone forcefully shakes a baby, the child's head rotates about the neck uncontrollably because infants' neck muscles aren't well developed and provide little support for their heads. This violent movement pitches the infant's brain back and forth within the skull, sometimes rupturing blood vessels and

nerves throughout the brain and tearing the brain tissue. The brain may strike the inside of the skull, causing bruising and bleeding to the brain.

The damage can be even greater when a shaking episode ends with an impact (hitting a wall or a crib mattress, for example), because the forces of acceleration and deceleration associated with an impact are so strong. After the shaking, swelling in the brain can cause enormous pressure within the skull, compressing blood vessels and increasing overall injury to its delicate structure7.

Normal interaction with a child, like bouncing the baby on a knee, will not cause these injuries, although it's important to never shake a baby under any circumstances because gentle shaking can rapidly escalate. The more serious the child's neurological injury, the more severe the symptoms and the shorter the period of time between the shaking and the appearance of symptoms. From the time of the shaking these children do not look or act as usual - they may not eat or sleep or play normally.

Babies who are shaken may be brought to medical attention by a caregiver who offers no history of injury, a vague account of events or an explanation that is not consistent with the physical findings. Unless the physician is aware of the possibility of abuse and knowledgeable about the signs of Shaken Baby Syndrome, the cause of these children's symptoms can be missed. The outcome for infants who suffer brain damage from shaking can range from no apparent effects to permanent disability, including developmental delay, seizures and/or paralysis, blindness and even death. Survivors may have significant delayed effects of neurological injury resulting in a range of impairments seen over the course of the child's life, including cognitive deficits and behavioral problems.

The identification, evaluation, investigation, management and prevention of Shaken Baby Syndrome require a multi-disciplinary approach that relies on the knowledge, skills, mandate and jurisdictional responsibilities of key disciplines. There is a need for shared commitment and coordination among health, child welfare, police, social services, justice and education professionals, as well as the community at large. Knowledge of Shaken Baby Syndrome should be provided in the professional education of all the involved disciplines, and ongoing education needs to be provided as new developments occur in the field8.

6.2 NEED FOR THE STUDY

Shaken baby syndrome is the medical term used to describe the injuries resulting from shaking an infant or young child. Introduced in medical literature in 1972, shaken baby syndrome occurs when a child is shaken violently as part of an adult or caregivers pattern of abuse or because an adult or caregiver momentarily succumbs to the frustration of having to respond to a crying baby. Shaken baby syndrome is a clearly definable medical condition. A proper response requires integration of specific clinical management and community intervention in an interdisciplinary fashion9.

It is likely that most children with Shaken Baby Syndrome will require special services for the duration of their lives. These services may include health and mental health care, speech and language, infant stimulation, rehabilitation and special education. Additional supports such as residential placement, adapted housing and employment advocacy may also be needed. Long-term effects are experienced by birth, adoptive and foster families of children affected by Shaken Baby Syndrome. Non-abusing parents may require additional support from health, social and legal services.

According to the National Center on Shaken Baby Syndrome, doctors often fail to recognize the causes of head trauma in children who were victims
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of shaken baby syndrome because the children usually do not exhibit external signs of injury. In a study done by the National Center, researchers found that if a child had normal respiration, no seizures, no facial or scalp injury, and came from an intact family, the probability that abusive head trauma would be recognized was less than one in five (1999)10. Specific evidence of previous cranial injuries (eg, old intracranial hemorrhages) from shaking episodes is found in about 33% to 40% of all cases. As with other forms of physical abuse, males are more often perpetrators than are females. However, in an individual case, gender should not be considered when trying to identify a possible perpetrator.

The stress of a caregiver can feel in looking after an infant. When exhausted or frustrated by a baby's crying, some people react violently and shake the child. Other situations known to trigger shaking are toileting and feeding difficulties. As with other forms of child abuse, shaking may be repeated and accompany other kinds of maltreatment. The maltreatment of children, including nonaccidental trauma, continues to be problematic for children, families, and other care providers. Despite efforts of child protective services and health care providers alike, the maltreatment of children remains an all too common occurrence.

An article looked at 75 cases of shaken baby syndrome and found that 85% had retinal hemorrhages; 81% were bilateral; 82% were confluent, multiple, and multilayered; and traumatic retinoschisis was present in one third. There was no association between the side of the intracranial bleeding and the retinal bleeding; and there was no correlation between the presence of impact and the presence of retinal hemorrhages. The 29 patients with raised intracranial pressure did not differ in type, extent or frequency of retinal findings compared with the rest of the patients. No correlation was found between the side of the intracranial bleeding and the side of the retinal hemorrhages, thus not
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supporting the theory of direct tracking of blood through the optic nerve into the retina11.

There are no accurate statistics, but experts estimate the incidence to be between 1,000 to 1,500 infants per year. According to the Centers for Disease Control and Prevention, of the almost 2,000 children who die from abuse or neglect each year, shaken baby syndrome accounts for 10%-12% of them. Most commonly, the victim of shaken baby syndrome is between three and eight months old; however, it has been reported in newborns and in children up to 4 years of age. In addition, 25% of all children diagnosed with shaken baby syndrome die from their injuries. Cases are more common in urban regions and in autumn and winter months. The risk of a child suffering non-accidental head injury by one year is one in 4,058. These brain injuries occur almost exclusively in young infants. The median age at acute admission was 2.2 months, younger than the average age of five months reported, and no child was older than 12 months. Our, more precise, measurement of incidence for non-accidental head injury in infants less than one year will enable epidemiological surveillance to assess the impact of any future legislative changes and the effectiveness of health education packages in preventing shaken baby syndrome12. The investigator presented the shaken baby syndrome on journal club in our college. It was a very interesting topic which everyone was not aware of it. So further, the investigator concluded that it would be a great contribution and it is important to enlighten the caregiver about the shaken baby syndrome. Hence, the investigator planned to designed planned teaching programme.

6.3 STATEMENT OF PROBLEM

A Study To Assess The Effectiveness Of Planned Teaching Programme (PTP) On Knowledge And Attitude Regarding Shaken Baby Syndrome Among Caregivers of Infants In Selected Urban Area, Bengaluru.

6.4 OBJECTIVES
1. To assess the existing knowledge regarding shaken baby syndrome among caregivers of infants in urban area. 2. To assess the attitude regarding shaken baby syndrome among caregivers of infants in urban area. 3. To evaluate the effectiveness of planned teaching programmed on knowledge of shaken baby syndrome among caregivers of infants. 4. To correlate knowledge and attitude regarding shaken baby syndrome among caregivers of infants. 5. To find out the association between knowledge with that of the selected demographic variables.

6.5 OPERATIONAL DEFINITION

1. Effectiveness: It determines the extent to which the planned teaching programme has achieved the desired effect in improving the knowledge regarding shaken baby syndrome among caregivers of infants.

2. Planned teaching programme: It refers to systematically developed instructional video cum lecture session designed by the investigator regarding shaken baby syndrome such as definition, causes,

mechanisms, sign and syndrome and treatment.

3. Knowledge: It refers to the correct responses of the caregivers to the items on shaken baby syndrome measured by structural interview schedule and expressed in terms of knowledge scores.
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4. Attitude : It refers to opinion, belief and feelings expressed by the caregivers on shaken baby syndrome, which will be measured by Likert scale. 5. Shaken baby syndrome: It refers to an non intentional injury caused by vigorously shaking an infant, often in anger, to get a child to stop crying/whining of infants. 6. Caregivers of infants: It refers to those who take care the infants by the caregivers like mother, father, grandparents and relatives.

6.6 ASSUMPTIONS
1. The caregivers of infants may have inadequate knowledge regarding shaken baby syndrome. 2. The caregivers of infants may have different belief and ideas regarding shaken baby syndrome. 3. Planned teaching programmed may improve the knowledge and attitude regarding shaken baby syndrome among caregivers of infants.

6.7 HYPOTHESIS
H1- There will be significant correlation between knowledge and attitude regarding shaken baby syndrome among caregivers of infants. H 2- There will be significant association between the knowledge and attitude score among caregivers of infants with selected demographic variables.

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6.8 REVIEW OF LITERATURE

Literature review is a key step in the research process, the task of reviewing involves the identification, selection of critical analysis and reporting of existing information on topic of interest13. The main goal of literature review is to develop a strong knowledge base to carryout research scholarly activities in education and to improve the knowledge and attitude regarding shaken baby syndrome among caregivers of infants. In this study the relevant literature reviewed has been organized and presented under the following headings: Literature related to traumatic physical abuse. Literature related to incidence report on shaken baby syndrome. Literature related to awareness on shaken baby syndrome among caregivers. Literature related to traumatic physical abuse An article discusses on abusive head trauma (AHT) has greater mortality and morbidity than any other form of physical abuse. Therefore, early recognition and accurate diagnosis are essential for comprehensive

investigation and appropriate treatment of infants who present with this devastating traumatic injury. Advanced practice nurses need to have a thorough understanding of abusive head trauma in order to promptly and accurately assess and manage these infants. Using a case-based approach, the epidemiology, pathophysiology, mechanisms of injury, clinical presentation, diagnosis, and treatment of abusive head trauma are described14. A retrospective observational examined forensic evidence from 112 cases referred for abusive head trauma over a seven-year period. Compare 29 cases in which a perpetrator confessed to violence toward the child with 83 cases in which there was no confession. There was no statistically significant difference between the two groups for any of the variables studied. Shaking
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was described as extremely violent (100%) and was repeated (55%) from two to 30 times (mean: 10) because it stopped the infant's crying (62.5%). Impact was uncommon (24%). No correlation was found between repeated shaking and subdural hemorrhage densities15. A descriptive study analyzed non-inflicted injuries and compared them with abusive head injuries in children under six years of age. Severe retinal hemorrhages were seen in five of the 233 (2%) children in the non-inflicted group and in 18 of the 54 (33%) in the abuse group. Retinal pathology from major trauma mimicking shaken baby syndrome is old news. Its incidence is dramatically lower than that resulting from inflicted head injury and because of the obvious major trauma history it does not present a diagnostic dilemma16. A literature search was conducted and drawn together into a review aimed at informing practitioners working with children who had a brain injury in infancy. As there are so few evidence-based studies specifically looking at children who have sustained a traumatic brain injury( TBI) in infancy, ideas are drawn from a range of studies, including different age ranges and difficulties other than traumatic brain injury. This paper outlines the issues around measuring outcomes for children following traumatic brain injury in the first year of life. An explanation of outcomes which are more likely for children following traumatic brain injury in infancy is provided, in the areas of mortality; convulsions; endocrine problems; sensory and motor skills; cognitive processing; language; academic attainments; executive functions; and psychosocial difficulties. The key factors influencing these outcomes are then set out, including severity of injury; pre-morbid situation; genetics; family factors and interventions17. An experimental study on Inflicted neuro-trauma in infancy conducted on Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, reveals that two infants with non-accidental inflicted neuro-trauma are reported. One presented with sudden onset lethargy, respiratory difficulty and
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unexplained seizures. There were bilateral retinal bleeds and extradural hemorrhage. Other was a well thriving child who had two seizures and was noted to lack visual fixation. Retinal hemorrhages and chronic subdural and intra-parenchymal hemorrhages were subsequently discovered. It highlight the importance of suspecting child abuse in infants with sudden unexplained unresponsiveness, seizures or respiratory difficulty and the unusual occurrence of extradural haemorrhage18. A descriptive study in 2004 found that, an estimated 903,000 children were victims of maltreatment in 2001. It is of particular concern when the maltreatment ends with a fatality; that same year, an estimated 1,300 child fatalities occurred as a direct result of maltreatment. Of these fatalities, 41% occurred in children under the age of one year, and 85% occurred in children under age six. The best estimates on the incidence of physical abuse in the causation of child fatalities ranges from 19% to 30%( National Clearinghouse on Child Abuse and Neglect Information, 2004). Physical abuse is the leading cause of serious head injury in infants. Although physical abuse in the past has been a diagnosis of exclusion, data regarding the nature and frequency of head trauma consistently support the need for a presumption of child abuse when a child younger than 1 year has suffered an intracranial injury19.
Literature related to incidence report on shaken baby syndrome

Evidence base for shaken baby syndrome appeared in the May 29, 2004 issue of the British Medical Journal. Shaking a child to "produce whiplash forces that result in subdural and retinal bleeding," omitting the most important element in this condition: brain injury itself. They elaborate that the "theory" of shaken baby syndrome rests on some core assumptions, including t "the injury an infant receives from shaking is invariably severe." 30%-40% of newly diagnosed shaken baby cases had medical evidence of previously undiagnosed head injury. The diagnosis was ultimately made when the children had subsequent severe episodes of abuse, with computer tomography evidence of both acute and older subdural hematoma and brain injuries 20.
13

A Comparative study

was conducted on the cognitive squealed of

school-aged victims of Shaken Baby Syndrome, Quebec Canada, that a clinical group was formed of 11 children diagnosed with shaken baby syndrome .The children were matched for age, gender, socio-economic status, and family composition to 11 healthy Quebec children, who made up the control group. A battery of composite tests was developed to assess the children's main cognitive functions and was administered individually to Set 22 children. A univariate ttest was used to compare the performances of the two groups. The mean age of the children in the clinical and control groups at the time of the assessment was 87.64 months and 90.18 months, respectively. Pairing and birth data were equivalent for both groups. Significant weaknesses were noted in the clinical group for intelligence quotient (IQ), working memory, mental organization, alternation, and inhibition. These deficits seemed to have a greater impact on the verbal sphere of the children's mental functioning21. A descriptive study on Shaken baby syndrome, conducted on Department of Pediatrics, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry, India-A 35-day male infant with presumed shaken baby syndrome is reported. First born child to mother educated up to middle school and father tailor by occupation was brought from a remote village 180 kms away from JIPMER. Poor feeding, focal chronic seizures were the initial symptoms. The fundus examination revealed fresh preretinal and vitreous hemorrhages. CT Brain showed right sided subdural hemorrhage with subarachnoid extension and midline shift. He had a normal platelet count and coagulation profile. The sensorial deteriorated and infant expired despite adequate ventilator support22. A descriptive study was conducted on an evidence-based review on retinal hemorrhages and shaken baby syndrome. Studies found a 53-80% incidence of retinal hemorrhages with abusive head injury and a 0-10% incidence with proven severe accidental trauma. Retinal hemorrhages are found bilaterally 62.5-100% of the time in shaken baby syndrome cases, and flame14

shaped hemorrhages are the most common. The incidence of retinal hemorrhages from convulsions, chest compressions, forceful vomiting, and severe persistent coughing in the absence of another condition known to cause retinal hemorrhages is 0.7%, 0-2.3%, 0%, and 0%, respectively23. A non-experimental study was conducted on Shaken baby syndrome masquerading as apparent life threatening event. Departments of Pediatrics, Advanced Pediatric Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India. A variety of diseases and disorders can present as an acute life-threatening event among which shaken baby syndrome has been recently recognized. A high index of suspicion along with an ophthalmologic evaluation and cranial imaging helps to identify this form of child abuse, which needs multidisciplinary management24. Literature related to awareness on shaken baby syndrome among caregivers A descriptive study on Shaken Baby Syndrome awareness was conducted in American. Using a sample of 288 undergraduate students, it developed a measure of attitudes around infant care practices. A total of 264 community participants completed a revised survey. Between-group

comparisons, exploratory factor analyses, and internal consistency tests were employed to determine the directionality and reliability of any scale structure present in the data. A five factor structure fits the data reliably, and each of these factors seems to represent a unique dimension. Implications for using this measure clinically and preventatively are discussed25.

A prospective study on The Shaken Baby Syndrome Awareness showed that 49 items on the first version of the Awareness Assessment ranged across five categories. Students from varied demographic backgrounds were invited to participate; no restrictions were placed on age, education, sex, or ethnicity. This sample had a mean age of 19 years (range 1731) and was
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composed of 72% females. Nearly 40% of respondents reported that they regularly care for children (subsequently referred to as child care status). Finally, this sample self-identified as predominantly White (83%), followed by Asian, African American, and Latino representation (6%, 5%, and 4%, respectively; the remaining 2% were categorized as bi-racial or other) .Based on the evidence in the Shaken Baby Syndrome literature suggesting that perpetrators of shaken baby violence shook the infants in their care in order to stop a cry, discipline the child, or in the course of what they believed to be harmless play26.

A randomized controlled trial study on, do educational materials change knowledge and behavior about crying and shaken baby syndrome in U.S.A. that a randomized controlled trial in which 1279 mothers received materials from the Period of PURPLE Crying program. Two months after giving birth, the mothers completed a telephone survey to assess their knowledge and behavior. The mean score (range 0100 points) for knowledge about infant crying was greater among mothers who received the PURPLE materials (63.8 points) than among mothers who received the control materials (58.4 points) (difference 5.4 points, 95% confidence interval [CI] 4.1 to 6.5 points). Compared with mothers who received control materials, mothers who received the PURPLE materials reported sharing information about walking away if frustrated more often (51.5% v. 38.5%, difference 13.0%, 95% CI 6.9% to 19.2%), the dangers of shaking (49.3% v. 36.4%, difference 12.9%, 95% CI 6.8% to 19.0%), and infant crying (67.6% v. 60.0%, difference 7.6%, 95% CI 1.7% to 13.5%). Walking away during inconsolable crying was significantly higher among mothers who received the PURPLE materials than among those who received control materials (0.067 v. 0.039 events per day, rate ratio 1.7, 95% CI 1.1 to 2.6).The receipt of the Period of PURPLE Crying materials led to higher maternal scores for knowledge about infant crying and for some behaviors considered to be important for the prevention of shaking27.

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7.MATERIALS AND METHODS

7.1 SOURCE OF DATA

The data will be collected from the caregivers of infants aged from birth to1 year.

7.2 METHODS OF DATA COLLECTION

I. Research design Pre- experimental: one group pre-test post-test design. II. Research variables Dependent variable: knowledge and attitude regarding shaken baby syndrome among caregivers of infants. Independent variables: Planned teaching programme regarding shaken baby syndrome. Demographic variables: The demographic variables includes caregiver of infants, age, educational status, type of family, religion, family income and source of information.

III. Setting: The study will be conducted in selected urban area, in Bengaluru depending on availability of subjects and feasibility of conducting study. IV. Population The population of the study will comprises all the caregivers of infants aged from birth to 1 year.

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V.

Sample

The caregivers of infants who are fulfilling the inclusion criteria will be the sample. Sample size will be 60. VI. Criteria for sample collection Inclusion criteria: 1. 2. 3. The caregivers of infants who are residing in selected urban area. Willing to participate in the study. Those who understands Kannada and English.

Exclusion criteria: Who are not available at the time of data collection.

VII. Sampling technique Non probability purposive sampling technique will be used in this study.

VIII. Tool for data collection

SECTION A: comprises of demographic data such as caregiver of infants, age,

educational status, type of family, religion, family income and source of information.
SECTION B: comprises of structured interview schedule to assess the knowledge regarding shaken baby syndrome among caregivers of infants. SECTION C: Likert scale to assess the attitude regarding shaken baby syndrome among caregivers of infants. SECTION D: Planned teaching programme on knowledge regarding shaken baby syndrome among caregivers of infants.

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IX. Method of data collection Phase -1: Assess the existing knowledge and attitude regarding shaken baby syndrome among caregivers of infants with the help of planned teaching programme. Phase -2: Planned teaching programme will be given regarding shaken baby syndrome among caregivers of infants. Phase -3: After a period of one week level of knowledge will be reassessed within the same group using same questionnaire. Duration of the study : 4-6 weeks.

X. Plan for data analysis: Numerical data obtained from sample will be organized and analyzed with the use of both descriptive and inferential statistics. Master coding sheet will be prepared based on the numerical data obtained from the sample. Descriptive statistics: 1. Frequency, percentage distribution will be used to study the demographic variables regarding caregivers of infants. 2. Mean, median, range and standard deviation will be used to describe the level of knowledge regarding shaken baby syndrome among shaken baby syndrome among

caregivers in infants. Inferential statistics: 1. Paired t test will be used to compare the pre and post test knowledge and infants.
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attitude regarding shaken baby syndrome among caregivers in

2.

Chi-square test will be used to associate knowledge and attitude regarding shaken baby syndrome among caregivers in infants with selected demographic variables. Level of significance will be set at 0.05 to interpret the hypothesis and finding. Analyzed data will be represented in the form of tables, graphs and figures.

XI. Projected outcome: As the investigator has planned for planned teaching programme, there will be increase in knowledge and change in the attitude regarding shaken baby syndrome among caregivers of infants.

7.3 Does the study require any investigations or interventions to the patients or other human beings or animals? Yes, with prior consent from sample the study will be conducted in selected urban area. The study will require intervention in the form of planned teaching programme only. No other intervention which cause any harm will be done for the subjects.

7.4 Has ethical clearance obtained from your Institution?

Yes, the permission will be obtained from concerned authority and subjects. Privacy, confidentiality and anonymity will be guarded.
Scientific objectivity of the study will be maintained with honesty and

impartiality.
Ethical clearance certificate has been enclosed for the verification.

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8.

LIST OF REFERENCES

1. Dorothy .L. Wong, Essentials of pediatric nursing 6th edition; Mosby A Hareous health science company , missocui (2008):687. 2. Randell C. Alexander. Shaken Baby Syndrome: Rotational Cranial njuries Technical Report 2001 Jul; 108: 206-210. 3. American academy of pediatrics. Shaken Baby Syndrome: Rotational Cranial Injuries Technical Report Committee on Child Abuse and 1.

Neglect Paediatrics 2001 july; 108: 206-210 . 4. Suzanne Franklin Carbaugh. Understanding Shaken Baby Syndrome;W.B. Saunder 2004 may: 4(2). 5. Deborah tuerkheimer. shaken-baby syndrome:2010 sept 22. Available from http://www.thestar.com/topic/charlessmith. 6. American Academy of Pediatrics. Committee on Child Abuse and Neglect. Distinguishing Sudden Infant Death Syndrome from child abuse fatalities.1994; (94): 124-126. 7. Dr. Marcelina Mian. Suspected Child Abuse and Neglect Program, Joint Statement on Shaken Baby Syndrome: Centre for Healthy Human Development (formerly part of Health Canada).Available from: www.phacaspc.gc.ca/dca-dea/.../jointstatement_web-eng.php. 8. American Academy of Pediatrics. Committee on Child Abuse and Neglect. Shaken baby syndrome: Rotational cranial injuries Technical report. 2001; 108:206-10. 9. Review of National Center on Shaken Baby Syndrome. 2007 Sept10, available from: http://www.dontshake.com/. 10. Jenny, C. Abusive head trauma: An analysis of missed cases. Journal of the American Medical Association,2007 sept; 281:621-626.Available from: http://www.dontshake.com/. 11. Robert M. Reece. The Quarterly Update What Does The Recent Literature Tell Us About Shaken Baby Syndrome. Available from:www.dontshaken.org/sbs.php?topNavID=3&subNavID=30.
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12. Togioka BM. Retinal hemorrhages and shaken baby syndrome: an evidence-based review. 2009 Jul;37(1):98-106. 13. Polit D F, Beck C T. Nursing research principles and methods. 7th ed.New Delhi :Wolters Kluwer health(India) Pvt Ltd;2007;88-89. 14. Ceballos S,G. abusive head trauma. 2007 Aug;96(8):1164-1168. 15. Adamsbaum C, Rey-Salmon C. Abusive head trauma: judicial admissions highlight violent and repetitive shaking. 2010 sept;126(3):572-573. 16. Aryan HE, Levy ML. Retinal hemorrhage and pediatric brain injury: etiology and review of the literature. 2005 Aug;12(6):624-31. 17. Ashton R. Practitioner review: beyond shaken baby syndrome: what influences the outcomes for infants following traumatic brain injury 2010 Sep;51(9):967-80. 18. Jose B, Azad RV. Inflicted neuro-trauma in infancy. 2009 Sep;76(9):954-5.

19. The evidence base for shaken baby syndrome Response. The British Medical Journal.2004 May 29. 20. Brodeur AE. Child Maltreatment: A Clinical Guide and Reference. St Louis: GW Medical Publishing. Available from:en.wikipedia.org/wiki/shaken_baby_syndrome. 21. Stipanicic A, Nolin P. Comparative study of the cognitive sequelae of school-aged victims of Shaken Baby Syndrome. Child Abuse Negl. 2008 Mar;32(3):415-428. 22. Arun Babu T, Venkatesh C. Shaken baby syndrome. 2010 Mar;77(3):318320. 23. Jayawant S. Subdural haemorrhages in infants: population based study.1998; 317: 1558-1561. 24. Ray M. Shaken baby syndrome masquerading as apparent life threatening event.2005_Jan; 72(1):85.
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25. Beth S. Russell, Preston A. Britner. Measuring Shaken Baby Syndrome awareness.2006 April. 26. Lazoritz & Palusci. The Shaken Baby Syndrome Awareness 2006 (15):765 777. 27. Ronald G. Barr. Do educational materials change knowledge and behavior about crying and shaken baby syndrome.2009 Mar 31.Available from:www.cmaj.ca/cgi/content/full/180/7/727.

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9.Signature of the candidate

10. Remarks of the guide

: The synopsis of the present study is appropriate to update the caregivers knowledge and study is genuine,

relevant, feasible and benefiting.

individually

11 Name and designation

11.1 Guide

: Mrs. Arockia Mary, Assoc. prof

11.2 Signature

11.3 Co-guide (if any)

: Nil

11.4 Signature

11.5 Head of the department

: Mrs. Arockia Mary, Assoc. prof

11.6 Signature

12.1 Remarks of the principal

: This study is relevant, feasible and appropriate for the specialty chosen.

12.2 Signature

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