Shaken baby syndrome

Definition

Shaken baby syndrome (SBS) is a collective term for the internal head injuries a baby or young child sustains from being violently shaken.

Description

Shaken baby syndrome was first described in medical literature in 1972. Physicians earlier labeled these injuries as accidental, but as more about child abuse became known, more cases of this syndrome were properly diagnosed.

Demographics

Every year, nearly 50,000 children in the United States are forcefully shaken by their caretakers. More than 60 percent of these children are boys. Nearly 2,000 children die every year as a result of being shaken. The victims are on average six to eight months old, but may be as old as five years or as young as a few days.

Men are more likely than women to shake a child; typically, these men are in their early 20s and are the baby's father or the mother's boyfriend. Women who inflict SBS are more likely to be babysitters or child care providers than the baby's mother. The shaking may occur as a response of frustration to the baby's inconsolable crying or as an action of routine abuse.

Causes and symptoms

Infants and small children are especially vulnerable to SBS because their neck muscles are still too weak to adequately support their disproportionately large heads, and their young brain tissue and blood vessels are extremely fragile. When an infant is vigorously shaken by the arms, legs, shoulders, or chest, the whiplash motion repeatedly jars the baby's brain with tremendous force, causing internal damage and bleeding. While there may be no obvious external signs of injury following shaking, the child may suffer internally from brain bleeding and bruising (called subdural hemorrhage and hematoma); brain swelling and damage (called cerebral edema); mental retardation ; blindness, hearing loss, paralysis, speech impairment, and learning disabilities; and death.

Physicians may have difficulty initially diagnosing SBS because there are usually few witnesses to give a reliable account of the events leading to the trauma, few if any external injuries, and, upon close examination, the physical findings may not agree with the account given. A shaken baby may present one or more signs, including vomiting ; difficulty breathing, sucking, swallowing, or making sounds; seizures; and altered consciousness.

When to call the doctor

A physician should be called when a baby exhibits one or more of the following: vomiting; difficulty breathing, sucking, swallowing, or making sounds; seizures; and altered consciousness. An unresponsive child should never be put to bed, but must be taken to a hospital for immediate care.

Diagnosis

To diagnose SBS, physicians look for at least one of three classic conditions: bleeding at the back of one or both eyes (retinal hemorrhage), subdural hematoma , or cerebral edema. The diagnosis is confirmed by the results of either a computed tomography scan (CT scan) or magnetic resonance imaging (MRI).

Treatment

Appropriate treatment is determined by the type and severity of the trauma. Physicians may medically manage both internal and external injuries. Behavioral and educational impairments as a result of the injuries require the attention of additional specialists. Children with SBS may need physical therapy, speech therapy, vision therapy, and special education services.

Prognosis

Unfortunately, children who receive violent shaking have a poor prognosis for complete recovery. Those who do not die may experience permanent blindness, mental retardation, seizure disorders, or loss of motor control.

Prevention

Shaken baby syndrome is preventable with public education. Adults must be actively taught that shaking a child is never acceptable and can cause severe injury or death.

Parental concerns

When the frustration from an incessantly crying baby becomes too much, caregivers should have a strategy for coping that does not harm the baby. The first step is to place the baby in a crib or playpen and leave the room in order to calm down. Counting to 10 and taking deep breaths may help. A friend or relative may be called to come over and assist. A calm adult may then resume trying to comfort the baby. A warm bottle, a dry diaper, soft music, a bath, or a ride in a swing, stroller, or car may be offered to soothe a crying child. Crying may also indicate pain or illness, such as from abdominal cramps or an earache. If the crying persists, the child should be seen by a physician.

KEY TERMS

Cerebral edema —The collection of fluid in the brain, causing tissue to swell.

Hematoma —A localized collection of blood, often clotted, in body tissue or an organ, usually due to a break or tear in the wall of blood vessel.

Hemorrhage —Severe, massive bleeding that is difficult to control. The bleeding may be internal or external.

Retinal hemorrhage —Bleeding of the retina, a key structure in vision located at the back of the eye.

Subdural hematoma —A localized accumulation of blood, sometimes mixed with spinal fluid, in the space between the middle (arachnoid) and outer (dura mater) membranes covering the brain. It is caused by an injury to the head that tears blood vessels.

Resources

BOOKS

Antoon, Alia Y. and Donovan, Mary. "Brain injuries." In Nelson Textbook of Pediatrics. 17th ed. Ed. by Richard E. Behrman, et al., Philadelphia: Saunders, 2003, 330-7.

Augustyn, Marilyn, and Zuckerman, Barry. "Impact of viokence on children." In Nelson Textbook of Pediatrics. 17th ed. Ed. by Richard E. Behrman, et al., Philadelphia: Saunders, 2003, 120-1.

Lazoritz, Stephen, and Palusci, Vincent J. Shaken Baby Syndrome: A Multidisciplinary. Binghamton, NY: Haworth Press, Incorporated, 2002.

Minns, Robert, and Brown, Keith. Shaken Baby Syndrome and Other Non-Accidental Head Injuries in Children. London: MacKeith Press, 2003.

PERIODICALS

Carbaugh, S.F. "Family teaching toolbox. Preventing shaken baby syndrome." Advances in Neonatal Care 4, no. 2 (2004): 118-9.

Carbaugh, S.F. "Understanding shaken baby syndrome." Advances in Neonatal Care 4, no. 2 (2004): 105-14.

Evans, H.H. "The medical discovery of shaken baby syndrome and child physical abuse." Pediatric Rehabilitation 7, no. 3 (2004): 161-3.

Lin, C.L., et al. "External subdural drainage in the treatment of infantile chronic subdural hematoma." Journal of Trauma 57, no. 1 (2004): 104-7.

Sugarman, N. "Shaken Baby Syndrome: compensating the victims." Pediatric Rehabilitation 7, no. 3 (2004): 215-20.

ORGANIZATIONS

Brain Injury Association. 105 North Alfred Street, Alexandria, VA 22314. (800) 444-6443 or (703) 236-6000. Web site: http://www.biausa.org/Sportsfs.htm.

International Brain Injury Association. 1150 South Washington Street, Suite 210, Alexandria, VA 22314. (703) 683-8400. Web site: http://www.internationalbrain.org.

WEB SITES

"Please Don't Shake Me." National Center on Shaken Baby Sybdrome. Available online at http://www.dontshake.com .

"Shaken Baby Information Page." National Institute of Neurological Disorders and Stroke. Available online at http://www.ninds.nih.gov/health_and_medical/disorders/shakenbaby.htm .

"Shaken Baby Syndrome." Shaken Baby Alliance. Available online at http://www.shakenbaby.com .

"Shaken Baby Syndrome." The Arc. Available online at http://www.thearc.org/faqs/Shaken.html.asp.

L. Fleming Fallon, Jr., MD, DrPH