Injury: Shaken Baby Syndrome

Definition

Shaken baby syndrome (SBS) is a form of child abuse in which an adult forcefully shakes a baby or toddler by the arms, chest, or shoulders, causing the head to whiplash back and forth on the neck and leading to bleeding inside the skull from broken blood vessels. The syndrome was first identified by Dr. John Caffey (1895–1978), a pediatric radiolo-gist, who published a landmark paper on it in 1972.

Description

Shaken baby syndrome is a type of traumatic brain injury that results when a baby or young child is grasped by the upper body and shaken back and forth by a teenager or adult. A baby has a relatively large and heavy head in comparison to the rest of its body, and it has weaker neck muscles than older children or adults. When the baby is shaken, or its head is struck against a wall or other hard surface, its brain moves back and forth inside the skull, causing tissue to bruise and small blood vessels to break. Blood can collect inside the skull and put pressure on the brain, leading to permanent brain damage, seizures, or death.

Demographics

The American Academy of Pediatrics (AAP) estimates that there are between 600 and 1,400 cases of SBS in the United States each year,

though it is possible that the true number is higher because some cases are misdiagnosed as the result of accidental falls or auto accidents. What is known is that shaken baby syndrome is the most common cause of mortality and long-term disability in infants and young children due to physical abuse. The syndrome has been reported in infants as young as five days and children as old as five years, but most victims are two years of age or younger.

SBS occurs in all racial groups in the United States but is more likely to be caused by males than by females. Adult males in their early twenties are the perpetrators in 65 to 90 percent of cases; most often they are the baby's father or the mother'sboyfriend.Femaleperpetrators are more likely to be a teenage babysitter or nanny than the baby's mother. The usual trigger for the abuse is crying lasting for several hours or repeated diaper soiling, although in some cases involving men, the abuser is angry because he is jealous of the attention the baby receives from its mother.

Causes and Symptoms

The cause of SBS is brain damage resulting from bleeding beneath the skull and bruising of brain tissue due to the brain's moving up against the inside of the skull during shaking. In some cases the brain is also damaged by loss of its oxygen supply.

Advice for Caregivers about SBS (source: The Arc)

There are three key words to remember when dealing with a crying or fussy baby: Stop. Calm down. Try again:

• Stop: Do not handle the baby if you are upset or angry. Place the child in a safe place like a crib or playpen.
• Calm down: Leave the room but stay close enough to hear the baby. Listen to calming music for a short time; then call a friend or the hotline below for support or advice. Another approach is to run the vacuum cleaner; the noise will drown out the sound of the crying; it also calms some babies. Keep in mind, too, that the baby may be crying from an earache, teething, or other illness as well as hunger or a wet diaper. If the baby cannot be soothed and keeps crying for a long time, it is best to call the doctor.
• Try again: After calming down, try again to help the baby.

Keep the number of the Childhelp National Child Abuse Hotline on the refrigerator or near the telephone: 1-800-4-A-CHILD (1-800-422-4453). The hotline is staffed twenty-four hours a day, 365 days a year.

The symptoms of severe SBS include:

• Bleeding into the retina of the eye
• Bleeding into the space between the brain and the layers of tissue that cover the brain
• Swelling of the head from fluid accumulating in the tissues of the brain
• Damage to the spinal cord and soft tissues of the neck

• Fractures of the ribs or other bones
• Convulsions
• Loss of consciousness

Babies who are less severely injured when shaken may have symptoms that are easy to confuse with the symptoms of flu:

• Vomiting or other flu-like symptoms without fever or diarrhea
• Crankiness and irritability over a period of time
• Poor feeding, loss of appetite
• Breathing problems
• Unusual drowsiness

Diagnosis

The doctor's greatest help in making a correct diagnosis of shaken baby syndrome is a description of what happened by the perpetrator or a witness. In many cases an abuser will tell the doctor that the child fell or was in a car accident, or that the abuser shook the baby trying to revive it. One important clue is that the injuries caused by SBS are usually much more severe than would be caused by a fall or other accidental head injury.

The doctor can tell that a shaken baby has a closed-head injury by taking imaging studies, usually a CT scan or an MRI. X-ray studies will reveal broken ribs or other bones. Bleeding into the retina of the eye can be detected by an ophthalmologist (doctor who specializes in eye disorders). In some cases, the doctor may order laboratory tests to rule out meningitis and other infectious diseases that can affect the brain and cause a seizure or coma.

Treatment

Children with severe injuries from shaken baby syndrome require emergency treatment, usually brain surgery to relieve pressure on the brain and respiratory support to help them breathe. Treatment of the blindness, learning disorders, mental retardation, and other long-term consequences of SBS may last for the rest of the child's life. These children often need special education services, physical therapy, speech therapy, eye treatment, psychotherapy, and occupational therapy.

Prognosis

SBS has a high mortality rate. It is estimated that a third of the babies who are abused in this way will die; another third will suffer severe permanent injuries; and the remaining third will recover.

Prevention

Dr. Caffey believed in the value of education to prevent at least some instances of SBS. While some abusers are people with a history of substance abuse or poor impulse control, others do not understand how much an angry adolescent or adult can harm a baby by shaking it. Various prevention strategies that are used include showing videos about SBS to new parents; encouraging pediatricians to discuss the stresses of childrearing with parents and teach them some ways to soothe a crying child; asking social workers to help identify families at risk of child abuse; instructing workers in day care centers and others who work with small children about the syndrome; and advising parents to screen babysitters or nannies very carefully before hiring them for child care responsibilities.

Specific tips for managing the stress of caring for a crying infant are described in the sidebar.

The Future

It is difficult to tell whether the various preventive strategies for lowering the rate of shaken baby syndrome will have a significant effect in the years to come, as many abusive, addicted, or mentally disturbed people cannot be reached by educational measures. One hopeful development is that more doctors and nurses are aware of the syndrome and better able to diagnose it quickly.

SEE ALSO Child abuse; Whiplash

WORDS TO KNOW

Closed-head injury: An injury to the head in which the skull is not broken or penetrated.

Meningitis: Inflammation of the protective membranes that cover the brain and spinal cord.

Radiologist: A doctor who specializes in medical imaging techniques to diagnose or treat disease.

Retina: The layer of light-sensitive tissue at the back of the eyeball.

For more information

BOOKS

Peinkofer, James R. Silenced Angels: The Medical, Legal, and Social Aspects of Shaken Baby Syndrome. Westport, CT: Auburn House, 2001.

PERIODICALS

Foderaro, Lisa W. “A Simple Video Finds Success against Shaken Baby Abuse.” New York Times, May 29, 2001. Available online at http://query.nytimes.com/gst/fullpage.html?res=9B04EFD7153CF93AA15756C0A9679C8B63 &sec=&spon=&pagewanted=all (accessed April 30, 2008). This is an article about a video shown to new mothers at the Children's Hospital of Buffalo about shaken baby syndrome.

WEB SITES

The Arc of the United States. Fact Sheet on Shaken Baby Syndrome. Available online at http://www.thearc.org/NetCommunity/Page.aspx?&pid=1433&

(updated March 2004; accessed April 30, 2008). The Arc is a worldwide organization that provides support and services for people with intellectual and developmental disabilities.

National Center on Shaken Baby Syndrome. Frequently Asked Questions/Medical Facts. Available online at http://www.dontshake.org/Audience.aspx?categoryID=8&PageName=MedicalFactsAnswers.htm (accessed April 30, 2008).

National Center on Shaken Baby Syndrome. Physical Consequences of Shaking an Infant or Toddler. Available online at http://www.dontshake.com/clips/SBSPowerPoint_Lo.wmv (accessed April 30, 2008). This is an animation with voiceover of the effects of violent shaking within a baby's head. It takes about a minute and a half to play.

National Institute of Neurological Disorders and Stroke (NINDS). Shaken Baby

Syndrome Information Page. Available online at http://www.ninds.nih.gov/disorders/shakenbaby/shakenbaby.htm (updated February 14, 2007; accessed April 30, 2008).