Diseases

A classic triad most commonly seen consists of (1) single or multiple subdural hematomas (localized bleeding outside of the brain substance), (2) diffuse and multi-depth retinal hemorrhages, and (3) diffuse brain injury without a reasonable explanation for such severe (and often repeated) trauma. Several agencies, including the American Academy of Pediatrics, recommend that the term shaken baby syndrome be replaced with abusive head trauma. Such a change broadens the various mechanisms of injury commonly seen besides shaking. Blunt head trauma is commonly seen in addition to shaking. Common mechanisms of direct blows to the head include punching the infant, hitting the head or face with a hard object (for example, wooden spoon), or slamming the infant's head against the wall or floor. Because children may not present for evaluation with evidence of trauma (bruising, lacerations, etc.), a high index of suspicion must be maintained by those responsible for evaluating such children. Missed cases of shaken baby syndrome may be incorrectly diagnosed as viral infection (especially gastroenteritis, in which children will be lethargic and have a history of repeated vomiting) or accidental head injury (for example, fell while being carried by a parent, rolled off of a bed, or abuse by an older sibling). Multiple studies have demonstrated that, while the duration of shaking necessary to inflict such substantial trauma may be accomplished in 15-20 seconds, adult strength is necessary to inflict such damage (for example, parental perpetrators may attempt to blame a childhood sibling as the culprit). Likewise, rolling off of a bed or couch or being held during a parental fall are extremely unlikely to cause such injury. Documentation of old skeletal fractures, burns (commonly cigarette or hot water immersion), healing bruises, or ligature injury may be discovered during an investigation. Those most likely to inflict trauma on an infant tend to be the father (50%), stepfather, male partner of the mother (20%), female babysitters (17%), and the mother (12%).

Many studies have determined that what is felt to be incessant crying is the primary stimulus leading to a frustrated caregiver loosing control. Expectant parents must be counseled regarding the nature of crying and various management strategies for both the infant and themselves. It is important to underscore that many times there is no obvious or discernable cause for the infant's crying. Likewise, it is important for parents and all caregivers to understand that allowing an infant to cry for a reasonably short period (10-15 minutes) does not lead to short- or long-term physical or emotional-health issues. Most importantly, those caring for children must be assured that asking for help is an excellent strategy when they find themselves "at the end of their rope."

Neurologic side effects of either shaking or blunt skull trauma may span from developmental delays, seizure disorders, visual impairment, and blindness to death. Orthopedic consequences of inflicted trauma range from the need for recurrent surgery to permanent loss of function if the back (and thus spinal cord) is involved. Scarring of the skin is a common side effect of inflicted burns. Plastic and reconstructive surgery may be necessary depending on the nature of the trauma (for example, immersion into hot water). Emotional side effects may be obvious or subtle and may not necessarily be present or detectable at the time of diagnosis. Counseling and psychological support and intervention may require repeated or long-lasting attention.

The symptoms and signs of shaken baby syndrome have an extremely broad range to display. This range is due to the nature of the inflicted trauma, including the frequency, duration, and whether the result of a single event or multiple events. Behavioral changes may include the following:

1. Extreme irritability and high-pitched crying
2. Lethargy and poor feeding
3. Vomiting without obvious reason
4. Loss of social engagement (smiling, cooing, etc.)
5. Poor suck/swallow coordination
6. Unusual breathing patterns (continuous deep pattern or rapid and shallow pattern)

Physical changes associated with shaken baby syndrome may include the following:

1. Bruising of the body due either to the grip strength of the individual inflicting trauma or as a consequence of hitting or being hit by blunt objects (for example, wooden spoons)
2. Head trauma: bruising, swelling, and/or laceration of the scalp, deformity of the skull (commonly a depression due to a skull fracture)
3. Inability of the infant eyes to track or focus on an object
4. Abnormal increase in muscle tone or evidence of an increase in pressure of the structures of the skull (for example, brain)
5. Seizures
6. Hemorrhages of the retina
7. Bleeding of the surrounding or supporting structures of the brain or in the brain substance itself (most frequently diagnosed via CT or MRI studies)
8. Bleeding and/or drainage of clear fluid (spinal fluid -- clear fluid that surrounds the brain) from the nose or ear canal

It is crucial to note that many studies have demonstrated that 20%-50% of children who sustain shaken baby syndrome have evidence of other episodes of inflicted trauma, such as intentional burns, broken bones (most commonly rib and the long bones of the arms and legs), and/or bruising not consistent with routine and age-appropriate injury.

Risk factors for shaken baby syndrome (as well as other types of inflicted trauma on children) may be conceptualized into two broad categories: Family risk factors

1. Young and/or single parents
2. Lower educational background
3. Unstable family dynamics
4. Financial/food/housing concerns and stresses
5. Domestic violence
6. Drug/alcohol abuse
7. Parental mental illness, especially postpartum depression
8. Limited or no immediate support system (for example, relatives, church groups, etc.)
9. Unrelated adults staying in the home

Infant risk factors

1. Perinatal risk factors (for example, threatened miscarriage, prematurity, infant malformations, multiple births (twins, triplets, etc.)
2. Colicky infants -- often aggravated by the natural history of increase in infant crying during the first two months of life (see above)
3. Male gender
4. Unwanted pregnancy

Most caregivers will initiate a series of approaches in an effort to address a crying infant. Reviewing the feeding schedule and checking for a soiled diaper are common. Consideration of health problems (an ear infection or upper respiratory infection), the need to burp the child, or infant tiredness or boredom can all be considered. For infants who seem to have crying in association with feeding or evidence of gastroesophageal reflux (GER), a discussion with their pediatrician is in order. Breastfed infants may cry in response to certain foods (for example, caffeinated beverages) ingested by their mother. Rarely, infants will have continuous crying if a long hair (most commonly from a parent) has accidently wrapped around a toe or finger. Diagnosis is considered if prominent swelling and skin discoloration is noted at the site of the ligature. Various approaches to the crying infant are commonplace. These include picking up the baby and socially interacting with the child, walking and rocking the child, addressing the possibility of hunger or a soiled diaper, and a quick visual survey of the infant to confirm no unusual changes exist. It is important for parents to accept that the majority of the time their investigation will be fruitless in determining causation of their infant's crying. The fact that he or she cries is not an indictment of their parenting skills. There is generally no hidden management secret other than time and patience.

The first few months of childhood are tremendously stressful to new parents. Mothers (who often carry more than their fair share of this newly acquired responsibility) are struggling to recover from pregnancy, labor, and delivery as well as deal with an individual who is completely dependent upon them. Breastfeeding mothers may carry an even larger responsibility since they are uniquely responsible for their infant's nutrition. Studies of normal and healthy infants have demonstrated that the number of minutes per day spent crying increases weekly during the first two months of life, stabilizes for three to four weeks, and then drops remarkably. This mixture of physical and emotional parental exhaustion, coupled with what seems to be never-ending crying, can push many over the edge. High-risk infants (premature babies, those with chronic medical conditions, etc.) commonly extract an even higher toll on parents. This may be due to the more demanding requirements of such children and/or a belief of an increase in infant vulnerability. For some caregivers, physical punishment represents the only way to free themselves of their frustrations.

Dr. Robert Reece provided one definition of shaken baby syndrome (also called the shaken impact syndrome). He described the syndrome as "the constellation of signs and symptoms resulting from violent shaking or shaking and impacting the head of an infant or small child." The alternative descriptive phrase "abusive head trauma" serves as an umbrella term implying injury to the skull, brain, and spinal cord as a result of shaking and/or trauma to the head. Implicit in any terminology is that an adult purposefully inflicts such trauma on the infant. Research indicates that very young children (ages 4 and younger) are the most frequent victims of child fatalities. Although more recent statistics are not yet available, the National Child Abuse and Neglect Data System (NCANDS) data for 2010 demonstrated that children younger than 1 year accounted for 47.7 percent of fatalities; children younger than 4 years accounted for nearly four-fifths (79.4 percent) of fatalities. These children are the most vulnerable for many reasons, including their dependency, small size, and inability to defend themselves. Of these lethal events, inflicted head trauma is the primary cause of such mortality. Amazingly, the most frequent etiology (cause) of fatal head injury to children below 2 years of age is inflicted head trauma. Inflicted head trauma is a subset of the larger problem of child abuse (lethal and nonlethal). Unfortunately, solid statistics are limited regarding the incidence of shaken baby syndrome. This partially is due to various terms used in medical and hospital records as well as under-recognition of shaken baby syndrome since symptoms and signs may be more subtle than those of general body injury seen in globally battered children. CDC statistics reflect the broad problem of physical violence against children, reporting approximately 122,500 victims, of whom 840 died. Of those who died, 60% were boys.

The primary predictor for an optimal prognosis is establishing the diagnosis and thus removing the child (and any siblings) from the abusive home. The nature of the neurological injuries help shape realistic prognostic expectations. The "plastic" nature of the immature brain and peripheral nervous system allow those counseling caregivers of children who have sustained shaken baby syndrome to be more optimistic than those counseling after adult traumatic brain injury. One study found that approximately one-third of those who suffered abusive head injury have no discernable side effect; unfortunately, such a statistic implies that two-thirds of such victims will have residual long-term complications.

The first step in successful treatment for shaken baby syndrome demands accurate diagnosis and removal of the infant (and any siblings) from the household in which the abuse occurred. Once diagnosed, supportive care provides the mainstay of medical management. Neurosurgical procedures may be indicated as well as orthopedic management of bone fractures. Eye specialists (ophthalmologists) are critical in the evaluation and monitoring of retinal hemorrhages. Once the infant is medically stable, a series of developmental evaluations are necessary to provide a baseline at the time of diagnosis. Follow-up evaluations monitor for long-term side effects of head trauma. The perpetrator will need to undergo psychological evaluation.