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Shaken baby syndrome (SBS) describes a variety of outcomes that may occur as a result of shaking or hitting the head of an infant or small child. Shaken baby syndrome occurs when an abuser violently shakes an infant, creating a whiplash-type motion that causes acceleration-deceleration injuries (National Center on Shaken Baby Syndrome). SBS is a specific type of non-accidental trauma (physical child abuse). SBS is often coupled with striking of the infant against a hard object and, in these cases may be known as the shaken impact syndrome.

The injury, a major cause of mortality in infants, is often fatal and can produce lifelong disability from neurological damage. 10 to 12% of all child abuse deaths are due to SBS (Oral, 2003). These effects are due to destruction of brain cells secondary to the initial trauma, oxygen deprivation and swelling of the brain, which can raise intracranial pressure and damage delicate brain tissue. Retinal hemorrhages are also commonly found in children suffering from SBS, occurring in 50 to 90% of cases (Oral, 2003).

Subdural hematoma is commonly found in SBS victims, as are diffuse axonal injury (Ricci and Botash, 2005) and brain contusion. Subdural hematoma, the most common injury found in children suffering from SBS, is classically found on both sides of the brain. In other types of injury or disease, a subdural hematoma may be unilateral. Subarachnoid hemorrhage is also found in this type of trauma (Oral, 2003).

Most victims of SBS are under 1 year old (Wagner, 2005).

Signs and symptoms

Shaken infants may display irritability, failure to thrive, alterations in eating patterns, lethargy, vomiting, seizures, bulging or tense fontanels, increased size of the head, altered respirations, and dilated pupils (BIAUSA). Especially suggestive of this type of abuse are subdural hematomas that occur near the tentorium or along the back of the interhemispheric fissure (Wagner, 2005).

Fractures in the vertebrae and ribs may also be associated with this kind of abuse due to squeezing and impact forces (Oral, 2003).

Medical professionals strongly suspect shaking when a baby or small child presents with retinal hemorrhage, fractures or soft tissue injuries, subdural hemoatoma, and no history of trauma or a history of trauma that could not have caused injuries as serious as those the child has (Oral, 2003). No condition mimics all of the symptoms of SBS exactly, but those that must be ruled out include hydrocephalus, sudden infant death syndrome (SIDS), seizure disorders, and infectious or congenital diseases like meningitis and metabolic disorders (Oral, 2003).

Anatomy and pathophysiology

Several anatomical factors make infants susceptible to brain damage from shaking. Their heads are bigger and weigh more with respect to their bodies than adults' heads, and their neck muscles are weak and cannot prevent violent motions (Patel and Moorjani, 2005). Infants' brains are not myelinated; myelin sheaths form in childhood and are complete in adolescence. The brain water content is reduced as neurons gain myelin during development, so babies have a greater percentage of brain water than adults (Stock and Singer, 2004). Because of this higher water content, children's brains are softer and are much more susceptible to acceleration-deceleration injuries and diffuse axonal injury (Stock and Singer, 2004). Infants also have a larger subarachnoid space than young adults, and so the veins traversing the space are in greater danger of being torn during violent movement of the head, causing subdural hematoma (Patel and Moorjani, 2005).

Rotation injury is especially damaging and likely to occur in shaking trauma (Oral, 2003). The type of injuries caused by shaking injury are usually not caused by falls and impacts from normal play, which are mostly linear forces (Oral, 2003).

Prognosis

SBS kills about one third of its victims and permanently and severely disables another third (Oral, 2003). Problems resulting from SBS include learning disabilities, seizure disorders, speech disability, hydrocephalus, cerebral palsy, and visual disorders (Oral, 2003).

Prevention

Attention given to this diagnosis by the media has made caregivers more aware of the serious damage that can be done to children by violent shaking. Prevention of SBS is similar to the prevention of child abuse in general. Crying is a common trigger for shaking a baby; some experts have advised that caregivers should know that they are not always responsible when babies cry.

SBS as a medical/legal concept

SBS, which was initially described by Caffey in the 1970's, has been the subject of criticism by some scientists and jurists. In July of 2005, the Court of Appeals in the United Kingdom reversed or reduced three convictions of SBS, finding that the classic triad of retinal hemorrhage, subdural hematoma, and acute encephalopathy are not 100% diagnostic of SBS and that clinical history is also important. In their ruling, they upheld the clinical concept of SBS but dismissed two cases and reduced the sentence on a third based on their individual merits. In their words: "Whilst a strong pointer to NAHI on its own we do not think it possible to find that it must automatically and necessarily lead to a diagnosis of NAHI. All the circumstances, including the clinical picture, must be taken into account." The term "non-accidental trauma" was suggested instead of "SBS" in the March 27, 2004 number of BMJ - see case report , editorial and letter . These references, along with further BMJ articles in 2005, validated the concept of SBS within the clinical spectrum of non-accidental trauma and documented the wide variety of radiologic and pathologic findings in child abuse. There can never exist enough scientific data to convict a person solely based on "classic" findings.

See Also

• Louise Woodward
• Subdural hematoma
• Diffuse axonal injury

References

1. Brain Injury Association of America (BIAUSA). "Types of Brain Injury." Available.
2. National Center on Shaken Baby Syndrome. Available.
3. Oral R. 2003. Intentional head trauma in infants: Shaken baby syndrome. Virtual Children's Hospital.
4. Patel N and Moorjani B. 2005. "Neonatal Injuries in Child Abuse." Emedicine.com. Available.
5. Ricci LR and Botash AS. 2005. "Pediatrics, Child Abuse." Emedicine.com. Available.
6. Stock A and Singer L. 2004. "Head Trauma." Emedicine.com. Available.
7. Wagner AL. 2005. "Subdural Hematoma." Emedicine.com. Available.

External links

• DontShake.com - The National Center on Shaken Baby Syndrome
• SBSDefense.com - Shaken Baby Syndrome Defense
• ShakenBaby.com - The Shaken Baby Alliance

Video

• ExpertDigital.com - Graphic Demonstration (QuickTime)

• Autism
• Neurotrauma