Disease: Shaken Baby Syndrome (Abusive Head Trauma)

    Shaken baby syndrome facts

    • Inflicted trauma (especially shaken baby syndrome) is a leading cause of childhood (especially infant) mortality.
    • There are several risk factors associated with an increased risk for shaken baby syndrome.
    • Multiple behavioral symptoms and physical signs enable physicians to establish the diagnosis of shaken baby syndrome.
    • 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. Then, supportive care provides the mainstay of medical management.
    • Some victims of shaken baby syndrome may have either long-term or permanent consequences due to the type of abuse they experience.
    • Classes for parents discussing normal infant temperament and behavior may help expectant mothers and fathers have realistic expectations, thereby lessening the stress of their newborn's frustrating conduct.

    What is shaken baby syndrome?

    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. Recent literature cites the extraordinary statistic that 40% of childhood deaths as a consequence of child abuse involve children less than 12 months of age. 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.

    What causes shaken baby syndrome?

    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.

    What are the risk factors for shaken baby syndrome?

    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

    What are shaken baby syndrome symptoms and signs?

    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.

    How do physicians diagnose shaken baby syndrome?

    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%).

    What is the treatment for shaken baby syndrome?

    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.

    What are complications and long-term effects of shaken baby syndrome?

    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.

    What causes shaken baby syndrome?

    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.

    What are the risk factors for shaken baby syndrome?

    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

    What are shaken baby syndrome symptoms and signs?

    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.

    How do physicians diagnose shaken baby syndrome?

    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%).

    What is the treatment for shaken baby syndrome?

    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.

    What are complications and long-term effects of shaken baby syndrome?

    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.

    Source: http://www.rxlist.com

    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.

    Source: http://www.rxlist.com

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