Shaken Baby / Shaken Impact Syndrome

When a young au pair from Great Britain was charged in 1997 in the death of Matthew Eappen, an 8-month-old Massachusetts boy in her care, the case received phenomenal media coverage both in the United States and abroad. Lawyers for the prosecution and the defense waged a charged battle throughout the trial, trying to assign the blame for the baby's death. But when it was all over, the only thing that was clear was that Matthew's case had become one of the most publicized cases of shaken baby/shaken impact syndrome (SBS).

What Is SBS?

SBS is a form of inflicted head trauma. Head injury, as a form of child abuse, can be caused by direct blows to the head, dropping or throwing the child, or shaking the child. Head trauma is the leading cause of death in child abuse cases in the United States.

Unlike other forms of inflicted head trauma, SBS results from injuries caused by someone vigorously shaking an infant. Because of the anatomy of infants, they're at particular risk for injury from this kind of action. Therefore, the vast majority of incidents occur in infants who are younger than 1 year old. The average age of victims is between 3 and 8 months, although SBS is occasionally seen in children up to 4 years old.

The perpetrators in SBS cases are almost always parents or caregivers, who shake the baby out of frustration or stress when the little one is crying inconsolably. Sadly, the shaking has the desired effect: although at first the baby cries more out of fear, it eventually stops crying as the brain is damaged.

Approximately 60% of shaken babies are male, and children of families who live at or below the poverty level are at an increased risk for SBS as well as any type of child abuse. And it's estimated that the perpetrators in 65% to 90% of cases are males - usually either the baby's father or the mother's boyfriend, often someone in his early 20s.

How Does It Happen?

When someone forcefully shakes a baby, the child's head rotates about uncontrollably because infants' neck muscles aren't well developed and provide little support for their heads. The violent movement pitches the infant's brain back and forth within the skull, rupturing blood vessels and nerves throughout the brain and tearing the brain tissue. The brain strikes the inside of the skull, causing bruising and bleeding to the brain.

The damage is even greater when the shaking ends with an impact (hitting a wall or a crib mattress, for example), because the forces of acceleration and deceleration associated with an impact are so strong. After the shaking, swelling in the brain can cause enormous pressure within the skull, compressing blood vessels and increasing overall injury to its delicate structure.

Normal interaction with a child, like bouncing the baby on a knee, will not cause SBS, although it's important to never shake a baby under any circumstances because gentle shaking can rapidly escalate.

What Are the Effects?

SBS often causes irreversible damage. In the worst cases, the death rate is almost half of all babies involved.

Children who survive may have:

• partial or total blindness
• hearing loss
• seizures
• developmental delays
• impaired intellect
• speech and learning difficulties
• problems with memory and attention
• severe mental retardation
• paralysis (some particularly traumatic episodes leave children in a coma)

Even in milder cases, in which babies looks normal immediately after the shaking, they may eventually develop one or more of these problems. Sometimes the first sign of a problem isn't noticed until the child enters the school system and exhibits behavioral problems or learning difficulties. But by that time, it's more difficult to link these problems to a shaking incident from several years before.

What Are the Signs and Symptoms?

In any SBS case, the duration and force of the shaking, the number of episodes, and whether impact is involved all affect the severity of the infant's injuries. In the most violent cases, children may arrive at the emergency room unconscious, suffering seizures, or in shock. But, in many cases, infants may never be brought to medical attention if they don't exhibit such severe symptoms.

In less severe cases, a baby who has been shaken may experience:

• lethargy
• irritability
• vomiting
• poor sucking or swallowing
• decreased appetite
• lack of smiling or vocalizing
• rigidity
• seizures
• difficulty breathing
• altered consciousness
• unequal pupil size
• an inability to lift the head
• an inability to focus the eyes or track movement

How Is It Diagnosed?

Many cases of SBS are brought in for medical care as "silent injuries." In other words, parents or caregivers don't often provide a history that the child has had abusive head trauma or a shaking injury, so doctors don't know to look for subtle or physical signs. This "silent epidemic" can result in children having injuries that aren't identified in the medical system.

And again, in many cases, babies who don't have severe symptoms may never be brought to a doctor.

Unfortunately, unless a doctor has reason to suspect SBS, mild cases (in which the infant seems lethargic, fussy, or perhaps isn't feeding well) are often misdiagnosed as a viral illness or colic. Without a diagnosis of shaken baby syndrome and any resulting intervention with the parents or caregivers, these children may be shaken again, worsening any brain injury or damage.

If shaken baby syndrome is suspected, doctors may look for:

• hemorrhages in the retinas of the eyes (which are extremely rare in any accidental injuries, such as falls)
• skull fractures
• swelling of the brain
• subdural hematomas (blood collections pressing on the surface of the brain)
• rib and long bone (bones in the arms and legs) fractures
• bruises around the head, neck, or chest

The Child's Development and Education

What makes SBS so devastating is that it usually involves a total brain injury. Because the infant's immature brain has little stored information and few developed capacities to make up for the deficit, the brain's adaptive abilities are substantially impaired. For example, a child whose vision is severely impaired won't be able to learn through observation, which decreases the child's overall ability to learn.

The development of language, vision, balance, and motor coordination, all of which occur to varying degrees after birth, are particularly likely to be affected in any child who has SBS.

Such impairment can require rigorous physical and occupational therapy to help the child acquire skills that would have developed on their own had the brain injury not occurred. Therapists do this by providing a sensory-rich environment, which forces the child to be attentive.

Therapists often work one on one with a child, concentrating on building the child's ability to pay attention. They use sound and other stimuli to increase the child's interest in objects, such as repeatedly squeaking a toy near the child's ear. As they get older, kids who were shaken as babies may require special education and continued therapy to help with language development and daily living skills, such as dressing themselves.

Before age 3, a child can receive speech or physical therapy through the Department of Public Health. Federal law requires that each state provide these services for children who have developmental disabilities as a result of being shaken as babies.

Some schools are also increasingly providing information and developmental assessments for children under the age of 3. Parents can turn to a variety of rehabilitation and other therapists for early intervention services for children after abusive head trauma. Developmental assessments can assist in improving education outcomes as well as the overall well being of the child.

After a child who's been diagnosed with SBS turns 3, it's your school district's responsibility to provide additional special educational services.

Can SBS Be Prevented?
It is 100% preventable.

A key aspect of prevention of the syndrome is increasing awareness of the potential dangers of shaking. Some hospital-based programs have helped new parents identify and prevent shaking injuries and understand how to respond when infants cry.

Finding ways to alleviate the parent or caregiver's stress at the critical moments when a baby is crying can significantly reduce the risk to the child. One method that may help is author Dr. Harvey Karp's "five S's":

• Shushing (using "white noise," or rhythmic sounds that mimic the constant whir of noise in the womb, with things like vacuum cleaners, hair dryers, clothes dryers, a running tub, or a white noise CD)
• Side/stomach positioning (placing the baby on the left side - to help digestion - or on the belly while holding him or her, then putting the sleeping baby in the crib or bassinet on his or her back)
• Sucking (letting the baby breast feed or bottle-feed, or giving the baby a pacifier or finger to suck on)
• Swaddling (wrapping the baby up snugly in a blanket to help him or her feel more secure)
• Swinging gently (rocking in a chair, using an infant swing, or taking a car ride to help duplicate the constant motion the baby felt in the womb)

If a baby in your care won't stop crying, you an also try the following:

• Make sure the baby's basic needs are met (for example, he or she isn't hungry and doesn't need to be changed).
• Check for signs of illness, like fever or swollen gums.
• Rock or walk with the baby.
• Sing or talk to the baby.
• Offer the baby a pacifier or a noisy toy.
• Take the baby for a ride in a stroller or strapped into a child safety seat in the car.
• Hold the baby close against your body and breathe calmly and slowly.
• Call a friend or relative for support or to take care of the baby while you take a break.
• If nothing else works, put the baby on his or her back in the crib, close the door, and check on the baby in 10 minutes.
• Call your child's doctor if nothing seems to be helping your infant, in case there is a medical reason for the fussiness.

To prevent potential SBS, parents and caregivers of infants need help with responding to their own stress. It's important to talk to anyone caring for your baby about the dangers of shaking and how it can be prevented.

Article Courtesy of: KidsHealth.org
Updated and reviewed by: Vincent J. Palusci, MD, MS
Date reviewed: August 2004
Originally reviewed by: Steven Dowshen, MD, and Jane Crowley, PsyD

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