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PEDIATRICS Vol. 108 No. 1 July 2001, pp. 206-210
AMERICAN ACADEMY OF PEDIATRICS:
Shaken Baby Syndrome: Rotational Cranial Injuries
Technical
Report
Shaken baby syndrome is a serious and clearly
definable form of child abuse. It results from extreme rotational
cranial acceleration induced by violent shaking or shaking/impact,
which would be easily recognizable by others as dangerous. More
resources should be devoted to prevention of this and other forms of
child abuse.
ABSTRACT
Top
Abstract
Introduction
Conclusion
Recommendation
References
Physical abuse is the leading cause of serious head injury
in infants.1,2 Although physical abuse in the past has
been a diagnosis of exclusion, data regarding the nature and frequency
of head trauma consistently support the need for a presumption of child
abuse when a child younger than 1 year has suffered an intracranial
injury.1,2
Shaken baby syndrome is a serious form of child maltreatment most often
involving children younger than 2 years but may be seen in children up
to 5 years old.2-5 It occurs commonly, yet may be
misdiagnosed in its most subtle form and underdiagnosed in its most
serious form.6 Caretakers may misrepresent or claim to
have no knowledge of the cause of the brain injury. Caretakers who are
not responsible for the injuries may not know how they occurred.
Externally visible injuries are often absent. Given possible
difficulties in initially identifying an infant as having been
abusively shaken and the variability of the syndrome itself, physicians
must be extremely vigilant when dealing with any brain trauma in
infants and be familiar with radiologic and clinical findings that
support the diagnosis of shaken baby syndrome.
In 1972, pediatric radiologist John Caffey7
popularized the term "whiplash shaken baby syndrome" to describe a
constellation of clinical findings in infants, which included retinal
hemorrhages, subdural and/or subarachnoid hemorrhages, and little or no
evidence of external cranial trauma. One year earlier,
Guthkelch8 had postulated that whiplash forces caused
subdural hematomas by tearing cortical bridging veins. In the
mid-1970s, computed tomography (CT) began to be used to help with
diagnosis. The advent of magnetic resonance imaging (MRI) in the
mid-1980s has furthered the diagnostic capabilities.9
The act of shaking leading to shaken baby syndrome is so violent
that individuals observing it would recognize it as dangerous and
likely to kill the child. Shaken baby syndrome injuries are the result
of violent trauma. The constellation of these injuries does not occur
with short falls, seizures, or as a consequence of vaccination. Shaking
by itself may cause serious or fatal injuries.10,11 In
many instances, there may be other forms of head trauma, including impact injuries.10-12 Thus, the term shaken/slam syndrome
(or shaken-impact syndrome) may more accurately reflect the age range
of the victims (who are not always babies) and the mechanisms of injury
seen. Such shaking often results from tension and frustration generated
by a baby's crying or irritability, yet crying is not a legal
justification for such violence.13 Caretakers at risk for
abusive behavior generally have unrealistic expectations of their
children and may exhibit a role reversal whereby caretakers expect
their needs to be met by the child.14
Additionally, parents who are experiencing stress as a result of
environmental, social, biological, or financial situations may also be
more prone to impulsive and aggressive behavior. Those involved with
domestic violence and/or substance abuse may also be at higher risk of
inflicting shaken baby syndrome. Small children are particularly
vulnerable to such abuse because of the large disparity in size between
them and an adult-sized perpetrator.
Head injuries are the leading cause of traumatic death and the
leading cause of child abuse fatalities. Homicide is the leading cause
of injury-related deaths in infants younger than 4 years.2 Serious injuries in infants, particularly those that result in death,
are rarely accidental unless there is another clear explanation, such
as trauma from a motor vehicle crash. Billmire and
Meyers15 found that when uncomplicated documented severe
trauma such as that resulting in skull fractures were excluded, 95% of
serious intracranial injuries and 64% of all head injuries in infants younger than 1 year were attributable to child abuse. Bruce and Zimmerman5 documented that 80% of deaths from head trauma in infants and children younger than 2 years were the result of nonaccidental trauma. Contrary to early speculations,7,8 shaken baby syndrome is unlikely to be an isolated event. Evidence of
prior child abuse is common.16 Specific evidence of
previous cranial injuries (eg, old intracranial hemorrhages) from
shaking episodes is found in about 33% to 40% of all
cases.16,17 As with other forms of physical abuse, males
are more often perpetrators than are females.2,18 However,
in an individual case, gender should not be considered when trying to
identify a possible perpetrator.
Signs of shaken baby syndrome may vary from mild and nonspecific
to severe and immediately identifiable clinically as head trauma.6 There is a spectrum of the consequences of shaken baby syndrome, and less severe cases may not be brought to the attention of medical professionals and may never be diagnosed. A shaken
infant may suffer only moderate ocular or cerebral trauma. A victim of
sublethal shaking may have a history of poor feeding, vomiting,
lethargy, and/or irritability occurring for days or weeks. These
clinical signs of shaken baby syndrome are immediate and identifiable
as problematic, even to parents who are not medically knowledgeable.19 However, depending on the severity of
clinical signs, this may or may not result in caretakers seeking medical attention. These nonspecific signs are often minimized by
physicians or attributed to viral illness, feeding dysfunction, or
colic.6 In these relatively milder cases, signs may resolve without the true cause being discovered. If the child presents
later with indications for cerebral imaging (eg, altered consciousness
and other physical signs of head trauma), signs of older intracranial
trauma may retrospectively explain previously seen nonspecific signs
and also serve as markers of previous assaults.10,16 In
the most severe cases, which usually result in death or severe neurologic consequences, the child usually becomes immediately unconscious and suffers rapidly escalating, life-threatening central nervous system dysfunction.
A caretaker who violently shakes a young infant, causing
unconsciousness, may put the infant to bed hoping or expecting that the
baby will later recover.5 Thus, the opportunity for early
therapeutic intervention may be lost.6 When brought to
medical attention, the brain-injured infant may be convulsing, may have
altered consciousness, may not be able to suck or swallow, and may be
unable to track with eye movements, smile, or vocalize. Occasionally,
the comatose state may be unrecognized by caretakers or medical
providers who assume that the infant is sleeping, lethargic, or
suffering from a minor acute ailment or possibly an infection. Respiratory difficulty progressing to apnea or bradycardia, which requires cardiorespiratory resuscitation, results from severe injuries.4,5
Evidence of other injuries, such as bruises, rib fractures, long-bone
fractures, and abdominal injuries, should be meticulously searched for
and documented. Any external injuries should be documented with
forensic photographs labeled with the patient's name and the
date. Repeated physical examinations may reveal additional signs of
trauma. In 75% to 90% of cases, unilateral or bilateral retinal
hemorrhages are present but may be missed unless the child is examined
by a pediatric ophthalmologist, pediatric neurologist, pediatric
neurosurgeon, or other experienced physician who is familiar with such
hemorrhages, has the proper equipment, and dilates the child's
pupils.4,5,21 The number, character, location, and size of
retinal hemorrhages after a shaking injury vary from case to case. More
severe retinal hemorrhages are associated with more dire brain
injury.22 Retinal and vitreous hemorrhages and
nonhemorrhagic changes, including retinal folds and traumatic
retinoschisis, are characteristic of shaken baby
syndrome.21,23,24
At times, the clinical signs suggest meningitis, and a spinal tap
yields bloody cerebrospinal fluid.4 Centrifuged spinal
fluid that is xanthochromic should raise the suspicion of cerebral
trauma that is at least several hours old and not the result of a
traumatic spinal tap. Because of confusing respiratory symptoms, chest
roentgenograms may be obtained and may appear normal or show
unexplained rib fractures. The shaken infant is often mildly to
moderately anemic.25 Clotting dysfunction from cerebral
trauma should be assessed initially and followed up. Mild to moderate
changes in coagulation studies are common with brain trauma and
occasionally severe (eg, disseminated intravascular coagulation).26 High amylase levels may signify pancreatic damage, and elevated transaminase levels may indicate occult liver injury.27
CT has the first-line role in the imaging evaluation of a
brain-injured child, adequately demonstrating injuries that need urgent
intervention. CT often fails to reveal some aspects of the injury, and
some false-negative results occur, particularly early in the evolution
of cerebral edema.28 The initial CT evaluation should be
performed without intravenous contrast and should be assessed using
bone and soft-tissue windows. CT is generally the method of choice for
demonstrating subarachnoid hemorrhage, mass effect, and large
extra-axial hemorrhages.28 CT should be repeated after a
time interval or if the neurologic picture changes
rapidly.29
MRI is of great value as an adjunct to CT in the evaluation of brain
injuries in infants.30 Because of the lack of universal
availability of the technology, physical limitations of access to MRI
when life support is required for critically ill infants or children,
and relative insensitivity to subarachnoid blood and fractures, MRI is
considered complementary to CT and should be obtained 2 to 3 days later
if possible. Sato et al28 have demonstrated a 50% greater
rate of detection of subdural hematomae using MRI, compared with CT.
The ability to detect and define intraparenchymal lesions of the brain
is substantially improved by use of MRI, yet in the study by Sato et
al,28 CT did not miss any surgically treatable
injuries. MRI and CT can assist in determining when injuries
occurred and substantiating repeated injuries by documenting changes in
the chemical states of hemoglobin in affected areas.28
A skeletal survey of the hands, feet, long bones, skull, spine, and
ribs should be obtained as soon as the infant's medical condition
permits. Skull films complement CT bone windows in detection of skull
fractures. In a retrospective series of abused children, skull films
were more sensitive and improved the confidence of diagnosis of skull
fracture, compared with CT.31 Skull fractures that are
multiple, bilateral, diastatic, or that cross suture lines are more
likely to be nonaccidental.31 Single or multiple fractures
of the midshaft or metaphysis of long bones or rib fractures may be
associated findings. Specialized views may be needed to delineate
subtle fractures.30 In selected patients, a skeletal
survey should be repeated after 2 weeks to better delineate new
fractures that may not be apparent until they begin to heal (a process
that does not become radiologically apparent for 7-10
days).30
Subdural hemorrhage caused by the disruption of small bridging
veins that connect the dura to the pia arachnoid is a common result of
shaking.7,8 Such hemorrhage may be most prominent in the
interhemispheric fissure and minimal over the convexities of the
hemispheres.5 Cerebral edema with subarachnoid hemorrhage
may be the only finding. A child may have subdural hemorrhages,
subarachnoid hemorrhages, or both. Intracranial or retinal hemorrhages
may be unilateral or bilateral. Visible cerebral contusions are
unusual, but diffuse axonal injury is common.32 However,
for technical reasons, it is often not possible to demonstrate this
pathologically or radiologically in individual cases. Isolated or
concomitant hypoxic-ischemic damage may result in mild to severe
cerebral edema initially and cerebral atrophy and/or infarction as a
later finding. Chronic extra-axial fluid collections, cerebral atrophy,
and cystic encephalomalacia are common late sequelae.29
Sequential cranial imaging studies are recommended. The diagnostic
entity of "benign subdural effusions" should be viewed with
caution, because multidisciplinary evaluations in previously described
cases were lacking.33
There is a high rate of morbidity and mortality among infant
victims of shaken baby syndrome.2,4,11,16 Mortality rates
range from 15%4 to 38%,10 with a median of
20% to 25%. In one series, of those infants who were comatose when
initially examined, 60% died or had profound mental retardation,
spastic quadriplegia, or severe motor dysfunction. Other infants
initially had seizures, irritability, or lethargy but had no
lacerations or infarctions of brain tissue. These children did not have
severely elevated intracranial pressure, subtle neurologic sequelae, or
persistent seizures.29 When severely brain-injured children survive, they may be cortically blind; have spasticity, seizure disorders, or microcephaly; or have chronic subdural fluid collections, enlarging ventricles, cerebral atrophy, encephalomalacia, or porencephalic cysts.28 The outcome of shaken infants who do not receive medical attention is presently unknown but may be
revealed later as learning, motor, or behavior problems of unknown
cause.
Because the differential diagnosis of head trauma is predominately
that of accidental versus inflicted injury, prompt and accurate
investigation is essential. A carefully recorded time line of the
child's condition is of great assistance in determining when injuries
may have occurred. Suspicion of serious head injury as a result of
abuse must be reported immediately to the appropriate authorities. This
facilitates a thorough investigation before the histories become
clouded by time or caregivers compare or invent explanations. The
clinical team should include a physician who can immediately
resuscitate and stabilize the baby while diagnostic radiologic studies
are being done. Specialists in pediatric radiology, pediatric neurology
and/or pediatric neurosurgery, and ophthalmology and a pediatrician who
specializes in child abuse should form the diagnostic team. Many
children will need to be followed in a pediatric intensive care unit.
In rural or medically underserved areas in which one or more of these
specialists are not available, a regional consultation network for
child abuse cases should be developed. Careful follow-up by this same
team is desirable to document and treat ocular, developmental, and
neurologic sequelae of the trauma. Ideally, a physician who works with
a multidisciplinary child abuse team should be available to take a
broad but detailed history from the caretakers. Information regarding
symptom onset and information regarding the chain of caretakers needs
to be quickly passed on to mandated law enforcement and child
protection investigators. Physicians can provide interpretation of the
likely scenario, timing, and nature of the injuries
involved.34 If notified promptly, investigators may be
able to explore the scene of the injury and elicit detailed information
from the caretaker before defensive reactions develop. A psychosocial
assessment of the caretakers should be a part of this comprehensive
team approach. Siblings or other children in the same environment may have signs of inflicted trauma or repeated shaking.9 Therefore, medical and child protection assessments need to be available immediately to ensure the current and future safety of these
children.
As a part of anticipatory guidance, the pediatrician should ask
about caretaker stress, discipline practices, substance abuse, and
response to the crying infant. The efficacy of home visitation programs
in preventing intrafamilial physical abuse is established. Nationwide
home visitation programs have been repeatedly recommended by the US
Advisory Board on Child Abuse and Neglect.2,35 Because
males commit most physical abuse, special programs should also be
developed to target them. Shaken baby syndrome awareness programs that
erroneously state that shaken baby syndrome may be caused by bouncing a
child on a knee, by tossing him in the air, or even by rough play are
to be discouraged, because they are inaccurate and may cause parents
who have not abused their child to feel guilty.1 Whether
or not educational efforts will prevent critically stressed or
homicidal adults from violently shaking babies needs to be evaluated.
The prevention of extrafamilial abuse in out-of-home care settings is
more problematic. Careful checking of references, frequent unannounced
visits, and conversations with others who use the same caretaker may be
valuable, but there are no data available to verify the efficacy of
these preventive measures as there are for home visitation programs.
Shaken baby syndrome is a clearly definable medical condition. A
proper response requires integration of specific clinical management
and community intervention in an interdisciplinary fashion. Greater
attention and resources should be devoted to prevention of abusive
injuries.
The American Academy of Pediatrics recommends that pediatricians:
INTRODUCTION
Top
Abstract
Introduction
Conclusion
Recommendation
References
HISTORY
ETIOLOGY
EPIDEMIOLOGY
CLINICAL FEATURES AND EVALUATION
RADIOLOGY
PATHOLOGY
OUTCOME AND CONSEQUENCES
CLINICAL AND COMMUNITY MANAGEMENT OF ABUSIVE HEAD INJURIES
PREVENTION
SUMMARY
Top
Abstract
Introduction
Conclusion
Recommendation
References
RECOMMENDATIONS
Top
Abstract
Introduction
Conclusion
Recommendation
References
Committee on Child Abuse and Neglect, 2000-2001
Steven W. Kairys, MD, MPH, Chairperson
Randell C. Alexander, MD, PhD
Robert W. Block, MD
V. Denise Everett, MD
Lt Col Kent P. Hymel, MD
Carole Jenny, MD, MBA
Liaison Representatives
Gene Ann Shelley, PhD
Centers for Disease Control and Prevention
David L. Corwin, MD
American Academy of Child and Adolescent Psychiatry
Section Liaison
Robert M. Reece, MD
Section on Child Abuse and Neglect
Staff
Tammy Piazza Hurley
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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CT, computed tomography; MRI, magnetic resonance imaging.
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REFERENCES |
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Abstract
Introduction
Conclusion
Recommendation
References
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- Alexander R, Levitt C, Smith W. Abusive head trauma. In: Reece RM, Ludwig S, eds. Child Abuse: Medical Diagnosis and Management. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2001:47-80
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Pediatrics (ISSN 0031 4005). Copyright ©2001 by the American Academy of Pediatrics
The following policy statement is a revision:
- Abusive Head Trauma in Infants and Children
- Cindy W. Christian, Robert Block and the Committee on Child Abuse and Neglect
Pediatrics 2009 123: 1409-1411.[Abstract] [Full Text] [PDF]
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