Shaken Baby/Shaken Impact Syndrome
July 19, 2004, KidsHealth.org
Several years ago, when a young au pair from Great Britain was charged in the death of the 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 Matthew Eappen'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 the leading cause of death in child abuse cases in the United States. The syndrome results from injuries caused by someone vigorously shaking an infant, usually for 5 to 20 seconds, which causes brain damage. In some cases, the shaking is accompanied by a final impact to the baby's head against a bed, chair, or other surface.
Although SBS is occasionally seen in children up to 4 years old, 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. 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 (and any type of child abuse).
How It Happens
When someone forcefully shakes a baby, the child's head rotates about uncontrollably because infants' neck muscles are not well developed and provide little support for the head. 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 is important never to shake a baby under any circumstances because gentle shaking can rapidly escalate. Pediatrician Allan DeJong, MD, says, "When you shake your baby hard enough to give them these injuries, you know you've crossed the line. This is something violent."
To diagnose SBS, doctors 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, and bruises around the head, neck, or chest.
SBS often has irreparable consequences. In the worst cases, the death rate is almost half of all babies involved. Children who survive may suffer partial or total blindness, hearing loss, seizures, developmental delays, impaired intellect, speech and learning difficulties, problems with memory and attention, or paralysis (some particularly traumatic episodes leave children in a coma). Severe mental retardation may also result.
Even in milder cases, where the baby looks normal immediately after the shaking, he 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. By that time, however, it is more difficult to link these problems to a shaking incident from several years before.
Effects of SBS
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, where the infants don't exhibit such severe symptoms, they may never be brought to medical attention.
In milder cases, the infant may seem lethargic or irritable or perhaps will not be feeding well. Unfortunately, unless a doctor has reason to suspect SBS, these cases are often misdiagnosed as a viral illness or colic. "Their brain may have been scrambled [by the shaking], but not to the point of significant brain injury, yet they could have been a shaken baby," Dr. DeJong notes. Lacking a diagnosis of SBS and subsequent intervention, these children may be shaken again, worsening any brain injury or damage.
Besides lethargy, a baby who has been shaken may experience 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 his head, or an inability to focus his eyes or track movement.
What makes SBS so devastating is that it usually involves a total brain injury. Because the infant's brain has little stored information and few developed capacities to make up for the deficit, the brain's adaptive abilities are substantially impaired, says Jane Crowley, PsyD, a pediatric rehabilitation psychologist. For example, a child whose vision is severely impaired will not be able to learn through observation, which decreases his 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 was a victim of 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 his ability to pay attention. Therapists use sound and other stimuli to increase the child's interest in objects, such as repeatedly squeaking a toy near his ear. As he gets older, a child who was shaken as a baby may require special education and continued therapy to help with language development and daily living skills, such as dressing himself.
Can SBS Be Prevented?
While the consequences of SBS are terrible, it is important to remember that the syndrome is 100% preventable. The perpetrators in SBS cases are almost always parents or caregivers, who shake the baby out of frustration when he is crying inconsolably. It is estimated that males, often in their early 20s, usually either the baby's father or the mother's boyfriend, are the perpetrators in 65% to 90% of cases. Caregivers who shake babies usually do so out of the stress of dealing with a fussy baby. Sadly, the shaking has the desired effect: although at first the baby cries more out of fear, he eventually stops crying as his brain is damaged.
Finding ways to alleviate the caregiver's stress at these critical moments will significantly reduce the risk to the child. If a baby in your care won't stop crying, try the following:
- make sure the baby's basic needs are met (for example, he 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 him
- offer the baby a pacifier or a noisy toy
- take him for a ride in his stroller or in his car seat in the car
- swaddle the baby snugly in a blanket
- turn on the stereo, run the vacuum cleaner or the clothes dryer, or run water in the tub (babies like rhythmic noise)
- 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 back in his crib, close the door, and check on him in 10 minutes