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==Overview==
{{SK}} abusive head trauma, the battered-child syndrome, the whiplash shaken infant syndrome, nonaccidental head injury, nonaccidental head trauma, inflicted traumatic brain injury,  shaken impact syndrome
'''Shaken baby syndrome''' ('''SBS''') is a form of [[child abuse]] that is thought to occur when an abuser violently shakes an infant or small child, creating a [[whiplash (medicine)|whiplash]]-type motion that causes acceleration-deceleration injuries.  The injury is estimated to affect between 1,200 and 1,600 children every year in the USA.<!--
  --><ref name="NCIPC_factsheet">{{cite web | author=National Center for Injury Prevention and Control | title=Child Maltreatment: Fact Sheet | publisher=[[Centers for Disease Control and Prevention]] (CDC) | url=http://www.cdc.gov/ncipc/factsheets/cmfacts.htm | date=7th September 2006 }}</ref> A remarkable feature of SBS is the typical lack of external evidence of trauma. The combination of shaking with striking of the infant against a hard object is sometimes termed the '''shaken impact syndrome'''. 
 
The concept of SBS was initially described in the early 1970s, based on a theory and a wide variety of circumstances by Dr. John Caffey, a radiologist, as well as Dr. Norman Guthkelch, a neurosurgeon.<!--
  --><ref>{{cite journal | author=Caffey J | title=On the theory and practice of shaking infants. Its potential residual effects of permanent brain damage and mental retardation | journal=Amer J Dis Child | year=1972 | volume=124 | pages=161-169 | url=http://archpedi.ama-assn.org/content/vol124/issue2/index.dtl}} - in Archives of Pediatrics & Adolescent Medicine</ref><ref>{{cite journal | author = David TJ| title = Shaken baby (shaken impact) syndrome: non-accidental head injury in infancy. | journal = J R Soc Med | volume = 92 | issue = 11 | pages = 556-61 | year = 1999 | id = PMID 10703491 | url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=10703491 | format=PDF}}</ref>
SBS, a major cause of mortality in infants, is often fatal and can produce lifelong disability from [[brain damage|neurological damage]].  Up to 50% of deaths related to child abuse are reportedly due to shaken baby syndrome.<ref>{{cite book | author= Montelenone JA, Brodeur AE. | title= Child maltreatment, a clinical guide and reference. | date=1994 | publisher= GW Medical Publishing. St Louis}}</ref>  About 25% to 30% of infant victims with SBS die from their injuries.{{fact|date=Sepbember, 2007}}  Nonfatal consequences of SBS include varying degrees of visual impairment (e.g., [[blindness]]), motor impairment (e.g. [[cerebral palsy]]) and [[cognitive deficit|cognitive impairment]]s.
 
==Signs and symptoms==
The signs associated with inflicted SBS include retinal hemorrhages, [[petechia]]e (small, pinpoint hemorrhages) on the body or face, multiple fractures of the long bones, and [[subdural hematoma]]s.<!--
  --><ref name="Clemetson2006">{{cite journal | author=Clemetson CAB | title=Caffey Revisited: A Commentary on the Origin of "Shaken Baby Syndrome." | journal=J Am Phys Surg | year=2006 | month=Spring | volume=11 | issue=1 | pages=20-1 | url=http://www.jpands.org/vol11no1/clemetson.pdf | format=PDF}}</ref>
These signs have evolved through the years as the accepted and recognized signs of child abuse and the shaken baby syndrome. Additional effects of SBS are [[diffuse axonal injury]], [[hypoxia (medical)|oxygen deprivation]] and [[cerebral edema|swelling of the brain]], which can raise [[intracranial pressure]] and damage delicate brain tissue.
 
Most victims of SBS are under one year old. Victims of SBS may display irritability, [[failure to thrive]], alterations in eating patterns, [[lethargy]], [[vomiting]], [[seizure]]s, bulging or tense [[fontanel]]s, increased size of the head, altered respirations, and dilated [[pupil]]s.<ref name="biausa">[http://www.biausa.org/Pages/types_of_brain_injury.html#shaken Types of brain injury: Shaken baby syndrome]. Brain Injury Association of America.  Retrieved on September 24, 2007.</ref> Medical professionals strongly suspect shaking as the cause of injuries when a baby or small child presents with retinal hemorrhage, [[bone fracture|fractures]], [[soft tissue]] injuries or subdural hematoma, that cannot be explained by accidental trauma or other medical conditions. No alternative condition mimics all of the symptoms of SBS exactly, but those that must be ruled out include [[hydrocephalus]], [[sudden infant death syndrome]] (SIDS), [[seizure disorder]]s, and [[infectious disease|infectious]] or [[congenital disease]]s like [[meningitis]] and [[metabolic disorder]]s.<!--
  --><ref name="Oral">{{cite web | author=Oral R | title=Intentional head yrauma in infants: Shaken baby syndrome | publisher=Virtual Children's Hospital | date=August 2003 | url=http://web.archive.org/web/20050214084615/http://www.vh.org/pediatric/provider/pediatrics/shakenimpactsyndrome/ | format=Archived }}</ref>
 
[[Fracture]]s of the [[vertebrae]] and [[ribs]] may also be associated with SBS. Although several [[bone disorder]]s may also cause increased vulnerability to fractures, they can be distinguished from inflicted trauma by other characteristic alterations of the bones, by [[genetic testing|gene tests]], and by the absence of corroborative evidence of abuse. The principal disorders known to cause increased susceptibility to fracture without other obvious evidence of bone abnormality are the various moderate-severity forms of [[osteogenesis imperfecta]].<!--
  --><ref>{{cite web | title=Fast Facts on Osteogenesis Imperfecta | url=http://www.oif.org/site/PageServer?pagename=FastFacts | publisher=Osteogenesis Imperfecta Foundation | date=August 2005 }}</ref>
Although bone disease of prematurity, [[rickets]] due to vitamin D deficiency,<!--
  --><ref>{{cite web | author=Chudgar P | title=Radiology In Rickets | publisher=Pediatric Oncall - Child Health Care | url=http://www.pediatriconcall.com/fordoctor/BiochemicalProfile/radiology_in_rickets.asp}}</ref> [[Scurvy]] (vitamin C deficiency),<!--
  --><ref>{{cite web | author=Chudgar P | title=Radiology In Scurvy | publisher=Pediatric Oncall - Child Health Care | url=http://www.pediatriconcall.com/fordoctor/DiseasesandCondition/radiologic_scurvy.asp }}</ref><!--
  --><ref name="Scheibner V">{{cite journal | author = Scheibner V | title = "Shaken Baby Syndrome Diagnosis on Shaky Ground." | journal = “Journal of the Australasian College of Nutritional and Environmental Medicine” | volume = 20 | issue = 2 | pages = 5-8,15 |
url= http://www.acnem.org/journal/pdf_files/20-2_august_2001/20-2_shaken_baby_syndrome.pdf | format=PDF | year = 2001 | month =Aug }}</ref>
copper deficiency and [[Menkes disease]] can increase fracture susceptibility, the bone disease is accompanied by additional evidence allowing it to be easily distinguished from abuse in nearly all cases.<!--
  --><ref>{{cite journal | author = Paterson C, Burns J, McAllion S | title = Osteogenesis imperfecta: the distinction from child abuse and the recognition of a variant form. | journal = Am J Med Genet | volume = 45 | issue = 2 | pages = 187-92 | year = 1993 | month=January 15 | id = PMID 8456801}}</ref><!--
  --><ref>{{cite web | author=Paterson C | title=Bone diseases that lead to false allegations of non-accidental injury | work=NCHR's Symposium "Corruption and miscarriages of justice in child care cases" in  Gothenburg, Sweden | date=June 5, 2004 | url=http://www.nkmr.org/english/bone_diseases_that_lead_to_false_allegations_of_child_abuse.htm | }}</ref><!--
  --><ref>{{cite journal | author=Paterson C | title=Radiological features of the brittle bone diseases | journal=Journal of Diagnostic Radiography and Imaging | year=2003 | volume=5 | pages=39-45 | url=http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=337357#top | format=Abstract | doi=10.1017/S1460472803000075}}</ref>
In addition to [[Barlow's Disease]]<!--
  --><ref name="Möller">{{cite web | title=Möller-Barlow Disease | url=http://www.whonamedit.com/synd.cfm/1151.html | publisher=[[Who Named It]]}}</ref><!--
  --><ref>{{cite journal | author= | title= “Medical History - Infantile scurvy: the centenary of Barlow's disease”| url= http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1550031&blobtype=pdf
| format=PDF  |  journal= British Medical Journal |  volume = 287 |  date=December 17, 1983}}</ref><!--
  --><ref name="Clemetson2004">{{cite journal | author=Clemetson CAB | title=Was it "shaken baby" or a variant of Barlow's disease? | journal=J Am Phys Surg" | year=2004 | volume=9 | pages=78-80 | url=http://www.jpands.org/vol9no3/clemetson.pdf | format=PDF}}</ref> or scurvy,<!-- 
--><ref>{{cite book | author= Hess, A. | title= Scurvy Past and Present. | date=1920 | publisher= J.P. Lippincott Company. Philadelphia and London. 1920}}</ref><!--
  --><ref>{{cite web | author=Rothschild B, Sebes J | title=Scurvy | url=http://www.emedicine.com/radio/topic628.htm | publisher=[[Emedicine|eMedicine.com]]}}</ref><!--
  --><ref>{{cite journal | author=Suman R, Dabi D | title= Scurvy-An Unusual Cause of  Proptosis? | journal=Indian Pediatrics | year=1998 | volume=35 | pages=915-6 | url=http://www.indianpediatrics.net/sep1998/sep-915-916.htm }}</ref><!--
  --><ref>{{cite journal | author = Sloan B, Kulwin D, Kersten R | title = "Scurvy causing bilateral orbital hemorrhage." | journal = Arch Ophthalmol | volume = 117 | issue = 6 | pages = 842-3 | url=http://archopht.ama-assn.org/cgi/content/extract/117/6/842 | year = 1999 | month=Jun | id = PMID 10369606 | format=Abstract}}</ref>
a number of medical conditions,<!--
  --><ref>{{cite journal | author = Rutty GN, Smith CM, Malia RG | title = Late-form hemorrhagic disease of the newborn: a fatal case report with illustration of investigations that may assist in avoiding the mistaken diagnosis of child abuse.| journal = Forensic med Pathol. | volume = 20 | issue = 1 | pages = 48-51 | year = 199 | month= Mar | id = PMID  10208337}}</ref> including malformations,<!-- 
  --><ref>{{cite journal | author = Beraud C, Sobotska F, Cret E. | title =  Osseous scurvy in an 11-month-old infant. Radiological course. | journal = J Radiol Electrol Med Nuc. | volume = 56 | issue = 6-7 | pages = 527-30 | year = 1975 | month=Jun-Jul | id = PMID 1177197 |
url=}} </ref> premature infants,<!--
--><ref>{{cite journal | author = Fledelius HC| title = Retinal haemorrhages in premature infants: a pathogenetic alternative diagnosis to child abuse. | journal = Acta Ophthalmologica Scandinavica  | volume = 83 | issue = 4 | pages = 424-427 | url= http://www.ingentaconnect.com/search/article?title=Shaken+Baby&title_type=tka&year_from=1998&year_to=2007&database=1&pageSize=20&index=6 | year = 2005 | month= Aug  }}</ref> can mimic SBS, even before birth.<!--
--><ref name=“Cushing”>{{cite journal | author = Cushing H | title = Reprint of “Concerning Surgical Intervention for the Intracranial Hemorrhages of the New-born” (1905) | journal = Child's Nervous System | volume = 16 | issue= Classics in Pediatric Neurosurgery |pages = 484-492|  year = 2000 | id = PMID 11007498 | url= http://www.springerlink.com/content/ue6mbcn20g5ae45j/ }}</ref><!--
  --><ref name=“Williams 1997”>{{cite book | author=''Williams Obstetrics'' | title= Diseases and Injuries of the Fetus and Newborn| volume= 20 | chapter=Chapter 20 | date=1997 | pages=page 997-998 | publisher= Appleton & Lange, Stamford, CT | id=ISBN 0-8365-9638-X}}</ref><!--
  --><ref name=“Williams 2005”>{{cite book | author=''Williams Obstetrics'' | title= Diseases and Injuries of the Fetus and Newborn| volume= 22 | chapter=Chapter 29 | date=2005 | pages=page 649-691 | publisher= McGraw-Hill Companies | id=ISBN 0-07-141315-4}}</ref><!--
  --><ref name=“Looney”>{{cite journal | author =  Looney CB, et.al| title =  Intracranial Hemorrhage in Asymptomatic Neonates: Prevalence on MR Images and Relationship to Obstetric and Neonatal Risk Factors | journal = Radiology
| volume = 242 | pages = 535-541|  year = 2007 | id = PMID 17179400 | url= http://radiology.rsnajnls.org/cgi/content/abstract/242/2/535 }}</ref><!--
--><ref>{{cite journal | author= Position Statement: Fetus and Newborn Committee, Canadian Paediatric Society (CPS)  | title= “Routine screening cranial ultrasound examinations for the prediction of long term neurodevelopmental outcomes in preterm infants.”|journal= Paediatrics & Child Health" | year=2001 | volume=6 | issue=(1) | pages=39-43 | url= http://www.cps.ca/english/statements/FN/fn01-01.htm }}</ref>
 
Examination by an experienced [[ophthalmologist]] is often critical in diagnosing shaken baby syndrome, as particular forms of ocular bleeding are quite characteristic of this condition.<!--
  --><ref>{{cite web | author= | title= Shaken Baby Syndrome Resources |
url= http://www.aao.org/education/library/statements/shaken_baby.cfm#ocular
| work=| publisher= American Academy of Ophthalmology }}</ref>
 
Some medical experts assert that "no case studies have ever been undertaken to probe even a partial list of possible confounding variables/phenomena, such as the presence of intracranial cysts or fluid collections, hydrocephalus, congenital and inherited diseases, infection, coagulation disorders and venous thrombosis, recent immunizations,"<!--
  --><ref>{{cite journal | author = Devin F, Roques G, Rodor P and Weiller PJ. | title = "Occlusion of central retinal vein after hepatitis B vaccination."  | journal = “Lancet” | volume = 347 | issue = 9015 | pages = 1626 | year = 1996 | month=June 8 | id = PMID 8667894 |
url=}} </ref> ''medications, birth-related brain injuries,''<!--
    --><ref>{{cite journal | author = Schoenfeld MD, Buckman G, Nissenkorn MD, Cohen S, Ben-Sira I, Ovadia J. | title = "Retinal Hemorrhages on the Newborn Following Labor Induced by Oxytocin or Dinoprostone." | journal = Arch Opthalmol | volume = 103 | issue = 7 | pages = 932-4 | year = 1985 | month=Jul | id = PMID 3860196 | url= http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed}} </ref> "or recent or remote head trauma. Until and unless these and probably many more factors are evaluated, it is inappropriate to select one mechanism only and ignore the rest of the potential causes."<!--
  --><ref>{{cite journal | author=Leestma J | title="Shaken Baby Syndrome": Do Confessions by Alleged Perpetrators Validate the Concept? | journal=J Am Phys Surg | year=2006 | volume=11 | pages=14-6 | url=http://www.jpands.org/vol11no1/leestma.pdf | format=PDF }}</ref>
 
In 2005, a review of several ophthalmology studies and their findings concerning "inflicted childhood neurotrauma" (SBS) was published in the UK, in the quarterly ophthalmology publication ''Focus.''<!--
    --><ref name="Newman W">{{cite journal | author = Newman W | title = Inflicted Childhood Neurotrauma - Non Member Update Contribution | journal = "Focus" - Occasional Update From The Royal College of Ophthalmologists | volume = 80 | issue = 33 |  year = 2005 | month= Spring  | url= http://www.rcophth.ac.uk/docs/members/focus-collegenews/FocusSpring05.pdf | format=PDF }}</ref> One of the studies "found a correlation between intra-ocular bleeding, anterior optic nerve haemorrhage and subdural haematomas. Post mortem findings of vitreous traction at the apex of retinal folds and the edge of dome shaped haemorrhages and retinoschisis gives some supporting evidence that vitreous forces may cause this shearing damage. There is no adequate model to test this experimentally, so this remains hypothesis, not established fact."<!-- 
    --><ref>{{cite journal | author = Green MA, Lieberman G, Milroy CM, Parsons MA | title = Ocular and cerebral trauma in non-accidental injury in infancy: underlying mechanisms and implications for paediatric practice | journal = Br J Ophthalmol. | volume = 80 | issue = 4 | pages = 282-7 | year = 1996 | month=Apr | id = PMID 8703874 |
url= http://bjo.bmjjournals.com/cgi/content/abstract/80/4/282}}</ref>
 
The main scientific finding of two additional studies<!--
--><ref name="Geddes I">{{cite journal | author = Geddes J, Hackshaw A, Vowles G, Nickols C, Whitwell H | title = Neuropathology of inflicted head injury in children. I. Patterns of brain damage. | journal = Brain | volume = 124 | issue = Pt 7 | pages = 1290-8 | year = 2001 | month=Jul | id = PMID 11408324 | url=http://brain.oxfordjournals.org/cgi/content/full/124/7/1290}}</ref><!--
  --><ref name = "Geddes II">{{cite journal | author = Geddes J, Vowles G, Hackshaw A, Nickols C, Scott I, Whitwell H | title = Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants. | journal = Brain | volume = 124 | issue = Pt 7 | pages = 1299-306 | year = 2001 | month=Jul | id = PMID 11408325 | url=http://brain.oxfordjournals.org/cgi/content/full/124/7/1299}}</ref> from the ''Focus'' article "was that in cases of retinal haemorrhages with thin film subdurals and in the absence of other injuries that the pathological finding is more commonly that of hypoxic ischaemic encephalopathy rather than diffuse axonal injury. Regardless of the recent debate the observational evidence to date remains that children with non accidental injury may have no visible retinal haemorrhages, whilst non accidental injury and birth are the only circumstances in which multiple retinal haemorrhages in differing layers of the retina have been accurately documented."<!--
  --><ref name="Newman W"/>
 
The following references documented cases of retinal hemorrhages from accidental head trauma<!--
  --><ref>{{cite journal | author = Lantz P E, Sinal S H, Stanton C A and Weaver, Jr R G
| title =  Perimacular retinal folds from childhood head trauma. | journal = BMJ | volume = 328 | issue = 7442 | pages = 754-6 |
url= http://bmj.bmjjournals.com/cgi/reprint/328/7442/754?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Perimacular&searchid=1&FIRSTINDEX=0&volume=328&issue=7442&resourcetype=HWCIT | year = 2004 | month=Mar | id = PMID 15044292}}</ref>
a videotaped minor fall,<!--
  --><ref>{{cite journal | author = Goldsmith W, Plunkett J | title =  Review: A biomechanical analysis of the causes of traumatic brain injury in infants and children. | journal = Am J Forensic Med Pathol. | volume = 25 | issue = 2 | pages = 89-100 | year = 2004 | month=Jun | id = PMID 15166757 |
url= http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed}} </ref>
osteogenesis imperfecta<!--
    --><ref>{{cite journal | author = Ganesh A, Jenny C, Geyer J, Shouldice M, Levin AV.
| title = Retinal hemorrhages in type I osteogenesis imperfecta after minor trauma. | journal = Ophthalmology | volume = 111 | issue = 7 | pages = 1428-31| year = 2004 | month=Jul | id = PMID 15234150 |
url= }}</ref>
indicating that shaking is not the only possible cause of injury.  According to one author, "the presence of retinal hemorrhages is neither necessary nor sufficient for the diagnosis of child abuse."<!--
    --><ref>{{cite journal | author = Aryan1 HE, Ghosheh FR, Rahul Jandial R, Levy1ML
| title =  Retinal hemorrhage and pediatric brain injury: etiology and review of the literature.
| journal = J Clin Neurosci. | volume = 12 | issue = 6 | pages = 624-31 | year = 2005 | month=Oct | id = PMID 16115547  |
url= }}</ref> A postvaccinial ocular syndrome was reported as early as 1948,<ref>{{cite journal | author = Rosen E | title = A postvaccinial ocular syndrome |  journal = Am J Ophthalmol | volume = 31 | issue =  | pages = 1443-53 | year = 1948}}</ref> recent papers have been published concerning the occlusion of central retinal vein after hepatitis B vaccination,<!--
--><ref>{{cite journal | author = Devin F, Roques G, Disdier P, Rodor F, Weiller PJ. | title = Occlusion of central retinal vein after hepatitis B vaccination syndrome.|journal= Lancet|volume= 347|pages= 1626| year= 1996|month= Jun 8|id= PMID 8667894 }}</ref> "The compounding effects of [[anoxia]] or [[hypoxia]], [[anemia]], [[thrombocytopenia]], mild [[coagulopathy]], obstruction of retinal venous flow, or possible age-related anatomic variations in the retinal vasculature are not well understood."<!--
    --><ref name="Forbes">{{cite journal | author = Forbes BJ, Christian CW, Judkins AR, Kryston K.
| title =  Inflicted childhood neurotrauma (shaken baby syndrome): ophthalmic findings.
| journal = J Pediatr Ophthalmol Strabismus. | volume = 41 | issue = 2 | pages = 80-8 | year = 2004 | month= Mar-Apr | id = PMID 15089062  |
url=}}</ref>
 
==Anatomy and pathophysiology==
People under the age of three years are especially susceptible to brain damage from shaking.<ref name="Forbes"/> This is due to several anatomical factors. 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.<ref name="patel">{{cite web | author= Patel N and Moorjani B | title="Neonatal injuries in child abuse." | url= http://www.emedicine.com/neuro/topic238.htm |date=2007
| publisher=[[Emedicine|eMedicine.com]]}}</ref>  Infants' brains are not [[myelin]]ated; myelin sheaths form in childhood and are complete in [[adolescence]].  The brain water content is reduced as [[neuron]]s gain myelin during development, so babies have a greater percentage of brain water than adults do.<ref name="Singh">Singh J and Stock A. 2006. [http://www.emedicine.com/ped/topic929.htm Head Trauma].  Emedicine.com. Retrieved on September 23, 2007.</ref> Because of this higher water content, children's brains are softer and are much more susceptible to acceleration-deceleration injuries and diffuse axonal injury.<ref name="Singh"/> 
 
Rotation injury is especially damaging and likely to occur in shaking trauma.<!--
  --><ref name="Oral"/>
The type of injuries caused by shaking injury are usually not caused by falls and impacts from normal play, which are mostly linear forces.<!--
  --><ref name="Oral"/>
 
Rotation injury is also referred to as diffuse axonal injury (DAI). A report in 2001, reviewed the brains of 37 infants aged 9 months or less, all of whom died from inflicted head injuries, and 14 control infants who died of other causes. Axonal damage was identified using immunohistochemistry for ß-amyloid precursor protein. The observation that the predominant histological abnormality in cases of inflicted head injury in the very young is diffuse hypoxic brain damage, not DAI, can be explained in one of two ways: either the unmyelinated axon of the immature cerebral hemispheres is relatively resistant to traumatic damage, or in shaking-type injuries the brain is not exposed to the forces necessary to produce DAI.''<!--
  --><ref name="Geddes II"/> Apparently a critical point was missed or overlooked in a paper published in 1968<!--
  --><ref>{{cite journal | author = Ommaya AK, Faas F, Yarnell P | title = Whiplash injury and brain damage: an experimental study. | journal = JAMA | volume = 22 | issue = 204(4) | pages = 285-9 | year = 1968 | id = PMID 4967499}}</ref>
concerning the results of bioengineering study in conjunction with the U.S. Department of Transportation. This experiment showed, qualitatively, that rotation alone could indeed produce intracranial injury, though it was not shown quantitatively that human beings could generate the required rotational acceleration by manual shaking. This critical omission was not addressed until 19 years later, when it was shown quantitatively that impact was required to generate adequate force. Guthkelch, Caffey, and others either were not aware of, or disregarded, this critical missing piece of information. In the intervening years, and even up to the present, numerous references are made to infants sustaining inflicted brain injury by manual shaking. Yet no laboratory proof of this possibility has ever been put forth. In fact, the available experimental evidence began as far back as 1943, addressed directly in 1987<!--
  --><ref name="Duhaime">{{cite journal | author = Duhaime A, Gennarelli T, Thibault L, Bruce D, Margulies S, Wiser R | title = The shaken baby syndrome. A clinical, pathological, and biomechanical study. | journal = J Neurosurg | volume = 66 | issue = 3 | pages = 409-15 | year = 1987 | id = PMID 3819836}}</ref> and reproduced in 2003,<!--
  --><ref name="Prange">{{cite journal | author = Prange M, Coats B, Duhaime A, Margulies S | title = Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants. | journal = J Neurosurg | volume = 99 | issue = 1 | pages = 143-50 | year = 2003 | month=Mar | id = PMID 12854757 | url=http://scholar.google.com/scholar?hl=en&lr=&q=cache:IVXo29ZXQdkJ:www.thejns-net.org/jns/issues/v99n1/pdf/n0990143.pdf+author:%22Prange%22+intitle:%22Anthropomorphic+simulations+of+falls,+shakes,+and+...%22}}</ref>
seems to indicate the contrary.<!--
  --><ref name="Uscinski">{{cite journal | author=Uscinski R | title=The Shaken Baby Syndrome | journal=J Am Phys Surg | year=2004 | month=Fall | volume=9 | issue=3 | pages=76-7 | url=http://www.jpands.org/vol9no3/uscinski.pdf | format=PDF}}</ref><!--
  --><ref name="Ommaya">{{cite journal | author = Ommaya A, Goldsmith W, Thibault L | title = Biomechanics and neuropathology of adult and paediatric head injury. | journal = Br J Neurosurg | volume = 16 | issue = 3 | pages = 220-42 | year = 2002 | month=Jun | id = PMID 12201393}}</ref><!--
  --><ref name="Commonwealth">{{cite web | author=Commonwealth Of Kentucky VS. Christopher A. Davis | title=Case No.04-CR 205 | publisher=Greenup Circuit Court | url=http://www.aapsonline.org/sbs/daubert.pdf | format=PDF }}</ref>
 
"The assessment of the mechanical causation of injury requires training and experience in Injury Biomechanics, a distinct discipline not taught in medical school. Lack of education and experience in Injury Biomechanics, amongst other factors, has led in practice to the proliferation and propagation of inaccurate and sometimes erroneous information on SBS injury mechanisms in the literature." A recent biomechanical experiment in 2005, demonstrated that "forceful shaking can severely injure or kill an infant, this is because the cervical spine would be severely injured and not because subdural hematomas would be caused by high head rotational accelerations. Furthermore, shaking cervical spine injury can occur at much lower levels of head velocity and acceleration than those reported for the SBS. These findings are consistent with the physical laws of injury biomechanics as well as our collective understanding of the fragile infant cervical spine from (1) clinical obstetric experience, (2) automotive medicine and crash safety experience, and (3) common parental experience. We have determined that an infant head subjected to the levels of rotational velocity and acceleration called for in the SBS literature, would experience forces on the infant neck far exceeding the limits for structural failure of the cervical spine. Furthermore, shaking cervical spine injury can occur at much lower levels of head velocity and acceleration than those reported for the SBS.<!--
  --><ref name="Bandak">{{cite journal | author = Bandak F | title = Shaken baby syndrome: a biomechanics analysis of injury mechanisms. | journal = Forensic Sci Int | volume = 151 | issue = 1 | pages = 71-9 | year = 2005 | month=June 30 | id = PMID 15885948}}</ref>
 
In 2004, a Scottish database collected data for five years on cases of  suspected non-accidental head injury diagnosed after a multiagency assessment and included cases with uncoerced confessions of perpetrators and criminal convictions. Several patterns appeared allowing  the categorization of the cases into four predominant types: Hyperacute encephalopathy (6% of all cases); Acute encephalopathy (53% of cases (SBS));  Subacute non-encephalopathic presentation (19% of cases);  Chronic extracerebral presentation (22% of cases). Infants can be traumatically injured in many ways, and many instances are unwitnessed. Thus the generic term non-accidental head injury or inflicted traumatic brain injury is occasionally used in preference to shaken baby syndrome, which implies a specific mechanism of injury.<!--
  --><ref name="Minns">{{cite journal | author = Minns R, Busuttil A | title = Patterns of presentation of the shaken baby syndrome: four types of inflicted brain injury predominate. | journal = BMJ | volume = 328 | issue = 7442 | pages = 766 | year = 2004 | month=March 27 | id = PMID 15044297 | url=http://bmj.bmjjournals.com/cgi/content/full/328/7442/766}}</ref>
An earlier detailed neuropathological study was publish in the UK in 2001, which included immunocytochemistry for microscopic damage.<!--
--><ref name="Geddes I ">{{cite journal | author = Geddes J, Hackshaw A, Vowles G, Nickols C, Whitwell H | title = Neuropathology of inflicted head injury in children. I. Patterns of brain damage. | journal = Brain | volume = 124 | issue = Pt 7 | pages = 1290-8 | year = 2001 | month=Jul | id = PMID 11408324 | url=http://brain.oxfordjournals.org/cgi/content/full/124/7/1290}}</ref>
 
==Prognosis==
SBS kills about one third of its victims and permanently and severely disables another third.<!--
  --><ref name="Oral"/>
Problems resulting from SBS include learning disabilities, seizure disorders, speech disability, hydrocephalus, behavioral problems, [[cerebral palsy]], and visual disorders.<!--
  --><ref name="Oral"/>
 
== Prevention ==
Prevention is similar to the prevention of [[child abuse]] in general. New parents, babysitters, and other caregivers should be warned about the dangers of shaking infants.  Crying is a common trigger for creating irritation and frustration in the caregiver. Some experts have advised that caregivers need strategies to cope with their own frustrations; for example, they should be reminded that they are not always responsible when babies cry.
 
== SBS as a medicolegal concept ==
The legal import of shaken baby syndrome varies according to circumstances, often involving child welfare and criminal investigations.  Such investigations determine whether children are judged safe to remain in their parents / caregivers' care, and whether an individual may be charged with assault, child endangerment, or homicide. 
 
Since the inception of "whiplash shaking" evolving into SBS, the concept has been the subject of criticism by some scientists and jurists for years.
 
In April 2006, a Daubert hearing (a mini-trial within a trial, conducted before the judge only, not the jury, over the validity and admissibility of expert opinion testimony) was conducted concerning the admissibility of proposed medical and scientific evidence in a Kentucky Circuit Court case.<!--
  --><ref name="Commonwealth">Commonwealth Of Kentucky VS. Christopher A. Davis, Greenup Circuit Court [http://www.aapsonline.org/sbs/daubert.pdf CASE NO.04-CR 205]</ref>
A Grand Jury had indicted the defendant of first-degree criminal abuse by violently shaking a child. The Defendant alleges that the child's medical records indicate that the only significant injury for the victim was a subdural hematoma and retinal hemorrhaging and there was no significant bruising, fractures, or evidence of impact. The Commonwealth's case was based upon the theory of shaken baby syndrome.
 
The Court after hearing expert testimony and reviewing the evidence, issued the following conclusion and opinion:
"The Court can further conclude that based on the medical signs and symptoms, the clinical medical and scientific research communities are in disagreement as to whether it is possible to determine if a given head injury is due to an accident or abuse. Therefore, the Court finds that because the Daubert test has not been met, neither party can call a witness to give an expert opinion as to whether a child's head injury is due to a shaken baby syndrome when only the child exhibits a subdural hematoma and bilateral ocular bleeding. Either party can call a witness to give an expert opinion as to the cause of the injury being due to shaken baby syndrome, if and only, the child exhibits a subdural hematoma and bilateral ocular bleeding, and any other indicia of abuse present such as long-bone injuries, a fractured skull, bruising, or other indications that abuse has occurred."
 
The trial court's ruling is not considered binding legal precedent. The Commonwealth of Kentucky has appealed the ruling to the state's intermediate appellate court.<!--
  -->.<ref>Commonwealth v. Christopher A. Davis, Kentucky Court of Appeals, 2006-CA-002237 [http://apps.kycourts.net/Appeals/COA_Dockets.shtm]</ref>
 
In the Summer of 2006 a review of the Shaken Baby Syndrome and the Shaken Impact Syndrome was published in the ''Military Law Review''. This legal review contains an extensive examination of the divergent views of the scientific literature, in addition to examining the divergent views of the legal parameters involving a trial. <!--
  --><ref>{{cite journal | author =  Lt. Colonel MD Ramsey  | title =  "A Nuts And Bolts Approach To Litigating The Shaken Baby Or Shaken Impact Syndrome."
| journal =  Military Law Review - US Department of Army Pamphlet | volume =  27-100-188 | issue = | pages = 1-37 | year = 2006  | month = Summer  |  id =  ISSN 0026-4040 | url=
http://www.loc.gov/rr/frd/Military_Law/Military_Law_Review/pdf-files/188-summer-2006.pdf  }}</ref>
 
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.<!--
  --><ref>{{cite news | author= | title=Shaken baby convictions overturned | url=http://www.guardian.co.uk/child/story/0,,1533200,00.html  | work=Special Reports | date=Thursday July 21, 2005  | publisher=Guardian Unlimited }}</ref>
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 [non-accidental head injury] 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 edition of the ''[[British Medical Journal]]''<!--
  --><ref name="Minns">{{cite journal | author=Minns R, Busuttil A | title=Patterns of presentation of the shaken baby syndrome -- Four types of inflicted brain injury predominate | journal=BMJ | year=2004 | month=27 March | volume=328 | pages=766 | url=http://bmj.bmjjournals.com/cgi/content/full/328/7442/766 | doi=10.1136/bmj.328.7442.766}}- provides links to Editorials and a Clinical review</ref>
 
==Alternative hypotheses== 
 
An additional, alternative explanation for some incidents contemplated as shaken baby syndrome has been proposed. This explanation suggests that a [[vitamin C]] deficiency may sometimes play a role in the pathogenesis of shaken baby syndrome,<!--
  --><ref name="ClemetsonCAB">{{cite journal | author = Clemetson CAB | title = Capillary Fragility as a Cause of Substantial Hemorrhage in Infants." | journal = Medical Hypotheses And Research | volume = 1 | issue = 2/3 | pages = 121-129 | url= http://www.journal-mhr.com/PDF_Files/vol_1_2/1_2N3_PDFs/1_2N3_5.pdf| year = 2004 | month=Jul |format=PDF  }}</ref><!--
  --><ref name="Scheibner V">{{cite journal | author = Scheibner V | title = Shaken Baby Syndrome Diagnosis on Shaky Ground." | journal = “Journal of the Australasian College of Nutritional and Environmental Medicine” | volume = 20 | issue = 2 | pages = 5-8,15 |
url= http://www.acnem.org/journal/pdf_files/20-2_august_2001/20-2_shaken_baby_syndrome.pdf | format=PDF | year = 2001 | month=Aug }}</ref><!-- 
--><ref>{{cite book | author= Hess, A. | title= Scurvy Past and Present. | date=1920 | publisher= J.P. Lippincott Company. Philadelphia and London. 1920}}</ref><!--
--><ref>{{cite journal | author= | title= “Medical History - Infantile scurvy: the centenary of Barlow's disease”| url= http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1550031&blobtype=pdf
| format=PDF  |  journal= British Medical Journal |  volume = 287 |  date=December 17, 1983}}</ref><!--
  --><ref>{{cite journal | author= Rajakumar K| title= "Infantile Scurvy: A Historical Perspective”| pages= 76 |url= http://pediatrics.aappublications.org/cgi/reprint/108/4/e76.pdf | format=PDF  |  journal= Pediatrics |  volume = 108 |  year= 2001}}</ref> citing that the current SBS pathology determination may be seriously flawed or incomplete<!--
  --><ref name="patel"/><!--
--><ref>{{cite web | author=  Ricci LR and Botash AS | title= "Pediatrics, Child Abuse." | url= http://www.emedicine.com/emerg/topic368.htm  | publisher=[[Emedicine|eMedicine.com]]}}</ref><!--
  --><ref>{{cite journal | author = Fung ELW, Sung RYT, Nelson EAS, Poon WS | title = Unexplained subdural. hematoma in young children: is it always child abuse? | journal = "Pediatr. Int." | volume = 44 | issue = 1 | pages = 37-42 | url= http://www.blackwell-synergy.com/doi/abs/10.1046/j.1442-200X.2002.01500.x | year = 2002 | month=Jul | doi:10.1046/j.1442-200X.2002.01500.x}}</ref> This contested hypothesis is based upon a speculated marginal, near scorbutic condition or lack of essential nutrient(s) repletion and a potential elevated histamine level.<!--
  --><ref name="Clemetson2004">{{cite journal | author=Clemetson CAB | title=Was it "shaken baby" or a variant of Barlow's disease? | journal=J Am Phys Surg" | year=2004 | volume=9 | pages=78-80 | url=http://www.jpands.org/vol9no3/clemetson.pdf | format=PDF}}</ref><!--
--><ref name="Clemetson2006">{{cite journal | author=Clemetson CAB | title=Caffey Revisited: A Commentary on the Origin of "Shaken Baby Syndrome." | journal=J Am Phys Surg | year=2006 | month=Spring | volume=11 | issue=1 | pages=20-1 | url=http://www.jpands.org/vol11no1/clemetson.pdf | format=PDF}}</ref><!--
  --><ref>{{cite book | author= Johnston, C.S. | title= Ascorbic Acid; Biochemistry and Biomedical Cell Biology | volume=25 | chapter=Chapter 10) The Antihistamine Action of Ascorbic Acid | date=1996 | pages=page 189 | publisher= Plenum Press | id=ISBN 978-0-306-45148-5}}</ref><!--
  --><ref>{{cite journal | author = Johnston C S, Martin L J, and Cai X | title = Antihistamine effect of supplemental ascorbic acid and neutrophil chemotaxis.
| journal = J Am Coll Nutr | volume = 11 | issue = 2 | pages = 172-6 | url= http://www.jacn.org/cgi/content/abstract/11/2/172 | year = 1992 | month=Apr | id = PMID 1578094}}</ref><!--
--><ref>{{cite journal | author =Majno G, Palade GE | title =  I. The effect histamine and serotonin on  vascular permeability. An electron microscopic study. | journal = J Biophys Biochem Cytol | volume = 11 | issue = 3 | pages = 571-605 | year = 1961 | month=Dec | id = PMID 14468625 |
url=http://www.jcb.org/cgi/reprint/11/3/571| format=PDF}}</ref><!--
  --><ref>{{cite journal | author = Majno G, Palade GE, Schoefl GI. | title = II. The site of action of histamine and serotonin along the vascular tree: a topographic study. | journal = J Biophys Biochem Cytol | volume = 11 | issue = 3 | pages = 607-626 | year = 1961 | month=Dec | id = PMID 14468625 |
url=http://www.jcb.org/cgi/reprint/11/3/607 | format=PDF}}</ref><!--
  --><ref>{{cite journal | author =  Gore I, Fujinami T, Shirahama T. | title =  Endothelial changes produced by ascorbic acid deficiency in guinea pigs. | journal = Arch Pathol
| volume = 80 | issue = 2 | pages = 371-376 |  year = 1965 | month=Oct | id = PMID 5319838 |
url= http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed
}}</ref>
 
The proponents of such hypotheses often question the adequacy of nutrient tissue levels, especially vitamin C,<!--
  --><ref>{{cite journal | author = Dettman G| title = Factor "X", sub-clinical scurvy and S.I.D.S. Historical. Part 1.  | journal = Australas Nurses J |  volume = 7 | issue = 7 | pages = 2-5 | url= http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=418769&query_hl=18&itool=pubmed_docsum| year = 1978 | month= Mar | id = PMID 418769}}</ref><!-- 
--><ref>{{cite journal | author = Kalokerinos A | title = The sudden infant death syndrome. Part 2. Definition. Further clinical observations.| journal = Australas Nurses J |  volume = 7 | issue = 7 | pages = 6-8 | url= http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=418773&query_hl=1&itool=pubmed_docsum | year = 1978 | month= Mar | id = PMID 418769}}</ref><!--
  --><ref>{{cite journal | author = Kalokerinos A, Dettman A | title = The sudden infant death syndrome in Western Australia.  | journal = Med J Aust. |  volume = 2 | issue = 1 | pages = 31-32 | url= http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=979792&query_hl=5&itool=pubmed_DocSum | year = 1976 | month= July 3| id = PMID 979792 }}</ref> for those children currently or recently ill, bacterial infections, those with higher individual requirements, those suffering from environmental challenges (e.g. allergies), and perhaps transient vaccination related stresses.<!--
  --><ref>{{cite book | author=Institute of Medicine (IOM) | title= Adverse Effects of Pertussis and Rubella Vaccines  | chapter=Chapter 6) Evidence Concerning Pertussis Vaccines and Other Illnesses and Conditions -- Protracted Inconsolable Crying and Screaming | chapterurl=http://newton.nap.edu/books/0309044995/html/165.html | date=1991 | pages=page 165 | publisher=The National Academies Press | id=ISBN 0-309-04499-5}}</ref>  However, no cases of [[scurvy]] mimicking SBS or [[crib death]] have been reported, and scurvy typically occurs later in infancy, rarely causes death or intracranial bleeding, and is accompanied by other changes of the bones and skin and invariably an unusually deficient dietary history.
 
A number of medical personnel recommend that all SBS pathology determinations should include vitamin C repletion history and histamine/vitamin C levels. Additional medical recommendations for the use of vitamins and nutrients as a preventive measure, particularly vitamin C, should be used especially for children with known, projected or suspected stresses/conditions (vaccines) that may deplete certain nutrients.<!--
  --><ref >{{cite journal | author=Hattersley, JG | title=The Answer to Crib Death "Sudden Infant Death Syndrome" (SIDS) | journal=Journal of Orthomolecular Medicine | year=1993 | volume=8 | number=4 | pages=229-245 | url=http://www.seanet.com/~alexs/ascorbate/199x/hattersley-jg-j_orthomol_med-1993-v8-n4-p229.htm}}</ref><!-- 
  --><ref>{{cite book | author= Lendon H. Smith, MD and Joseph Hattersley | title= ''The Infant Survival Guide: Protecting Your Baby from the Dangers of Crib Death, Vaccines and Other Environmental Hazards''  | date=August 30, 2000 | publisher= Smart Publications; 1st edition | id= ISBN-10: 1890572128 - ISBN-13: 978-1890572129 }}</ref><!-- 
  --><ref>{{cite book | author= Lendon H. Smith, MD | title= ''How to Raise a Healthy Child'' | date= January 25, 1998 | publisher= M. Evans and Company, Inc. |id= ISBN-10:0871318229 - ISBN-13:978-0871318220 }}</ref>
 
Although a Barlow’s disease variant (infantile scurvy) may be the most common disease, other diagnoses such as fragile bone disease, hemorrhagic disease of the newborn (vitamin K deficiency) and glutaric aciduria type 1 must also be considered. Gestational problems affecting both mother and fetus, the birthing process, prematurity and nutritional deficits can accelerate skeletal and hemorrhagic pathologies that can also mimic SBS, even before birth.<!--
  --><ref name="ClemetsonCAB">{{cite journal | author = Clemetson CAB | title = Capillary Fragility as a Cause of Substantial Hemorrhage in Infants." | journal = Medical Hypotheses And Research | volume = 1 | issue = 2/3 | pages = 121-129 | url= http://www.journal-mhr.com/PDF_Files/vol_1_2/1_2N3_PDFs/1_2N3_5.pdf| year = 2004 | month=Jul |format=PDF  }}</ref><!--
  --><ref name=“Cushing”>{{cite journal | author = Cushing H | title = Reprint of “Concerning Surgical Intervention for the Intracranial Hemorrhages of the New-born” (1905) | journal = Child's Nervous System | volume = 16 | issue= Classics in Pediatric Neurosurgery |pages = 484-492|  year = 2000 | id = PMID 11007498 | url= http://www.springerlink.com/content/ue6mbcn20g5ae45j/ }}</ref><!--
  --><ref name=“Williams 1997”>{{cite book | author=''Williams Obstetrics'' | title= Diseases and Injuries of the Fetus and Newborn| volume= 20 | chapter=Chapter 20 | date=1997 | pages=page 997-998 | publisher= Appleton & Lange, Stamford, CT | id=ISBN 0-8365-9638-X}}</ref><!--
  --><ref name=“Williams 2005”>{{cite book | author=''Williams Obstetrics'' | title= Diseases and Injuries of the Fetus and Newborn| volume= 22 | chapter=Chapter 29 | date=2005 | pages=page 649-691 | publisher= McGraw-Hill Companies | id=ISBN 0-07-141315-4}}</ref><!--
  --><ref name=“Looney”>{{cite journal | author =  Looney CB, et.al| title =  Intracranial Hemorrhage in Asymptomatic Neonates: Prevalence on MR Images and Relationship to Obstetric and Neonatal Risk Factors | journal = Radiology
| volume = 242 | pages = 535-541|  year = 2007 | id = PMID 17179400 | url= http://radiology.rsnajnls.org/cgi/content/abstract/242/2/535 }}</ref> These views are not widely known, utilized or explored in conventional medicine. Nevertheless, favorable court rulings<!--
  --><ref name="Commonwealth">Commonwealth Of Kentucky VS. Christopher A. Davis, Greenup Circuit Court [http://www.aapsonline.org/sbs/daubert.pdf CASE NO.04-CR 205]</ref> and evidentiary commentary on flawed SBS determinations have been demonstrated by biomechanical studies over the years.<!--
  --><ref name="Ommaya">{{cite journal | author = Ommaya AK, Faas F, Yarnell P | title = Whiplash injury and brain damage: an experimental study. | journal = JAMA | volume = 22 | issue = 204(4) | pages = 285-9 | year = 1968 | id = PMID 4967499}}</ref><!--
  --><ref name="Duhaime">{{cite journal | author = Duhaime A, Gennarelli T, Thibault L, Bruce D, Margulies S, Wiser R | title = The shaken baby syndrome. A clinical, pathological, and biomechanical study. | journal = J Neurosurg | volume = 66 | issue = 3 | pages = 409-15 | year = 1987 | id = PMID 3819836}}</ref><!--
  --><ref name="Prange">{{cite journal | author = Prange M, Coats B, Duhaime A, Margulies S | title = Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants. | journal = J Neurosurg | volume = 99 | issue = 1 | pages = 143-50 | year = 2003 | month=Mar | id = PMID 12854757 | url=http://scholar.google.com/scholar?hl=en&lr=&q=cache:IVXo29ZXQdkJ:www.thejns-net.org/jns/issues/v99n1/pdf/n0990143.pdf+author:%22Prange%22+intitle:%22Anthropomorphic+simulations+of+falls,+shakes,+and+...%22}}</ref><!--
  --><ref name="Uscinski">{{cite journal | author=Uscinski R | title=The Shaken Baby Syndrome | journal=J Am Phys Surg | year=2004 | month=Fall | volume=9 | issue=3 | pages=76-7 | url=http://www.jpands.org/vol9no3/uscinski.pdf | format=PDF}}</ref><!--
  --><ref>{{cite journal | author = Ommaya A, Goldsmith W, Thibault L | title = Biomechanics and neuropathology of adult and paediatric head injury. | journal = Br J Neurosurg | volume = 16 | issue = 3 | pages = 220-42 | year = 2002 | month=Jun | id = PMID 12201393}}</ref><!--
  --><ref name="Bandak">{{cite journal | author = Bandak F | title = Shaken baby syndrome: a biomechanics analysis of injury mechanisms. | journal = Forensic Sci Int | volume = 151 | issue = 1 | pages = 71-9 | year = 2005 | month=June 30 | id = PMID 15885948}}</ref><!--
  --><ref name="Bandak F">{{cite journal | author=Bandak F | title=Response to the Letter to the Editor | journal=Forensic Sci Int. | volume=157 | issue=1 | date=10 February 2006 | doi=10.1016/j.forsciint.2006.01.001}} which refers to<br>{{cite journal | author=Marguliesa S, Prangeb M, Myersc B, Maltesed M, Jie S, Ningf X, Fisherg J, Arbogasth K and Christianh C | title=Letter to the Editor: Shaken baby syndrome: A flawed biomechanical analysis | journal=Forensic Sci Int. | date=24 January 2006 | doi=10.1016/j.forsciint.2005.12.018}}</ref>
 
In addition, it has been suggested that severe adverse reactions to vaccinations may be an alternative cause of SBS. <!--
 
  --><ref>{{cite journal | author = Buttram HE| title = Shaken Baby Syndrome or Vaccine-Induced Encephalitis? |  journal= Medical Sentinel | volume = 6 | issue = 3 | pages = 83-89| year = 2001  | month = Fall  | url= http://www.haciendapub.com/buttram.html }}</ref><!--
 
  --><ref>{{cite journal | author =  Goodwin J  | title = Was It Murder Or A Bad Vaccine? | journal = Redbook | volume = 6 | issue = | pages =158-175 | year = 2000  | month = Sept }}</ref>
 
==See also==
* Louise Woodward - was famously convicted of killing Matthew Eappen in 1997 by shaking baby syndrome.
* Alan Yurko - sentenced to life in prison + 10 years (1998) without parole for the murder of his son, supposedly due to shaking baby syndrome. "Bad Science" from the ''"Orlando Weekly"'' (2003) [http://www.truthinjustice.org/yurko.htm]. Case was vacated on second appeal and Alan Yurko was subsequently released from prison on August 27, 2004 [http://www.accessmylibrary.com/premium/0286/0286-8540218.html]. Information on Case of Alan Yurko - Shaken Baby Syndrome [http://www.aapsonline.org/judicial/yurko.htm]
* [[C. Alan B. Clemetson]]
* [[Child abuse]]
 
==Footnotes==
<div class="references-small"><references/></div>
 
===Video===
* [http://www.expertdigital.com/shakenbaby.html ExpertDigital.com] - Graphic Demonstration (Windows Media)


==Overview==
==Overview==
Abusive head trauma (AHT), commonly known as shaken baby syndrome (SBS), is the [[injury]] to the [[skull]]/intracranial structures due to violent shaking and/or abrupt impact in children aged less than 5 years. AHT is caused by shaking [[injuries]] from repetitive and rapid [[flexion]], [[extension]], and [[rotation]] of the [[head]] and [[neck]] usually following parental frustration over an infant that does not stop crying. [[Retinal]] [[hemorrhages]] and subdural [[hematoma|hematomas]] associated with [[spine]] injuries and/or [[bone]] raise high suspision for shaken baby syndrome. Noncontrast head [[CT]] is the initial [[Radiology|radiologic]] workup for evaluating intracranial [[injury]] due to abusive [[head trauma]] (AHT). The [[prognosis]] of AHT is associated with the extent of damage seen on [[CT scan]] and [[MRI]]. The initial management of AHT is to maintain the patient's [[airway]] and [[circulation]]. [[Vital signs]], oxygenation, and [[intracranial pressure |intracranial pressure (ICP)]] should be monitored. Increased [[intracranial pressure]] (IICP) and [[seizures]] should be managed. Decompressive [[craniectomy]] may be required.


==Historical Perspective==
==Historical Perspective==
[Disease name] was first discovered by [name of scientist], a [nationality + occupation], in [year]/during/following [event].
* In 1945, Dr. John Caffey reported [[pediatric]] cases with chronic [[subdural hematoma]] and [[long bone]] fractures.<ref name="pmid20995763">{{cite journal| author=CAFFEY J| title=Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. | journal=Am J Roentgenol Radium Ther | year= 1946 | volume= 56 | issue= 2 | pages= 163-73 | pmid=20995763 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20995763  }} </ref>
 
* Later, Dr. Caffey discovered the association between traumatic shaking, [[subdural hematoma]], and [[retinal]] hemorrhage.<ref name="pmid4559532">{{cite journal| author=Caffey J| title=On the theory and practice of shaking infants. Its potential residual effects of permanent brain damage and mental retardation. | journal=Am J Dis Child | year= 1972 | volume= 124 | issue= 2 | pages= 161-9 | pmid=4559532 | doi=10.1001/archpedi.1972.02110140011001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4559532  }} </ref>
The association between [important risk factor/cause] and [disease name] was made in/during [year/event].
* In 1962, Henry Kempe used the term 'the battered-child syndrome'.<ref name="pmid14455086">{{cite journal| author=KEMPE CH, SILVERMAN FN, STEELE BF, DROEGEMUELLER W, SILVER HK| title=The battered-child syndrome. | journal=JAMA | year= 1962 | volume= 181 | issue=  | pages= 17-24 | pmid=14455086 | doi=10.1001/jama.1962.03050270019004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14455086  }} </ref>
 
* In 1974, Caffey used 'the [[whiplash]] shaken infant syndrome' for infants with injures from shaking the extremities with [[whiplash]] induced [[bleeding]] inside the brain and eye.<ref name="pmid4416579">{{cite journal| author=Caffey J| title=The whiplash shaken infant syndrome: manual shaking by the extremities with whiplash-induced intracranial and intraocular bleedings, linked with residual permanent brain damage and mental retardation. | journal=Pediatrics | year= 1974 | volume= 54 | issue= 4 | pages= 396-403 | pmid=4416579 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4416579  }} </ref>
In [year], [scientist] was the first to discover the association between [risk factor] and the development of [disease name].
* 'Shaken baby syndrome' (SBS) has been used for decades to describe abusive [[head trauma]] (AHT) or inflicted traumatic [[brain injury]] on infants and young pediatric patients.<ref name="pmid15044268">{{cite journal| author=Harding B, Risdon RA, Krous HF| title=Shaken baby syndrome. | journal=BMJ | year= 2004 | volume= 328 | issue= 7442 | pages= 720-1 | pmid=15044268 | doi=10.1136/bmj.328.7442.720 | pmc=381309 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15044268  }} </ref>
 
* Other terms for SBS include: nonaccidental [[head injury]] or trauma, inflicted traumatic [[brain injury]], or shaken impact syndrome.<ref name="pmid15926388">{{cite journal| author=Vinchon M, Defoort-Dhellemmes S, Desurmont M, Dhellemmes P| title=Accidental and nonaccidental head injuries in infants: a prospective study. | journal=J Neurosurg | year= 2005 | volume= 102 | issue= 4 Suppl | pages= 380-4 | pmid=15926388 | doi=10.3171/ped.2005.102.4.0380 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15926388  }} </ref><ref name="pmid2671890">{{cite journal| author=Bruce DA, Zimmerman RA| title=Shaken impact syndrome. | journal=Pediatr Ann | year= 1989 | volume= 18 | issue= 8 | pages= 482-4, 486-9, 492-4 | pmid=2671890 | doi=10.3928/0090-4481-19890801-07 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2671890  }} </ref>
In [year], [gene] mutations were first implicated in the pathogenesis of [disease name].
* The [[American Academy of Pediatrics]] and the [[Centers for Disease Control and Prevention|Centers for Disease Control and Prevention (CDC)]] recommend the term 'abusive head trauma' (AHT).<ref name="pmid19403508">{{cite journal| author=Christian CW, Block R, Committee on Child Abuse and Neglect. American Academy of Pediatrics| title=Abusive head trauma in infants and children. | journal=Pediatrics | year= 2009 | volume= 123 | issue= 5 | pages= 1409-11 | pmid=19403508 | doi=10.1542/peds.2009-0408 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19403508  }} </ref><ref name="urlwww.cdc.gov">{{cite web |url=https://www.cdc.gov/ViolencePrevention/pdf/PedHeadTrauma-a.pdf |title=www.cdc.gov |format= |work= |accessdate=}}</ref>
 
There have been several outbreaks of [disease name], including -----.
 
In [year], [diagnostic test/therapy] was developed by [scientist] to treat/diagnose [disease name].


==Classification==
==Classification==
There is no established system for the classification of [disease name].
The modified grading system of abusive head trauma (AHT) is as the following:<ref name="pmid28574318">{{cite journal| author=Khan NR, Fraser BD, Nguyen V, Moore K, Boop S, Vaughn BN | display-authors=etal| title=Pediatric abusive head trauma and stroke. | journal=J Neurosurg Pediatr | year= 2017 | volume= 20 | issue= 2 | pages= 183-190 | pmid=28574318 | doi=10.3171/2017.4.PEDS16650 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28574318  }} </ref>
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
! colspan="3" style="background: #4479BA; text-align: center;" | {{fontcolor|#000|'''Modified Grading System of Abusive Head Trauma (AHT)
(Modified Table from Khan et al.: Pediatric abusive head trauma and stroke.
J Neurosurg Pediatr 2017;20:183e90.)<ref name="pmid28574318">{{cite journal| author=Khan NR, Fraser BD, Nguyen V, Moore K, Boop S, Vaughn BN | display-authors=etal| title=Pediatric abusive head trauma and stroke. | journal=J Neurosurg Pediatr | year= 2017 | volume= 20 | issue= 2 | pages= 183-190 | pmid=28574318 | doi=10.3171/2017.4.PEDS16650 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28574318  }} </ref>'''}} 
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''Grade'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''Description'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''Brain Infarction Seen on CT or MRI'''
|-
|style="padding: 5px 5px; background: #4479BA;" align="center"|'''1'''
|style="padding: 5px 5px; background: #DCDCDC;|[[Skull]] [[fracture]] alone +/- associated [[craniofacial]] soft-tissue [[injury]]
|style="padding: 5px 5px; background: #DCDCDC;" align="center"| -
|-
|style="padding: 5px 5px; background: #4479BA;" align="center"|'''2a'''
|style="padding: 5px 5px; background: #DCDCDC;|
* [[Intracranial hemorrhage]] not requiring surgical intervention


OR
or


[Disease name] may be classified according to [classification method] into [number] subtypes/groups: [group1], [group2], [group3], and [group4].
* [[Cerebral edema]] not requiring surgical intervention
|style="padding: 5px 5px; background: #DCDCDC;" align="center"|No
|-
|style="padding: 5px 5px; background: #4479BA;" align="center"|'''2b'''
|style="padding: 5px 5px; background: #DCDCDC;|
* [[Intracranial hemorrhage]] not requiring surgical intervention


OR
or


[Disease name] may be classified into [large number > 6] subtypes based on [classification method 1], [classification method 2], and [classification method 3].
* [[Cerebral edema]] not requiring surgical intervention.
[Disease name] may be classified into several subtypes based on [classification method 1], [classification method 2], and [classification method 3].
|style="padding: 5px 5px; background: #DCDCDC;" align="center"|Yes
|-
|style="padding: 5px 5px; background: #4479BA;" align="center"|'''3a'''
|style="padding: 5px 5px; background: #DCDCDC;|
* [[Intracranial hemorrhage]] requiring surgery or procedure


OR
or


Based on the duration of symptoms, [disease name] may be classified as either acute or chronic.
* [[Cerebral edema]] requiring surgery or procedure


OR
or


If the staging system involves specific and characteristic findings and features:
* Death due to intracranial [[injuries]].
According to the [staging system + reference], there are [number] stages of [malignancy name] based on the [finding1], [finding2], and [finding3]. Each stage is assigned a [letter/number1] and a [letter/number2] that designate the [feature1] and [feature2].
|style="padding: 5px 5px; background: #DCDCDC;" align="center"|No
|-
|style="padding: 5px 5px; background: #4479BA;" align="center"|'''3b'''
|style="padding: 5px 5px; background: #DCDCDC;|
* [[Intracranial hemorrhage]] requiring surgery or procedure


OR
or


The staging of [malignancy name] is based on the [staging system].
* [[Cerebral edema]] requiring surgery or procedure


OR
or


There is no established system for the staging of [malignancy name].
* Death due to intracranial [[injuries]].  
|style="padding: 5px 5px; background: #DCDCDC;" align="center"|Yes
|}


==Pathophysiology==
==Pathophysiology==
The exact pathogenesis of [disease name] is not fully understood.
AHT is caused by shaking [[injuries]] from repetitive and rapid [[flexion]], [[extension]], and [[rotation]] of the [[head]] and [[neck]] and may result in:<ref name="pmid9632450">{{cite journal| author=Duhaime AC, Christian CW, Rorke LB, Zimmerman RA| title=Nonaccidental head injury in infants--the "shaken-baby syndrome". | journal=N Engl J Med | year= 1998 | volume= 338 | issue= 25 | pages= 1822-9 | pmid=9632450 | doi=10.1056/NEJM199806183382507 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9632450  }} </ref><ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref>


OR
* Tearing of the [[vessels]] due to the rapid striking of the [[brain]] on the [[skull]] result in [[bleeding]]. Consequently, the enlarging [[hematoma]] may cause pressure within the [[skull]] and lead to increased [[intracranial pressure]] (IICP) and additional injury to the [[brain]].  
 
It is thought that [disease name] is the result of / is mediated by / is produced by / is caused by either [hypothesis 1], [hypothesis 2], or [hypothesis 3].
 
OR
 
[Pathogen name] is usually transmitted via the [transmission route] route to the human host.
 
OR
 
Following transmission/ingestion, the [pathogen] uses the [entry site] to invade the [cell name] cell.
 
OR


* Sheering forces across the [[brain]] may injure nerve [[axons]] and lead to diffuse [[axonal]] disruption.
* Greater [[parenchymal]] movement


[Disease or malignancy name] arises from [cell name]s, which are [cell type] cells that are normally involved in [function of cells].
* The head may hit an object and result in [[lacerations]], [[bruises]], and [[fractures]].  


OR
AHT includes primary and secondary injuries: <ref name="pmid22303964">{{cite journal| author=Pinto PS, Meoded A, Poretti A, Tekes A, Huisman TA| title=The unique features of traumatic brain injury in children. review of the characteristics of the pediatric skull and brain, mechanisms of trauma, patterns of injury, complications, and their imaging findings--part 2. | journal=J Neuroimaging | year= 2012 | volume= 22 | issue= 2 | pages= e18-41 | pmid=22303964 | doi=10.1111/j.1552-6569.2011.00690.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22303964  }} </ref>
* Primary [[injuries]] is the consequence of the initial direct [[trauma]] and may include:
** [[Skull fracture]]
** [[Epidural]], subdural, [[subarachnoid]], and intraparenchymal [[hemorrhages]]
** Cortical [[contusion]]
** Diffuse [[axonal]] injury
* Secondary injuries are [[inflammatory]] changes causing impairments in [[neurons]] and the [[microcirculation]] of the [[brain]] and include the [[complications]] of the primary injuries:
** Diffuse [[brain edema]]
** [[Herniation]]
** [[Infarction]] or [[cerebrovascular]] accidents


The progression to [disease name] usually involves the [molecular pathway].
The neurometabolic cascade of AHT is similar to traumatic [[brain injury]]:<ref name="pmid12937489">{{cite journal| author=Giza CC, Hovda DA| title=The Neurometabolic Cascade of Concussion. | journal=J Athl Train | year= 2001 | volume= 36 | issue= 3 | pages= 228-235 | pmid=12937489 | doi= | pmc=155411 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12937489  }} </ref>


OR
* [[Depolarization]] 
* Release of excitatory [[neurotransmitters]] 
* [[Potassium]] efflux
* Increased activity of [[membrane]] pumps
* [[Hyperglycolysis]]
* [[Lactate]] accumulation
* [[Calcium]] influx
* Decreased production of [[ATP]]
* [[Calpain]] activation and initiation of [[apoptosis]]
* Axolemmal disruption and [[calcium]] influx
* [[Neurofilament]] compaction
* [[Microtubule]] disassembly
* [[Axonal]] swelling and [[axotomy]]


The pathophysiology of [disease/malignancy] depends on the histological subtype.
Children are more susceptible to [[head]] injuries at younger ages because:
* The [[skull]] is easily compressed and therefore causes [[injuries]] to the underlying [[brain]] tissue.
* The [[head]] is larger (in proportion to the rest of the body) and as they fall it is usually injured first.
* The [[brain]] is more likely to suffer acceleration-deceleration [[injuries]] due to higher water content compared to adults.


==Causes==
==Causes==
Disease name] may be caused by [cause1], [cause2], or [cause3].
AHT is caused by shaking [[injuries]] from repetitive and rapid [[flexion]], [[extension]], and [[rotation]] of the [[head]] and [[neck]].<ref name="pmid9632450">{{cite journal| author=Duhaime AC, Christian CW, Rorke LB, Zimmerman RA| title=Nonaccidental head injury in infants--the "shaken-baby syndrome". | journal=N Engl J Med | year= 1998 | volume= 338 | issue= 25 | pages= 1822-9 | pmid=9632450 | doi=10.1056/NEJM199806183382507 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9632450  }} </ref>
 
OR
 
Common causes of [disease] include [cause1], [cause2], and [cause3].
 
OR
 
The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].
 
OR
 
The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click [[Pericarditis causes#Overview|here]].


==Differentiating Shaken Baby Syndrome from Other Diseases==
==Differentiating Shaken Baby Syndrome from Other Diseases==
Line 333: Line 141:
Shaken baby syndrome must be differentiated from the following conditions:<ref name="pmid23530171">{{cite journal| author=Carpenter SL, Abshire TC, Anderst JD, Section on Hematology/Oncology and Committee on Child Abuse and Neglect of the American Academy of Pediatrics| title=Evaluating for suspected child abuse: conditions that predispose to bleeding. | journal=Pediatrics | year= 2013 | volume= 131 | issue= 4 | pages= e1357-73 | pmid=23530171 | doi=10.1542/peds.2013-0196 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23530171  }} </ref><ref name="pmid7660304">{{cite journal| author=Weissgold DJ, Budenz DL, Hood I, Rorke LB| title=Ruptured vascular malformation masquerading as battered/shaken baby syndrome: a nearly tragic mistake. | journal=Surv Ophthalmol | year= 1995 | volume= 39 | issue= 6 | pages= 509-12 | pmid=7660304 | doi=10.1016/s0039-6257(05)80058-x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7660304  }} </ref><ref name="pmid22614777">{{cite journal| author=Agrawal S, Peters MJ, Adams GG, Pierce CM| title=Prevalence of retinal hemorrhages in critically ill children. | journal=Pediatrics | year= 2012 | volume= 129 | issue= 6 | pages= e1388-96 | pmid=22614777 | doi=10.1542/peds.2011-2772 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22614777  }} </ref><ref name="pmid12483361">{{cite journal| author=Nassogne MC, Sharrard M, Hertz-Pannier L, Armengaud D, Touati G, Delonlay-Debeney P | display-authors=etal| title=Massive subdural haematomas in Menkes disease mimicking shaken baby syndrome. | journal=Childs Nerv Syst | year= 2002 | volume= 18 | issue= 12 | pages= 729-31 | pmid=12483361 | doi=10.1007/s00381-002-0630-z | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12483361  }} </ref><ref name="pmid15234150">{{cite journal| author=Ganesh A, Jenny C, Geyer J, Shouldice M, Levin AV| title=Retinal hemorrhages in type I osteogenesis imperfecta after minor trauma. | journal=Ophthalmology | year= 2004 | volume= 111 | issue= 7 | pages= 1428-31 | pmid=15234150 | doi=10.1016/j.ophtha.2003.10.028 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15234150  }} </ref><ref name="pmid17465389">{{cite journal| author=Bishop FS, Liu JK, McCall TD, Brockmeyer DL| title=Glutaric aciduria type 1 presenting as bilateral subdural hematomas mimicking nonaccidental trauma. Case report and review of the literature. | journal=J Neurosurg | year= 2007 | volume= 106 | issue= 3 Suppl | pages= 222-6 | pmid=17465389 | doi=10.3171/ped.2007.106.3.222 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17465389  }} </ref><ref name="pmid16183447">{{cite journal| author=Brousseau TJ, Kissoon N, McIntosh B| title=Vitamin K deficiency mimicking child abuse. | journal=J Emerg Med | year= 2005 | volume= 29 | issue= 3 | pages= 283-8 | pmid=16183447 | doi=10.1016/j.jemermed.2005.02.009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16183447  }} </ref>
Shaken baby syndrome must be differentiated from the following conditions:<ref name="pmid23530171">{{cite journal| author=Carpenter SL, Abshire TC, Anderst JD, Section on Hematology/Oncology and Committee on Child Abuse and Neglect of the American Academy of Pediatrics| title=Evaluating for suspected child abuse: conditions that predispose to bleeding. | journal=Pediatrics | year= 2013 | volume= 131 | issue= 4 | pages= e1357-73 | pmid=23530171 | doi=10.1542/peds.2013-0196 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23530171  }} </ref><ref name="pmid7660304">{{cite journal| author=Weissgold DJ, Budenz DL, Hood I, Rorke LB| title=Ruptured vascular malformation masquerading as battered/shaken baby syndrome: a nearly tragic mistake. | journal=Surv Ophthalmol | year= 1995 | volume= 39 | issue= 6 | pages= 509-12 | pmid=7660304 | doi=10.1016/s0039-6257(05)80058-x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7660304  }} </ref><ref name="pmid22614777">{{cite journal| author=Agrawal S, Peters MJ, Adams GG, Pierce CM| title=Prevalence of retinal hemorrhages in critically ill children. | journal=Pediatrics | year= 2012 | volume= 129 | issue= 6 | pages= e1388-96 | pmid=22614777 | doi=10.1542/peds.2011-2772 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22614777  }} </ref><ref name="pmid12483361">{{cite journal| author=Nassogne MC, Sharrard M, Hertz-Pannier L, Armengaud D, Touati G, Delonlay-Debeney P | display-authors=etal| title=Massive subdural haematomas in Menkes disease mimicking shaken baby syndrome. | journal=Childs Nerv Syst | year= 2002 | volume= 18 | issue= 12 | pages= 729-31 | pmid=12483361 | doi=10.1007/s00381-002-0630-z | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12483361  }} </ref><ref name="pmid15234150">{{cite journal| author=Ganesh A, Jenny C, Geyer J, Shouldice M, Levin AV| title=Retinal hemorrhages in type I osteogenesis imperfecta after minor trauma. | journal=Ophthalmology | year= 2004 | volume= 111 | issue= 7 | pages= 1428-31 | pmid=15234150 | doi=10.1016/j.ophtha.2003.10.028 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15234150  }} </ref><ref name="pmid17465389">{{cite journal| author=Bishop FS, Liu JK, McCall TD, Brockmeyer DL| title=Glutaric aciduria type 1 presenting as bilateral subdural hematomas mimicking nonaccidental trauma. Case report and review of the literature. | journal=J Neurosurg | year= 2007 | volume= 106 | issue= 3 Suppl | pages= 222-6 | pmid=17465389 | doi=10.3171/ped.2007.106.3.222 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17465389  }} </ref><ref name="pmid16183447">{{cite journal| author=Brousseau TJ, Kissoon N, McIntosh B| title=Vitamin K deficiency mimicking child abuse. | journal=J Emerg Med | year= 2005 | volume= 29 | issue= 3 | pages= 283-8 | pmid=16183447 | doi=10.1016/j.jemermed.2005.02.009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16183447  }} </ref>


* Accidental [[head trauma]] that may cause:
*Accidental [[head trauma]] that may cause:
** [[Epidural hemorrhage]]
**[[Epidural hemorrhage]]
** [[Subdural hemorrhage]]
**[[Subdural hemorrhage]]
** [[Subarachnoid hemorrhage]]
**[[Subarachnoid hemorrhage]]
** [[Cerebellar]] hemorrhage
**[[Cerebellar]] hemorrhage
** [[Parenchymal]] hemorrhage
**[[Parenchymal]] hemorrhage
* [[Bleeding diathesis]]
*[[Bleeding diathesis]]
* [[Arteriovenous malformation]]  
*[[Arteriovenous malformation]]
* [[Stroke]]
*[[Stroke]]
* [[Neoplastic]] conditions  
*[[Neoplastic]] conditions
* [[Metabolic disorders]]  
*[[Metabolic disorders]]
* [[Glutaric aciduria]]  
*[[Glutaric aciduria]]
* [[Vitamin K deficiency]]  
*[[Vitamin K deficiency]]
* [[Connective tissue diseases]]
*[[Connective tissue diseases]]
* [[Osteogenesis imperfecta]]
*[[Osteogenesis imperfecta]]


==Epidemiology and Demographics==
==Epidemiology and Demographics==
The incidence/prevalence of [disease name] is approximately [number range] per 100,000 individuals worldwide.
OR
In [year], the incidence/prevalence of [disease name] was estimated to be [number range] cases per 100,000 individuals worldwide.
OR
In [year], the incidence of [disease name] is approximately [number range] per 100,000 individuals with a case-fatality rate of [number range]%.
Patients of all age groups may develop [disease name].
OR
The incidence of [disease name] increases with age; the median age at diagnosis is [#] years.
OR
[Disease name] commonly affects individuals younger than/older than [number of years] years of age.
OR
[Chronic disease name] is usually first diagnosed among [age group].
OR
[Acute disease name] commonly affects [age group].
There is no racial predilection to [disease name].
OR
[Disease name] usually affects individuals of the [race 1] race. [Race 2] individuals are less likely to develop [disease name].
[Disease name] affects men and women equally.
OR
[Gender 1] are more commonly affected by [disease name] than [gender 2]. The [gender 1] to [gender 2] ratio is approximately [number > 1] to 1.
The majority of [disease name] cases are reported in [geographical region].
OR


[Disease name] is a common/rare disease that tends to affect [patient population 1] and [patient population 2].
*The exact [[incidence]] of shaken baby syndrome/abusive head trauma (AHT) is unknown.<ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref>
*In a population-based study, the [[incidence]] of AHT was reported to be 29.7 cases per 100,000 children younger than one year in the United States.<ref name="pmid12902365">{{cite journal| author=Keenan HT, Runyan DK, Marshall SW, Nocera MA, Merten DF, Sinal SH| title=A population-based study of inflicted traumatic brain injury in young children. | journal=JAMA | year= 2003 | volume= 290 | issue= 5 | pages= 621-6 | pmid=12902365 | doi=10.1001/jama.290.5.621 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12902365  }} </ref>
*In another study, the [[incidence]] of AHT was reported to be 24.6 cases per 100,000 children younger than one year in Scotland.<ref name="pmid11075773">{{cite journal| author=Barlow KM, Minns RA| title=Annual incidence of shaken impact syndrome in young children. | journal=Lancet | year= 2000 | volume= 356 | issue= 9241 | pages= 1571-2 | pmid=11075773 | doi=10.1016/S0140-6736(00)03130-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11075773  }} </ref>
*Shaken baby syndrome/AHT is the leading cause of death due to [[Head injury|head injuries]] in children younger than 2 years, worldwide.<ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref>


==Risk Factors==
==Risk Factors==
There are no established risk factors for [disease name].
Common [[risk factors]] in the development of shaken baby syndrome/AHT include factors that increase the risk of [[child abuse]] and may include:<ref name="pmid1959075">{{cite journal| author=Smith JA, Adler RG| title=Children hospitalized with child abuse and neglect: a case-control study. | journal=Child Abuse Negl | year= 1991 | volume= 15 | issue= 4 | pages= 437-45 | pmid=1959075 | doi=10.1016/0145-2134(91)90027-b | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1959075  }} </ref><ref name="pmid19034044">{{cite journal| author=Catherine NL, Ko JJ, Barr RG| title=Getting the word out: advice on crying and colic in popular parenting magazines. | journal=J Dev Behav Pediatr | year= 2008 | volume= 29 | issue= 6 | pages= 508-11 | pmid=19034044 | doi=10.1097/DBP.0b013e31818d0c0c | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19034044  }} </ref><ref name="pmid23535075">{{cite journal| author=Niederkrotenthaler T, Xu L, Parks SE, Sugerman DE| title=Descriptive factors of abusive head trauma in young children--United States, 2000-2009. | journal=Child Abuse Negl | year= 2013 | volume= 37 | issue= 7 | pages= 446-55 | pmid=23535075 | doi=10.1016/j.chiabu.2013.02.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23535075  }} </ref><ref name="pmid53080">{{cite journal| author=Smith SM, Hanson R| title=Interpersonal relationships and child-rearing practices in 214 parents of battered children. | journal=Br J Psychiatry | year= 1975 | volume= 127 | issue=  | pages= 513-25 | pmid=53080 | doi=10.1192/bjp.127.6.513 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=53080  }} </ref><ref name="pmid4075043">{{cite journal| author=Oliver JE| title=Successive generations of child maltreatment: social and medical disorders in the parents. | journal=Br J Psychiatry | year= 1985 | volume= 147 | issue=  | pages= 484-90 | pmid=4075043 | doi=10.1192/bjp.147.5.484 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4075043  }} </ref><ref name="pmid4005662">{{cite journal| author=Benedict MI, White RB, Cornely DA| title=Maternal perinatal risk factors and child abuse. | journal=Child Abuse Negl | year= 1985 | volume= 9 | issue= 2 | pages= 217-24 | pmid=4005662 | doi=10.1016/0145-2134(85)90014-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4005662  }} </ref><ref name="pmid710189">{{cite journal| author=Garbarino J, Crouter A| title=Defining the comminity context for parent-child relations: the correlates of child maltreatment. | journal=Child Dev | year= 1978 | volume= 49 | issue= 3 | pages= 604-16 | pmid=710189 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=710189  }} </ref><ref name="pmid8591089">{{cite journal| author=Muller RT, Hunter JE, Stollak G| title=The intergenerational transmission of corporal punishment: a comparison of social learning and temperament models. | journal=Child Abuse Negl | year= 1995 | volume= 19 | issue= 11 | pages= 1323-35 | pmid=8591089 | doi=10.1016/0145-2134(95)00103-f | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8591089  }} </ref>
 
OR
 
The most potent risk factor in the development of [disease name] is [risk factor 1]. Other risk factors include [risk factor 2], [risk factor 3], and [risk factor 4].
 
OR
 
Common risk factors in the development of [disease name] include [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
 
OR


Common risk factors in the development of [disease name] may be occupational, environmental, genetic, and viral.
*Infantile colic
*Inconsolable cry
*Child [[Disability]]
*Lack of parental frustration tolerance
*Lack of prenatal and childcare experience
*Low education level
*Low socioeconomic status
*Single-parent families
*Young parents without support
*Community isolation
*Limited recreational facilities
*Poverty


==Screening==
==Screening==
There is insufficient evidence to recommend routine screening for [disease/malignancy].
There is insufficient evidence to recommend routine [[screening]] for shaken baby syndrome.
 
OR
 
According to the [guideline name], screening for [disease name] is not recommended.
 
OR
 
According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
Children with AHT are more likely to experience the following compared to children with accidental [[head trauma]]:<ref name="pmid17473092">{{cite journal| author=Hymel KP, Makoroff KL, Laskey AL, Conaway MR, Blackman JA| title=Mechanisms, clinical presentations, injuries, and outcomes from inflicted versus noninflicted head trauma during infancy: results of a prospective, multicentered, comparative study. | journal=Pediatrics | year= 2007 | volume= 119 | issue= 5 | pages= 922-9 | pmid=17473092 | doi=10.1542/peds.2006-3111 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17473092  }} </ref><ref name="pmid31451610">{{cite journal| author=Palusci VJ, Council on Child Abuse and Neglect. Kay AJ, Batra E, Section on Child Death Review and Prevention. Moon RY | display-authors=etal| title=Identifying Child Abuse Fatalities During Infancy. | journal=Pediatrics | year= 2019 | volume= 144 | issue= 3 | pages=  | pmid=31451610 | doi=10.1542/peds.2019-2076 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31451610  }} </ref>


OR
* Worse outcomes
* Cardiorespiratory compromise
* Diffuse cerebral [[hypoxia]]-[[ischemia]]
* Deeper [[brain injury|brain injuries]]
* Death


Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
[[Complications]] of AHT may include:<ref name="pmid23640154">{{cite journal| author=Tilak GS, Pollock AN| title=Missed opportunities in fatal child abuse. | journal=Pediatr Emerg Care | year= 2013 | volume= 29 | issue= 5 | pages= 685-7 | pmid=23640154 | doi=10.1097/PEC.0b013e31828f3e39 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23640154  }} </ref><ref name="pmid17473092">{{cite journal| author=Hymel KP, Makoroff KL, Laskey AL, Conaway MR, Blackman JA| title=Mechanisms, clinical presentations, injuries, and outcomes from inflicted versus noninflicted head trauma during infancy: results of a prospective, multicentered, comparative study. | journal=Pediatrics | year= 2007 | volume= 119 | issue= 5 | pages= 922-9 | pmid=17473092 | doi=10.1542/peds.2006-3111 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17473092  }} </ref><ref name="pmid26299396">{{cite journal| author=Lind K, Toure H, Brugel D, Meyer P, Laurent-Vannier A, Chevignard M| title=Extended follow-up of neurological, cognitive, behavioral and academic outcomes after severe abusive head trauma. | journal=Child Abuse Negl | year= 2016 | volume= 51 | issue=  | pages= 358-67 | pmid=26299396 | doi=10.1016/j.chiabu.2015.08.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26299396  }} </ref><ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref>


OR
* [[Blindness]]
* [[Seizures]]
* [[Attention deficit]]
* Behavior difficulties
* [[Learning difficulties]]
* [[Sensory]] impairment
* Motor dysfunction
* Severe handicaps
* Decreased quality of life
* Death


Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.
The [[prognosis]] of AHT is associated with the extent of damage seen on [[CT scan]] and [[MRI]].<ref name="pmid22778309">{{cite journal| author=Piteau SJ, Ward MG, Barrowman NJ, Plint AC| title=Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review. | journal=Pediatrics | year= 2012 | volume= 130 | issue= 2 | pages= 315-23 | pmid=22778309 | doi=10.1542/peds.2011-1545 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22778309  }} </ref>


==Diagnosis==
==Diagnosis==
===Diagnostic Study of Choice===
[[Retinal]] [[hemorrhages]] and subdural [[Hematoma|hematomas]] associated with [[spine]] injuries and/or [[bone]] raise high suspision for shaken baby syndrome.<ref name="pmid25501728">{{cite journal| author=Nadarasa J, Deck C, Meyer F, Willinger R, Raul JS| title=Update on injury mechanisms in abusive head trauma--shaken baby syndrome. | journal=Pediatr Radiol | year= 2014 | volume= 44 Suppl 4 | issue=  | pages= S565-70 | pmid=25501728 | doi=10.1007/s00247-014-3168-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25501728  }} </ref>
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].


OR
===Clinical Evaluation===
The clinical work-up of shaken baby syndrome should include:<ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref>


The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
*Comprehensive history
*[[Physical examination]]
*[[Laboratory]] tests
*[[Imaging]]
*[[Consultation]] with specialists


OR
===History and Symptoms===


The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
'''History'''


OR
The following should be considered in the history of shaken baby syndrome/AHT:<ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref>


There are no established criteria for the diagnosis of [disease name].
*Open-ended questions should be asked by [[physicians]]
*Caretakers should be interviewed separately
*An inconsistent or changing history may suggest AHT or [[child abuse]]
*The most common history suggestive of abusive head trauma (AHT) are:
**History of non-accidental [[trauma]]
**History of falling from a low height


===History and Symptoms===
'''Symptoms'''
The majority of patients with [disease name] are asymptomatic.


OR
Symptoms of shaken baby syndrome/AHT may include:<ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref>


The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].
*[[Vomiting]]
*[[Poor feeding]]
*Decreased interaction
*[[Irritability]]
*[[Sleepiness]] and [[lethargy]]
*[[Hypothermia]]
*[[Bradycardia]]
*[[Respiratory distress]]
*[[Apnea]]
*[[Seizures]]


===Physical Examination===
===Physical Examination===
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
The following [[signs]] should be considered on the [[physical examination]] of shaken baby syndrome/AHT:<ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref>
 
OR
 
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
 
OR


The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
*Decreased level of [[consciousness]]
*[[Cardiovascular collapse]]
*Bulging [[fontanel]]
*[[Hydrocephalus]]
*[[Microcephaly]]
*[[Subdural hematoma]]
*[[Retinal]] hemorrhages
*[[Fractures]] in [[long bone]], [[metaphysis]], and [[rib]]
*Lack of external [[injury]]
*Bruises ([[ears]], [[neck]], or [[trunk]])


===Laboratory Findings===
===Laboratory Findings===
Line 483: Line 265:
Laboratory tests for shaken baby syndrome should include:<ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref>  
Laboratory tests for shaken baby syndrome should include:<ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref>  


* [[Complete blood cell count|Complete blood cell count (CBC)]] with [[platelet]] count  
*[[Complete blood cell count|Complete blood cell count (CBC)]] with [[platelet]] count
* [[Prothrombin time (PT)]]
*[[Prothrombin time (PT)]]
* [[Partial thromboplastin time|Partial thromboplastin time (PTT)]]
*[[Partial thromboplastin time|Partial thromboplastin time (PTT)]]
* Chemistry panel  
*Chemistry panel
* [[Aspartate aminotransferase|Aspartate aminotransferase (AST)]]
*[[Aspartate aminotransferase|Aspartate aminotransferase (AST)]]
* [[Alanine aminotransferase |Alanine aminotransferase (ALT)]]
*[[Alanine aminotransferase |Alanine aminotransferase (ALT)]]
* [[Amylase]]
*[[Amylase]]
* [[Lipase]]
*[[Lipase]]
* [[Urinalysis]]
*[[Urinalysis]]


===Electrocardiogram===
===Electrocardiogram===
Line 498: Line 280:
===X-ray===
===X-ray===
There are no specific [[x-ray]] findings associated with shaken baby syndrome, however, in order to identify [[child abuse]] in children aged less than two years with unexplained [[trauma]],  a [[skeletal]] survey should be performed with [[Radiograph|radiographs]] of the:<ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref>
There are no specific [[x-ray]] findings associated with shaken baby syndrome, however, in order to identify [[child abuse]] in children aged less than two years with unexplained [[trauma]],  a [[skeletal]] survey should be performed with [[Radiograph|radiographs]] of the:<ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref>
* [[Skull]]
 
* [[Spine]]
*[[Skull]]
* [[Ribs]]  
*[[Spine]]
* [[Long bones]]
*[[Ribs]]
*[[Long bones]]


===Echocardiography or Ultrasound===
===Echocardiography or Ultrasound===
Line 508: Line 291:
===CT scan===
===CT scan===
Noncontrast [[head]] [[CT]] is the initial radiologic workup for evaluating [[intracranial injury]] due to abusive head trauma (AHT).<ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref><ref name="pmid16882816">{{cite journal| author=Tung GA, Kumar M, Richardson RC, Jenny C, Brown WD| title=Comparison of accidental and nonaccidental traumatic head injury in children on noncontrast computed tomography. | journal=Pediatrics | year= 2006 | volume= 118 | issue= 2 | pages= 626-33 | pmid=16882816 | doi=10.1542/peds.2006-0130 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16882816  }} </ref> [[CT]] is helpful in detecting:<ref name="pmid16882816">{{cite journal| author=Tung GA, Kumar M, Richardson RC, Jenny C, Brown WD| title=Comparison of accidental and nonaccidental traumatic head injury in children on noncontrast computed tomography. | journal=Pediatrics | year= 2006 | volume= 118 | issue= 2 | pages= 626-33 | pmid=16882816 | doi=10.1542/peds.2006-0130 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16882816  }} </ref>
Noncontrast [[head]] [[CT]] is the initial radiologic workup for evaluating [[intracranial injury]] due to abusive head trauma (AHT).<ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref><ref name="pmid16882816">{{cite journal| author=Tung GA, Kumar M, Richardson RC, Jenny C, Brown WD| title=Comparison of accidental and nonaccidental traumatic head injury in children on noncontrast computed tomography. | journal=Pediatrics | year= 2006 | volume= 118 | issue= 2 | pages= 626-33 | pmid=16882816 | doi=10.1542/peds.2006-0130 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16882816  }} </ref> [[CT]] is helpful in detecting:<ref name="pmid16882816">{{cite journal| author=Tung GA, Kumar M, Richardson RC, Jenny C, Brown WD| title=Comparison of accidental and nonaccidental traumatic head injury in children on noncontrast computed tomography. | journal=Pediatrics | year= 2006 | volume= 118 | issue= 2 | pages= 626-33 | pmid=16882816 | doi=10.1542/peds.2006-0130 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16882816  }} </ref>
* [[Skull fracture]]
 
* [[Intracranial hemorrhage]]  
*[[Skull fracture]]
* [[Ischemic]] changes  
*[[Intracranial hemorrhage]]
* [[Brain edema]]
*[[Ischemic]] changes
*[[Brain edema]]


===MRI===
===MRI===
[[MRI]] may be helpful in:<ref name="pmid10447132">{{cite journal| author=Barlow KM, Gibson RJ, McPhillips M, Minns RA| title=Magnetic resonance imaging in acute non-accidental head injury. | journal=Acta Paediatr | year= 1999 | volume= 88 | issue= 7 | pages= 734-40 | pmid=10447132 | doi=10.1080/08035259950169017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10447132  }} </ref>
[[MRI]] may be helpful in:<ref name="pmid10447132">{{cite journal| author=Barlow KM, Gibson RJ, McPhillips M, Minns RA| title=Magnetic resonance imaging in acute non-accidental head injury. | journal=Acta Paediatr | year= 1999 | volume= 88 | issue= 7 | pages= 734-40 | pmid=10447132 | doi=10.1080/08035259950169017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10447132  }} </ref>
* Detecting [[subacute]] and [[chronic]] subdural bleeding
 
* Evaluating the extent of [[injuries]] in the [[parenchyma]]
*Detecting [[subacute]] and [[chronic]] subdural bleeding
* Differentiating [[chronic]] subdural from [[subarachnoid]] collections
*Evaluating the extent of [[injuries]] in the [[parenchyma]]
*Differentiating [[chronic]] subdural from [[subarachnoid]] collections


===Other Imaging Findings===
===Other Imaging Findings===
Line 527: Line 312:
==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===
There is no treatment for [disease name]; the mainstay of therapy is supportive care.


OR
* [[Vital signs]] should be monitored.


Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
* The initial care of AHT is to maintain the patient's [[airway]], [[breathing]], and [[circulation]].<ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref>


OR
* Patients without impairment of [[consciousness]] may be managed with supportive care.<ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref>


The majority of cases of [disease name] are self-limited and require only supportive care.
* [[Hypotension]] is treated with fluids.


OR
* [[Intubation]] and [[mechanical ventilation]] are required in patients with moderate impairment of consciousness, severe respiratory insufficiency, or hemodynamic instability.<ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref>


[Disease name] is a medical emergency and requires prompt treatment.
* [[Oxygenation]] should be monitored with a [[pulse oximeter]].


OR
* [[Intracranial pressure |Intracranial pressure (ICP)]] should be monitored.<ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref>
 
** Maintain [[ICP]] below 20 mmHg and minimal [[cerebral perfusion pressure |cerebral perfusion pressure (CPP)]] over 40 mmHg.<ref name="pmid23234472">{{cite journal| author=Chesnut RM, Temkin N, Carney N, Dikmen S, Rondina C, Videtta W | display-authors=etal| title=A trial of intracranial-pressure monitoring in traumatic brain injury. | journal=N Engl J Med | year= 2012 | volume= 367 | issue= 26 | pages= 2471-81 | pmid=23234472 | doi=10.1056/NEJMoa1207363 | pmc=3565432 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23234472  }} </ref>
The mainstay of treatment for [disease name] is [therapy].
** The age-dependent [[CPP]] is recommended as the following:
 
*** 50 mmHg for 2-6 years
OR
*** 55 mmHg for 7-10 years
 
*** 60 mmHg for 11-16 years
The optimal therapy for [malignancy name] depends on the stage at diagnosis.
 
* Increased intracranial pressure (IICP) should be decreased in order to prevent secondary [[brain injury]] by:<ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref>
OR
**  [[Hyperventilation]]
 
*** Maintain the [[PaCO2]] at 25-30 mmHg (since excessive [[hyperventilation]] and [[hypocapnia]] result in [[vasoconstriction]] and decreased cerebral perfusion, [[capnography]] is recommended to monitor end-tidal CO2)
[Therapy] is recommended among all patients who develop [disease name].
** Raise the head to 30 degree
 
*** Improves [[venous return]] without affecting [[cerebral blood flow]]
OR
** [[Hypertonic]] agents may be used in moderate IICP.
 
*** 3% hypertonic [[saline]] bolus 2-6 ml/kg, followed by 0.1-1 ml/kg/hour till the upper limit of serum [[osmolarity]] 360 or [[sodium]] level 155 g/dl.
Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
** [[Mannitol]]
 
*** 0.25-1 gm/kg [[IV]] every 4-6 hours with the upper limit of serum [[osmolarity]] 320.
OR
** [[Sedation]] with [[barbiturates]] may be needed in persistent IICP.
 
*** [[Barbiturates]] decrease cerebral [[metabolism]] and in turn decrease [[cerebral blood flow]] and therefore, reduce [[ICP]].
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
*** [[Thiopental]] or [[pentobarbital]]
 
OR
 
Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].


OR
* Continuous EEG (cEEG) monitoring should be performed and [[antiepileptic |antiepileptic drug]] may be used to reduce the risk for early posttraumatic seizures (EPTS).<ref name="pmid23842589">{{cite journal| author=Hasbani DM, Topjian AA, Friess SH, Kilbaugh TJ, Berg RA, Christian CW | display-authors=etal| title=Nonconvulsive electrographic seizures are common in children with abusive head trauma*. | journal=Pediatr Crit Care Med | year= 2013 | volume= 14 | issue= 7 | pages= 709-15 | pmid=23842589 | doi=10.1097/PCC.0b013e3182917b83 | pmc=4082326 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23842589  }} </ref><ref name="pmid21381863">{{cite journal| author=Liesemer K, Bratton SL, Zebrack CM, Brockmeyer D, Statler KD| title=Early post-traumatic seizures in moderate to severe pediatric traumatic brain injury: rates, risk factors, and clinical features. | journal=J Neurotrauma | year= 2011 | volume= 28 | issue= 5 | pages= 755-62 | pmid=21381863 | doi=10.1089/neu.2010.1518 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21381863  }} </ref>
** [[Seizure]] may occur at any stage.


Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
* Stepwise [[hypothermia]] keeps the body temperature between 32 C and 33 C for 48 hours and [[neuromuscular]] blockade may be helpful in preventing [[shivering]].
** Therapeutic [[hypothermia]] may reduce:<ref name="pmid19271965">{{cite journal| author=Adelson PD| title=Hypothermia following pediatric traumatic brain injury. | journal=J Neurotrauma | year= 2009 | volume= 26 | issue= 3 | pages= 429-36 | pmid=19271965 | doi=10.1089/neu.2008.0571 | pmc=2744377 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19271965  }} </ref>
*** [[Inflammation]]
*** [[Cell death]]
*** [[Excitotoxicity]]
*** Acute [[seizures]]
*** [[Cerebral]] [[metabolic]] demands


===Surgery===
===Surgery===
Surgical intervention is not recommended for the management of [disease name].
[[Decompressive craniectomy]] (limits secondary brain injury by removing part of the skull and allowing brain swelling which ) is indicated when there is:<ref name="pmid8835209">{{cite journal| author=Cho DY, Wang YC, Chi CS| title=Decompressive craniotomy for acute shaken/impact baby syndrome. | journal=Pediatr Neurosurg | year= 1995 | volume= 23 | issue= 4 | pages= 192-8 | pmid=8835209 | doi=10.1159/000120958 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8835209  }} </ref>
 
* No response to prior treatments
OR
* [[Neurologic]] deterioration
 
* Signs of [[herniation]]
Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either [indication 1], [indication 2], and [indication 3]
 
OR
 
The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either [indication 1], [indication 2], and/or [indication 3].
 
OR
 
The feasibility of surgery depends on the stage of [malignancy] at diagnosis.
 
OR
 
Surgery is the mainstay of treatment for [disease or malignancy].


===Primary Prevention===
===Primary Prevention===
There are no established measures for the primary prevention of [disease name].
[[Prevention]] of AHT includes:<ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref><ref name="pmid19034044">{{cite journal| author=Catherine NL, Ko JJ, Barr RG| title=Getting the word out: advice on crying and colic in popular parenting magazines. | journal=J Dev Behav Pediatr | year= 2008 | volume= 29 | issue= 6 | pages= 508-11 | pmid=19034044 | doi=10.1097/DBP.0b013e31818d0c0c | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19034044  }} </ref>
 
* Decrease in [[child abuse]] and [[maltreatment]]
OR
* Parental education with public service announcements, family resource centers, and home visit programs in:
 
** Parenting
There are no available vaccines against [disease name].
** [[Child development]]
 
** Dealing with a child's cry
OR
** Parental resilience
 
** Danger of shaking a baby
Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
** Social support
 
OR
 
[Vaccine name] vaccine is recommended for [patient population] to prevent [disease name]. Other primary prevention strategies include [strategy 1], [strategy 2], and [strategy 3].


===Secondary Prevention===
===Secondary Prevention===
There are no established measures for the secondary prevention of [disease name].
[[Retinal]] [[hemorrhages]] and subdural [[Hematoma|hematomas]] associated with [[spine]] injuries and/or [[bone]] raise high suspision for shaken baby syndrome.<ref name="pmid25501728">{{cite journal| author=Nadarasa J, Deck C, Meyer F, Willinger R, Raul JS| title=Update on injury mechanisms in abusive head trauma--shaken baby syndrome. | journal=Pediatr Radiol | year= 2014 | volume= 44 Suppl 4 | issue=  | pages= S565-70 | pmid=25501728 | doi=10.1007/s00247-014-3168-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25501728  }} </ref>
 
OR


Effective measures for the secondary prevention of [disease name] include [strategy 1], [strategy 2], and [strategy 3].
Healthcare providers should report suspected [[child abuse]] to child protective services.<ref name="pmid32330675">{{cite journal| author=Hung KL| title=Pediatric abusive head trauma. | journal=Biomed J | year= 2020 | volume= 43 | issue= 3 | pages= 240-250 | pmid=32330675 | doi=10.1016/j.bj.2020.03.008 | pmc=7424091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32330675  }} </ref>


==References==
==References==

Latest revision as of 14:37, 22 September 2020

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Shaken baby syndrome
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Shakiba Hassanzadeh, MD[2]

Synonyms and keywords: abusive head trauma, the battered-child syndrome, the whiplash shaken infant syndrome, nonaccidental head injury, nonaccidental head trauma, inflicted traumatic brain injury, shaken impact syndrome

Overview

Abusive head trauma (AHT), commonly known as shaken baby syndrome (SBS), is the injury to the skull/intracranial structures due to violent shaking and/or abrupt impact in children aged less than 5 years. AHT is caused by shaking injuries from repetitive and rapid flexion, extension, and rotation of the head and neck usually following parental frustration over an infant that does not stop crying. Retinal hemorrhages and subdural hematomas associated with spine injuries and/or bone raise high suspision for shaken baby syndrome. Noncontrast head CT is the initial radiologic workup for evaluating intracranial injury due to abusive head trauma (AHT). The prognosis of AHT is associated with the extent of damage seen on CT scan and MRI. The initial management of AHT is to maintain the patient's airway and circulation. Vital signs, oxygenation, and intracranial pressure (ICP) should be monitored. Increased intracranial pressure (IICP) and seizures should be managed. Decompressive craniectomy may be required.

Historical Perspective

Classification

The modified grading system of abusive head trauma (AHT) is as the following:[10]

Modified Grading System of Abusive Head Trauma (AHT)

(Modified Table from Khan et al.: Pediatric abusive head trauma and stroke. J Neurosurg Pediatr 2017;20:183e90.)[10] 

Grade Description Brain Infarction Seen on CT or MRI
1 Skull fracture alone +/- associated craniofacial soft-tissue injury -
2a

or

No
2b

or

Yes
3a

or

or

No
3b

or

or

Yes

Pathophysiology

AHT is caused by shaking injuries from repetitive and rapid flexion, extension, and rotation of the head and neck and may result in:[11][12]

  • Sheering forces across the brain may injure nerve axons and lead to diffuse axonal disruption.

AHT includes primary and secondary injuries: [13]

The neurometabolic cascade of AHT is similar to traumatic brain injury:[14]

Children are more susceptible to head injuries at younger ages because:

  • The skull is easily compressed and therefore causes injuries to the underlying brain tissue.
  • The head is larger (in proportion to the rest of the body) and as they fall it is usually injured first.
  • The brain is more likely to suffer acceleration-deceleration injuries due to higher water content compared to adults.

Causes

AHT is caused by shaking injuries from repetitive and rapid flexion, extension, and rotation of the head and neck.[11]

Differentiating Shaken Baby Syndrome from Other Diseases

Shaken baby syndrome must be differentiated from the following conditions:[15][16][17][18][19][20][21]

Epidemiology and Demographics

  • The exact incidence of shaken baby syndrome/abusive head trauma (AHT) is unknown.[12]
  • In a population-based study, the incidence of AHT was reported to be 29.7 cases per 100,000 children younger than one year in the United States.[22]
  • In another study, the incidence of AHT was reported to be 24.6 cases per 100,000 children younger than one year in Scotland.[23]
  • Shaken baby syndrome/AHT is the leading cause of death due to head injuries in children younger than 2 years, worldwide.[12]

Risk Factors

Common risk factors in the development of shaken baby syndrome/AHT include factors that increase the risk of child abuse and may include:[24][25][26][27][28][29][30][31]

  • Infantile colic
  • Inconsolable cry
  • Child Disability
  • Lack of parental frustration tolerance
  • Lack of prenatal and childcare experience
  • Low education level
  • Low socioeconomic status
  • Single-parent families
  • Young parents without support
  • Community isolation
  • Limited recreational facilities
  • Poverty

Screening

There is insufficient evidence to recommend routine screening for shaken baby syndrome.

Natural History, Complications, and Prognosis

Children with AHT are more likely to experience the following compared to children with accidental head trauma:[32][33]

Complications of AHT may include:[34][32][35][12]

The prognosis of AHT is associated with the extent of damage seen on CT scan and MRI.[36]

Diagnosis

Retinal hemorrhages and subdural hematomas associated with spine injuries and/or bone raise high suspision for shaken baby syndrome.[37]

Clinical Evaluation

The clinical work-up of shaken baby syndrome should include:[12]

History and Symptoms

History

The following should be considered in the history of shaken baby syndrome/AHT:[12]

  • Open-ended questions should be asked by physicians
  • Caretakers should be interviewed separately
  • An inconsistent or changing history may suggest AHT or child abuse
  • The most common history suggestive of abusive head trauma (AHT) are:
    • History of non-accidental trauma
    • History of falling from a low height

Symptoms

Symptoms of shaken baby syndrome/AHT may include:[12]

Physical Examination

The following signs should be considered on the physical examination of shaken baby syndrome/AHT:[12]

Laboratory Findings

Laboratory tests for shaken baby syndrome should include:[12]

Electrocardiogram

There are no ECG findings associated with shaken baby syndrome.

X-ray

There are no specific x-ray findings associated with shaken baby syndrome, however, in order to identify child abuse in children aged less than two years with unexplained trauma, a skeletal survey should be performed with radiographs of the:[12]

Echocardiography or Ultrasound

There are no echocardiography or ultrasound findings associated with shaken baby syndrome.

CT scan

Noncontrast head CT is the initial radiologic workup for evaluating intracranial injury due to abusive head trauma (AHT).[12][38] CT is helpful in detecting:[38]

MRI

MRI may be helpful in:[39]

Other Imaging Findings

There are no other imaging findings associated with shaken baby syndrome.

Other Diagnostic Studies

There are no other diagnostic studies associated with shaken baby syndrome.

Treatment

Medical Therapy

  • Patients without impairment of consciousness may be managed with supportive care.[12]
  • Continuous EEG (cEEG) monitoring should be performed and antiepileptic drug may be used to reduce the risk for early posttraumatic seizures (EPTS).[41][42]

Surgery

Decompressive craniectomy (limits secondary brain injury by removing part of the skull and allowing brain swelling which ) is indicated when there is:[44]

Primary Prevention

Prevention of AHT includes:[12][25]

  • Decrease in child abuse and maltreatment
  • Parental education with public service announcements, family resource centers, and home visit programs in:
    • Parenting
    • Child development
    • Dealing with a child's cry
    • Parental resilience
    • Danger of shaking a baby
    • Social support

Secondary Prevention

Retinal hemorrhages and subdural hematomas associated with spine injuries and/or bone raise high suspision for shaken baby syndrome.[37]

Healthcare providers should report suspected child abuse to child protective services.[12]

References

  1. ↑ CAFFEY J (1946). "Multiple fractures in the long bones of infants suffering from chronic subdural hematoma". Am J Roentgenol Radium Ther. 56 (2): 163–73. PMID 20995763.
  2. ↑ Caffey J (1972). "On the theory and practice of shaking infants. Its potential residual effects of permanent brain damage and mental retardation". Am J Dis Child. 124 (2): 161–9. doi:10.1001/archpedi.1972.02110140011001. PMID 4559532.
  3. ↑ KEMPE CH, SILVERMAN FN, STEELE BF, DROEGEMUELLER W, SILVER HK (1962). "The battered-child syndrome". JAMA. 181: 17–24. doi:10.1001/jama.1962.03050270019004. PMID 14455086.
  4. ↑ Caffey J (1974). "The whiplash shaken infant syndrome: manual shaking by the extremities with whiplash-induced intracranial and intraocular bleedings, linked with residual permanent brain damage and mental retardation". Pediatrics. 54 (4): 396–403. PMID 4416579.
  5. ↑ Harding B, Risdon RA, Krous HF (2004). "Shaken baby syndrome". BMJ. 328 (7442): 720–1. doi:10.1136/bmj.328.7442.720. PMC 381309. PMID 15044268.
  6. ↑ Vinchon M, Defoort-Dhellemmes S, Desurmont M, Dhellemmes P (2005). "Accidental and nonaccidental head injuries in infants: a prospective study". J Neurosurg. 102 (4 Suppl): 380–4. doi:10.3171/ped.2005.102.4.0380. PMID 15926388.
  7. ↑ Bruce DA, Zimmerman RA (1989). "Shaken impact syndrome". Pediatr Ann. 18 (8): 482–4, 486–9, 492–4. doi:10.3928/0090-4481-19890801-07. PMID 2671890.
  8. ↑ Christian CW, Block R, Committee on Child Abuse and Neglect. American Academy of Pediatrics (2009). "Abusive head trauma in infants and children". Pediatrics. 123 (5): 1409–11. doi:10.1542/peds.2009-0408. PMID 19403508.
  9. ↑ "www.cdc.gov" (PDF).
  10. ↑ 10.0 10.1 Khan NR, Fraser BD, Nguyen V, Moore K, Boop S, Vaughn BN; et al. (2017). "Pediatric abusive head trauma and stroke". J Neurosurg Pediatr. 20 (2): 183–190. doi:10.3171/2017.4.PEDS16650. PMID 28574318.
  11. ↑ 11.0 11.1 Duhaime AC, Christian CW, Rorke LB, Zimmerman RA (1998). "Nonaccidental head injury in infants--the "shaken-baby syndrome"". N Engl J Med. 338 (25): 1822–9. doi:10.1056/NEJM199806183382507. PMID 9632450.
  12. ↑ 12.00 12.01 12.02 12.03 12.04 12.05 12.06 12.07 12.08 12.09 12.10 12.11 12.12 12.13 12.14 12.15 12.16 12.17 Hung KL (2020). "Pediatric abusive head trauma". Biomed J. 43 (3): 240–250. doi:10.1016/j.bj.2020.03.008. PMC 7424091 Check |pmc= value (help). PMID 32330675 Check |pmid= value (help).
  13. ↑ Pinto PS, Meoded A, Poretti A, Tekes A, Huisman TA (2012). "The unique features of traumatic brain injury in children. review of the characteristics of the pediatric skull and brain, mechanisms of trauma, patterns of injury, complications, and their imaging findings--part 2". J Neuroimaging. 22 (2): e18–41. doi:10.1111/j.1552-6569.2011.00690.x. PMID 22303964.
  14. ↑ Giza CC, Hovda DA (2001). "The Neurometabolic Cascade of Concussion". J Athl Train. 36 (3): 228–235. PMC 155411. PMID 12937489.
  15. ↑ Carpenter SL, Abshire TC, Anderst JD, Section on Hematology/Oncology and Committee on Child Abuse and Neglect of the American Academy of Pediatrics (2013). "Evaluating for suspected child abuse: conditions that predispose to bleeding". Pediatrics. 131 (4): e1357–73. doi:10.1542/peds.2013-0196. PMID 23530171.
  16. ↑ Weissgold DJ, Budenz DL, Hood I, Rorke LB (1995). "Ruptured vascular malformation masquerading as battered/shaken baby syndrome: a nearly tragic mistake". Surv Ophthalmol. 39 (6): 509–12. doi:10.1016/s0039-6257(05)80058-x. PMID 7660304.
  17. ↑ Agrawal S, Peters MJ, Adams GG, Pierce CM (2012). "Prevalence of retinal hemorrhages in critically ill children". Pediatrics. 129 (6): e1388–96. doi:10.1542/peds.2011-2772. PMID 22614777.
  18. ↑ Nassogne MC, Sharrard M, Hertz-Pannier L, Armengaud D, Touati G, Delonlay-Debeney P; et al. (2002). "Massive subdural haematomas in Menkes disease mimicking shaken baby syndrome". Childs Nerv Syst. 18 (12): 729–31. doi:10.1007/s00381-002-0630-z. PMID 12483361.
  19. ↑ Ganesh A, Jenny C, Geyer J, Shouldice M, Levin AV (2004). "Retinal hemorrhages in type I osteogenesis imperfecta after minor trauma". Ophthalmology. 111 (7): 1428–31. doi:10.1016/j.ophtha.2003.10.028. PMID 15234150.
  20. ↑ Bishop FS, Liu JK, McCall TD, Brockmeyer DL (2007). "Glutaric aciduria type 1 presenting as bilateral subdural hematomas mimicking nonaccidental trauma. Case report and review of the literature". J Neurosurg. 106 (3 Suppl): 222–6. doi:10.3171/ped.2007.106.3.222. PMID 17465389.
  21. ↑ Brousseau TJ, Kissoon N, McIntosh B (2005). "Vitamin K deficiency mimicking child abuse". J Emerg Med. 29 (3): 283–8. doi:10.1016/j.jemermed.2005.02.009. PMID 16183447.
  22. ↑ Keenan HT, Runyan DK, Marshall SW, Nocera MA, Merten DF, Sinal SH (2003). "A population-based study of inflicted traumatic brain injury in young children". JAMA. 290 (5): 621–6. doi:10.1001/jama.290.5.621. PMID 12902365.
  23. ↑ Barlow KM, Minns RA (2000). "Annual incidence of shaken impact syndrome in young children". Lancet. 356 (9241): 1571–2. doi:10.1016/S0140-6736(00)03130-5. PMID 11075773.
  24. ↑ Smith JA, Adler RG (1991). "Children hospitalized with child abuse and neglect: a case-control study". Child Abuse Negl. 15 (4): 437–45. doi:10.1016/0145-2134(91)90027-b. PMID 1959075.
  25. ↑ 25.0 25.1 Catherine NL, Ko JJ, Barr RG (2008). "Getting the word out: advice on crying and colic in popular parenting magazines". J Dev Behav Pediatr. 29 (6): 508–11. doi:10.1097/DBP.0b013e31818d0c0c. PMID 19034044.
  26. ↑ Niederkrotenthaler T, Xu L, Parks SE, Sugerman DE (2013). "Descriptive factors of abusive head trauma in young children--United States, 2000-2009". Child Abuse Negl. 37 (7): 446–55. doi:10.1016/j.chiabu.2013.02.002. PMID 23535075.
  27. ↑ Smith SM, Hanson R (1975). "Interpersonal relationships and child-rearing practices in 214 parents of battered children". Br J Psychiatry. 127: 513–25. doi:10.1192/bjp.127.6.513. PMID 53080.
  28. ↑ Oliver JE (1985). "Successive generations of child maltreatment: social and medical disorders in the parents". Br J Psychiatry. 147: 484–90. doi:10.1192/bjp.147.5.484. PMID 4075043.
  29. ↑ Benedict MI, White RB, Cornely DA (1985). "Maternal perinatal risk factors and child abuse". Child Abuse Negl. 9 (2): 217–24. doi:10.1016/0145-2134(85)90014-6. PMID 4005662.
  30. ↑ Garbarino J, Crouter A (1978). "Defining the comminity context for parent-child relations: the correlates of child maltreatment". Child Dev. 49 (3): 604–16. PMID 710189.
  31. ↑ Muller RT, Hunter JE, Stollak G (1995). "The intergenerational transmission of corporal punishment: a comparison of social learning and temperament models". Child Abuse Negl. 19 (11): 1323–35. doi:10.1016/0145-2134(95)00103-f. PMID 8591089.
  32. ↑ 32.0 32.1 Hymel KP, Makoroff KL, Laskey AL, Conaway MR, Blackman JA (2007). "Mechanisms, clinical presentations, injuries, and outcomes from inflicted versus noninflicted head trauma during infancy: results of a prospective, multicentered, comparative study". Pediatrics. 119 (5): 922–9. doi:10.1542/peds.2006-3111. PMID 17473092.
  33. ↑ Palusci VJ, Council on Child Abuse and Neglect. Kay AJ, Batra E, Section on Child Death Review and Prevention. Moon RY; et al. (2019). "Identifying Child Abuse Fatalities During Infancy". Pediatrics. 144 (3). doi:10.1542/peds.2019-2076. PMID 31451610.
  34. ↑ Tilak GS, Pollock AN (2013). "Missed opportunities in fatal child abuse". Pediatr Emerg Care. 29 (5): 685–7. doi:10.1097/PEC.0b013e31828f3e39. PMID 23640154.
  35. ↑ Lind K, Toure H, Brugel D, Meyer P, Laurent-Vannier A, Chevignard M (2016). "Extended follow-up of neurological, cognitive, behavioral and academic outcomes after severe abusive head trauma". Child Abuse Negl. 51: 358–67. doi:10.1016/j.chiabu.2015.08.001. PMID 26299396.
  36. ↑ Piteau SJ, Ward MG, Barrowman NJ, Plint AC (2012). "Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review". Pediatrics. 130 (2): 315–23. doi:10.1542/peds.2011-1545. PMID 22778309.
  37. ↑ 37.0 37.1 Nadarasa J, Deck C, Meyer F, Willinger R, Raul JS (2014). "Update on injury mechanisms in abusive head trauma--shaken baby syndrome". Pediatr Radiol. 44 Suppl 4: S565–70. doi:10.1007/s00247-014-3168-9. PMID 25501728.
  38. ↑ 38.0 38.1 Tung GA, Kumar M, Richardson RC, Jenny C, Brown WD (2006). "Comparison of accidental and nonaccidental traumatic head injury in children on noncontrast computed tomography". Pediatrics. 118 (2): 626–33. doi:10.1542/peds.2006-0130. PMID 16882816.
  39. ↑ Barlow KM, Gibson RJ, McPhillips M, Minns RA (1999). "Magnetic resonance imaging in acute non-accidental head injury". Acta Paediatr. 88 (7): 734–40. doi:10.1080/08035259950169017. PMID 10447132.
  40. ↑ Chesnut RM, Temkin N, Carney N, Dikmen S, Rondina C, Videtta W; et al. (2012). "A trial of intracranial-pressure monitoring in traumatic brain injury". N Engl J Med. 367 (26): 2471–81. doi:10.1056/NEJMoa1207363. PMC 3565432. PMID 23234472.
  41. ↑ Hasbani DM, Topjian AA, Friess SH, Kilbaugh TJ, Berg RA, Christian CW; et al. (2013). "Nonconvulsive electrographic seizures are common in children with abusive head trauma*". Pediatr Crit Care Med. 14 (7): 709–15. doi:10.1097/PCC.0b013e3182917b83. PMC 4082326. PMID 23842589.
  42. ↑ Liesemer K, Bratton SL, Zebrack CM, Brockmeyer D, Statler KD (2011). "Early post-traumatic seizures in moderate to severe pediatric traumatic brain injury: rates, risk factors, and clinical features". J Neurotrauma. 28 (5): 755–62. doi:10.1089/neu.2010.1518. PMID 21381863.
  43. ↑ Adelson PD (2009). "Hypothermia following pediatric traumatic brain injury". J Neurotrauma. 26 (3): 429–36. doi:10.1089/neu.2008.0571. PMC 2744377. PMID 19271965.
  44. ↑ Cho DY, Wang YC, Chi CS (1995). "Decompressive craniotomy for acute shaken/impact baby syndrome". Pediatr Neurosurg. 23 (4): 192–8. doi:10.1159/000120958. PMID 8835209.


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