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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.<!--
  --> 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.<!--
  -->
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.  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.<!--
  -->
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. 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.<!--
  -->
 
[[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]].<!--
  -->
Although bone disease of prematurity, [[rickets]] due to vitamin D deficiency,<!--
  --> [[Scurvy]] (vitamin C deficiency),<!--
  --><!--
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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.<!--
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In addition to [[Barlow's Disease]]<!--
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  --> or scurvy,<!-- 
--><!--
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a number of medical conditions,<!--
  --> including malformations,<!-- 
  --> premature infants,<!--
--> can mimic SBS, even before birth.<!--
--><!--
  --><!--
  --><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><!--
  --><!--
-->
 
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.<!--
  -->
 
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,"<!--
  --> ''medications, birth-related brain injuries,''<!--
    --> "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."<!--
  -->
 
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.''<!--
    --> 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."<!-- 
    -->
 
The main scientific finding of two additional studies<!--
--><!--
  --> 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<!--
  -->
a videotaped minor fall,<!--
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osteogenesis imperfecta<!--
    -->
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."<!--
    --> A postvaccinial ocular syndrome was reported as early as 1948, recent papers have been published concerning the occlusion of central retinal vein after hepatitis B vaccination,<!--
--> "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."<!--
    -->
 
==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.  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. 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<!--
  -->''
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<!--
  --> and reproduced in 2003,<!--
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seems to indicate the contrary.<!--
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"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.<!--
  -->
 
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.<!--
  -->
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.<!--
  -->.
 
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. <!--
  -->
 
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.<!--
  -->
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="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><!-- 
  --><!--
--><!--
  --> citing that the current SBS pathology determination may be seriously flawed or incomplete<!--
  --><ref name="patel" /><!--
--><!--
  --> 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><!--
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  --><!--
--><!--
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The proponents of such hypotheses often question the adequacy of nutrient tissue levels, especially vitamin C,<!--
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--><!--
  --> 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.<!--
  -->  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.<!--
  --><!-- 
  --><!-- 
  -->
 
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 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 addition, it has been suggested that severe adverse reactions to vaccinations may be an alternative cause of SBS. <!--
 
  --><!--
 
  -->
 
==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==
Line 289: Line 92:


==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 375: Line 181:


==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==
Line 394: Line 192:
* Death
* Death


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>
[[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>


* [[Blindness]]
* [[Blindness]]
Line 410: Line 208:


==Diagnosis==
==Diagnosis==
[[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>
===Clinical Evaluation===
===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 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>
Line 512: 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
*** 55 mmHg for 7-10 years
*** 60 mmHg for 11-16 years
* 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>
**  [[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)
** Raise the head to 30 degree
*** Improves [[venous return]] without affecting [[cerebral blood flow]]
** [[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.
** [[Mannitol]]
*** 0.25-1 gm/kg [[IV]] every 4-6 hours with the upper limit of serum [[osmolarity]] 320.
** [[Sedation]] with [[barbiturates]] may be needed in persistent IICP.
*** [[Barbiturates]] decrease cerebral [[metabolism]] and in turn decrease [[cerebral blood flow]] and therefore, reduce [[ICP]].
*** [[Thiopental]] or [[pentobarbital]]


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.  
The optimal therapy for [malignancy name] depends on the stage at diagnosis.


OR
* 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>
[Therapy] is recommended among all patients who develop [disease name].
*** [[Inflammation]]
 
*** [[Cell death]]  
OR
*** [[Excitotoxicity]]
 
*** Acute [[seizures]]
Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
*** [[Cerebral]] [[metabolic]] demands
 
OR
 
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
 
OR
 
Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
 
OR
 
Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].


===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

For patient information click here

Shaken baby syndrome
ICD-9 995.55
MedlinePlus 000004

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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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