Shaken baby syndrome
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|Shaken baby syndrome|
Editor-In-Chief: C. Michael Gibson, M.S., M.D.  Associate Editor(s)-in-Chief: Shakiba Hassanzadeh, MD
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
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.
- In 1945, Dr. John Caffey reported pediatric cases with chronic subdural hematoma and long bone fractures.
- Later, Dr. Caffey discovered the association between traumatic shaking, subdural hematoma, and retinal hemorrhage.
- In 1962, Henry Kempe used the term 'the battered-child syndrome'.
- 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.
- '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.
- Other terms for SBS include: nonaccidental head injury or trauma, inflicted traumatic brain injury, or shaken impact syndrome.
- The American Academy of Pediatrics and the Centers for Disease Control and Prevention (CDC) recommend the term 'abusive head trauma' (AHT).
The modified grading system of abusive head trauma (AHT) is as the following:
|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.)
|Grade||Description||Brain Infarction Seen on CT or MRI|
|1||Skull fracture alone +/- associated craniofacial soft-tissue injury||-|
AHT is caused by shaking injuries from repetitive and rapid flexion, extension, and rotation of the head and neck and may result in:
- 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.
- Greater parenchymal movement
- The head may hit an object and result in lacerations, bruises, and fractures.
AHT includes primary and secondary injuries: 
- 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
- Infarction or cerebrovascular accidents
The neurometabolic cascade of AHT is similar to traumatic brain injury:
- Release of excitatory neurotransmitters
- Potassium efflux
- Increased activity of membrane pumps
- 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
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.
AHT is caused by shaking injuries from repetitive and rapid flexion, extension, and rotation of the head and neck.
Differentiating Shaken Baby Syndrome from Other Diseases
Shaken baby syndrome must be differentiated from the following conditions:
- Accidental head trauma that may cause:
- Epidural hemorrhage
- Subdural hemorrhage
- Subarachnoid hemorrhage
- Cerebellar hemorrhage
- Parenchymal hemorrhage
- Bleeding diathesis
- Arteriovenous malformation
- Neoplastic conditions
- Metabolic disorders
- Glutaric aciduria
- Vitamin K deficiency
- Connective tissue diseases
- Osteogenesis imperfecta
Epidemiology and Demographics
- The exact incidence of shaken baby syndrome/abusive head trauma (AHT) is unknown.
- 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.
- In another study, the incidence of AHT was reported to be 24.6 cases per 100,000 children younger than one year in Scotland.
- Shaken baby syndrome/AHT is the leading cause of death due to head injuries in children younger than 2 years, worldwide.
Common risk factors in the development of shaken baby syndrome/AHT include factors that increase the risk of child abuse and may include:
- 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
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:
- Worse outcomes
- Cardiorespiratory compromise
- Diffuse cerebral hypoxia-ischemia
- Deeper brain injuries
Complications of AHT may include:
- Attention deficit
- Behavior difficulties
- Learning difficulties
- Sensory impairment
- Motor dysfunction
- Severe handicaps
- Decreased quality of life
The prognosis of AHT is associated with the extent of damage seen on CT scan and MRI.
Retinal hemorrhages and subdural hematomas associated with spine injuries and/or bone raise high suspision for shaken baby syndrome.
The clinical work-up of shaken baby syndrome should include:
- Comprehensive history
- Physical examination
- Laboratory tests
- Consultation with specialists
History and Symptoms
The following should be considered in the history of shaken baby syndrome/AHT:
- 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 of shaken baby syndrome/AHT may include:
- Poor feeding
- Decreased interaction
- Sleepiness and lethargy
- Respiratory distress
The following signs should be considered on the physical examination of shaken baby syndrome/AHT:
- Decreased level of consciousness
- Cardiovascular collapse
- Bulging fontanel
- Subdural hematoma
- Retinal hemorrhages
- Fractures in long bone, metaphysis, and rib
- Lack of external injury
- Bruises (ears, neck, or trunk)
Laboratory tests for shaken baby syndrome should include:
- Complete blood cell count (CBC) with platelet count
- Prothrombin time (PT)
- Partial thromboplastin time (PTT)
- Chemistry panel
- Aspartate aminotransferase (AST)
- Alanine aminotransferase (ALT)
There are no ECG findings associated with shaken baby syndrome.
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:
Echocardiography or Ultrasound
There are no echocardiography or ultrasound findings associated with shaken baby syndrome.
Noncontrast head CT is the initial radiologic workup for evaluating intracranial injury due to abusive head trauma (AHT). CT is helpful in detecting:
- Detecting subacute and chronic subdural bleeding
- Evaluating the extent of injuries in the parenchyma
- Differentiating chronic subdural from subarachnoid collections
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.
- Vital signs should be monitored.
- The initial care of AHT is to maintain the patient's airway, breathing, and circulation.
- Patients without impairment of consciousness may be managed with supportive care.
- Hypotension is treated with fluids.
- Intubation and mechanical ventilation are required in patients with moderate impairment of consciousness, severe respiratory insufficiency, or hemodynamic instability.
- Oxygenation should be monitored with a pulse oximeter.
- Intracranial pressure (ICP) should be monitored.
- Maintain ICP below 20 mmHg and minimal cerebral perfusion pressure (CPP) over 40 mmHg.
- 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:
- 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.
- 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
- Continuous EEG (cEEG) monitoring should be performed and antiepileptic drug may be used to reduce the risk for early posttraumatic seizures (EPTS).
- Seizure may occur at any stage.
- 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:
- Cell death
- Acute seizures
- Cerebral metabolic demands
- Therapeutic hypothermia may reduce:
Decompressive craniectomy (limits secondary brain injury by removing part of the skull and allowing brain swelling which ) is indicated when there is:
- No response to prior treatments
- Neurologic deterioration
- Signs of herniation
Prevention of AHT includes:
- Decrease in child abuse and maltreatment
- Parental education with public service announcements, family resource centers, and home visit programs in:
- Child development
- Dealing with a child's cry
- Parental resilience
- Danger of shaking a baby
- Social support
Retinal hemorrhages and subdural hematomas associated with spine injuries and/or bone raise high suspision for shaken baby syndrome.
Healthcare providers should report suspected child abuse to child protective services.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ "www.cdc.gov" (PDF).
- ↑ 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.
- ↑ 11.0 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.
- ↑ 12.00 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
- ↑ 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.
- ↑ Giza CC, Hovda DA (2001). "The Neurometabolic Cascade of Concussion". J Athl Train. 36 (3): 228–235. PMC 155411. PMID 12937489.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 25.0 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 32.0 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 37.0 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.
- ↑ 38.0 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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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