Shaken baby syndrome

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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

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