Shaken Baby Syndrome

What is shaken baby syndrome?

Shaken baby syndrome (SBS) refers to brain damage that is caused when a baby is shaken, slammed, or thrown against an object. It is a form of child abuse. Some experts use the term shaken-impact syndrome to emphasize that serious damage from throwing a child against a surface can equal that of shaking.¹ Many health professionals prefer the term "intentional head injury," or IHI, because a child's injuries result directly from a caregiver's loss of control; the types of injuries are often the same or similar regardless of whether they were inflicted by shaking or slamming.

Normal play activities, such as bouncing a child on a knee or gently tossing a child in the air, do not cause shaken baby syndrome.¹

Shaken baby syndrome most frequently occurs in children younger than 2 years, and is most common in babies younger than 1 year of age. However, children up to age 5 can be affected. It is the most common cause of traumatic death in young children.

What causes the brain damage?

Experts believe that the rapid forward and backward head movement that occurs during violent shaking, throwing, or slamming against an object causes a baby's brain to shear and forcefully collide with the skull. This movement can tear blood vessels in a baby's brain, causing bleeding and swelling of surrounding tissue. Nerve cells may die from being stretched or sheared. Bleeding into and around the retina in the eyes can also occur.

Young children are more likely to sustain brain damage when they are shaken or thrown against an object because they have:

• Heavy, large heads for their body size. Also, the shape of young children's heads allows for more brain movement than in adults.
• Weak neck muscles that do not support the head well.
• Developing brains with delicate blood vessels.

What are the symptoms?

Symptoms of shaken baby syndrome vary depending on a child's age, the number of episodes of abuse, the duration of an episode, and the degree of force used.

Mild injuries may cause vague symptoms such as irritability, sluggishness, vomiting, and a poor appetite. More severe injuries may cause bleeding inside one or both eyes (retinal hemorrhages), seizures, a slow heartbeat, or difficulty breathing. If the child has trouble breathing or if brain swelling cuts off blood supply, oxygen to the brain is reduced and further damage results. Permanent brain damage or death may follow.

Symptoms may develop rapidly, especially in a severely injured child. Other times, it can take several days for the swelling of brain tissue to produce symptoms. Often the caregiver responsible for the abuse puts the child to bed in the hope that symptoms will improve with rest. By the time the child is taken to a health professional, symptoms have become severe enough to demand urgent care. Babies and children who stop breathing and lose consciousness require cardiopulmonary resuscitation (CPR). In some cases, the child may be in a coma before a caregiver seeks medical care.

Shaken babies may also have signs of other types of physical abuse, such as broken bones, bruises, or burns.

How is shaken baby syndrome diagnosed?

Health professionals may first suspect shaken baby syndrome when caregivers give vague or inconsistent information about what has happened to the injured child. For example, the parent may tell a health professional that the child fell out of bed and then later say that the injury was caused by an older sibling or a pet.

Shaken baby syndrome can be difficult to diagnose right away because obvious physical signs of abuse are usually absent. Symptoms such as poor appetite, irritability, sluggishness and vomiting may at first seem to be related to an infection, such as the flu or meningitis. It may take several episodes of abuse or a more severe injury with obvious symptoms before abuse from shaking is recognized as a possible cause.

Diagnosis is confirmed through a detailed medical history, physical exam, blood tests to detect bleeding problems, and imaging tests such as X-rays, a computed tomography (CT) scan of the head, or magnetic resonance imaging (MRI)

A child may also have tests to rule out other conditions. For example, a doctor may check a baby's spinal fluid for signs of meningitis by doing a lumbar puncture. Blood found in this sample could indicate a shaking injury.

Although each state has its own reporting procedure, a health professional who suspects shaken baby syndrome is required to notify local child welfare officials and law enforcement agencies.

How is it treated?

A child with shaken baby syndrome requires hospitalization, sometimes in an intensive care unit (ICU). Brain swelling or lack of oxygen to the brain are frequent complications that require immediate treatment. Oxygen therapy and/or a ventilator may be used to help the child breathe. The child may be given medication to help reduce swelling in the brain. A cooling mattress that helps to lower the child's body temperature and reduce brain swelling may also be tried. A child who has severe bleeding on the brain may need surgery to drain the fluid.

Other treatment is specific to the child's symptoms, such as medication to control seizures and physical therapy for disabilities.

What are the long-term problems from shaken baby syndrome?

About 20% to 25% of children who are forcefully shaken or thrown against an object die from their injuries.¹ Those who survive may have brain and vision damage, which can cause serious problems that last their entire lives. These problems may include:

• Seizures, which are sudden bursts of abnormal electrical activity in the brain. A baby may have uncontrolled muscle movement and be unable to speak, see, or interact normally.
• Spasticity, which is muscle stiffness caused by a problem with the brain and spinal cord that results in stiff, awkward movements.
• Mental retardation that can affect every area of a child's life, such as learning to talk or being able to care for himself or herself in the future.
• Impaired vision or blindness.
• Learning or behavior problems. Some related behavior or learning problems may not appear until the child enters school.
• Physical or emotional growth delays.

Frequently Asked Questions

Symptoms of shaken baby syndrome may appear right away or within several days. The child's age, the number of abusive episodes, and degree of force used are the primary factors that affect when symptoms develop and how severe they are.

Mild or vague symptoms

Vague symptoms may include irritability, sluggishness, vomiting, and a poor appetite. At first, caregivers and health professionals may assume that these symptoms are related to a common illness such as the flu. Meningitis may first be suspected when these symptoms are more severe.

Severe symptoms

In the most severe cases, a child loses consciousness or stops breathing right after being shaken or thrown. The caregiver may attempt to perform cardiopulmonary resuscitation (CPR) and later claim that the CPR caused the brain damage or other injuries. The caregiver responsible for the abuse may put the child to bed, hoping the condition will improve after the child rests. By the time the caregiver seeks medical attention, the child may be comatose and unable to suck, swallow, smile, make sounds, or follow the movement of an object with his or her eyes. The child may also have great difficulty breathing or may completely stop breathing, have a slow heart rate, and require CPR. These children usually either die or develop severe brain damage.¹

Other symptoms

Bleeding inside one or both eyes is a common symptom of shaken baby syndrome that can be detected by a pediatric eye specialist (ophthalmologist). Also, a child may have broken bones, often in the ribs or arms and legs, from violent shaking. Sometimes a child will have signs of other types of physical abuse, such as bruises or burns.

Long-term problems

About 20% to 25% of children who are forcefully shaken or thrown die from their injuries.¹ Those who live may have brain damage and one or more of the following complications:¹

• Impaired vision or blindness
• Seizures, which are sudden bursts of abnormal electrical activity in the brain. A baby may have uncontrolled muscle movement and be unable to speak, see, or interact normally.
• Inability to move (paralysis)
• Mental retardation that can affect every area of a child's life, such as learning to talk or being able to care for himself or herself in later years
• Learning disabilities, which are problems related to understanding or using spoken or written language
• Emotional difficulties or behavior problems

Shaken baby syndrome can be difficult to diagnose. The diagnosis can be complicated by:

• Vague symptoms. Irritability, sluggishness, vomiting, and a poor appetite that are often symptoms of shaken baby syndrome also occur with common illnesses, such as the flu, ear infections, stomach flu (gastroenteritis), and kidney infections.
• The lack of visible signs of injury, such as bruises or broken bones.
• One or both parents not knowing that their baby was abused.
• Caregivers not admitting when they have harmed a baby. They may make up stories to explain why a child has signs of trauma.
• Caregivers not seeking medical care right away after they have injured the child. This commonly occurs because the caregiver wants to avoid responsibility and hopes symptoms will go away after the child rests.

Health professionals may suspect shaken baby syndrome when the adults are vague or misleading about what has happened to the child, especially when symptoms are severe and indicate intentional head injury. Diagnosis is confirmed by:

• A medical history with a detailed time line of symptoms. This history includes noting changes in the child's behavior and when they occurred. This information helps doctors determine when an injury was likely to have occurred.
• A physical examination to look for signs of injury and increased blood pressure.
• Tests to help doctors identify injuries that are commonly associated with shaken baby syndrome.
  • A computed tomography (CT) scan generally is the first test that is done to determine the presence of brain injury. Scans may be repeated to monitor the condition of the child's brain.
  • A magnetic resonance imaging (MRI) test may be used along with a CT scan. Images from this test may help doctors understand more about a child's injuries, such as when they are likely to have occurred.
  • A lumbar puncture (LP) allows a doctor to look for blood in the fluid around the child's spinal cord. The fluid may also be examined for signs of infection that may indicate meningitis as a possible cause for a child's symptoms.
  • X-rays are taken to check for broken bones. X-rays may be repeated 2 weeks later because breaks in bones are sometimes not seen until they begin to heal (healing begins 7 to 10 days after a break). The types of X-rays usually taken are:
    • Skull X-ray.
    • Extremity X-ray.
    • Spinal X-ray.
    • Chest X-ray.

A child may have blood tests to rule out other conditions, such as rare blood disorders and metabolic conditions.

Each state has its own reporting procedures for child abuse or neglect, which includes shaken baby syndrome. Generally, a health professional who suspects shaken baby syndrome must notify local child welfare officials and law enforcement agencies. The person who is suspected of injuring the baby is then questioned and evaluated along with anyone else who provided care for the child. Any other children who were cared for by the suspect should be examined. Older children are interviewed; children age 3 years and younger should have skeletal X-rays taken.

The authorities' primary goal is to protect the baby and other children in the home from further injury. The person who caused the injury may be legally charged and tried for assault.

A child with shaken baby syndrome is admitted to a hospital for observation and treatment. Doctors will closely monitor the child for signs of brain swelling and difficulty breathing, which can lead to the death of brain cells or a stroke. If signs of these problems develop, the child is admitted to an intensive care unit (ICU) where he or she is treated with oxygen therapy and/or a ventilator. A neurosurgeon may treat the bleeding and swelling in the brain, which sometimes requires surgery.

Other treatment depends on the child's specific injuries. For example, a cast is applied to any broken bones and cuts are stitched or bandaged. A child who develops seizures is evaluated by a neurologist who may prescribe anticonvulsant medication. Other types of specialists assess, treat, and monitor children who have long-term care issues, such as those related to mental retardation or physical disabilities.

Other children in the care of the suspected abuser must be protected and examined for injury.

A wide variety of counseling therapies may be used for both children and parents. Specific treatment depends on the type of abuse, who inflicted it, in what setting it occurred, and the child's age. Health and legal professionals work as a team to develop the most effective program using their training, experience, judgment, and creativity.²

Parents may regain custody of their children after they have lost guardianship because of child abuse or neglect. Whether they do so depends on the severity of the abuse or neglect and a professional evaluation of their rehabilitation progress. In severe cases, future contact between parent and child must be supervised. Sometimes parents lose all parental rights.

Intentional injury is a crime. Police perform site investigations and interview other caregivers. If intentional injury is suspected, the caregiver will be charged and tried in a criminal court.

What to do if you suspect shaken baby syndrome

• Call 911 or other emergency services immediately if a child is unconscious, is having difficulty breathing, or is in immediate danger of further abuse. The 911 operator will guide you through resuscitation procedures if they are needed.
• If you suspect child abuse and the child is not in immediate danger, contact your local child protective services or police. Do not confront the suspected abuser. This may cause more harm to the child. Another resource is ChildHelp, a nonprofit agency that can provide telephone numbers and information about how to report suspected or observed child abuse or neglect. The national Child Abuse Hot Line number is 1-800-4-A-CHILD (1-800-422-4453). The U.S. Administration of Children and Families, under the Department of Health and Human Services, has established a Children's Bureau that supports the states in the delivery of child welfare services designed to protect children and strengthen families.³ For more information, see the Other Places to Get Help section of this topic

Keep in mind that the types of falls that occur during normal play, from an infant swing, from a low surface such as an adult bed or couch, or even down stairs, will not cause shaken baby syndrome. It is the violent shaking, throwing, or slamming of a child that results in this type of injury. Although caregivers often first state that these types of scenarios have caused a child's injuries, most later confess to having shaken or slammed a baby against an object.

Help prevent shaken baby syndrome

• Never shake a baby. Also, do not slap or hit a child of any age on the face or head. A child's brain is very delicate. Shaking, slapping, or hitting a child can cause serious harm, even though it may not leave any obvious sign of damage.
• Learn about normal child development and behavior so that your expectations of your children are realistic. Many quality parenting courses are available that can help you learn how to effectively manage the demands and responsibilities of caring for children. All parents and caregivers need to know how to react effectively to difficult behavior without resorting to violence or corporal punishment. These classes are especially valuable if you have a history of being abused. Talk to your health professional or call your local hospital to find classes in your community.
• Learn stress-relief and other healthy coping strategies. Taking care of yourself—by exercising, eating well, and getting rest—can help keep your stress level down. A variety of other strategies may also help depending on your background and interests. For example, you may find that self-help books or groups, religious organizations, or exercise classes such as yoga are helpful. Anger management classes or professional counseling may sometimes also help. For more information, see the topic Stress Management.
• Screen your potential child care providers to determine their child care skills and abilities.
  • Get a police background check on a prospective child care provider.
  • Choose a child care center that has a good reputation and that is licensed in your state.
  • Visit your child's caregiver without warning to get an idea of what kind of care is given when an observation is not expected.
• Seek financial assistance and support for child care if needed. This is especially important for young or single mothers. Contact your health professional or local hospital for community organizations that can help you.
• Take a break when you are feeling overwhelmed. Ask a friend, relative, or neighbor if they would be willing to help. Also, find out if your community offers respite care services, which provide occasional care for a family member. Have a list ready with names and numbers that you can call. Try planning ahead, such as scheduling this care on a weekly basis.
• Be an advocate for inexperienced and overwhelmed parents. Child abuse becomes less likely if parents or caregivers feel supported. Little things can help, such as offering to bring dinner for overtired parents when you see a need. On a larger scale, you may encourage community leaders to offer parenting classes. Also, support individuals or organizations that help parents who are at risk of abusing their children.

Organizations

• Choosing Child Care
• Crying, Age 3 and Younger
• Growth and Development, Ages 1 to 12 Months
• Growth and Development, Newborn

Citations

1. Committee on Child Abuse and Neglect, American Academy of Pediatrics (2001). Shaken baby syndrome: Rotational cranial injuries—Technical report. Pediatrics, 108(1): 206–210.

2. Saunders BE, et al., eds. (2004). Child Physical and Sexual Abuse: Guidelines for Treatment (Revised). Charleston, SC: National Crime Victims Research and Treatment Center. Also available online: http://www.musc.edu/cvc/guidelinesfinal.pdf.

3. Administration for Children and Families, U.S. Department of Health and Human Services (2002). How to Report Suspected Child Abuse and Neglect. Children's Bureau Factsheets/Publications. Available online: http://www.acf.hhs.gov/programs/cb/publications/rpt_abu.htm.

Author:	Amy Fackler, MA	Last Updated April 8, 2005
Medical Review:	Michael J. Sexton, MD - Pediatrics Charles F. Johnson, MD - Pediatrics/Child Abuse
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