Shaken Baby Syndrome

Topic Overview

What is shaken baby syndrome?

Shaken baby syndrome (SBS) is a form of child abuse. It refers to brain injury that happens to the child. It occurs when someone shakes a baby or slams or throws a baby against an object. A child could be shaken by the arms, legs, chest, or shoulders.

Some experts use the term shaken-impact syndrome, because injury from throwing a child against a surface can equal that of shaking.¹ Many doctors use the term "abusive head trauma" or "intentional head injury."

Shaken baby syndrome often occurs when a baby won't stop crying and a caregiver shakes a baby out of frustration. To help prevent this problem, learn healthy ways to relieve stress and anger, and carefully choose your child care providers.

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

Shaken baby syndrome occurs mostly in children younger than 3, and is most common in babies younger than 1 year of age. But it also can affect children up to age 5. Shaken baby syndrome can cause serious long-term problems.

What causes the brain injury?

Shaking or throwing a child, or slamming the child against an object causes uncontrollable forward, backward, and twisting head movement. Brain tissue, blood vessels, and nerves tear. The child's skull can hit the brain with force, causing brain tissue to bleed and swell.

Young children are most likely to have brain injury when they are shaken or thrown because they have:

• Heavy, large heads for their body size.
• Weak neck muscles that do not hold up the head well.
• Delicate blood vessels in their brains.

What are the symptoms?

Symptoms vary among kids based on their age, how often they've been abused, how long they were abused each time, and how much force was used.

Mild injuries may cause subtle symptoms. A child may vomit or be fussy or grouchy, sluggish, or not very hungry. More severe injuries may cause seizures, a slow heartbeat, trouble hearing, or bleeding inside one or both eyes.

It is important to get help if something doesn't seem right with your baby. Shaken baby syndrome may cause only mild symptoms at first, but any head injury in a young child can be dangerous. A child who has trouble breathing, is unconscious, or has seizures needs hospital care right away.

Symptoms can start quickly, especially in a badly injured child. Other times, it may take a few days for brain swelling to show symptoms. Often the caregiver who shook the child puts the child to bed in the hope that symptoms will get better with rest. By the time the child gets to a doctor, the child needs urgent care. In some cases, the child may be in a coma before a caregiver seeks help.

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

How is shaken baby syndrome diagnosed?

Doctors may first suspect shaken baby syndrome when caregivers give vague or changing information about what has happened to the sick child. For example, the caregiver may tell a doctor that the child fell out of bed and then later say that a sibling or a pet caused the injury.

Shaken baby syndrome can be hard to detect because often there aren't clear signs of abuse. A baby may vomit, have a poor appetite, or be fussy or sluggish. These symptoms may at first seem related to an infection, such as the flu or meningitis. Sadly, you may not find out that shaken baby syndrome caused your child's injury until repeated abuse or more severe harm occurs.

Doctors check for shaken baby syndrome in several ways. They ask for a child's medical history. They may also do a physical exam and blood tests. Imaging tests such as X-rays, a CT scan, or an MRI can look for bleeding problems or other injury.

A doctor may also do tests to rule out other conditions. For example, a lumbar puncture checks a baby's spinal fluid for signs of meningitis. Blood found in this sample could point to a shaking injury.

A doctor who suspects shaken baby syndrome must report it to the local child welfare office and police.

If you suspect child abuse and the child is not in immediate danger, call local child protective services or the police. Do not confront the person who may have abused the child. This may cause more harm to the child.

How is it treated?

A child with shaken baby syndrome needs to be in the hospital, sometimes in an intensive care unit (ICU). Oxygen therapy may be used to help the child breathe. Doctors may give the child medicine to help ease brain swelling. Sometimes a cooling mattress will help lower the child's body temperature and reduce brain swelling too. A child who has severe bleeding in the brain may need surgery.

Depending on the symptoms, doctors may try seizure medicine, physical therapy, or other treatments.

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

About 1 out of 4 children who are forcefully shaken or thrown against an object die from their injuries.¹ Those who survive may have brain and vision problems that can last forever. These problems can 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.
• Muscle stiffness (spasticity) 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.
• Blindness or trouble seeing.
• Physical or emotional growth delays.
• Learning or behavior problems that may not appear until the child starts school.

Frequently Asked Questions

Symptoms

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 main factors that affect when symptoms appear and how severe they are. Trust your instincts if something doesn't seem right with your child.

Mild or vague symptoms

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

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 child's 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 have long-lasting problems from severe brain injury.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 problems:¹

• Blindness, or trouble seeing or hearing
• 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

Exams and Tests

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 exam 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.

Treatment Overview

A child with shaken baby syndrome is admitted to a hospital for observation and treatment. Doctors will closely monitor the child. They watch 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 occur, 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. Sometimes surgery is needed.

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.

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 child's caregiver will be charged and tried in a criminal court.

Home Treatment

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 Child Welfare Information Gateway. The Gateway helps states provide child welfare services that are designed to protect children and strengthen families. 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 injury.
• 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 staying active, 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.

Other Places To Get Help

Online Resources

Organizations

Related Information

• Child Abuse and Neglect
• Choosing Child Care
• Crying, Age 3 and Younger
• Growth and Development, Ages 1 to 12 Months
• Growth and Development, Ages 2 to 5 Years
• Growth and Development, Newborn
• Head Injury, Age 3 and Younger
• Stress Management

References

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.

Other Works Consulted

• 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.

• The Arc (2004). Shaken Baby Syndrome. Silver Spring, MD: The Arc. Available online: http://www.thearc.org/faqs/shakenbabysyndrome.doc.

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