Abstract
Shaken Baby Syndrome (SBS) is the generic name for the medical consequences caused by a particular form of child abuse: violently shaking infants and causing their heads to follow an abrupt whiplash motion. SBS is accompanied by a specific triad of clinical signs: subdural hematoma (cerebral bleeding), retinal bleeding (eye fundus bleeding) and brain swelling. The consequences of SBS are severe – with long term or permanent neural disabilities and in 20-25% cases death. In the medical community SBS is controversial as there are opposite sides advocating that either SBS is a violent form of child abuse or that is should be included in a wider category of “Non-Accidental Head Injuries”. Literature review on SBS shows that it is sometimes undiagnosed, underdiagnosed or misdiagnosed indicating a necessity for a standard procedure guide to follow when the suspicion arises. The focus should also be shifted on prevention by counseling the caregivers, which are also the abusers in the majority of cases, offering them accurate information and the possibility to calibrate their expectations to normal.
Shaken Baby Syndrome (SBS) is a set of clinical manifestations linked with physical child abuse, more specifically, violent shaking that causes a whiplash motion of the infant’s head. SBS is characterized by the concomitant occurrence of subdural hematoma, retinal bleeding and brain swelling, also known as “the triad”. In the majority of cases no sign of external trauma is visible. Epidemiologically wise, SBS can occur in children up to 5 years but the most exposed and vulnerable group are infants and children under 2 years old. The estimated mortality in SBS varies between 15% and 38% with a median of 20-25%, totaling up to almost half of infants death related to child abuse. The non-fatal cases of SBS are usually associated with long term or permanent consequences such as visual, motor or cognitive impairments. In the case of SBS, where the caregiver is usually the abuser, the risk factors are diverse: parent’s unrealistic expectations towards the child, emotional stress, substance abuse and other psycho-emotional and social conjunctures that can trigger a violent shaking episode. ("Shaken Baby Syndrome: Rotational Cranial Injuries Technical Report", 2001).
SBS is highly controversial and its particularities have split the medical community in two sides. On one side SBS is considered a violent form of child abuse that is consistent with a specific clinical manifestation (the triad: subdural hematoma, retinal bleeding and brain swelling) and the absence of signs of external violence. This hypothesis is validated by the fact that head injuries caused by accidents are specific with a linear force while the injuries caused by SBS are induced by a whiplash motion ("Shaken Baby Syndrome: Rotational Cranial Injuries Technical Report", 2001). On the other side, there are claims that SBS is sometimes misdiagnosed and that in some cases the necropsy findings are not consistent with the clinical interpretation. This does not mean that the existence of SDS is disputed but rather that is sometimes impossible to judge all the information and implicitly to have a 100% certainty that the trauma is caused by abusive and violent shaking. Due to these situations in which the post-mortem findings show that the fatal brain injury may have other causes besides SBS, some voices of the medical community advocate for eliminating the term “Shaken Baby Syndrome” and instead using a more generic, non-specific term such as “Non-Accidental Head Injury (NAHI)” or “Abusive Head Trauma (AHT)” (Minns, 2004).
SBS is diagnosed when at least the triad signs are observed. Along with subdural hematomas, retinal bleeding and brain swelling fractures of the vertebras, long bones (humerus, radius, ulna) and ribs are also associated with SBS. However, literature review on SBS shows that it is frequently undiagnosed, underdiagnosed or misdiagnosed. Even in the clear cases of SBS, proper actions (i.e. confronting the caregiver, notifying authorities) is rarely taken (Matschke et al., 2009) , in spite of the fact that up to 40% of the SBS victims have been submitted to prior abuse ("Shaken Baby Syndrome: Rotational Cranial Injuries Technical Report", 2001). While each of the SBS hallmark medical findings can have numerous other causes, their simultaneous occurrence is usually a sufficient ground for an accurate diagnose. In SBS the encephalopathy manifestations are considerably diffuse – vomiting, sleepiness, motor impairment, and crying and most of the time don’t indicate such a specific abuse. Furthermore, some of the causes of the subdural bleedings such as the tear of subdural veins or the bridging veins elude imaging investigations and are most of the time visible only in the necropsy (Squier, 2011). That is why the retinal bleeding is usually the clinical finding that confirm the SBS suspicion. Statistic evidence show that retinal bleeding occurs in about 85% of SBS meaning that 15% of the cases are harder to diagnose and alternative signs such as gripping marks, bone cracks or fractures, signs of previous abuse are needed to confirm and validate the diagnose.
Another controversy of SBS is about the force required to induce brain injuries while shaking a baby. This led to the appearance of folkloric beliefs that SBS may be caused by rough play, bouncing a child, tossing a child in the air which are all false hypothesis ("Shaken Baby Syndrome: Rotational Cranial Injuries Technical Report", 2001). Furthermore, if unintentional and normal activities that involve bouncing and gentle shaking could cause SBS it would lead to a much higher clinical incidence (Harding, 2004). While the force is an unknown variable in SBS intention of abuse is a fact. While it may occur under specific circumstance such as stress or substance abuse, the violent shaking is associated with intent (usually the aim is to stop the baby from crying or to discipline). The force applied, the intensity and the duration of the shake are variables that relate to the patterns of presentation of SBS which varies from hyperacute encephalopathy (broken neck, 6%), acute encephalopathy (53%), subacute non-encephalopathic presentation (19%), and chronic extracerebral presentation (22%) (Minns, 2004). Due to their nonspecific neurological manifestation and the diffusion of neurological symptoms The subacute non-encephalopathic and the chronic extracerebral presentations are frequently undiagnosed, underdiagnosed or misdiagnosed.
In spite of the controversy related to its name and of the difficulty of proper diagnose the focus of the medical act should be on confirming or infirming even the slightest suspicion of SBS as the consequences to its victims are permanent or even fatal. A standard protocol in case of SBS suspicion should be developed and applied involving multidisciplinary approach (neurology, ophthalmology, medical imaging) and standardized examinations (lab tests, radiology, eye tests). Escalation to authorities should also be a standard step of the procedure. Last but not least, it is also vital to provide psychological support for the caregiver. Counseling services and awareness problems should be available for caregivers such as mothers who could suffer from post-partum depression, parents that cannot cope with their baby crying and in general for any caregiver that has deformed expectations from the infant.
References:
Shaken Baby Syndrome: Rotational Cranial Injuries Technical Report. (2001). PEDIATRICS, 108(1), 206-210. http://dx.doi.org/10.1542/peds.108.1.206
Minns, R. (2004). Patterns of presentation of the shaken baby syndrome: Four types of inflicted brain injury predominate. BMJ, 328(7442), 766-766. http://dx.doi.org/10.1136/bmj.328.7442.766
Matschke, J., Hermmann, B., Sperhake, J., Korber, F., Bajanowski, T., & Glatzel, M. (2009). Shaken baby syndrome: A Common Variant of Non-Accidental Head Injury in Infants. Dtsch Arztebl Int, 106(13), 211-222. Retrieved from https://www.researchgate.net/profile/Bernhard_Herrmann/publication/26243051_Shaken_baby_syndrome_-_A_common_variant_of_nonaccidental_head_injury_in_infants/links/5459ee950cf2bccc4912e434.pdf
Squier, W. (2011). The “Shaken Baby” syndrome: pathology and mechanisms. Acta Neuropathologica, 122(5), 519-542. http://dx.doi.org/10.1007/s00401-011-0875-2
Harding, B. (2004). Shaken baby syndrome. BMJ, 328(7442), 720-721. http://dx.doi.org/10.1136/bmj.328.7442.720
