Shaken Baby Syndrome
Until the 1960s, child abuse was not considered a medical problem in the United States, and physician involvement in child abuse cases was limited. In the 1960s, doctors began reporting on clinical signs and radiographic findings of child abuse that resulted from intentional trauma. In 1972 , Dr. John Caffey, a pediatric radiologist, named a syndrome “parent-infant-stress syndrome” or “battered baby syndrome” when an infant presented with radiological and physical findings associated with child abuse and the “whip-lash-shaking and jerking” of infants. In the decades that followed, it was termed Shaken Baby Syndrome (SBS). In 2009, the American Academy of Pediatrics reclassified “shaken baby syndrome” as abusive head trauma (AHT) to be more inclusive of all the ways a child’s head can be injured through abuse, including but not limited to violent shaking. For this summary we will focus only on the AHT caused by SBS.
SBS is a potentially preventable form of physical abuse that results in brain injury in a child or infant. The average age of injury is nine months but can range to 5 years. Boys appear to be more frequent victims of SBS. This preventable injury costs $1.2 to $1.6 billion in hospitalization every year and many innocent lives are lost. There are approximately 50,000 cases of SBS in the United States annually, and approximately 38% of shaken infants die. Of those children who survive, almost 50% have significant cognitive or neurological deficits.
Children at risk
A crying baby is more likely to suffer from SBS as parents shake the baby out of frustration to prevent or control crying.
Infants born with low birth weight /illness or infants who require hospitalization after birth can lack parental bonding.
Caregivers who are at high risk for becoming abusers are often those who have unrealistic expectations of children, expecting the child to fulfill their emotional needs.
Unwanted infants or fussy babies may be more at risk due to a perceived burden by caretaker or partner. Lack of sleep and a feeling of inadequate parenting may compound this belief.
Domestic violence in the home, drug and alcohol abuse, mental and emotional distresses in caretakers including postpartum depression and lack of external support.
Economic issues and other stressors for parents including unemployment and lack of stable housing
Biological parents are the most common perpetrators in cases of SBS, with boyfriends of mothers the next most likely abusers. In the past, men were thought to be the main perpetrators of SBS, but research now suggests that women are just as likely to shake their infants. When comparing the extent of injuries, men cause more traumatic injury because they are usually physically stronger than women.
Pathophysiology
SBS is most common in children under age four, with children under one year of age at most risk. The infant brain has higher water content than that of the adult brain, and it is incompletely myelinated. This demyelination makes the nerves and vessels more susceptible to tearing. The infant brain is more gelatinous and is easily compressed and distorted within the skull during a shaking episode. The infant’s brain is immature and needs flexibility for birthing and room to grow, so fontanelles are open at birth. Fontanelles are the space between the bones of the skull in an infant where ossification is not complete and the bones are not fully fused together. These are known as an infant’s soft spots in their head where the skull is not completed to protect the brain. The posterior fontanelle closes at 2-3 months. The anterior fontanelle closes between 9-18 months of age. During this time before closure the brain is at its most vulnerable.
The force involved in shaking an infant or child causes a coup contrecoup injury. A coup contrecoup injury is when the force of shaking causes the brain to impact suddenly on the front of the skull and energy then forces the brain back to the posterior part of the skull. This is a form of acceleration-deceleration injury. This can result in focal or diffuse injuries. It may result in cerebral contusions (bruising and swelling of brain tissue) and shearing (tearing) of blood vessels with subsequent subdural or subarachnoid hemorrhages. Subdural hemorrhage can be either unilateral or bilateral, although it is more commonly a bilateral injury. Shearing forces can sever nerve roots and branches.
Anatomically, infants and young children have very immature neck muscles with large and heavy heads in proportion to their bodies. This accounts for head lag observed during the first months of life. It takes several years for the head and body ratio to align. The shaking motion in an infants with poor muscle control can lead to spinal cord and or neck injuries.
History
Protecting and advocating for children is one of the most important actions a nurse can take in cases of suspected abuse; however, healthcare professionals should not make assumptions, concluding that every child that presents with certain symptoms is a victim of abuse. The role of the nurse is to accurately assess the patient and deliver care in a professional and objective manner. In cases of suspected SBS, discriminating abuse from other conditions is imperative.
Nursing documentation is crucial in cases of suspected SBS. Questions should be posed to assess the child, not to find fault or mistreat the parents or caregivers. Details as to what happened before, during and after the care-seeking incident may assist first responders in identifying injuries. Some caretakers will admit to shaking a baby when the child is found unresponsive. CPR guidelines state to gently shake an unresponsive child and see if they respond. However, in a state of panic, the shaking may not be gentle. Rib fractures must also be considered with the performance of CPR.
History pertaining to the general health of the child should include:
Birth history – weight, preterm, feeding, complications, NICU admission
Medical history –up to date on immunizations, hospitalizations, ED visits, last pediatrician visit
Recent issues – excessive crying, eating difficulties, sleep changes, behavioral changes
Environment – who lives in the home, siblings, primary caretaker, support system
Trauma history – recent fall or trauma in the last 3-5 days
Experts have investigated whether practices such as tossing a baby into the air, swings and other playful maneuvers might cause brain damage by a similar shaking mechanism. Currently, it is generally accepted that such playful practices do not result in injuries to the young child’s brain. The type of shaking that is thought to result in significant brain injury involves holding the child by the thorax or an extremity and violently shaking the child back and forth.
The parents’ concern, responses, or lack thereof to the child’s condition may be documented without bias. Not all parents respond in the same manner and judgment should not be placed on coping styles. Document all interactions with family or visitors and their behavior towards the child in a factual manner.
Healthcare professionals are classified as mandatory reporters and have a duty to report suspected or confirmed child abuse, including SBS. Nurses and other healthcare professionals should describe objective medical observations and treatments when reporting potential abuse to state authorities. Nurses should follow state law and facility policy when reporting suspected abuse.
Signs and Symptoms
Victims of SBS may present to a clinic, pediatricians office, or emergency department. Initial complaint may be identical to any child with a flu or mild illness. In the majority of cases, there are no visible signs of outward trauma or other injuries. Internal injuries are typically the only injuries suffered by the infant or child, which is part of the reason for the diagnosis of shaken baby syndrome rather than the assumption that such injuries are caused by falls or trauma. It is imperative that the nurse fully evaluate the child and family for any signs of inconsistency in the history of events.
The most common presentation for SBS is:
Vomiting
Increased irritability or uncontrollable crying
High pitched crying
Poor sucking
Listlessness
Significant changes in sleeping patterns
Bulging fontanels, separated skull sutures, or increased head circumference
Seizures
Respiratory distress or periods of apnea
Unresponsiveness or inability to be awakened
Coma
Diagnosis
The diagnosis of shaken baby syndrome is inferred by physicians when the injuries of the infant are consistent with shaken baby syndrome and when these injuries cannot be explained by other causes such as trauma, illness, accident or disease.
The three major criteria to date are:
1) Subdural hematoma
2) Retinal hemorrhage
3) Cerebral edema
Additional criteria have recently been added to the standard triad. They include:
– Rib fracture
– Seizures
– Long-bone fractures
-Bruises on the head or neck
-Apnea
The greater number of these criteria observed, the greater the likelihood of SBS.
Retinal hemorrhages are produced when venous congestion causes rupture of the retinal vasculature. Retinal hemorrhages can be seen as early as 48 hours before any intracranial lesions can be detected on brain CT or MRI. They are seen in up to 80% of children with SBS.
According to the 2015 guidelines on child physical abuse from the American Academy of Pediatrics, a skeletal survey for any child < 2 years with suspicious injuries can identify injuries that may exist in abused children and is very useful in the evaluation of suspected abuse. The true nature of the problem is often discovered only after CT is performed and evidence of intracranial pathology is found.
Differential Diagnostic Considerations
Other problems to be considered include the following:
Accidental trauma
Arteriovenous malformation
Bleeding disorders
Connective tissue disorder – osteogenesis imperfecta
Metabolic disorders
Structural mass or tumor
Infantile rickets
Birth trauma
Though not definitive, diagnosis laboratory studies may assist in identifying factors of abuse and or neglect. Leukocytosis and anemia is seen in approximately 50% of patients with SBS. Serum chemistry findings are usually normal, but they may reveal evidence of liver trauma or acidosis. Cerebrospinal fluid may be bloody, possibly indicating subarachnoid hemorrhage. Urinalysis should be performed for organic acids to rule out a diagnosis of genetic or metabolic disorders such as glutaric aciduria.
Treatment
Over the last decade many groups have challenged the current criteria for diagnosing SBS. In the end, regardless of the cause of injury these patients sustain substantial brain injury and nursing care should focus on maintaining optimal intracranial pressure and preserving motor and cognitive development. Hospitalization of a child, whether it involves short term or long term, creates a crisis for the child and family.
Base line information as to weight, length, and head circumference should be obtained. Calculations for appropriate emergency medications should be done prior to the need for them. There are several Glascow coma scale variations for infants and young children. Evaluation of eye opening, crying movement, and pain response are calculated as a baseline and followed frequently to assess changes in neurological function.
Intracranial monitoring may be necessary, especially when intracranial pressure is elevated due to cerebral edema and or subdural hematoma. Surgical evacuation may be necessary. Seizure precautions should be prophylactically instituted in all patients.
Long Term Sequela
The nonfatal consequences of shaken baby syndrome can vary according to degree of severity of the injuries. A range of injuries may result from SBS such as permanent brain injury, paralysis, blindness, hearing impairment, seizures, cerebral palsy, and delayed motor skill development, behavioral difficulties or permanent vegetative state. Physical, speech, occupational and social services all may play a part in the child’s recovery. Plan of care for activities are based on developmental stage, comorbid factors and the sequela that the child sustained.
Prevention
The federal Child Abuse Prevention and Treatment Act was adopted and implemented in 1974. Funds from this act have assisted communities in improving practices in the prevention and treatment of child abuse and neglect. In 2001, information related to SBS was given to all new parents in New York before discharge of a newborn. In addition, follow-up phone calls 6 to 7 months after discharge were obtained to evaluate the retention of SBS information by parents. Parents indicated that the information provided was helpful and a significant decrease (60%) in the incidence of SBS occurred in the New York areas studied. The best educational programs are directed at prevention of physical abuse, such as the Healthy Families America program. Interventions focusing on improving parent coping skills should be especially targeted at parents who report excessive infant crying. Improving parent coping skills may be beneficial both for the prevention of SBS and for the prevention of abuse in later childhood.
The National Center on Shaken Baby Syndrome (NCSBS) has a program called “Dads 101,” which is offered to military personnel, men in prison, youth detention centers, and halfway houses, and in conjunction with hospital prenatal care programs. The letters in the acronym PURPLE (Peak of crying, Unexpected, Resists soothing, Pain-like face, Long lasting, Evening) describe behavioral characteristics through which normal babies progress and that parents and caregivers often report as frustrating. The goal of this program is to decrease parent frustration and stress that can lead to the infant shaking. Nurses in a wide variety of clinical settings are in a strategic position for the early identification and intervention for families at risk for SBS. Prevention through parent, caregiver, and community-wide education programs is the best option for infants who are at risk for SBS.
References:
Gabaeff, SC. (2016). Exploring the controversy in child abuse pediatrics and false accusations of abuse. Legal Medicine, 16, 90-97. Retrieved from https://www.clinicalkey.com/#!/content/journal/1-s2.0-S1344622315300523.
National Center on Shaken Baby Syndrome. Retrieved from https://www.dontshake.org/.
Preventing Abusive Head Trauma in Children. Retrieved from https://www.cdc.gov/violenceprevention/childabuseandneglect/Abusive-Head-Trauma.html.
Stewart, TC et.. al. (2011). Shaken baby syndrome and a triple-dose strategy for its prevention. J Trauma, 71 (6), 1801-7. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/221828921.
Wyszynski, ME. (1999). Shaken baby syndrome: identification, intervention, and prevention. Clin Excell Nurse Pract., 3 (5), 262-7. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/10763623.
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