Shaken baby syndrome
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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
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.
- In 1945, Dr. John Caffey reported pediatric cases with chronic subdural hematoma and long bone fractures.
- Later, Dr. Caffey discovered the association between traumatic shaking, subdural hematoma, and retinal hemorrhage.
- In 1962, Henry Kempe used the term 'the battered-child syndrome'.
- In 1974, Caffey used 'the whiplash shaken infant syndrome' for infants with injures from shaking the extremities with whiplash induced bleeding inside the brain and eye.
- 'Shaken baby syndrome' (SBS) has been used for decades to describe abusive head trauma (AHT) or inflicted traumatic brain injury on infants and young pediatric patients.
- Other terms for SBS include: nonaccidental head injury or trauma, inflicted traumatic brain injury, or shaken impact syndrome.
- The American Academy of Pediatrics and the Centers for Disease Control and Prevention (CDC) recommend the term 'abusive head trauma' (AHT).
The modified grading system of abusive head trauma (AHT) is as the following:
|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.)
|Grade||Description||Brain Infarction Seen on CT or MRI|
|1||Skull fracture alone +/- associated craniofacial soft-tissue injury||-|
- Tearing of the vessels due to the rapid striking of the brain on the skull result in bleeding. Consequently, the enlarging hematoma may cause pressure within the skull and lead to increased intracranial pressure (IICP) and additional injury to the brain.
- Greater parenchymal movement
AHT includes primary and secondary injuries: 
- Primary injuries is the consequence of the initial direct trauma and may include:
- Secondary injuries are inflammatory changes causing impairments in neurons and the microcirculation of the brain and include the complications of the primary injuries:
- Release of excitatory neurotransmitters
- Potassium efflux
- Increased activity of membrane pumps
- Lactate accumulation
- Calcium influx
- Decreased production of ATP
- Calpain activation and initiation of apoptosis
- Axolemmal disruption and calcium influx
- Neurofilament compaction
- Microtubule disassembly
- Axonal swelling and axotomy
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.
Differentiating Shaken Baby Syndrome from Other Diseases
- Accidental head trauma that may cause:
- Bleeding diathesis
- Arteriovenous malformation
- Neoplastic conditions
- Metabolic disorders
- Glutaric aciduria
- Vitamin K deficiency
- Connective tissue diseases
- Osteogenesis imperfecta
Epidemiology and Demographics
- The exact incidence of shaken baby syndrome/abusive head trauma (AHT) is unknown.
- 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.
- In another study, the incidence of AHT was reported to be 24.6 cases per 100,000 children younger than one year in Scotland.
- Shaken baby syndrome/AHT is the leading cause of death due to head injuries in children younger than 2 years, worldwide.
- 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
There is insufficient evidence to recommend routine screening for shaken baby syndrome.
Natural History, Complications, and Prognosis
- Worse outcomes
- Cardiorespiratory compromise
- Diffuse cerebral hypoxia-ischemia
- Deeper brain injuries
- Attention deficit
- Behavior difficulties
- Learning difficulties
- Sensory impairment
- Motor dysfunction
- Severe handicaps
- Decreased quality of life
The clinical work-up of shaken baby syndrome should include:
History and Symptoms
The following should be considered in the history of shaken baby syndrome/AHT:
- 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 of shaken baby syndrome/AHT may include:
- Poor feeding
- Decreased interaction
- Sleepiness and lethargy
- Respiratory distress
- Decreased level of consciousness
- Cardiovascular collapse
- Bulging fontanel
- Subdural hematoma
- Retinal hemorrhages
- Fractures in long bone, metaphysis, and rib
- Lack of external injury
- Bruises (ears, neck, or trunk)
Laboratory tests for shaken baby syndrome should include:
- Complete blood cell count (CBC) with platelet count
- Prothrombin time (PT)
- Partial thromboplastin time (PTT)
- Chemistry panel
- Aspartate aminotransferase (AST)
- Alanine aminotransferase (ALT)
There are no ECG findings associated with shaken baby syndrome.
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:
Echocardiography or Ultrasound
- Detecting subacute and chronic subdural bleeding
- Evaluating the extent of injuries in the parenchyma
- Differentiating chronic subdural from subarachnoid collections
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.
- Vital signs should be monitored.
- Hypotension is treated with fluids.
- Intubation and mechanical ventilation are required in patients with moderate impairment of consciousness, severe respiratory insufficiency, or hemodynamic instability.
- Intracranial pressure (ICP) should be monitored.
- Increased intracranial pressure (IICP) should be decreased in order to prevent secondary brain injury by:
- Raise the head to 30 degree
- Hypertonic agents may be used in moderate IICP.
- Sedation with barbiturates may be needed in persistent IICP.
- Continuous EEG (cEEG) monitoring should be performed and antiepileptic drug may be used to reduce the risk for early posttraumatic seizures (EPTS).
- Seizure may occur at any stage.
- Stepwise hypothermia keeps the body temperature between 32 C and 33 C for 48 hours and neuromuscular blockade may be helpful in preventing shivering.
- Decrease in child abuse and maltreatment
- Parental education with public service announcements, family resource centers, and home visit programs in:
- Child development
- Dealing with a child's cry
- Parental resilience
- Danger of shaking a baby
- Social support
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