A 4-month-old was brought to the emergency department. His parents reported he was vomiting after meals, sleeping more than usual, and lacking motivation. This sounds like perhaps a viral infection, right?
Eleven days later, the child was still exhibiting these symptoms and was brought to the emergency department, dehydrated, and needed hospitalization. A CT scan revealed a hemorrhage in his brain and subsequent x-rays showed he had a few broken ribs.
The child was a victim of shaken baby syndrome. He now has permanent brain damage.
I'm Sandra Alexander. Thanks for tuning into this CDC Expert Video Commentary on Medscape.
I'd like to talk to you about shaken baby syndrome, the diagnostic indicators to help identify infants who have been shaken, and ways that you can help prevent this tragic form of child abuse and preventable public health problem.
Shaken baby syndrome (SBS) is a preventable and often severe form of physical child abuse resulting from violently shaking an infant by the shoulders, arms, or legs. SBS may result from both shaking alone or from shaking with impact, such as slamming a child against a wall.
At least 1 of every 4 babies who is violently shaken dies. And nearly all survivors of SBS suffer serious health consequences, including mental retardation or developmental delays, cerebral palsy, severe motor dysfunction, blindness, and/or seizures.
The forceful shaking that causes SBS does not happen in normal play. Claims by perpetrators that the highly traumatic internal injuries that characterize SBS resulted from a short fall off a bed or sofa, or from "playing with the baby" are false. While bouncing an infant on a knee or tossing him or her in the air can be risky, the injuries that result from SBS are not caused by these types of activities.
Often there are no obvious external physical signs, such as bruising or bleeding, to indicate an injury. So clinicians should also observe for the following and initiate further investigations if SBS is suspected:
Any infant or young child who presents with a history that is not plausible or consistent with the presenting signs and symptoms;
The presence of a new adult partner in the home;
A history of delay in seeking medical attention;
A previous history or suspicion of abuse;
The absence of a primary caregiver at the onset of injury;
Physical evidence of multiple injuries at varying stages of healing; or
Unexplained changes in neurologic status, unexplained shock, and/or cardiovascular collapse.
There are a number of diagnostic tools that are used to assess the possibility of SBS. In addition to a thorough history and physical exam, imaging of the brain by computed tomography and magnetic resonance imaging helps to establish the extent of the injuries and determine whether there may have been multiple episodes. Ophthalmology examinations and skeletal surveys add important information regarding the mechanisms of injuries. Other medical tests such as liver and pancreatic enzymes, urinalysis, and complete blood count can also help to establish the full range of injuries possibly suffered by the child.
Remember that SBS is not only a crime; it is a preventable public health problem. Because inconsolable crying is a primary trigger for shaking a baby, do your part during routine medical visits by asking parents how they are coping with parenthood and their feelings of stress. Talk with them about the steps they can take when feeling frustrated with a crying baby, such as putting the baby safely in a crib on his or her back, making sure that he or she is safe, walking away and calling a friend or a help line, while checking on the baby every 5 to 10 minutes. Emphasize that crying is normal for babies and that it will get better. Provide a referral and follow-up for parents who may need counseling or additional support or resources.
Sandra P. Alexander, MEd, has 40 years' experience in child abuse prevention including hands-on CPS casework and supervision in South Carolina, prevention programming and advocacy, and 18 years of nonprofit management in child abuse prevention organizations. Currently, she is a subject matter expert in child maltreatment in the Division of Violence Prevention (DVP), National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention (CDC). She works on CDC child maltreatment prevention initiatives including leadership for DVP's Knowledge to Action Child Maltreatment Prevention Consortium and a cross-division Shaken Baby Prevention Initiative. She also represents the CDC on other national child maltreatment initiatives. Previous positions include Executive Director of Prevent Child Abuse Georgia, founding board member and Executive Director of the Council on Child Abuse and Neglect (now Prevent Child Abuse South Carolina), and consultant for the National Center on Grandparents Raising Grandchildren at Georgia State University. She is a past board president of the American Professional Society on the Abuse of Children (APSAC) and former chair and current prevention advocate for the Fulton County (Atlanta) Child Fatality Review Committee. She has developed numerous prevention programs including shaken baby prevention, provided training on prevention nationally and internationally, and served as a prevention voice for local and national media. Sandra authored the chapter on "Prevention" in Child Maltreatment -- A Comprehensive Photographic Reference Identifying Potential Child Abuse published by G.W. Medical Publishing in 2005 and "Preventing Future Deaths Through Effective Prevention Recommendations and Actions," in Child Fatality Review, published by G.W. Medical Publishing in 2007. She is currently co-editing a book on child maltreatment prevention.
Public Information from the CDC and Medscape
Cite this: Sandra P. Alexander. CDC Expert Commentary: Shaken Baby Syndrome: Making the Diagnosis - Medscape - Aug 23, 2010.