Shaken baby syndrome

Shaken baby syndrome
Other namesAbusive head trauma, non-accidental head injury, non-accidental trauma
An intraparenchymal bleed with overlying skull fracture from shaken baby syndrome
SpecialtyPediatrics
SymptomsVariable[1]
ComplicationsSeizures, visual impairment, cerebral palsy, cognitive impairment[2][1]
Usual onsetLess than 5 years old[3]
CausesDisputed, proponents argue blunt trauma and vigorous shaking
Frequency3 per 10,000 babies per year (US)[1]
Deaths≈25% risk of death[3]

Shaken baby syndrome (SBS), also known as abusive head trauma (AHT), is a controversial and scientifically disputed[4][5][6] medical condition in children younger than five years old,[3] hypothesized to be caused by blunt trauma, vigorous shaking, or a combination of both.[4][1]

According to literature, the condition is caused by violent shaking with or without blunt impact that can lead to long-term health consequences for infants or children.[3] Diagnosis can be difficult,[1] but is generally characterized by the "triad" of findings: retinal hemorrhage, encephalopathy, and subdural hematoma.[7] A CT scan of the head is typically recommended if a concern is present.[1] If there are concerning findings on the CT scan, a full work-up for child abuse often occurs, including an eye exam and skeletal survey. Retinal hemorrhage is highly associated with AHT, occurring in 78% of cases of AHT versus 5% of cases of non-abusive head trauma,[8][9] although such findings rely on contested methodology.[10][5][6] A 2023 review concluded "research has shown the triad is not sufficient to infer shaking or abuse and the shaking hypothesis does not meet the standards of evidence-based medicine", and argued the symptoms may arise from naturally occurring retinal haemorrhage.[5]

The concept is controversial in child abuse pediatrics, with critics arguing it is an unproven hypothesis that has little diagnostic accuracy.[4][11] Diagnosis has proven to be both challenging and contentious for medical professionals because objective witnesses to the initial trauma are generally unavailable,[12] and when independent witnesses to shaking are available, the associated injuries are less likely to occur.[13] This is said to be particularly problematic when the trauma is deemed 'non-accidental.'[12] Some medical professionals propose that SBS is the result of respiratory abnormalities leading to hypoxia and swelling of the brain.[14] Symptoms of SBS may also be non-specific markers of the degree of intracranial pathology.[15] The courtroom has become a forum for conflicting theories with which generally accepted medical literature has not been reconciled.[16] There are often no outwardly visible signs of trauma, despite the presence of severe internal brain and eye injury.[1]

According to proponents, SBS is the leading cause of fatal head injuries in children under two,[16] with a risk of death of about 25%.[3] This figure has been criticized for circular reasoning, selection bias and that violent shaking very rarely causes serious injury.[17][18] The most common symptoms are said to be retinal bleeds, multiple fractures of the long bones, and subdural hematomas (bleeding in the brain).[19] Educating new parents appears to be beneficial in decreasing rates of the condition,[1] although other studies have shown that education does not change rates.[20] SBS is estimated to occur in three to four per 10,000 babies per year.[1]

One source states retinal hemorrhage (bleeding) occurs in around 85% of SBS cases and the severity of retinal hemorrhage correlates with severity of head injury.[8] Others contend this is based on circular reasoning and selection bias.[21] RHs are very rare when infants are actually witnessed to have been shaken.[13] The type of retinal bleeds are often believed to be particularly characteristic of this condition, making the finding useful in establishing the diagnosis,[22] although again such patterns are not found when shaking is independently witnessed,[13] and is almost certainly due to selection bias.[21]

Infants may display irritability, failure to thrive, alterations in eating patterns, lethargy, vomiting, seizures, bulging or tense fontanelles (the soft spots on a baby's head), increased size of the head, altered breathing, and dilated pupils, although all these clinical findings are generic and are known to have a range of causes, with shaking certainly not the most common cause of any of them. Complications include seizures, visual impairment, hearing loss, epilepsy, cerebral palsy, cognitive impairment, cardiac arrest, coma, and death.[1][2][23]

  1. ^ a b c d e f g h i j Shaahinfar A, Whitelaw KD, Mansour KM (June 2015). "Update on abusive head trauma". Current Opinion in Pediatrics. 27 (3): 308–314. doi:10.1097/mop.0000000000000207. PMID 25768258. S2CID 38035821.
  2. ^ a b Advanced Pediatric Assessment, Second Edition (2 ed.). Springer Publishing Company. 2014. p. 484. ISBN 978-0-8261-6176-5. Archived from the original on 5 November 2017.
  3. ^ a b c d e "Preventing Abusive Head Trauma in Children". www.cdc.gov. 4 April 2017. Archived from the original on 11 June 2017. Retrieved 9 June 2017.
  4. ^ a b c Gabaeff SC (1 January 2016). "Exploring the controversy in child abuse pediatrics and false accusations of abuse". Legal Medicine. 18: 90–97. doi:10.1016/j.legalmed.2015.12.004. ISSN 1344-6223. PMID 26832385.
  5. ^ a b c Squier W (2024). "Retinodural haemorrhage of infancy, abusive head trauma, shaken baby syndrome: The continuing quest for evidence". Developmental Medicine & Child Neurology. 66 (3): 290–297. doi:10.1111/dmcn.15676. ISSN 1469-8749. PMID 37353945.
  6. ^ a b Findley KA, Rossant C, Sasakura K, Schneps L, Squier W, Wester K, eds. (8 June 2023). Shaken Baby Syndrome: Investigating the Abusive Head Trauma Controversy (1 ed.). Cambridge University Press. doi:10.1017/9781009177894. ISBN 978-1-009-17789-4.
  7. ^ Cite error: The named reference :4 was invoked but never defined (see the help page).
  8. ^ a b Maguire SA, Watts PO, Shaw AD, Holden S, Taylor RH, Watkins WJ, et al. (January 2013). "Retinal haemorrhages and related findings in abusive and non-abusive head trauma: a systematic review". Eye. 27 (1): 28–36. doi:10.1038/eye.2012.213. PMC 3545381. PMID 23079748.
  9. ^ Christian CW, Block R (May 2009). "Abusive head trauma in infants and children". Pediatrics. 123 (5): 1409–1411. doi:10.1542/peds.2009-0408. PMID 19403508. S2CID 23001705.
  10. ^ Lynøe N, Elinder G, Hallberg B, Rosén M, Sundgren P, Eriksson A (2017). "Insufficient evidence for 'shaken baby syndrome' – a systematic review". Acta Paediatrica. 106 (7): 1021–1027. doi:10.1111/apa.13760. PMID 28130787.
  11. ^ Lynøe N, Elinder G, Hallberg B, Rosén M, Sundgren P, Eriksson A (2017). "Insufficient evidence for 'shaken baby syndrome' – a systematic review". Acta Paediatrica. 106 (7): 1021–1027. doi:10.1111/apa.13760. ISSN 0803-5253. PMID 28130787.
  12. ^ a b Vinchon M (October 2017). "Shaken baby syndrome: what certainty do we have?". Child's Nervous System. 33 (10): 1727–1733. doi:10.1007/s00381-017-3517-8. PMID 29149395. S2CID 22053709.
  13. ^ a b c Brook C (2024). "Witnessing abusive head trauma: Accidents show higher rates of intracranial pathologies than shaking". Annals of the Child Neurology Society. 2 (3): 206–211. doi:10.1002/cns3.20084. ISSN 2831-3267.
  14. ^ Geddes JF, Tasker RC, Hackshaw AK, Nickols CD, Adams GG, Whitwell HL, et al. (February 2003). "Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in 'shaken baby syndrome'?". Neuropathology and Applied Neurobiology. 29 (1): 14–22. doi:10.1046/j.1365-2990.2003.00434.x. PMID 12581336.
  15. ^ Brook C (2024). "Retino-dural hemorrhages in infants are markers of degree of intracranial pathology, not of violent shaking". Annals of the Child Neurology Society. 2 (2). doi:10.1002/cns3.20065.
  16. ^ a b "Consensus Statement: Abusive Head Trauma in Infants and Young Children". Pediatrics. 142 (2). August 2018. doi:10.1542/peds.2018-1504. PMID 30061300. S2CID 51878771.
  17. ^ Brook C (2024). "Witnessing abusive head trauma: Accidents show higher rates of intracranial pathologies than shaking". Annals of the Child Neurology Society. 2 (3). doi:10.1002/cns3.20084.
  18. ^ Feldman KW, Melville JD, Johnson KL, Valvano TJ, Piper AC, Lakin KL, et al. (2022). "Abusive head trauma follows witnessed infant shaking". Child Abuse Review. 31 (3). doi:10.1002/car.2739.
  19. ^ "NINDS Shaken Baby Syndrome information page". National Institute of Neurological Disorders and Stroke. 14 February 2014. Archived from the original on 29 May 2014. Retrieved 23 June 2008.
  20. ^ Lynøe N, Eriksson A (2021). "Why Programs for Managing Colicky Crying Fail to Prevent Abusive Head Trauma and Suggestions for Improvement". JAMA Pediatrics. 175 (7): 671–672. doi:10.1001/jamapediatrics.2021.0455. PMID 33900370.
  21. ^ a b Brook C (2024). "Retino-dural hemorrhages in infants are markers of degree of intracranial pathology, not of violent shaking". Annals of the Child Neurology Society. 2 (2): 146–152. doi:10.1002/cns3.20065. ISSN 2831-3267.
  22. ^ Levin AV (November 2010). "Retinal hemorrhage in abusive head trauma". Pediatrics. 126 (5): 961–970. doi:10.1542/peds.2010-1220. PMID 20921069. S2CID 11456829. Archived from the original on 20 October 2014.
  23. ^ Nadarasa J, Deck C, Meyer F, Willinger R, Raul JS (December 2014). "Update on injury mechanisms in abusive head trauma--shaken baby syndrome". Pediatric Radiology. 44 (S4): S565 – S570. doi:10.1007/s00247-014-3168-9. PMID 25501728.
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