Shaken baby syndrome

Shaken baby syndrome also known as abusive head trauma, shaken impact syndrome, inflicted head injury or whiplash shake syndrome, is a serious brain, head or neck injury from physical child abuse. Shaken baby syndrome happens when someone forcefully shakes a baby or hits the baby against something hard. Most cases happen when a parent or caregiver is angry, tired, or upset because a baby won’t stop crying or the child can’t do something they expect, like toilet train. People should never shake a baby for any reason.

Shaken baby syndrome destroys a child’s brain cells and prevents his or her brain from getting enough oxygen. Shaken baby syndrome is a form of child abuse that can result in permanent brain damage or death. At least one of every four babies who are violently shaken dies from shaken baby syndrome ¹.

Shaken baby syndrome is preventable. Help is available for parents who are at risk of harming a child. Parents also can educate other caregivers about the dangers of shaken baby syndrome.

All babies cry and do things that can frustrate caregivers; however, not all caregivers are prepared to care for a baby.

Babies especially babies ages 2 to 4 months, newborn to one year and toddlers younger than 2 years old, are at greatest risk of injury from shaking. Rarely, it can happen in children up to 5 years old. It can happen to boys or girls in any family. At special risk for abuse are children who have a lot of special needs or health problems that make them cry a lot, like colic and gastroesophageal reflux.

Shaking them violently can trigger a “whiplash” effect that can lead to internal injuries, including bleeding in the brain or in the eyes. Often there are no obvious external physical signs, such as bruising or bleeding, to indicate an injury.

In more severe cases of shaken baby syndrome, babies may exhibit the following ²:

• Unresponsiveness
• Loss of consciousness
• Breathing problems (irregular breathing or not breathing)
• No pulse

Babies suffering lesser damage from shaken baby syndrome may exhibit some of the following ²:

• Change in sleeping pattern or inability to be awakened
• Vomiting
• Convulsions or seizures
• Irritability
• Uncontrollable crying
• Inability to be consoled
• Inability to nurse or eat

Shaken baby syndrome can potentially result in the following consequences:

• Death
• Blindness
• Mental retardation or developmental delays (any significant lags in a child’s physical, cognitive, behavioral, emotional, or social development, in comparison with norms) ³ and learning disabilities
• Cerebral palsy
• Severe motor dysfunction (muscle weakness or paralysis)
• Spasticity (a condition in which certain muscles are continuously contracted—this contraction causes stiffness or tightness of the muscles and may interfere with movement, speech, and manner of walking) ⁴
• Seizures

Emergency treatment for a baby who has been shaken usually includes life-sustaining measures such as respiratory support and surgery to stop internal bleeding and bleeding in the brain. Doctors may use brain scans, such as MRI and CT, to make a more definite diagnosis.

In comparison with accidental traumatic brain injury in infants, shaken baby injuries have a much worse prognosis. Damage to the retina of the eye can cause blindness. The majority of infants who survive severe shaking will have some form of neurological or mental disability, such as cerebral palsy or cognitive impairment, which may not be fully apparent before 6 years of age. Children with shaken baby syndrome may require lifelong medical care.

Can tossing my baby in the air or rough play cause shaken baby syndrome?

Shaken baby syndrome is a form of child abuse that happens when an infant or small child is violently shaken. Shaken injuries are not caused by:

• Bouncing a baby on your knee.
• Tossing a baby in the air.
• Jogging or bicycling with your baby.
• Falls off a couch or other furniture.
• Sudden stops in a car or driving over bumps.

Although the activities listed above can be dangerous and are not recommended, they will likely not cause shaken baby syndrome injuries.

Why is shaking a baby dangerous?

Violent shaking for just a few seconds has the potential to cause severe injuries. While shaking may cause injury to children of any age, children are most susceptible to being injured during their first year of life. Factors that contribute to a baby’s vulnerability include:

• Babies heads are heavy and large in proportion to their body size.
• Babies have weak neck muscles.
• Babies have fragile, undeveloped brains.
• There is a large size and strength difference between the victim and the perpetrator.

How much force is necessary to cause injuries in shaken baby syndrome or abusive head trauma? How many times do you have to shake an infant or young child to cause damage?

The injuries seen in cases of shaken baby syndrome or abusive head trauma are caused by violent shaking and, in some cases, impact. This is due to the rapid and repeated acceleration and deceleration of the victim’s head whipping back and forth and side to side. Shaking injuries are not caused by casual or accidental handling of children. Shaking injuries require massive, violent force. One shake is all it takes to cause traumatic brain injuries in an infant.

Shaken baby syndrome facts

Most cases of shaken baby syndrome or abusive head trauma happen to babies. However, it is difficult to know the exact number of shaken baby syndrome cases per year because many cases of shaken baby syndrome are underreported and/or never receive a diagnosis. However, a study of North Carolina shaken baby syndrome cases suggests that as many as three to four children a day experience severe or fatal head injury from child abuse in the United States ⁵.

• Shaken baby syndrome or abusive head trauma is the leading cause of physical child abuse deaths in the U.S.
• There are approximately 1,300 reported cases of shaken baby syndrome  or abusive head trauma in the U.S. each year ⁶.
• Babies less than 1 year of age (with the highest risk period at 2 to 4 months) ⁷ are at greatest risk for shaken baby syndrome because they cry longer and more frequently, and are easier to shake than older and larger children ².
• Shaken baby syndrome injuries have been reported in children up to age 5 ⁸.
• Shaken baby syndrome is the result of violent shaking that leads to a brain injury, which is much like an adult may sustain in repeated car crashes. It is child abuse, not play. This is why claims by perpetrators that the highly traumatic internal injuries that characterize shaken baby syndrome resulted from merely “playing with the baby” are false. While jogging an infant on your knee or tossing him or her in the air can be very risky, the injuries that result from shaken baby syndrome are not caused by these types of activities ⁹.
• The most common trigger for shaking a baby is inconsolable or excessive crying—a normal phase in infant development ¹⁰.
• Parents and their partners account for the majority of perpetrators. Biological fathers, stepfathers, and mothers’ boyfriends are responsible for the majority of cases, followed by mothers ⁵.
• In most shaken baby syndrome cases there is evidence of some form of prior physical abuse, including prior shaking ¹¹.
• Upwards of 80% of surviving victims of shaken baby syndrome or abusive head trauma suffer lifelong disabilities.
• Approximately 25% of victims of shaken baby syndrome or abusive head trauma die.

Shaken baby syndrome causes

Shaken baby syndrome happens when someone:

• uses force to shake a child
• uses force to throw or drop a child on purpose
• hits the child’s head or neck against an object, like the floor or furniture, or hits the child’s head or neck with an object

Shaking a baby is so harmful because:

• Infants have poor neck strength and their heads are large compared with the size of their bodies. This lets the head move around a lot when shaken.
• When the head moves around, the baby or child’s brain moves back and forth inside the skull. This can tear blood vessels and nerves inside the brain, causing bleeding and nerve damage.
• The brain may hit against the inside of the skull, causing brain bruising and bleeding on the outside of the brain.
• Brain swelling builds pressure in the skull. This pressure makes it hard for blood, carrying oxygen and nutrients, to reach the brain, further harming it.

Babies have weak neck muscles and often struggle to support their heavy heads. If a baby is forcefully shaken, his or her fragile brain moves back and forth inside the skull. This causes bruising, swelling and bleeding.

Shaken baby syndrome usually occurs when a parent or caregiver severely shakes a baby or toddler due to frustration or anger — often because the child won’t stop crying.

Shaken baby syndrome isn’t usually caused by bouncing a child on your knee, minor falls or even rough play.

Risk factors for shaken baby syndrome

The following things may make parents or caregivers more likely to forcefully shake a baby and cause shaken baby syndrome:

• Unrealistic expectations of babies
• Young or single parenthood
• Stress
• Domestic violence
• Alcohol or substance abuse
• Unstable family situations
• Depression
• A history of mistreatment as a child

Also, men are more likely to cause shaken baby syndrome than are women.

Shaken baby syndrome prevention

New parent education classes can help parents better understand the dangers of violent shaking and may provide tips to soothe a crying baby and manage stress.

When your crying baby can’t be calmed, you may be tempted to try anything to get the tears to stop — but it’s important to always treat your child gently. Nothing justifies shaking a child.

If you’re having trouble managing your emotions or the stress of parenthood, seek help. Your child’s doctor may offer a referral to a counselor or other mental health provider.

If other people help take care of your child — whether a hired caregiver, sibling or grandparent — make sure they know the dangers of shaken baby syndrome.

• Tell people caring for your baby to never shake the baby.
• Talk about normal crying so a caregiver is less likely to get upset.
• Talk about safe ways to calm a baby, such as swaddling, rocking, or singing.
• Let caregivers know it’s OK to put the baby or child in a safe place, walk away and take a break.

What to do when babies cry

Why do babies cry?

All newborns cry and get fussy sometimes. It’s normal for a baby to cry for 2–3 hours a day for the first 6 weeks. During the first 3 months of life, they cry more than at any other time.

New parents often are low on sleep and getting used to life with their little one. They’ll quickly learn to find out if their crying baby:

• is hungry
• is tired
• needs to be burped
• is overstimulated
• has a wet or dirty diaper
• is too hot or cold

Often, taking care of a baby’s needs is enough to soothe a baby. But sometimes, the crying goes on longer.

What is colic?

Some babies cry a lot more than others. A baby who cries more than 3 hours a day, more than 3 days a week, for at least 3 weeks might have colic. Usually, it starts when a baby is 2–5 weeks old and ends by the time the baby is 3–4 months old.

Colic happens to a lot of newborns. It’s hard to see your baby cry so much, but colic isn’t caused by anything a parent did or didn’t do. The good news is babies outgrow colic.

What can help a crying baby?

You can’t spoil your baby with too much attention. To soothe a crying baby:

• First, make sure your baby doesn’t have a fever. In a baby, a fever is a temperature of 100.4°F (38°C). Call the doctor right away if your baby does have a fever.
• Make sure your baby isn’t hungry and has a clean diaper.
• Rock or walk with the baby.
• Sing or talk to your baby.
• Offer the baby a pacifier.
• Take the baby for a ride in a stroller.
• Hold your baby close against your body and take calm, slow breaths.
• Give the baby a warm bath.
• Pat or rub the baby’s back.
• Place your baby across your lap on his or her belly and rub your baby’s back.
• Put your baby in a swing or vibrating seat. The motion may be soothing.
• Put your baby in an infant car seat in the back of the car and go for a ride. Often, the vibration and movement of the car are calming.
• Play music — some babies respond to sound as well as movement.

Some babies need less stimulation. Babies 2 months and younger may do well swaddled, lying on their back in the crib with the lights very dim or dark. Make sure the swaddle isn’t too tight. Stop swaddling when the baby is starting to be able to roll over.

When a baby won’t stop crying

If a baby in your care won’t stop crying:

• Call a friend or relative for support or to take care of the baby while you take a break.
• If nothing else works, put the baby on their back in an empty crib (without loose blankets or stuffed animals), close the door, and check on the baby in 10 minutes. During that 10 minutes, do something to try to relax and calm down. Try washing your face, breathing deeply, or listening to music.

Call your doctor if nothing seems to be helping the baby, in case there is a medical reason for the fussiness.

Shaken baby syndrome signs and symptoms

In the most severe shaken baby syndrome cases, babies and children may come to the emergency room, hospital, or doctor’s office not awake, having seizures, or in shock.

In less severe shaken baby syndrome cases, symptoms and signs may include:

• Extreme fussiness, irritability or cranky and hard to comfort
• Move less than usual
• Not smile or coo
• Difficulty staying awake
• Grab-type bruises on arms or chest
• Trouble breathing
• Poor eating or eat less than usual
• Vomiting
• Have trouble sucking or swallowing
• Pale or bluish skin
• Seem stiff
• Have seizures
• Paralysis
• Have pupils (the dark spots in center of the eyes) that aren’t the same size
• Be unable to lift their head
• Have trouble focusing their eyes or tracking movement
• Head or forehead appears larger than usual
• Soft spot on head appears to be bulging
• Decreased level of consciousness
• Coma

You may not see any signs of physical injury to the child’s outer body. Sometimes, the face is bruised. Injuries that might not be immediately seen include bleeding in the brain and eyes, spinal cord damage, and fractures of the ribs, skull, legs and other bones. Many children with shaken baby syndrome show signs and symptoms of prior child abuse.

In mild cases of shaken baby syndrome, a child may appear normal after being shaken, but over time he or she may develop health or behavioral problems.

Shaken baby syndrome symptoms later in life

Even brief shaking of an infant can cause irreversible brain damage. Many children affected by shaken baby syndrome die.

Survivors of shaken baby syndrome may require lifelong medical care for conditions such as:

• Visual disabilities or blindness
• Mental retardation or developmental delays (any significant lags in a child’s physical, cognitive, behavioral, emotional, or social development, in comparison with norms) ³ and learning disabilities
• Cerebral palsy
• Severe motor dysfunction (muscle weakness or paralysis)
• Spasticity (a condition in which certain muscles are continuously contracted—this contraction causes stiffness or tightness of the muscles and may interfere with movement, speech, and manner of walking) ⁴
• Seizures
• Learning disabilities
• Physical disabilities
• Hearing impairment
• Speech disabilities
• Behavior disorders
• Cognitive impairment
• Death

Shaken baby syndrome diagnosis

Parents or caregivers often won’t say that the child was shaken or hit, so doctors may not know to check for head injury. Many signs of abusive head trauma, like fussiness and throwing up, are common in routine childhood illnesses. So it can be hard for doctors to figure out that a baby was harmed.

A child who’s been forcefully shaken may need to be examined by many different medical specialists, as well as an expert in child abuse.

If abusive head trauma is suspected, doctors will:

• Do an eye exam to look for bleeding inside the eyes.
• Order X-rays of all the bones to look for new or healing breaks, which happen most in the arms, legs, skull, and ribs.
• Order a CT or MRI of the head to look for:
  • broken bones in the head (skull fractures)
  • brain swelling
  • brain bleeding

Shaken baby syndrome treatment

Depending on the extent of the injuries, the baby may need to be monitored in a pediatric intensive care unit.

Emergency treatment for a child who has been shaken may include breathing support and surgery to stop bleeding in the brain.

After shaken baby syndrome or abusive head trauma,a child may need long-term care from a team of health experts, such as:

• brain doctors (neurologist)
• brain surgeons (neurosurgeon)
• eye doctors (ophthalmologist)
• hormone doctors (endocrinologist)

They also need a pediatrician who can manage their ongoing complex care. They also might need support from therapists, such as:

• rehab medicine
• speech-language therapy
• physical therapy (PT)
• occupational therapy (OT)

Before age 3, a child can receive free speech therapy or physical therapy through state-run programs. After age 3, the child’s school district’s provides any needed special educational services.

As kids get older, they may need special schooling and ongoing help to build language and daily living skills, like dressing.

Long term effects of shaken baby syndrome

Shaken baby syndrome or abusive head trauma often causes life-long harm to the brain and, sometimes, death.

Babies and children who survive may have:

• poor eyesight, partial or total blindness
• hearing loss
• seizures
• delayed development
• intellectual disability
• behavior issues
• problems with speech and learning
• problems with memory and focus
• cerebral palsy
• weakness or problems moving parts of the body
• problems with hormones controlled by the brain

If a child’s problems are mild, they might not be noticed until the child starts school and has problems with learning, focus, or behavior.

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