SBS/AHT (shaken baby syndrome/abusive head trauma) is a term used to describe the constellation of signs and symptoms resulting from violent shaking or shaking and impacting of the head of an infant or small child.

Physical Signs/Symptoms:

There are various signs and symptoms of shaken baby syndrome. The consequences of less severe cases may not be brought to the attention of medical professionals and may never be diagnosed. In most severe cases, which usually result in death or severe neurological consequences, the child usually becomes immediately unconscious and suffers rapidly escalating, life-threatening central nervous system dysfunction.

Any of these injuries can lead to severe disability or death. If you suspect a child has been shaken, seek medical attention immediately. This could be the difference between life and death.

Common Symptoms of Shaken Baby Syndrome:

• Lethargy / decreased muscle tone
• Extreme irritability
• Decreased appetite, poor feeding or vomiting for no apparent reason
• Grab-type bruises on arms or chest are rare
• No smiling or vocalization
• Poor sucking or swallowing
• Rigidity or posturing
• Difficulty breathing
• Seizures
• Head or forehead appears larger than usual or soft-spot on head appears to be bulging
• Inability to lift head
• Inability of eyes to focus or track movement or unequal size of pupils

What Happens:

• The brain rotates within the skull cavity, injuring or destroying brain tissue.
• When shaking occurs, blood vessels feeding the brain can be torn, leading to bleeding around the brain.
• Blood pools within the skull, sometimes creating more pressure within the skull and possibly causing additional brain damage.
• Retinal (back of the eye) bleeding is very common

Immediate Consequences:

• Breathing may stop or be compromised
• Extreme irritability
• Seizures
• Limp arms and legs or rigidity/posturing
• Decreased level of consciousness
• Vomiting; poor feeding
• Inability to suck or swallow
• Heart may stop
• Death

 Long-Term Consequences:

• Learning disabilities
• Physical disabilities
• Visual disabilities or blindness
• Hearing impairment
• Speech disabilities
• Cerebral Palsy
• Seizures
• Behavior disorders
• Cognitive impairment
• Death

 Why:

• Babies’ heads are relatively large and heavy, making up about 25% of their total body weight. Their neck muscles are too weak to support such a disproportionately large head.
• Babies’ brains are immature and more easily injured by shaking.
• Babies’ blood vessels around the brain are more susceptible to tearing than older children or adults.

 When:

• Often, perpetrators shake an infant or child out of frustration or anger. This most often occurs when the baby won’t stop crying. Other triggering events include toilet training difficulties and feeding problems.

 Can a Short Fall Produce the Medical Findings of Shaken Baby Syndrome?

David L. Chadwick, MD

In a large number of cases infants with the findings of shaken baby syndrome are brought for care with a history from the caretaker that the change in the baby’s condition followed a short fall from a bed, couch, chair, counter or another item of household furniture. What is the chance that this history might be true under these circumstances?

Most child abuse pediatricians would answer that question with words to the effect that the probability of a life-threatening head injury resulting from a fall of less than 4 ½ feet is remote. It is also unlikely that even a long free fall of 10-20 ft. with a serious head injury would produce the severe eye findings that are usually a part of SBS. The language about probability takes its origin from the facts that a zero probability of any event cannot be proven without an infinite number of observations, but a huge anecdotal pediatric experience of short falls supports a conclusion that they are almost always benign. In addition, it has been difficult to document the numbers of short falls that are affecting infants and toddlers so the precise expression of probability that a scientist might like is still not in hand although we are moving closer to it. In Plunkett’s videotaped case epidural hematoma was not excluded; an undescribed surgical procedure preceded death (and the autopsy) in that case.

We can now state with some confidence that the probability of a fatal injury (with SBS pathology) resulting from a short fall of an infant or toddler cannot be greater than 1 per million children aged 0-5 yrs./year, and is likely to be less than that. This is a probability estimate based on population. An estimate based on numbers of short falls would be many times as large, but varied by age. Toddlers fall from ground level at a rate of about 4 times per day, and from low elevated surfaces about every other day. Infants fall much less frequently but may fall from a low elevated surface about 4-5 times in the first year after birth.

The probability of short fall death could even be zero, although zero can only be proved in an eternity. Published, isolated case reports of short fall deaths can be found , and most depend on the statements of caretakers. Many of these statements are incorrect  All have some problem with validity as do the 13 cases that make up the deaths attributed to short falls by medical examiners in 5 years in California and which provide the one-in-a-million risk figure . That figure can be compared with the numbers of deaths of infants and young children in California attributed to homicide that provide a rate of about 30/million young children/yr.

Ultimately, a caretaker’s statement about an event that occurred in a private setting cannot be objectively confirmed or contradicted.

Rare short fall deaths may occur with epidural hematomas or with subdural bleeding caused by pre-existing medical conditions such as coagulopathies or arterio-venous malformations, but these can be excluded in most cases. Pre-existing brain abnormalities may also cause confusion although they are generally easily recognized.