This article about new research seeking to lower the number of babies dying or becoming disabled after being shaken caught my attention on BBC News. The latest research comes after Remari Collins passed away in August 2020 from shakings caused by his 43-year-old father, Marcus Carter, when he refused to settle into their Easton, Bristol, home. Dr Marl Lyttle, the head of research at the University of the West of England, stated that numerous UK centres have reported seeing an increase in the number of infants with brain damage. It emphasises the necessity of accurate knowledge regarding shaken baby syndrome (SBS).

A newborn or young infant violently shaken may have traumatic brain damage (SBS). It can result in bleeding, bruising, and swelling as the brain bounces back and forth against the skull.

Want to learn more about the intricate aspects of SBS? Keep scrolling for a comprehensive understanding of the causes, signs, preventative measures and the significance of support for the families impacted by this distressing illness.

Overview

The majority of deaths or severe brain damage brought on by child abuse is "SBS". It is specific to the infant stage because their anatomical features are distinct. Markers of shaking injury include subdural and retinal haemorrhages. The word whiplash shaken infant syndrome was first used in 1974 by American radiologist John Caffey. The first person to identify shaking as the source of subdural haemorrhage in babies was the British neurosurgeon Guthkelch.

Estimating the frequency of baby shakes in Britain is a difficult task. The yearly incidence of inflicted subdural haemorrhage was 21.0 and 24.6 per 100,000 children under one year old in two recent British studies. Most of the kids were younger than six months old. When children cry for extended periods without comfort, they are shaken or thrown to the ground in rage.¹

For prevention, the American Academy of Paediatrics advises parents and carers to become more knowledgeable about the risks associated with shaking babies and to learn safe ways to comfort and manage a crying child. It entails understanding the dangers of violently shaking a baby as well as the causes, signs, risk factors, and treatments for SBS. Conversely, a high level of awareness of SBS should aid in preventing the emergence of its consequences.²

Causes and risk factors

Assigned males at birth (AMAB) are more likely to commit SBS crimes, with biological fathers being the frequent abusers. The research also raises the possibility that AMAB partners or stepfathers may have participated in these horrible deeds. Both birthing parents (mothers) and assigned females at birth (AFAB) babysitters identify as SBS perpetrators. In general, 72% of incidents had AMAB perpetrators as they are more prone to produce SBS when they "shake" youngsters because of their superior physical strength.

AFAB are more understanding of the needs and expectations of the infants. Overall, the data points to the involvement of both parties in this abuse. The disturbed child may put a significant other under stress, which could lead to the adult abusing the youngster. Additionally, some data suggests those with explosive personality disorder and a tendency towards rage are more likely to commit such acts.³

The likelihood of SBS increases because of specific risk factors like:

• Age of infants
• The victims are younger than a year old, and in two-thirds, they are younger than six months. Most of them are first-born children.
• Multiple or unwanted pregnancies
• History of family abuse
• Preterm delivery
• Perinatal medical complications
• Birthing parent-child separation during the neonatal period (first month)
• Sleep disorders
• Feeding difficulties
• Social and family isolation
• Disadvantaged environment⁴

Mechanism of injury

• A head injury occurs due to two forces

• Bridging veins extending from the cortex to the dural venous sinus are torn and stretched by brain movement inside the subdural region
• In the absence of a history of severe head trauma, it offers solid proof of shaking
• Recent studies have demonstrated that, as the image below illustrates, the initial brain damage from intense shaking is due to hypoxia

• Necropsies on these neonates show damage to the brainstem. This injury is specific to infancy when the head is large with poor neck muscle tone. During shaking, the head pivots, resulting in a strain injury at the craniocervical joint
• The likelihood of harm increases with the infant's age. Vigorous physical treatment without head support can cause the same histological brain alterations associated with shaking injury in very preterm newborns as in older children
• It is rare to find superficial foci of haemorrhagic necrosis due to contusions. Subarachnoid haemorrhages, similar to subdural haemorrhages, are tiny and of no clinical significance and are also commonly seen in infants¹

Symptoms and diagnostic criteria

The graphic shows the warning signs and symptoms of SBS.

A comprehensive medical evaluation and analysis of multiple criteria are necessary for SBS diagnosis.

Physical examination 

The most common history in cases of abusive head trauma is one without trauma or a fall from a low height. More than 90% of newborns experiencing shaking exhibit acute signs and symptoms of an abusive head injury. The examination results include bruises on the neck, torso, or ears in kids under four years old, fontanel bulging, brain atrophy, frenulum injuries, hydrocephalus, ligature marks, retinal haemorrhages, long bone, metaphyseal, rib fractures and subdural haematoma. 

Imaging studies

When diagnosing intracranial damage resulting from abusive head trauma, the head CT scan is an effective diagnostic tool. It's usually best to do an MRI after a head CT scan. An MRI can identify subacute and chronic subdural blood, differentiate between chronic subdural and subarachnoid collection, and determine the degree of a parenchymal lesion.

If a child under two years old has severe unexplained injuries, they should have a skeletal survey done. Simple radiographs of the ribs, spine, skull, and long bones constitute a skeleton series. A skeletal survey or routine chest X-rays reveal the fractures. As an alternative to skeletal surveys, bone scans work when there is a strong possibility of fractures missed by the skeletal survey. Bone scans are more expensive, challenging to execute and subject the kid to more radiation.

Ophthalmologic examination

Getting an appointment with an ophthalmologist in the first 24 hours is vital. Retinal abnormalities indicate the forces associated with shaking.

Laboratory tests

Complete blood cell count (CBC) with platelet count, chemical panel, prothrombin time, partial thromboplastin time (PTT), lipase, amylase, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and urinalysis are all recommended tests.

Paediatrician consultation for child abuse

Open-ended inquiries avoid unnecessary bias and discover other plausible reasons for injuries, which clinicians should use. An inconsistent history indicates abusive head trauma and maltreatment of children.⁵

Management

Several abusive head trauma treatments are supportive. Therapy maintains adequate blood and low intracranial pressure to achieve optimal cerebral perfusion pressure (CPP). Three-tier therapy applies in the treatment plan shown in the table.

Consequences and long-term effects

Complications consist of:

• Acquired microcephalus
• Cortical blindness
• Developmental delay
• Hearing loss
• Hydrocephalus
• Learning disabilities
• Retinal haemorrhages
• Macular thinning
• Retinal pigment epithelial atrophy
• Seizures
• Rigid muscles
• Weakness⁵

The degree of SBS's long-term consequences varies. Behavioural issues, severe cognitive and developmental retardation, stroke, and blindness are among the functional diseases that a large percentage of survivors still experience today.¹⁰

FAQs

What legal implications are associated with SBS?

Criminal investigations and child welfare are among the legal ramifications of SBS. These inquiries will ascertain whether it is safe for kids to stay under the supervision of their parents or other primary carers and if someone faces charges of crime like assault or homicide. It is necessary for all the disciplines working on this element of the issue—social workers, police officers, attorneys, judges, probation officers—to be aware of the causes, consequences, and outcomes for these kids to provide the best possible intervention.⁶

Which five Ss apply to soothe a baby?

The five "S's"—swaddling, side/stomach position, sucking, swinging, and shushing sounds that simulate "womb-like" sensations—are techniques for reducing crying and enhancing sleep.⁷

How can you prevent SBS?

SBS is preventable. The Canadian Paediatric Society and Health Canada released a Joint Statement in 2001, advising the general public and specific audiences to avoid shaking infants and seek support in managing their needs. In addition, it advises against entrusting unskilled carers or people who struggle with anger management to watch after a child, even for a short period. Identification and protection of children in danger of abuse is the duty of physicians. For specific high-risk populations and families with a history of abuse, community-based public health efforts guide as a way to avoid child maltreatment in general.⁸

How long will a child with SBS live?

About 25% of infants with SBS pass away in a matter of days or weeks, making the prognosis poor. About 75% of survivors experience long-term damage.⁹

Summary

SBS is a severe kind of child abuse that may adversely impact a baby's growth and health. It usually affects babies under a year old, and its characteristic is a baby shaken violently, resulting in traumatic brain damage. This type of child abuse is avoidable and has a lasting impact on the affected infants and their families. We should strive to create a safer environment for infants, guaranteeing their health, well-being, and general development by raising awareness, advocating preventive measures, and assisting the carers.