Shaking Baby Syndrome

1. Shaking Baby Syndrome Mallory Sanzeri, Brittany Bonne Jodelle Bennett, Allison Buehler

2. What is Shaking Baby Syndrome? • Shaking baby syndrome is a serious form of child abuse caused by violent shaking of infants and young children. • The most common trigger leading to caregivers violently shaking a baby is crying.

3. WHO IS AT RISK? • Low educations status • Poverty • Unemployment • Teenage or single parenthood • Domestic violence • Drug abuse • Lack of parenting skills • Poor coping skills • Low birth weight (premature, disabled are at increased risk for SBS). • Children less than 1 year of age • African American • America Native • Alaska Native

4. Where? Each year in the United States there are approximately 1,300 infants who are hospitalized or die from Shaken Baby Syndrome It is very hard to monitor Shaking Baby Syndrome in other areas of the world including 3rd world countries because, there is no reporting of these acts and because many of these countries do not have child protective laws against child maltreatment. In many other countries there are no laws banning parents from disciplining their children in any way they see fit. Many of places that shaking baby syndrome take place is in the privacy of a home or daycare. That is why it is hard to get evidence to prove who was actually shaking the baby!

5. When? • The earliest citations of Shaken Baby Syndrome research traces back to 1968 involving monkeys subjected to collisions and violent accelerations. • Diagnosis of the syndrome, typically made when pathologists find a combination of brain swelling, retinal bleeding and tissue damage to brain linings, has won broad acceptance since it was first coined in the early 1970s. • SBS cases have been prosecuted around the world for the past 30 years.

6. Pathophysiology of SBS • Infants have a large head-to-body ratio, weak neck muscles, and a large amount of water in the brain. Violent shaking causes the brain to rotate within the skull, resulting in shearing forces tearing blood vessels and neurons. The characteristic injuries that occur are intracranial bleeding (subdural and subarachnoid hematomas) and retinal hemorrhages, but they may also include fractures of the ribs and long bones. Most often there are no signs of external injury. SBS is often not an isolated event. In one study 45% of the children with inflicted traumatic brain injury caused by shaking showed some evidence of prior injury

7. Clinical Manifestations (Signs and Symptoms) LESS SEVERE SIGNS AND SYMPTOMS • Generalized flu symptoms Unresponsive with impending death • Vomiting Irritability • Pour feeding Listlessness SEVERE SIGNS AND SYMPTOMS • Seizures Posturing • Alterations in levels of consciousness Apnea • Bradycardia Blindness • Cerebral palsy Death • Blindness Hearing Loss • Developmental delays • Cognitive, motor, mental impairments

9. Figure 2. A 6-month-old boy with shaken baby syndrome A. T2WI shows bilateral subdural fluid collection and no apparent abnormalities in the brain parenchyma. B. Sagittal T1WI shows an acute subdural hematoma as a small linear hyperintensity located in the occipital area (arrow). C,D. DWI clearly shows the extent of parenchymal abnormality as hyperintense lesions with decreased ADC in bilateral fronto-parieto-occipital white matter. This distribution is not related to the location of the acute subdural hematoma and is similar to that of hypoxic-ischemic encephalopathy.

10. A. On T2WI, the gray-white matter delineation is unclear and multiple intraparenchymal hemorrhages are noted probably due to shearing injury (arrows).B,C. DWI shows diffuse and extensive hyperintensity in the gray and white matter with decreased ADC that represents cytotoxic edema presumably resulting from excitotoxic injury. Only the right frontal lobe is relatively spared (arrow). www.neurographics.org/2/1/1/3.shtml

11. What is the controversy? Does Shaking Baby Syndrome Exist?

12. Controversy • One side of the believes from the mainstream medical opinion that shaken baby syndrome (SBS) is a valid diagnosis. They believe that decades of clinical experience and criminal confessions in which a parent has admitted to shaking a child with symptoms of SBS is complete evidence of the syndrome. • The other side is a growing number of skeptics the now claiming that the evidence for the symptoms is not accurate and the medical models for supporting SBS are questionable.

13. Controversy cont. Diagnosis of SBS vs. Accidental Falls What is the minimum height requirement for damage to a baby? A one year old child generated a force of 109 times the acceleration due to gravity when dropped from a sofa onto its head, when shaking a dummy the force was only 7G, less than a pillow fight. Out of 3357 falls recorded only 21 resulted in a concussion or fracture. Injuries from falls are infrequent and predominantly trivial. http://www.youtube.com/watch?v=OMnMP8rbW9U

14. Case Study "It is known from case records that SBS is misdiagnosed/overdiagnosed. It is not only a problem in medicine but a problem in the justice system." -Patrick Barnes of Stanford University • Neal Haynes of Rantoul, IL was charged in a civil case in October 2005 for shaking his 3-month-old son Jake. Although not accused of shaking the baby, the mother, Christy, was also charged with abuse and neglect for permitting the alleged shaking. • The doctors overlooked any other possibility for the hematomas after the diagnosis of SBS was made • By December 2005 Jake’s head circumference was swollen above the 97th percentile in which doctors concluded was from the terrible abuse.

15. Case Study • A 3.55 -months-old baby was admitted to the PICU after having experienced an acute episode of loss of consciousness. The parents referred that the child became choked during food intake. The infant vomited, got a congested face followed by cyanosis, and became unconscious. During transport to an emergency department, the father applied the Heimlich maneuver, shaking the baby forcefully. At the Emergency Service cardiopulmonary resuscitation was instituted and the patient was transferred to our hospital. On admission, the child was pale and hypotonic and had a Gasgow coma score of 11 together with a full anterior fontanel.

16. Case study continued • After a few minutes the child had almost completely recovered but showed poor reactivity and did not pursue with his eyes. There was no external marks of trauma. • CT of the head: subdural and subarachnoid hemorrhage • Lumbar puncture: hemorrhage in the cerebrospinal fluid • Eye examination: vitreous and retinal hemorrhages. • The child was discharged 2 weeks after admission and at 13 months of age the child appeared slightly retarded for his age and has a squint. • In our patient, the pediatricians suspected to be facing a case of abusive head injury, while the social and forensic investigations supported the accidental nature of this child's injuries

17. Case Report • A 3.5 month-old girl was admitted to the hospital for lethargy. The baby was brought in by her mother, who claimed that the baby fell off the cradle, around 6 hours ago. The sum of the results of the clinical and neuroimaging examination (retinal hemorrhages and subdural hematomas) was indicative of violent shaking of the baby. The forensic expert consulted and the mother and father underwent questioning regarding the circumstances of the abuse. The case history given by both patents revealed that the mother had indeed violently shaken her baby’s head by grabbing her cheeks but at an attempt to revive the babe after loss of consciousness after she fell out of the cradle.

18. How is this case study Controversial? • Was the mom trying to revive her child after loss of consciousness from falling out o the crib or was she fully aware of what she was doing and attempted to control the child. • 1) There was no evidence that the story the family told could be confirmed. • 2)The sum of the results of the clinical and neuroimaging exam showed indicative evidence of violent shaking baby syndrome. • 3)CONTROVERY-who is right, how can they prove if it wasn’t accidental vs. intentional. Why did she wait 6 hours before going into the hospital?

19. The Louise-Woodward Case In 1997, Louise Woodwood, 19 years of age, was accused for shaking infant, Matthew Eappen (8 mo.), to the point of death. The court initially convicted her of second-degree manslaughter but later in a post-conviction her sentence was reduced to involuntary-manslaughter. -In her statement to the police, Woodward said that she “popped the baby on the bed” which lead to a dispute on the meaning behind this statement. “I Believe that the circumstances in which Defendant acted were characterized by confusion, inexperience, frustration immaturity, and some anger, but not malice supporting a conviction of second degree murder. Frustrated by her inability to quiet the crying child, she was a little rough with him,' under circumstances where another, perhaps wiser, person would have sought to restrain the physical impulse.”

20. Cultural Values • Coining • Cupping • Burning • Female genital mutilation (female circumcision) • Forced kneeling • Topical garlic application • Traditional remedies that contain lead