In the first year of life, 95% of serious head injuries other than of a motor vehicle accident, result from abuse. Bleeding in the outer lining of the brain of a young child , usually below 2 years old, is called subdural haemorrhage (see Fig. 1) Subdural bleeding together with fractured ribs and bleeding within the eye is called the shaken baby syndrome.

Causes

• It is now accepted that children with shaken baby syndrome (SBS) is caused by violent acceleration/deceleration injury from shaking (as in Fig. 2, Fig.3). The infant’s relatively large head and poor neck support make it predisposed to acceleration and deceleration forces associated with rotational forces, much like in a whiplash injury. The soft, pliable skull and brain lead to stress on the bridging veins which tear with the force applied, leading to a subdural haemorrhage.
• Impact injury – when the child is thrown violently against a wall, floor or other objects or is struck on the head/ face
• This usually happens when the parent or childminder does not know what to do with a crying baby, who continues to cry since the baby’s needs are not attended to, leading to frustration and impatience in handling the baby. The parent or childminder may then inadvertently shake the baby hard for a few seconds in an attempt to stop the baby from crying or slap the baby out of rage. In a few instances, the childminder has been known to shake the baby’s cradle so hard that the baby falls out of the cradle.

Epidemiology

About 20-30 babies are referred to Hospital Kuala Lumpur every year for SBS. This is just the tip of the iceberg as some of the babies may have died at home or before they can be referred from another hospital. Other babies may have milder SBS and treated for irritability and vomiting as infantile colic.

Signs and Symptoms

The infant usually presents to hospital with a history of

• poor feeding, vomiting on and off, low grade fever and later fits (chronic course of illness)
• a more acute onset of irritability, vomiting, fits, decreased responsiveness, coma, irregular breathing

There may be no skull fracture, bruising and in many cases the child looks well nourished. Other physical signs include

• child is usually pale
• retinal haemorrhages (bleeding on the inner lining of the eye) (Fig 4) – present in between 75-90% of shaken babies
• vitreous haemorrhage (bleeding in the vitreous part of the eye)
• multiple fractured ribs (caused by squeezing of the chest)
• skull fractures (with impact injury)

Outcome

The outcome depends on the severity of the shaking episode(s), as well as further injury to the brain during the fitting episode(s). Babies’ brains are very fragile and ‘bruise’ easily so the trauma from violent shaking and lack of blood supply to key areas of the brain during prolonged fits leads to a high chance of dying or severe learning and/or motor disability . The outcome is worse if the infant is unconscious on admission to the hospital.

Prevention

Shaken baby syndrome is very preventable. When as a parent or caregiver, you feel stressed or frustrated, you must remember NOT to shake the baby. Things you can do for a crying baby. Should the baby cry endlessly and you are at a loss as to what to do to help your baby, you should

• leave the baby in a safe place like a cot with the sides up or playpen, make sure your baby is comfortable and leave the room for a few minutes. Give yourself a few minutes to calm down
• call your friend or relative for assistance or help you with household matters or with the other children

As parents or caregivers, you should not feel guilty for not being able to stop the baby from crying after several attempts. Research has shown that it is normal for some babies to have persistent crying on and off especially in the first 6-8 weeks of life referred to as “PURPLE cry”. PURPLE is :

• P : Peaks around two months.
• U : Unpredictable, often happening for no apparent reason.
• R : Resistant to soothing.
• P : Pain-like expression on the baby’s face, even without any source of pain.
• L : Long bouts, lasting 30 to 40 minutes or more.
• E : Evening crying is common – what many parents know as the “witching hour” is now a scientifically proven fact

Babies do not die from crying too much but they may if SHAKEN!

Even in play, do not throw your baby high into the air or swing him around.

Rehabilitation

For babies with SBS who survive, they will usually require long term medical follow up to check their developmental progress, management of any fits or epilepsy, physiotherapy and occupational therapy for cerebral palsy. A small percentage of babies may end up doing well if there has not been much brain swelling and injury during the trauma, usually when the impact injury is a bigger component than the shaking component.

Support Groups

You can bring your baby to the nearest health clinic or hospital. You may be asked to admit your baby if you are unable to manage your baby alone at home.

Web links

US National Center on Shaken baby syndrome http://www.dontshake.com/