Shaken Baby Syndrome/Abusive Head Trauma (SBS/AHT) 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. The American Academy of Pediatrics (AAP) describes SBS as a subset of AHT with injuries having the potential to result in death or permanent neurologic disability.
Can Tossing My Baby in the Air or Rough Play Cause SBS?
SBS 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 SBS 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.
Possible Signs and Symptoms of SBS/AHT
- Lethargy / decreased muscle tone
- Extreme irritability
- Decreased appetite, poor feeding or vomiting for no apparent reason
- Grab-type bruises on arms or chest
- No smiling or vocalization
- Poor sucking or swallowing
- Rigidity or posturing
- Difficulty breathing
- Decreased level of consciousness
- Head or forehead appears larger than usual
- Soft spot on head appears to be bulging
- Inability to lift head
- Inability of eyes to focus or track movement
- Unequal size of pupils
Consequences of SBS/AHT
- Learning disabilities
- Physical disabilities
- Visual disabilities or blindness
- Hearing impairment
- Speech disabilities
- Cerebral Palsy
- Behavior disorders
- Cognitive impairment
Information on this page is not intended to replace advice by a health care professional. If you suspect a child has been shaken, seek immediate medical attention.
American Academy of Pediatrics
The use of broad medical terminology that is inclusive of all mechanisms of injury, including shaking, is required…The American Academy of Pediatrics supports prevention efforts that reduce the frequency of AHT and recognizes the utility of maintaining the use of the term “shaken baby syndrome” for prevention efforts.
The World Health Organization
… the baby will be considered a possible victim of ‘shaken baby syndrome’, a form of child abuse that involves the violent shaking of an infant…According to Dr Kieran Moran, forensic paediatrician at Sydney Children’s Hospital, babies are victims of violent shaking mainly in their first year of life, as that is often when they cry inconsolably and when parents and carers become most frustrated.
The American Association of Neurological Surgeons
Shaken Baby Syndrome (also known as Shaken Impact Syndrome) is a serious form of abuse inflicted upon a child. It usually occurs when a parent or other caregiver shakes a baby out of anger or frustration, often because the baby will not stop crying.
Canadian Joint Statement on Shaken Baby Syndrome/Abusive Head Trauma
Shaken Baby Syndrome is a collection of findings, all of which may not be present in any individual child with the condition. Injuries that characterize Shaken Baby Syndrome are intracranial hemorrhage (bleeding in and around the brain); retinal hemorrhage (bleeding in the retina of the eye); and fractures of the ribs and at the ends of the long bones.
The American Academy of Ophthalmology
Shaken Baby Syndrome is a subset of Abusive Head Trauma characterized by repetitive acceleration-deceleration forces with or without blunt head impact resulting in a unique complex of ocular, intracranial, and sometimes other injuries, usually in infants…it has become widely recognized as one of the most serious manifestations of physical child abuse.
The American Academy of Neurology
Shaken baby syndrome is a type of inflicted traumatic brain injury that happens when a baby is violently shaken. A baby has weak neck muscles and a large, heavy head. Shaking makes the fragile brain bounce back and forth inside the skull and causes bruising, swelling, and bleeding, which can lead to permanent, severe brain damage or death.
Centers for Disease Control and Prevention
Abusive head trauma (AHT), which includes shaken baby syndrome, is a preventable and severe form of physical child abuse that results in an injury to the brain of an infant or child. AHT is most common in children under age five, with children under one year of age at most risk. It is caused by violent shaking or blunt impact.
The Royal College of Ophthalmologists and The Royal College of Paediatrics and Child Health
A child suspected of abusive head injury is referred by paediatricians to an ophthalmologist for evaluation. The incidence of abusive head injury in children is highest in infancy and less frequently seen in children over 3 years of age. Retinal haemorrhages have a high positive predictive rate for abusive head injury.
French Society of Physical Medicine and Rehabilitation
SBS is a type of inflicted, non-accidental or abusive head injury caused by shaking (either alone or combined with an impact). It mainly occurs in babies under the age of one. It is thought that 180 to 200 children per year are victims of this type of abuse in France, although this value is certainly an underestimate. Failure to diagnose SBS increases the likelihood of recurrence.
Articles Everyone Should Know
These are some of the most relevant research articles about Shaken Baby Syndrome/Abusive Head Trauma that will aid a lay person wanting to learn more about this form of child abuse.
The list below contains the most recent research relevant to SBS/AHT published during the past year. The list cites the article’s title, author(s), title of the periodical or book, publication date and a link to the abstract or full article (if available). You may also click this link for a PubMed search on the terms 'shaken baby', 'shaken infant' and 'abusive head trauma'.
The importance of optic nerve sheath hemorrhage as a postmortem finding in cases of fatal abusive head trauma: a 13-year study in a tertiary hospital. Puanglumyai S, Lekawanvijit S. Forensic Science International. April 2017.
Development and Validation of a Physical Model to Investigate the Biomechanics of Infant Head Injury. Jones M, Darwall D, Khalid G, et al. Forensics Science International. April 2017.
Photographic assessment of retinal hemorrhages in infant head injury: the Childhood Hemorrhagic Retinopathy Study. Bhardwaj G, Jacobs MB, Martin FJ, et al. Journal of America Association for Pediatric Ophthalmology and Strabismus. February 2017.
Derivation and Validation of a Serum Biomarker Panel to Identify Infants with Acute Intracranial Hemorrhage. Berger RP, Pak BJ, Kolesnikova MD. JAMA Pediatrics. April 2017 [Epub ahead of print].
Cervical spine imaging for young children with inflicted trauma: Expanding the injury pattern. Baerg J, Thirumoorthi A, Vannix R. et al. Journal of Pediatric Surgery. January 2017 [Epub ahead of print].
Expert Witness Participation in Civil and Criminal Proceedings. Narang SK, Paul SR. Pediatrics. February 2017.
Initial response of the European Society of Paediatric Radiology and Society for Pediatric Radiology to the Swedish Agency for Health Technology Assessment and Assessment of Social Services' document on the triad of shaken baby syndrome. Offiah AC, Servaes S, Adamsbaum CS, et al. Pediatric Radiology. February 2017.
Diagnostic Performance of Ultrafast Brain MRI for Evaluation of Abusive Head Trauma. Kralik SF, Yasrebi M, Supakul N, et al. American Journal of Neuroradiology. February 2017. [Epub ahead of print]
Prevention of Pediatric Abusive Head Trauma: Time to Rethink Interventions and Reframe Messages. Leventhal JM, Asnes AG, Bechtel K. JAMA Pediatrics. January 2017.
Association of a Postnatal Parent Education Program for Abusive Head Trauma With Subsequent Pediatric Abusive Head Trauma Hospitalizaton Rates. Dias MS, Rottmund CM, Cappos KM. JAMA Pediatrics. January 2017.
Imaging and reporting considerations for suspected physical abuse (non-accidental injury) in infants and young children. Part 1: initial considerations and appendicular skeleton. Paddock M, Sprigg A, Offliah AC. Clinical Radiology. January 2017.
Imaging and reporting considerations for suspected physical abuse (non-accidental injury) in infants and young children. Part 2: axial skeleton and differential diagnoses. Paddock M, Sprigg A, Offliah AC. Clinical Radiology. Dec 2016.
Evaluation of the Hypothesis that Choking/ALTE May Mimic Abusive Head Trauma. Hansen JB, Frazier T, Moffat M, Zinkus T, Anderst JD. Academic Pediatrics. Dec. 2016. [Epub ahead of print]
Pediatric Abusive Head Trauma Prevention Initiatives: A Literature Review. Laterza Lopes NR, de Albuquerque Williams LC. Trauma, Violence, & Abuse. Nov 2016.
Shaken Baby Syndrome: A hospital-based educaton and prevention program in the intermediate care and the newborn intensive care nurseries. Lopez-Bushnell K, Torrez D, Robertson JV, Torrez C, Strickler L. Journal of Neonatal Nursing. Oct 2016.
Skin Lesions and Other Associated Findings in Children with Abusive Head Trauma. Luyet FM, Wipperfurth J, Palm A, Knox BL. Journal of Family Violence. Oct 2016.
Ophthalmologic Concerns in Abusive Head Trauma. Levin AL, Luyet FM, Knox BL. Journal of Family Violence. Sept 2016.
Subdural Hematoma Rebleeding in Relation to Abusive Head Trauma. Knox BL, Rorke-Adams LB, Luyet FM. Journal of Family Violence. Sept 2016.
Long-Term Outcomes Associated with Traumatic Brain Injury in Childhood and Adolescence: A Nationwide Swedish Cohort Study of a Wide Range of Medical and Social Outcomes. Sariaslan A, Sharp DJ, D'Onofrio BM, Larsson H, Fazel S. PLoS Med. August 2016.
Rapid MRI evaluation of acute intracranial hemorrhage in pediatric head trauma. Ryan ME, Jaju A, Ciolino JD, Alden T. Neuroradiology. August 2016.
Acceptance of Shaken Baby Syndrome and Abusive Head Trauma as Medical Diagnoses. Narang SK, Estrada C, Greenberg S, Lindberg DM. Pediatrics. July 2016. [Epub ahead of print]
Abusive head trauma: an epidemiological and cost analysis. Boop S, Axente M, Weatherford B, Klimo P Jr. J Neurosurg Pediatr. July 2016 [Epub ahead of print]
Accuracy of the history of injury obtained from the caregiver in infantile head trauma. Amagasa S, Matsui H, Tsuji S, Moriya T, Kinoshita K. Am J Emerg Med. June 2016. [Epub ahead of print]
The classic metaphyseal lesion and traumatic injury. Thackeray JD, Wannemacher J, Adler BH, Lindberg DM. Pediatr Radiol. July 2016.
Validation of the Pittsburgh Infant Brain Injury Score for Abusive Head Trauma. Berger RP, Fromkin J, Herman B, Pierce MC, Saladino RA, Flom L, Tyler-Kabara EC, McGinn T, Richichi R, Kochanek PM. Pediatrics. July 2016.
Fatal Abusive Head Trauma Among Children Aged <5 years - United States, 1999-2014. Spies EL, Klevens J. MMWR Morb Mortal Wkly Rep. May 2016.
Preventing Shaken Baby Syndrome: Evaluation of a Multiple-Setting Program. Stoltz HE, Brandon DJ, Wallace HS, Tucker EA. Journal of Family Issues. May 2016 [Epub ahead of print]
Rapid MRI evaluation of acute intracranial hemorrhage in pediatric head trauma. Ryan ME, Jaju A, Ciolino JD, Alden T. Neuroradiology. April 2016 [Epub ahead of print]
The natural history of retinal hemorrhage in pediatric head trauma. Binenbaum G, Chen W, Huang J, Ying GS, Forbes BJ. J AAPOS. April 2016.
Paid family leave's effect on hospital admissions for pediatric abusive head trauma. Klevens J, Luo F, Xu L, Peterson C, Latzman NE. Inj Prev. February 2016. [Epub ahead of print]
Hospital Variation in Cervical Spine Imaging of Young Children with Traumatic Brain Injury. Henry MK, Zonfrillo MR, French B, Song L, Feudtner C, Wood JN. Acad Pediatr. February 2016. [Epub ahead of print]
A statewide nurse training program for a hospital based infant abusive head trauma prevention program. Nocera M, Shanahan M, Murphy RA, Sullivan KM, Barr M, Price J, Zolotor A. Nurse Educ Pract. January 2016.
Pediatric Ophthalmologists' Experiences With Abusive Head Trauma. Sussenbach EC, Siatkowski RM, Ding K, Yanovitch TL. J Pediatr Ophthalmol Strabismus. January 2016.
Neuroimaging differential diagnoses to abusive head trauma. Girard N, Brunel H, Dory-Lautrec P, Chabrol B. Pediatr Radiol. December 2015. [Epub ahead of print]
Effectiveness of a Statewide Abusive Head Trauma Prevention Program in North Carolina. Zolotor AJ, Runyan DK, Shanahan M, Durrance CP, Nocera M, Sullivan K, Klevens J, Murphy R, Barr M, Barr RG. JAMA Pediatr. December 2015.
An evidence-based method for targeting an abusive head trauma prevention media campaign and its evaluation. Stewart TC, Gilliland J, Parry NG, Fraser DD. J Trauma Acute Care Surg. November 2015.
Development of a screening MRI for infants at risk for abusive head trauma. Flom L, Fromkin J, Panigrahy A, Tyler-Kabara E, Berger RP. Pediatr Radiol. November 2015. [Epub ahead of print]
Abusive head trauma: two case reports. Kanık A, İnce OT, Yeşiloğlu Ş, Eliaçık K, Bakiler AR. Turk Pediatri Ars. September 2015.
Validation of a Prediction Tool for Abusive Head Trauma. Cowley LE, Morris CB, Maguire SA, Farewell DM, Kemp AM. Pediatrics. August 2015.
Outcomes and factors associated with infant abusive head trauma in the US. Nuño M, Pelissier L, Varshneya K, Adamo MA, Drazin D. J Neurosurg Pediatr. July 2015. [Epub ahead of print]
Long-term outcome in a case of shaken baby syndrome. Bartschat S1, Richter C2, Stiller D2, Banschak S3. Med Sci Law. June 2015.
The evaluation of suspected child physical abuse. Christian CW; Committee on Child Abuse and Neglect, American Academy of Pediatrics. Pediatrics. May 2015.
What is Shaken Baby Syndrome/Abusive Head Trauma (SBS/AHT)?
The American Academy of Pediatrics describes Shaken Baby Syndrome as: a term often used by physicians and the public to describe abusive head trauma inflicted on infants and young children. Although shaking an infant has the potential to cause neurologic injury, blunt impact or a combination of shaking and blunt impact cause injury as well.
What happens to the brain during a shaking event?
An infant’s brain has a higher water content and less myelination than an adult brain and is more gelatinous and is easily compressed and distorted within the skull during a shaking episode. When shaken, the brain rotates relative to a more stationary skull, creating rotational and angular forces of the head. The lag time between the movement of the skull and the brain creates stress and tearing of blood vessels. The vessel injury leads to brain bleeding, or subdural hemorrhages.
What are subdural hemorrhages?
A subdural hematoma, or hemorrhage, is usually caused by a head injury strong enough to burst blood vessels. This can cause pooled blood to push on the brain. Trauma to the head tears blood vessels that run along the surface of the brain.How much force is necessary to cause injuries in Shaken Baby Syndrome/Abusive Head Trauma (SBS/AHT)? How many times do you have to shake an infant or young child to cause damage?
How much force is necessary to cause injuries in Shaken Baby Syndrome/Abusive Head Trauma (SBS/AHT)? How many times do you have to shake an infant or young child to cause damage?
The injuries seen in cases of SBS/AHT 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.
What is the retina of the eye?
The retina is a light-sensitive layer at the back of the eye that covers about 65 percent of its interior surface. Photosensitive cells calls rods and cones in the retina convert light energy into signals that are carried to the brain by the optic nerve. In the simplest terms, the retina is the lining of the inside of the eyes.
What happens to the eyes during a shaking event?
The same kind of violent motion that happens in the brain during shaking also occurs in the eye. When a child is violently shaken, the eyeball and its contents move back and forth in many different directions within the eye socket. The forces produced during a shaking episode may cause the layers of the retina to slide across each other creating stretching and shearing of the retinal vessels resulting in hemorrhages.What are retinal hemorrhages and what is their relationship to Shaken Baby Syndrome/Abusive Head Trauma (SBS/AHT)?
What are retinal hemorrhages and what is their relationship to Shaken Baby Syndrome/Abusive Head Trauma (SBS/AHT)?
Bleeding in the layers of the retina are called retinal hemorrhages. Retinal hemorrhages, especially those at the ora serrata and those involving many layers of the retina are frequently seen in SBS/AHT victims and are uncommon in other types of head injury. Retina hemorrhages typically happen in both eyes (bilateral) but can also be unilateral (one eye). This type of bleeding can only be viewed by a doctor using specialized equipment.
What other types of injuries might occur as a result of shaking?
Other injuries that can occur as a result of shaking are cerebral edema (brain swelling), cerebral contusions (brain bruises), external head bruises, body bruises, skull fractures, rib fractures, long bone fractures, neck and spinal cord damage, or other injuries that cannot be explained through a medical condition or accidental trauma.
Do falls cause injuries similar to Shaken Baby Syndrome/Abusive Head Trauma (SBS/AHT)?
Accidental falls, even down stairways, are not generally the cause of brain injuries in infants. Household falls from furniture or down stairs most commonly result in minor trauma. High-velocity impact injuries, falls from extreme heights, or falls onto extremely hard surfaces provide the opportunities for more severe injuries, like those seen in SBS/AHT injuries.
Predisposing factors in Shaken Baby Syndrome/Abusive Head Trauma (SBS/AHT)?
Common factors associated with increased risk of child abuse are often individual characteristics, substance abuse, and young age of the parent or caregivers; the age, health, physical, mental, emotional, and social development of the child; history of violence within the family structure; poverty and economic conditions, social attitudes, promotion of violence, and cultural norms of the community; lack of education and resources for the family.What are CT scans and MRIs and how are they used to diagnose Shaken Baby Syndrome/Abusive Head Trauma (SBS/AHT)?
What are CT scans and MRIs and how are they used to diagnose Shaken Baby Syndrome/Abusive Head Trauma (SBS/AHT)?
A CT (computed tomography) scan is an X-ray technique that produces a detailed cross-section of tissue structure. An MRI (magnetic resonance imaging) is medical imagining that gives pictures of organs and different structures of the body which gives different information about the body than can be seen with an X-ray, ultrasound, or CT scan.
A CT scan gives sufficient resolution and detail to allow a physician to evaluate an acute brain injury in an abused child. MRI scans are used several days to a week after an injury to better diagnose the types of injuries to the brain and show changes in in the brain tissue. Most skull fractures can be best shown with an X-ray.
How can the injuries be dated and the time of injuries be determined?
Clinical history, physiologic data, and imaging are the three (3) sources physicians use to establish the timing of head injuries.
What is the outcome or prognosis of victims of Shaken Baby Syndrome/Abusive Head Trauma (SBS/AHT)?
The outcomes for victims of SBS/AHT largely depend on the severity of the abuse. One third (1/3) of SBS/AHT victims who develop symptoms either do not have significant disabling conditions or the outcomes are less well-defined. Mild injuries might include learning disabilities, personality changes, or behavior problems. Other children have seizure disorders, developmental, or mental delays. Many children are left with blindness, profound reduced mental capacity, spastic diplegia (paralysis of both sides), or quadriplegia (all sides). Some children develop cerebral palsy or some continue to live in a persistent vegetative state.
How can Shaken Baby Syndrome/Abusive Head Trauma (AHT) be prevented?
Child abuse, and specifically SBS/AHT, is prevented through parent/caregiver education classes about normal infant crying patterns, increased general public awareness, respite care for overwhelmed parents/caretakers, parents having a plan of action for when they become upset or exhausted while taking care of an infant/child, a parent putting the infant/child down in a safe place and walking away until they regain composure, parents/caregivers asking for help from family members or friends, and having the infant/child evaluated by a doctor if there are concerns about the baby’s physical condition.
In the Midst of Child Abuse, the Face of an Angel
Lawrence R. Ricci, MD
Angel was then, and is even now, one of the most beautiful babies I have ever seen and I have seen many in my thirty years as a child abuse pediatrician. Yet, to look at her today, asleep against her foster mother’s shoulder, one could never guess at the devastation wrought upon her.
I first met Angel, then only a few months old, in the pediatric intensive care unit just before Christmas. She had been admitted unresponsive the night before. Her father had told the hospital staff that he had picked her up from her crib tochange her soaked diaper and as he did so she slipped from his grasp and fell back into her crib. He said she went limp and stopped breathing. He rushed her into his car and drove wildly to the local hospital. Eventually, Angel ended up in my hospital.
I was called in to see her after a CT scan showed subdural hematomas. Later, an MRI found evidence of parenchymal injury. An ophthalmology exam found such severe hemorrhages retinal hemorrhages that they were visible on the MRI.
Angel’s mother was at work when the injury occurred and only found out about it after Angel was rushed to the hospital. She told me what her boyfriend had told her, that Angel had fallen from his grasp into the crib. She said she had no reason to believe otherwise.
I finished the interview with Angel’s mother then spoke with her father. He was anxious and somewhat furtive. He told me that Angel had “peed everywhere,” on her clothes, in her bed. When he went to pick her up, she slipped from his grasp and fell onto the mattress. She immediately lost consciousness.
I ended the interview after a few more questions about the fall, and we both went back into the ICU, he to his baby’s side, me to the computer workstation to type my note. As I typed, Angel’s mother came up to me and said that she now knew what had happened. Her boyfriend had just then confessed to her that he had shaken Angel and that he wanted to talk to me.
I went into Angel’s hospital room. Her father was sitting on the cot with his head in his hands, Angel’s mother by his side consoling him. He didn’t look like a bad person; perpetrators rarely do.
Before I could speak he offered, “I’m sorry Doc. I lied. I shook her.”
I asked him why he had shaken her. “I picked her up from the crib. She was screaming and kicking and scratching at me, and I just lost it. I shook her.”
“Did the fall happen?”
“No, Doc. She didn’t fall. I shook her.”
And finally “What happened after you shook her?
“She went limp and stopped breathing. She looked dead. I know what I did was wrong. I’m sorry Doc.”
So there it was. I thanked him for telling me the truth. I told him it was the right thing to do and left to notify the police.
Months later, Angel’s father pled guilty to assault. He said at his sentencing that he had shaken Angel and that he was sorry. He is serving several years in prison.
All of that was yet to pass. Here was Angel in the ICU, profoundly brain damaged, never to awake, a victim of devastating violence, and for all the world she looked like a healthy, beautiful, three-month-old girl about to experience her first Christmas. Having seen too many shaken babies, it always astounds me how normal many of these babies look, few if any bruises, no obvious fractures, nothing to suggest the violence that had been perpetrated on them. To look at her in her hospital bed, surrounded by beeping instruments and tubes, intubated, not breathing, to look at her face and body, she looked fine, not a scratch, cherubic.
I saw her one last time several months later accompanied by her foster parents. Her functioning at a year was that of a one month old. Her existence, like that of a light switch without nuance, flipped between screaming/arching and deep sedation. She was quadriplegic, blind, and deaf. Her foster parents attend to her every day and every night, ceaselessly, religiously. I am myself not religious and have never said to anyone “God bless you.” I did to them. My eyes filling, I told them they were saints who deserved a special place in heaven.
There is something of a “debate” within the legal community and on the fringes of the scientific community about the existence of shaken baby syndrome. One argument offered is that confessions are always coerced. Another is that shaking cannot cause these injuries. Those who would say such things should talk to Angel’s father.
Yet, for Angel, none of this matters. Words and events orbit around her like so many errant planets: shaken baby prevention, child protective custody, termination of parental rights, grand jury, criminal prosecution, plea bargain, prison. Unknown and unknowing, immutably beautiful, she spins silently within her own dying sun.
God bless you Angel and may flights of angels sing thee to thy rest.
Re-posted with permission from Dr. Lawrence Ricci.