Shaken baby syndrome

DEFINITION: Signs and symptoms in an infant or young child resulting from violent shaking, including subdural hematomas, cerebral edema, and retinal hemorrhages.

SIGNIFICANCE: The incidence of shaken baby syndrome in the United States has been estimated to affect at least twelve hundred cases a year, as of 2012, according to the American Academy of Pediatrics. The actual number may be much higher, however, as many cases may not be brought to the attention of medical professionals. In addition, it is easy to miss the diagnosis of shaken baby syndrome, as generally no external injuries are visible. Forensic scientists must be aware of the signs and symptoms associated with the syndrome so that cases of child injury and death caused by abuse do not go unnoticed.

In the early 1970’s, John Caffey used the term “whiplash shaken infant syndrome” to describe the injuries caused in young children by violent shaking that are now commonly known as shaken baby syndrome (SBS). Others have used terms such as “shaken impact syndrome” and “shaken/slammed baby syndrome” to emphasize that impact of the child’s head against a hard or soft surface—such as a floor, wall, or mattress—often occurs in addition to the shaking.

Infliction of Injuries

In a typical scenario leading to SBS, an infant or toddler’s caretaker, irritated by the child’s incessant crying, grabs the small victim by the shoulders or chest and shakes the child forcefully back and forth. The child’s relatively large head, which is poorly supported by weak neck muscles, rolls around repeatedly. At the same time, the brain is exposed to acceleration, deceleration, and rotational forces that cause the bridging veins to shear, leading to the formation of subdural hematomas and swelling of the brain. Whether impact with an external object or surface is necessary to cause SBS remains subject to debate.

In milder cases, the baby becomes drowsy and ceases to cry. The abuser, having obtained the desired result, is likely to repeat the shaking on other occasions when again the irritable infant cannot be consoled. More severe manifestations of SBS, which tend to lead to contact with physicians, include vomiting, apnea, seizures, loss of consciousness, and death. Survivors of SBS require long-term follow-up, as they frequently face behavioral, learning, and developmental challenges later in life.

Forensic Evaluation

The collection and preservation of and the notification of appropriate authorities are necessary steps toward the successful prosecution of child abusers. In cases in which SBS is suspected, examining physicians need to search purposefully for clinical signs of maltreatment. When a small child has been shaken violently, retinal hemorrhages are generally present in both eyes. Accuracy in diagnosing retinal hemorrhages demands that an ophthalmologist evaluate the patient. A detailed description of the findings accompanied by drawings and photographs constitutes valuable evidence.

Another hallmark of SBS, subdural hematoma, is revealed only through imaging of the head, either by computed tomography (CT) or by magnetic resonance imaging (MRI). CT or MRI scanning will also help detect the presence of cerebral edema.

When SBS is suspected, examining physicians should obtain X-rays to look for old and new fractures, specifically of the skull, ribs, collarbone, and long bones. On rare occasions when bruising, swelling, and lacerations are present, documentation with the help of body diagrams and appropriately dated and labeled forensic photographs can be helpful in court. Additionally, health care workers need to obtain and document detailed from the caretakers of suspected victims of SBS. In cases of SBS, the severity of victims’ injuries usually does not correlate with caretakers’ descriptions of what happened to the children, and contradictory statements or changing stories are often given. Accurate diagnosis can be complicated by rare genetic disorders that produce similar symptoms.

Health professionals should be aware of the caretaker-related risk factors associated with child maltreatment. Although female babysitters have been shown to be responsible for a high incidence of abuse, severe often occurs at the hands of male caretakers—the abused children’s stepfathers or biological fathers or the boyfriends of the children’s mothers. Perpetrators are often alone with the children at the time injuries occur. Other factors that have been found to be associated with child maltreatment include poverty, drug abuse, significant life stressors, spousal abuse, low-birth weight infants, and young, unmarried mothers.

Autopsies should be performed in cases of unexplained infant death. Ideally, the pathologists assigned to such cases should be trained in pediatric forensic science.

The Courts and SBS

All US states mandate that suspected child abuse be reported to the appropriate authorities, but health care workers are often reluctant to report suspected cases. According to 2024 information from the National Center on Shaken Baby Syndrome, there were about 1,300 reported cases of shaken baby syndrome in the United States each year. Of those cases, about 25 percent were fatal, and 80 percent resulted in lifelong disabilities. Most child abuse cases are heard in civil court, the main focus of which is child safety. Civil court requires only a “preponderance” of proof to decide that abuse has taken place. Criminal courts become involved when death or severe injury has occurred; for convictions, the criminal system requires proof beyond a reasonable doubt.

The American judicial system struggles with rulings in cases of SBS. Judges and prosecutors often lack extensive knowledge about child abuse, and juries are reluctant to believe the presented evidence. In addition, the laws are poorly tailored to deal with violent infant death. Frequently abusers are not convicted, and those that are often receive mild sentences. One highly publicized case involving SBS was that of the young British au pair Louise Woodward, whom a found guilty of second-degree in the death of the child who had been in her care, eight-month-old Matthew Eappen. The presiding later reduced the to involuntary manslaughter.

Bibliography

"Abusive Head Trauma (Shaken Baby Syndrome)." American Academy of Pediatrics, n.d.

"Facts & Info." National Center on Shaken Baby Syndrome, 2024, www.dontshake.org/learn-more/item/114-facts-and-info. Accessed 18 Aug. 2024.

Kellogg, Nancy, and the Committee on Child Abuse and Neglect. “Evaluation of Suspected Child Physical Abuse.” Pediatrics 119 (2007): 1232–1241.

Monteleone, James A., and Armand E. Brodeur, eds. Child Maltreatment. 2d ed. St. Louis: G. W. Medical Publishing, 1998.

Morey, Ann-Janine. What Happened to Christopher: An American Family’s Story of Shaken Baby Syndrome. Carbondale: Southern Illinois University Press, 1998.

Peinkofer, James. Silenced Angels: The Medical, Legal, and Social Aspects of Shaken Baby Syndrome. Westport, Conn.: Auburn House, 2001.

Reece, Robert M., and Cindy Christian, eds. Child Abuse: Medical Diagnosis and Management. 3d ed. Elk Grove Village, Ill.: American Academy of Pediatrics, 2007.

Szalavitz, Maia. "The Shaky Science of Shaken Baby Syndrome." Time, January 17, 2012.