Abusive head trauma/inflicted traumatic brain injury or AHT
(also called shaken baby/shaken impact syndrome or SBS) is a form
of inflicted head trauma.
AHT can be caused by direct blows to the head, dropping or
throwing a child, or shaking a child. Head trauma is the leading
cause of death in child abuse cases in the United States.
How These Injuries Happen
Unlike other forms of inflicted head trauma, abusive head trauma
results from injuries caused by someone vigorously shaking a child.
Because the anatomy of infants puts them at particular risk for
injury from this kind of action, the vast majority of victims are
infants younger than 1 year old. The average age of victims is
between 3 and 8 months, although these injuries are occasionally
seen in children up to 4 years old.
The perpetrators in these cases are most often parents or
caregivers. Common triggers are frustration or stress when the
child is crying. Unfortunately, the shaking may have the desired
effect: although at first the baby cries more, he or she may
stop crying as the brain is damaged.
Approximately 60% of identified victims of shaking injury are
male, and children of families who live at or below the poverty
level are at an increased risk for these injuries as well as any
type of child abuse. It is estimated that the perpetrators in 65%
to 90% of cases are males - usually either the baby's father or
the mother's boyfriend, often someone in his early
twenties.
When someone forcefully shakes a baby, the child's head
rotates about the neck uncontrollably because infants' neck
muscles aren't well developed and provide little support for
their heads. This violent movement pitches the infant's brain
back and forth within the skull, sometimes rupturing blood vessels
and nerves throughout the brain and tearing the brain tissue. The
brain may strike the inside of the skull, causing bruising and
bleeding to the brain.
The damage can be even greater when a shaking episode ends with
an impact (hitting a wall or a crib mattress, for example), because
the forces of acceleration and deceleration associated with an
impact are so strong. After the shaking, swelling in the brain can
cause enormous pressure within the skull, compressing blood vessels
and increasing overall injury to its delicate structure.
Normal interaction with a child, like bouncing the baby on a
knee, will
not
cause these injuries, although it's important to
never
shake a baby under
any
circumstances because gentle shaking can rapidly escalate.
What Are the Effects?
AHT often causes irreversible damage. In the worst cases,
children die due to their injuries.
Children who survive may have:
- partial or total blindness
- hearing loss
- seizures
- developmental delays
- impaired intellect
- speech and learning difficulties
- problems with memory and attention
- severe mental retardation
- cerebral palsy
Even in milder cases, in which babies looks normal immediately
after the shaking, they may eventually develop one or more of these
problems. Sometimes the first sign of a problem isn't noticed
until the child enters the school system and exhibits behavioral
problems or learning difficulties. But by that time, it's more
difficult to link these problems to a shaking incident from several
years before.
Signs and Symptoms
In any abusive head trauma case, the duration and force of the
shaking, the number of episodes, and whether impact is involved all
affect the severity of the infant's injuries. In the most
violent cases, children may arrive at the emergency room
unconscious, suffering seizures, or in shock. But in many cases,
infants may
never
be brought to medical attention if they don't exhibit such
severe symptoms.
In less severe cases, a child who has been shaken may
experience:
- lethargy
- irritability
- vomiting
- poor sucking or swallowing
- decreased appetite
- lack of smiling or vocalizing
- rigidity
- seizures
- difficulty breathing
- altered consciousness
- unequal pupil size
- an inability to lift the head
- an inability to focus the eyes or track movement
Diagnosis
Many cases of AHT are brought in for medical care as
"silent injuries." In other words, parents or caregivers
don't often provide a history that the child has had abusive
head trauma or a shaking injury, so doctors don't know to look
for subtle or physical signs. This can sometimes result in children
having injuries that aren't identified in the medical
system.
And again, in many cases, babies who don't have severe
symptoms may
never
be brought to a doctor. Many of the less severe symptoms such
as vomiting or irritability may resolve and can have many
non-abusive causes.
Unfortunately, unless a doctor has reason to suspect child
abuse, mild cases (in which the infant seems lethargic, fussy, or
perhaps isn't feeding well) are often misdiagnosed as a viral
illness or colic. Without a diagnosis of child abuse and any
resulting intervention with the parents or caregivers, these
children may be shaken again, worsening any brain injury or
damage.
If shaken baby syndrome
is
suspected, doctors may look for:
- hemorrhages in the retinas of the eyes
- skull fractures
- swelling of the brain
- subdural hematomas (blood collections pressing on the surface
of the brain)
- rib and long bone (bones in the arms and legs) fractures
- bruises around the head, neck, or chest
The Child's Development and Education
What makes AHT so devastating is that it often involves a total
brain injury. For example, a child whose vision is severely
impaired won't be able to learn through observation, which
decreases the child's overall ability to learn.
The development of language, vision, balance, and motor
coordination, all of which occur to varying degrees after birth,
are particularly likely to be affected in any child who has
AHT.
Such impairment can require rigorous physical and occupational
therapy to help the child acquire skills that would have developed
on their own had the brain injury not occurred.
As they get older, kids who were shaken as babies may require
special education and continued therapy to help with language
development and daily living skills, such as dressing
themselves.
Before age 3, a child can receive speech or physical therapy
through the Department of Public Health/ Early Intervention.
Federal law requires that each state provide these services for
children who have developmental disabilities as a result of being
abused.
Some schools are also increasingly providing information and
developmental assessments for kids under the age of 3. Parents can
turn to a variety of rehabilitation and other therapists for early
intervention services for children after abusive head trauma.
Developmental assessments can assist in improving education
outcomes as well as the overall well-being of the child.
After a child who's been diagnosed with abusive head trauma
turns 3, it's the school district's responsibility to
provide additional special educational services.
Preventing AHT
Abusive head trauma
is
100% preventable. A key aspect of prevention is increasing
awareness of the potential dangers of shaking.
Finding ways to alleviate the parent or caregiver's stress
at the critical moments when a baby is crying can significantly
reduce the risk to the child. Some hospital-based programs have
helped new parents identify and prevent shaking injuries and
understand how to respond when infants cry.
The National Center on Shaken Baby Syndrome offers a prevention
program, the
Period of Purple Crying
, which seeks to help parents and other caregivers understand
crying in normal infants. By defining and describing the sometimes
inconsolable infant crying that can sometimes cause stress, anger,
and frustration in parents and caregivers, the program hopes to
educate and empower people to prevent AHT.
One method that may help is author Dr. Harvey Karp's
"five S's":
-
S
hushing (using "white noise" or rhythmic sounds that
mimic the constant whir of noise in the womb, with things like
vacuum cleaners, hair dryers, clothes dryers, a running tub, or a
white noise CD)
-
S
ide/stomach positioning (placing the baby on the left side - to
help digestion - or on the belly while holding him or her, then
putting the sleeping baby in the crib or bassinet on his or her
back)
-
S
ucking (letting the baby breastfeed or bottle-feed, or giving the
baby a pacifier or finger to suck on)
-
S
waddling (wrapping the baby up snugly in a blanket to help him or
her feel more secure)
-
S
winging gently (rocking in a chair, using an infant swing, or
taking a car ride to help duplicate the constant motion the baby
felt in the womb)
If a baby in your care won't stop crying, you can also try
the following:
- Make sure the baby's basic needs are met (for example, he
or she isn't hungry and doesn't need to be changed).
- Check for signs of illness, like fever or swollen gums.
- Rock or walk with the baby.
- Sing or talk to the baby.
- Offer the baby a pacifier or a noisy toy.
- Take the baby for a ride in a stroller or strapped into a
child safety seat in the car.
- Hold the baby close against your body and breathe calmly and
slowly.
- Call a friend or relative for support or to take care of the
baby while you take a break.
- If nothing else works, put the baby on his or her back in the
crib, close the door, and check on the baby in 10 minutes.
- Call your doctor if nothing seems to be helping your infant,
in case there is a medical reason for the fussiness.
To prevent potential AHT, parents and caregivers of infants need
to learn how to respond to their own stress. It's
important to talk to
anyone
caring for your baby about the dangers of shaking and how it can be
prevented.
Reviewed by:
Elaine Cabinum-Foeller, MD
Date reviewed: June 2008
Note: All information is for educational purposes only. For specific medical advice,
diagnoses, and treatment, consult your doctor.
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