Shaken baby syndrome (SBS) is a collection of medical problems that result from brain trauma in young children. This occurs when an infant or toddler is violently shaken, usually by a parent or caregiver who is frustrated or angry that the baby is crying. Oftentimes the shaking is followed by an impact to the head from being thrown onto a fixed surface. SBS is a form of child abuse.

There are an estimated 1,200 to 1,400 cases of SBS every year in the United States, according to the National Center on Shaken Baby Syndrome. It most often occurs in infants under 1 year old. The average age of infants with SBS is between 3 months and 8 months old, according to the American Academy of Family Physicians.

When a young child is shaken, the brain moves around inside the skull, which can cause brain damage and death. Up to 25 percent of children with SBS die, according to the American Academy of Pediatrics. Even when children with SBS survive, they may experience significant neurological, developmental and cognitive disabilities. Many may need lifelong medical care.  

Signs of SBS will differ, depending on the severity and duration of shaking, as well as how often the shaking was done. Child abuse using shaking rarely occurs only once. Signs may range from mild (e.g., lethargy, irritability, vomiting) to severe (e.g., seizures, breathing difficulties and loss of consciousness).

Diagnosing SBS may be difficult since the people responsible for the abuse rarely volunteer this information to health care professionals. Without a specific indication that the brain may be injured, mild symptoms of SBS may be confused with a viral infection or colic. Parents or caregivers who suspect their child has been shaken should tell a physician in order to prevent further injury. Imaging tests that reveal bleeding and swelling of the brain, and bleeding at the back of the eye (retinal hemorrhage) may indicate SBS – especially if no external physical injury to the child’s body is evident.  

Treatment of SBS will depend on the extent and severity of injuries sustained from shaking. It typically requires that an infant or toddler with SBS be hospitalized. Treatment methods may include resuscitation, medication and surgery.

Shaken baby syndrome (SBS) occurs after an infant or toddler has been violently shaken. It is a collection of serious medical problems resulting from nonaccidental head trauma, and it is considered a form of child abuse.   

It is not clear exactly how many children in the United States are affected by SBS. The National Center on Shaken Baby Syndrome estimates the number to be somewhere between 1,200 and 1,400 children every year.

SBS most commonly affects infants less than a year old, although it is sometimes seen in children up to the age of 5 years, according to the American Academy of Pediatrics (AAP). The average age of children with SBS is between 3 months and 8 months old, according to the American Academy of Family Physicians.

Shaking can cause serious brain trauma in young children. Toddlers, and especially babies in their first year, have weak neck muscles that are not strong enough to withstand abrupt movement. In addition, infants’ heads are disproportionately large and heavy, compared to their body size. Infant skull bones are thin and more flexible than adult bones, and there are spaces between the bones (fontanel). The brain’s blood vessels and nerves are more susceptible to rupture, and the brain is more easily injured.  

A child with SBS is often held by the shoulders, chest, arms or legs – then shaken. The shaking usually lasts just 5 to 10 seconds in most cases. Shaking an infant results in the child’s head making whiplash-type movements. The act is generally so violent that an observer would recognize it as being dangerous to the child. 

Shaking causes a child’s brain to move around inside the skull. This can cause bruising, bleeding of blood vessels and nerves throughout the brain, and swelling inside the skull. Swelling and collection of blood within the skull can cause enormous pressure in the head, which may affect breathing and heart rate. Brain cells damaged by bruising cannot be replaced – thus, the damage caused by SBS is often irreversible.

SBS may include shaking as well as physical impact to the head. A common scenario involves violently shaking an infant, then slamming him or her down on a couch, crib mattress or against a wall.   

Physical violence against children – including shaking – usually occurs before help is sought or obtained. Parents or caregivers may shake a child in order to stop crying. Because this can temporarily work (crying may stop because the brain has been damaged), the perpetrator may continue to use this method to quiet a child. Many children with SBS have a history of being shaken or otherwise physically abused.

Head injuries are the leading cause of child abuse fatalities. SBS results in death for up to 25 percent of infants with the syndrome, according to the AAP. Serious, nonfatal cases may result in coma. Many children with SBS will require lifelong medical care. Even infants who appear normal immediately after the shaking may develop complications, some of which may not appear until the child gets older. Long-term damage to the brain as a result of SBS includes:

• Visual disabilities and blindness
• Seizure disorders
• Motor impairment
• Spinal cord injuries and paralysis
• Hearing loss
• Learning disabilities (memory, attention)
• Speech difficulties
• Mental retardation

Shaken baby syndrome (SBS) results from an infant or toddler being violently or severely shaken. Parents or other caregivers may shake a child out of frustration or anger – usually due to an infant’s crying. The average age of children with SBS coincides with a difficult time in an infant’s life that usually involves a lot of crying. People who shake children are generally trying to quiet them; the shaking may not actually be intended to hurt them.

SBS does not occur as the result of activities such as bouncing a child on the knee, tossing him or her in the air or rough play.  

Factors that may put a child at increased risk of SBS include:

• Infancy. Most children with SBS are under the age of 1 year.
  
  
• Gender. More male children are victims of SBS than female children.
  
  
• Household income level. Children who live in households at or below the poverty level are at increased risk of physical abuse, including shaking. This may be due to the social and financial stress associated with living in poverty.
  
  
• Premature birth, multiple births. Children who were born prematurely, or as one of two or more children born at the same time, may face an increased risk of SBS.
  
  
• Chronic illness. A child who experiences repeated illness – thus, may spend more time crying – may be at higher risk of abuse.
  
  
• Difficult temperament. Children who are fussier than average are at a higher risk of physical abuse such as shaking.

Factors that increase the risk of inflicting abuse (including shaking) on a child include:

• Gender. Men inflict physical abuse – including shaking – upon children more often than women.
  
  
• Age. Perpetrators of SBS are often young adults.
  
  
• Young and/or single parents. Being a young and/or single parent is a risk factor for all forms of child abuse including SBS.
  
  
• Domestic violence. Parents or caretakers involved in domestic violence may be more likely to physically abuse their children.
  
  
• Substance abuse. Alcohol or drug use may lead to neglect and violence against children, including shaking.
  
  
• Unrealistic expectations of a child and/or a punitive child-rearing style. Parents or caregivers may be extremely disappointed in children that do not act according to expectations and may be more likely to cause them physical harm.
  
  
• stress. Excessive worry about financial, work or other matters can increase the likelihood that a parent or caretaker will impulsively shake their child when angry or frustrated.
  
  
• Depression. Parental depression is associated with an increased risk of inflicting harm on a child.

Children with shaken baby syndrome (SBS) may display no physical signs of child abuse on their bodies. Occasionally, however, there may be bruising in the area where a child was held while being shaken.

The signs of SBS range from mild to severe. Which signs appear in a particular child will depend on the force and duration of the shaking, as well as how often it occurred. Early detection of SBS may help prevent serious medical problems.

Some of the signs may be difficult to identify as SBS. They are often confused with a cold, the flu or colic. These signs may occur for days or weeks after a shaking incident. They include:

• Lethargy. A child with SBS may exhibit decreased alertness and have unusual difficulty staying awake.
  
  
• Irritability. This may appear as unusual fussiness in a young child. Parents may not be able to console a child with SBS.
  
  
• Vomiting. Repeated vomiting may occur in a young child with SBS.
  
  
• Poor sucking or swallowing. An inability or decreased ability to feed can result from brain trauma suffered by a child with SBS.
  
  
• Loss of appetite. Children with SBS may refuse feedings.
  
  
• Lack of smiling or vocalizing. This is noticeable in infants or toddlers who previously smiled or attempted to express themselves vocally but no longer do so.

There are additional, more obvious signs that something is seriously wrong with a child with SBS. These signs include:

• Seizures. A child’s eyes may roll back into the head, accompanied by sudden jerks or a stiffening of the body.
  
  
• Breathing difficulty. A child with SBS may appear to take only shallow breaths.
  
  
• Pale or bluish skin. May indicate a lack of oxygen.
  
  
• Loss of consciousness. When this occurs in children with SBS, they may appear to be asleep, but cannot be awakened.
  
  
• Dilated pupils. The pupils in the eyes of a child with SBS will appear larger than normal and will not shrink in response to light. This may occur in one or both eyes.
  
  
• Inability to lift the head.
  
  
• Inability to track objects with eye movements.

Diagnosing shaken baby syndrome (SBS) may be difficult. Parents or caregivers responsible for shaking a child rarely admit to the behavior. Caregivers not involved in the abuse may not be aware of the injury to the child. Also, children who have been shaken may not show external signs of injury. If a physician does not know to look for brain injury, mild signs of SBS (e.g., vomiting, irritability) may be confused with a viral infection, gastrointestinal disorder or colic. Parents who suspect their child has been shaken should tell a physician. This may help prevent further injury.  

If SBS is suspected, the following imaging tests may be conducted:

• Computed axial tomography (CAT scan). Multiple x-rays taken from different angles. In a child suspected of having SBS, CAT scans will be taken of the head. The initial CAT scan will be performed without injection of a contrast dye.
  
  
• Magnetic resonance imaging (MRI). Uses a magnetic field and radio waves (instead of x-rays) to create images of tissue and structures inside the body. In children with SBS, MRIs are usually performed several days to a week after diagnosis in order to confirm the extent of injury to brain tissue. This test is often used in conjunction with a CAT scan.

In addition, x-rays may be taken of a child’s arms, legs, skull, spine and ribs to identify any other signs of physical abuse. A spinal tap may be conducted to check for the presence of blood that may indicate brain trauma.

Tests that reveal bleeding and swelling of the brain, along with retinal hemorrhage (bleeding at the back of the eye) are classic signs of SBS. A diagnosis may be made based on these findings, along with the absence of any external signs of trauma to the body.

In cases of suspected SBS, consultation with specialists may be required. A pediatric ophthalmologist (eye specialist) can properly examine the eyes, which involves dilating the pupils so the entire retina may be examined. Pediatric radiologists (imaging specialist) can properly interpret imaging test results. A pediatric neurologist or neurosurgeon may also be required for treatment of SBS.

A child with shaken baby syndrome (SBS) will usually need to be hospitalized. Treatment of SBS will depend on the injuries sustained and the severity of those injuries. It will focus on addressing the most critical medical issues first, followed by identifying the extent of the injuries and delivering appropriate treatment.

For example, children with SBS who have stopped breathing and are unconscious when they appear at a medical facility (e.g., emergency room, physician’s office) will require CPR (cardiopulmonary resuscitation). A respirator (machine that mechanically induces breathing) may also be necessary. Medication may be provided to reduce swelling in the brain. Surgery may be required to stop bleeding and relieve pressure inside the head.

Many children with SBS will require long-term treatment. This may include medications (e.g., to control seizures) as well as physical and speech therapy (e.g., for those with developmental disabilities). Federal law allows children under the age of 3 with SBS to receive speech or physical therapy through the Department of Public Health. Special education efforts may be necessary for children with learning disabilities or mental retardation.

SBS is completely preventable. The biggest component of preventing SBS is educating parents and caregivers about the dangers of shaking a young child. It is never safe to shake a young child. Educational efforts may include how a parent or caregiver deals with a crying child. The first thing a parent should do is determine the cause of the crying. Is the child hungry or bored? Is the child wet? Identifying the cause may involve contacting the child’s pediatrician to ensure a medical condition or illness is not causing the crying.

Once the child’s needs have been met, parents may try a number of different methods to soothe or comfort a crying infant or toddler. These include:

• Sucking. This may soothe a child. Try offering the baby a pacifier. A feeding may be attempted, as long as the baby is hungry.
  
  
• Swaddling. Being swaddled (wrapped) in a blanket can provide warmth and comfort to some babies.
  
  
• Rock or swing. Rhythmic motion may soothe a crying child. This may include walking while holding the baby, placing the child in a stroller and going for a walk, or placing an infant or toddler in a car seat and going for a drive.
  
  
• Calming sounds. Try singing to the baby. Gentle lullabies may have a calming effect on children. Other rhythmic sounds or music (e.g., white noise, rainfall, ocean waves) may also work.
  
  
• Side/stomach positioning. Placing a baby on his/her left side may aid digestion. An infant may be placed belly-down while awake (the gentle pressure against the abdomen may help relieve gas). Sleeping babies should be placed on their back, to avoid the risk of SIDS (sudden infant death syndrome).

Another important element of preventing SBS is helping parents and caregivers deal with their feelings of anger or frustration. Some tips include:

• Step away from the situation. It is important to take a break away from the child when parents or caregivers feel they are about to lose control. As long as the baby’s needs have been met (e.g., the child is not hungry, soiled or ill), it is acceptable to allow the child to cry. Try leaving the baby alone in a safe place for 10 minutes.
  
  
• Relax and breathe. Deep breathing may help a frustrated or angry parent to calm down. Try going for a walk, if someone else is available to watch the child. Relaxing imagery may help parents or other caregivers calm themselves.
  
  
• Arrange back-up care. Arrange for someone else (e.g., friends, family, neighbors) to step in and take care of the child in times of emotional crisis, or when the caregiver needs rest.
  
  
• Get emotional support. Sharing feelings of frustration or helplessness with friends, family or others can provide much-needed emotional support for caregivers and help alleviate the stress of caring for a young child.
  
  
• Call for help. For help or information at moments of crisis, contact a physician or a 24-hour/7 day a week crisis line, such as Childhelp USA National Child Abuse Hotline (800-4-A-CHILD or 800-422-4453).  

Home visitation programs may also help prevent SBS. These community outreach programs have been recommended by the U.S. Advisory Board on Child Abuse and Neglect to reduce the risk of SBS. They involve visits and communication about child care between social service professionals and families with young children.   

Preventing abuse that occurs by caregivers other than the parents can be difficult. Parents should carefully evaluate anyone caring for their child (e.g., daycare providers, babysitters). Some tips include:

• Ask providers specifically how they cope with stress, deal with a crying baby and discipline a child.
  
  
• Carefully check all references.
  
  
• Make unannounced visits to observe the care being provided.
  
  
• Talk with others who have used the caretaker’s services.
  
  
• Parents should never leave a child with anyone who is angry, seems violent, or is drinking alcohol or using drugs.

Preparing questions in advance can help patients and parents have more meaningful discussions with their physicians regarding their child’s treatment options. The following questions related to shaken baby syndrome (SBS) may be helpful:

1. I think someone has been shaking my child. What do I do?
   
   
2. How can I tell if my child has been shaken?
   
   
3. Does any amount of shaking produce SBS?
   
   
4. How can I know how much damage has been done in a child who has been shaken?
   
   
5. What do I do if my child is a victim of SBS?
   
   
6. If I take my child to the emergency room, will I be arrested for child abuse?
   
   
7. What brain damage has my baby suffered as a result of SBS?
   
   
8. What medical complications does my child face as a result of his/her SBS?
   
   
9. My spouse has an awful temper. I'm frightened our baby may be hurt. What should I do?
   
   
10. I get really frustrated when my baby cries. What can I do to make sure I don’t hurt my baby when I feel overwhelmed?
    
    
11. Will bouncing my baby on the knee, or tossing him/her into the air cause SBS?
    
    
12. Will strapping my baby to my torso while I jog cause SBS?
    
    
13. What do I do if I suspect my daycare provider may be shaking children?
    
    
14. Do accidental falls cause injuries similar to SBS?