Shaken baby syndrome, a condition that was first identified decades ago, came into the forefront in the mid-1990s with a nanny case in Massachusetts. Since then, there has been vigorous debate on the mechanism of the injury caused by shaking, namely subdural hematomas, diffuse axonal injury, retinal hemorrhages, and fracture of posterior and anterlateral ribs or metaphyses of long bones. In this update, the diagnostic indicators to help identify infants who have been shaken and ways to help prevent shaken baby syndrome issues are discussed.
Historical note and terminology
The recognition that subdural hematoma and multiple long bone fractures were due to trauma was first made by John Caffey in 1946 (Caffey 1946). The term “whiplash shaken baby syndrome” was used by Caffey in 1972 to explain the combination of infantile subdural and subarachnoid hemorrhage, traction type metaphyseal fractures, and retinal hemorrhage found in multiple injured infants in the care of a nurse maid who admitted to vigorously shaking them in order to burp them (Caffey 1972). It was thought that the unique anatomy of the infant's head (disproportionately large with weak supporting neck musculature and relatively higher water content) made infants vulnerable to severe injury from shaking (Guthkelch 1971). Although the diagnosis was made on the basis of clinical and radiological findings, this term implied a specific mechanism of angular deceleration as a cause of cerebral concussion and subdural hematoma. Many others reported clinical and laboratory evidence for the damaging effects of angular acceleration during this time (Ommaya et al 1968; Ommaya and Gennarelli 1974). Central to this concept was the idea that caretakers might inflict these injuries unwittingly during the course of generally acceptable means of punishment or even play (Caffey 1974). Controversy exists as to the mechanism of actual injury. The term “shaken baby syndrome” has been questioned, as more recent series using clinical, biomechanical, radiological, and autopsy analysis suggest that many, if not most, cases have evidence of blunt impact to the head. Deceleration forces generated by shaking alone may not be of sufficient magnitude to cause the injuries seen compared to those caused by impact. The absence of scalp injuries may be secondary to dissipation of forces against a soft, padded surface (Hahn et al 1983; Duhaime et al 1987). Some authors prefer to use the term "shaking impact syndrome" to suggest the importance of angular deceleration as a mechanism of injury (Bruce and Zimmerman 1989; Duhaime and Sutton 1996). Leaders in the field of child maltreatment have suggested that a more medically descriptive term such as inflicted traumatic brain injury be used instead, as the term “shaken baby syndrome” implies knowledge of the exact cause of injury (Richards et al 2006).
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