ORIGINAL ARTICLE

The physical manifestations of shaken baby syndromeMegan A. Mraz, MSN, RN

Duquesne University (Doctoral Student), Pittsburgh, Pennsylvania; West Chester University (Instructor), West Chester, Pennsylvania; Alfred I. duPontHospital for Children (Staff Nurse), Wilmington, Delaware

KeywordsAbuse; forensic nursing; nursing intervention;

shaken baby syndrome.

CorrespondenceMegan A. Mraz, MSN, RN, 222 K Sturzebecker

Health Science Center, West Chester University,

West Chester, PA 19383. Tel: 610-436-4408;

E-mail: meganmraz@comcast.net

Received: May 29, 2007; accepted: October 11,

2007

doi: 10.1111/j.1939-3938.2009.01027.x

Abstract

Shaken baby syndrome (SBS) is a great concern for forensic nurses. Accuratediagnosis and treatment is essential. The purpose of this report is to reviewthe history of SBS, as well as the physical symptoms of a patient suspected ofsuffering from this form of abuse. Implications of SBS for the forensic nursewill be presented; this will include the education of families and caregivers andmethods of prevention.

Introduction

Shaken baby syndrome (SBS) is an infliction of traumaonto a younger child when he or she is violently shaken.This act initiates traumatic brain injury, as well as otherphysical devastation (Geddes & Plunkett, 2004). Theanatomy of a young child is that of a large head andweak neck muscles. The rigorous shaking back and forthcauses the brain to bounce against the skull. This resultsin swelling and bruising of the brain. The outcomes ofthese cases range from complete recovery, to permanentdamage, and even death in severe cases.

In 2001, an estimated 903,000 children were victimsof SBS. Additionally, 1,300 children were fatally injuredfrom SBS the same year (Miehl, 2005). Although inci-dences per year vary, it is estimated that 19% to 30% ofchild fatalities are a result of intentional injury. The abil-ity to detect SBS is difficult secondary to under reportingand misdiagnosis. There is no established set of symptomsthat indicate SBS; consequentially, many children whoare abused are inaccurately diagnosed with a bacterial orviral infection.

If the obvious signs of abuse are not present, then whatdo healthcare providers assess when abuse is suspected?While the infant may not have outward bruising andswelling, there are substantial internal injuries that maybe present and should be assessed for. Some examples are

cerebral edema; retinal and cerebral hemorrhaging; bonefractures, both old and new; cerebral atrophy; hydro-cephalus; papilledema; and cervical spine injury (Miehl,2005). For example, how does the physical presentationof a 2-year-old who was shaken differ from that of a 2-year-old who has sustained injury from falling off a setof monkey bars? This question is imperative to researchand investigation in the healthcare arena. Forensic nurseshave the educational background as well as the clinicalexpertise to provide vital input into this inquiry. Addi-tionally, forensic nurses have an obligation to be abreastof the most current research in order to provide thoroughand accurate participation as part of the multidisciplinaryteam that will help these victims. Presentation of SBS isbased on injuries sustained and caregiver reports of theprecipitating events. The purpose of this report is to detailthe evolution of SBS and current day research. Through-out the history of SBS, medicine has been able to moreclearly identify the various symptoms and physical pre-sentation of these victims. Finally, the forensic nurse’srole should come to include investigation, education, andefforts toward prevention of this form of abuse.

History

Child abuse was first introduced to America through ayoung girl by the name of Mary Ellen Connolly (Evans,

26 Journal of Forensic Nursing 5 (2009) 26–30 c© 2009 International Association of Forensic Nurses

M. A. Mraz The physical manifestations

2004). In 1864, Mary Ellen died and a review of her caseindicated that New York City police had encountered heron a number of occasions. However, during all these in-stances, a medical consult was never initiated. During thisperiod in history, child abuse was regarded as a societalproblem, not a medical concern. It was not until 1962that the notion of child abuse as a medical concern wasaddressed.

In 1946 a pediatric radiologist by the name of Dr. JohnCaffey introduced the concept of SBS, and termed it“whiplash shaken baby syndrome” (Miehl, 2005). He no-ticed that a series of internal injuries such as subdural andsubarachnoid hematoma and retinal hemorrhage wereconsistently present in these patients; however, Dr. Caf-fey did not observe any evidence of external injury. Hebelieved it was the anatomical proportions of the infant,as compared to the adult, that attributed to the sever-ity of these injuries. He proposed that the size of the in-fant head, 25% of the total body weight as opposed tothe 10% of an adult, in addition to the weak neck mus-cles, poor motor control, and higher concentration of wa-ter in the cranial cavity, contributed to the nature of thisinjury.

Current day research

As more research is conducted, healthcare providers havebetter guidelines on the clinical presentation of SBS.In addition to caregiver reports of precipitating eventsthat are inconsistent or unreasonable, as well as a de-lay in seeking medical attention, there are some spe-cific physical characteristics that are consistent with SBS.The hallmark of these manifestations is lack of externalinjury. Additionally, healthcare providers should assessfor bradypnea or apnea, changes in level of conscious-ness, bradycardia, bulging fontanels, and seizure activity(Miehl, 2005).

These initial symptoms should alert the healthcareprovider to further investigate for SBS. Various physi-cal manifestations should be examined in order to appro-priately diagnose SBS. The exploration of these physicalmanifestations and a thorough history of the events priorto injury will enable the health care professionals to as-certain the most accurate diagnosis.

Physical manifestations

While reviewing the various physical manifestations ofSBS, it is important to remember there is no one defin-ing characteristic. Typically, many of these manifestationspresent in the victim. Healthcare professionals cannot dis-regard other potential causes of these symptoms. SBS ismost often identified through a thorough physical exami-

nation and impeccable history of events leading up to thevictim’s admission.

Retinal hemorrhages are present in approximately75% of all SBS cases (Bechtel et al., 2004). In a recentstudy, it was concluded that retinal hemorrhages in aninfant should be considered a sign of child abuse untilproven otherwise. These researchers studied the medi-cal records of 100 infants with medical diagnosis of hy-poxia and hypertrophic pyloric stenosis, and in all casesnot one infant had retinal bleeding (Herr, 2004). A studyconducted by Keenan, Runyan, Marshall, Nocera, andMerten, compared the incidence of retinal hemorrhagebetween children with inflicted versus non-inflicted in-jury. It was determined that 76.3% of children sustainedretinal hemorrhages secondary to inflicted trauma as op-posed to 8.3% of children who sustained retinal hemor-rhages from non-inflicted trauma.

Finally, researchers Bonnier, Mesples, and Gressenslooked at the pathophysiology of sustained injury postshaking of animal subjects (2004). The researchers ac-quired a cohort of mice that were 8 days post-natal anddivided them into three groups: a control group, a shakengroup, and a shaken group that had been pre-medicated.The group of mice, who were shaken, were shaken for15 seconds on a rotating shaker. During the shaking therewas no evidence of hypoxia, such as changes in color orbreathing patterns. As expected, no mice in the controlgroup sustained retinal hemorrhage. Of the group micewho were shaken, 33% sustained retinal hemorrhage.

As forensic nurses, it is essential that a medical exami-nation is conducted in all instances of suspected abuse orsudden onset trauma. Presence of retinal hemorrhage isone of the first and earliest signs of inflicted intracranialinjury (Smith, 2004). Consequentially, early diagnosisof retinal hemorrhage may prevent further unnecessaryinjury and initiate early investigation into precipitatingevents.

Hematomas are the most common injury sustained inSBS (Keenan et al., 2001). When an infant is shaken,the forced movement of the brain within and against theskull can tear the vessels, resulting in a hematoma. Ad-ditionally, these forces develop injury of the nerve axonsthroughout the brain resulting in diffuse axonal injury.Hematomas can result in cerebral hypoxia, edema, andvasoocclusion (Zenel & Goldstein, 2002).

This type of injury requires accurate and immediate di-agnosis and intervention. Diagnosis is made via radiologicimaging such as CT scans and magnetic resonance imag-ing (MRI). Intervention may include surgical evacuationof the hematoma, ICP monitoring, and external ventric-ular draining.

Cerebral atrophy, one of the possible outcomes causedby hematomas, is a degeneration of cells within the brain.

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Moreover, it is a loss of neurons within the brain. Lo et al.(2003) found that 93.75% of their research sample, a co-hort of children who had been admitted to a Pennsyl-vania hospital for suspected intentional injury, sufferedfrom cerebral atrophy. Using MRI, the researchers ob-served 15 of their 16 participants developing cerebral at-rophy as early as 9 days post presentation (Lo et al.,2003). The incidence of cerebral atrophy is not docu-mented; this may be secondary to the poor prognosis as-sociated with the severity of this injury.

Hydrocephalus is the abnormal accumulation of cere-bral spinal fluid in the ventricles of the brain and occursin two forms: communicating and non-communicating.For infants who have suffered brain trauma, it is com-municating hydrocephalus that incurs; this is caused byinadequate absorption of cerebral spinal fluid when theventricular pathways are not obstructed (Ogershok et al.,2001).

Hydrocephalus is another complication of SBS thatforensic nurses should be aware of. According to Oger-shok et al. (2003), hydrocephalus has been rarely asso-ciated with SBS, yet frequently observed by physiciansand nurses in caring for these patients. Treatment for hy-drocephalus requires a surgically placed external ventric-ular drain during the immediate post-injury phase. Thiswill allow for normal levels of intracranial pressure. Asthe recovery process continues, the patient will be trialedwithout drainage support. Failure of the patient to absorband drain their own Cerebrospinal fluid (CSF) will resultin a permanent ventricular drain, or shunt.

Additional injury differs among infants who suffer in-flicted injury as opposed to those who suffer non-inflictedinjury. Research indicates that infants with inflicted in-jury are more likely to sustain rib fractures, long-bonefractures, and metaphyseal fracture (Keenan et al., 2004).For inflicted injury, 17.5% to 27.5% of infants suffer frac-ture as opposed to 2.8% to 6.9% of fractures sustainedfrom non-inflicted injury. In matters of skull fractures,there seems to be no disparity amongst inflicted versusnon-inflicted fractures.

If SBS is suspected, possible bone fractures should beinvestigated as soon as the patient is medically stable.This may not seem imperative as no external injurymay be observed. However, bone fractures may be keyin determining the cause of injury. Radiologic examina-tion such as bone scans and skeletal surveys will allowthe medical staff to establish sites of injury as well asprevent further injury (Miehl, 2005). Prior to the diag-nosis of fracture, injury should be suspected and mea-sures should be initiated to decrease further damage tothe bones. Some measures may include stabilization oflong bones and adhering to log rolling while turning thepatient.

It is believed an infant can fracture, possibly evenbreak, his or her cervical spine. This injury is secondaryto the whiplash type of motion that SBS demonstrates.C-spine injury can be diagnosed from an X-ray, and c-spine injury typically results in varying levels of paresisand plegia.

In 1968, a researcher by the name of Ommaya at-tempted to establish whether intracranial and neck in-juries could, in fact, be caused by whiplash. He took 19monkeys, secured them in a fiberglass carriage, and simu-lated an instant force of whiplash, comparable to the forceexerted on an infant when shaken, as well as injuries sus-tained during a motor vehicle collision. Findings showedthat 11 of the 19 monkeys suffered c-spine injury.

It was not until 2002 when a researcher by the nameof Uscinski completed a retrospective analysis of Om-maya’s study and confirmed these results can be appliedto injuries suffered in SBS. He formulated his confirma-tion by applying the principles of Newtonian physics toOmmaya’s study (Uscinski 2002).

When forensic nurses are on the scene of a suspectedcase of SBS, it is essential that they recall the possibilityof c-spine injury and stabilize the neck with a collar. Fur-ther injury to the c-spine while treating a patient maycause greater injury. The collar can be removed once thec-spine has been cleared. This usually occurs once thepatient has become neurologically and hemodynamicallystable.

Lack of external injury is one of the three classic signsof SBS (Smith, 2003). Lack of external injury may bepresent for initial responders. However, their treatmentmay cause external injuries to be present at subsequentevaluations. For example, the external injury observedby the forensic nurse who arrives at the scene may be fardifferent from the injury observed by the forensic nursewho will assesses the patient three days after the initialinsult when multiple IV attempts have been made, manyrounds of compressions have ensued, and a significantamount of generalized edema has developed.

Two independent case studies were presented by Ori-ent (2005) and Asamura (2003). In both cases, the vic-tims suffered no external injury. In Orient’s case reportan unresponsive 2-month-old infant presented to theemergency department with his father. The infant was di-agnosed with multiple cerebral hematomas, bilateral reti-nal hemorrhages, and rib fractures. No external injurywas observed (Orient, 2005). The second case report wasabout a 3-month-old infant in Japan, where SBS is rela-tively unknown. The father indicated he would shake thebaby while playing with him. The external examinationrevealed no injury. The internal examination revealedvarious subdural and subarachnoid hematomas, cerebraledema, and old bone fractures. The medical staff did not

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M. A. Mraz The physical manifestations

assess for retinal hemorrhage (Asamura et al., 2003). Inboth instances, the infants were diagnosed SBS, and bothcases lacked external injury.

A retrospective chart review was conducted by King,MacKay, and Sirnick to evaluate the presence of externalinjury in infants with diagnosed SBS (2003). A total of364 charts were reviewed, all charts were of patients withSBS as the diagnosis (King et al., 2003). This review indi-cated that 40% of all cases displayed no signs of externalinjury (King et al., 2003). This leaves 60% that did exhibitsigns of injury; however, because this was a retrospectivestudy, the authors acknowledged that hospital-inflictedinjury may have served as a reason for this statistic. Thislack of knowledge secondary to the retrospective analy-sis was regarded as a limitation to the study (King et al.,2003).

Papilledema is the swelling of the optic disc. This typeof injury is usually secondary to increased intracranialpressure. A study conducted by Ogershok, Haynes, andHogg reviewed cases of known SBS; follow-ups of thesecases showed evidence of papilledema. The aftermath ofpapilledema has rarely been documented in other diseaseprocesses where increased intracranial pressure is ob-served, such as a brain tumor. In terms of follow through,this injury is essential to assess for as well as continue re-search on (Ogershok et al., 2001). Forensic analysis oflong-term effects is crucial to these types of injury. Thelong-term outcomes of SBS have been difficult, at best,to research. There must be more emphasis placed on thesequelae to better understand the implications of SBS.

In addition to papilledema, there are countless otherlong-term outcomes associated with SBS. These include,but are not limited to, microcephaly, hemiparesis, ataxia,cerebral palsy, cortical blindness, epilepsy and otherseizure disorders, speech and language delays, global de-velopmental delay, and behavioral dysfunction (Barlowet al., 2005).

Implications for forensic nursing

One of the key responsibilities of a forensic nurse isto provide care to victims of crime through investi-gation, education, and prevention. All three of theseinitiatives include a sophisticated understanding of thephysical manifestations of SBS. Because the physicalmanifestations of SBS are not always clear, a great deal ofinvestigation is required for all possible presenting symp-toms. Forensic nurses must be well versed in the poten-tial injuries that may be sustained secondary to shaking.With this understanding, forensic nurses must dissemi-nate this knowledge to various health care providers, doc-tors, nurses, social workers, pathologists, and child abuseconsultants, as well as attorneys. Finally, as with many

forms of injury, prevention is vital. Forensic nurses mustperpetuate their knowledge to high-risk families and sit-uations. This can be achieved through ongoing research,presentations, and seminars.

Investigation

Currently, in order to further understand the implicationsof shaking, researchers are testing the concept of rigid-body modelling for identification of physical symptomsof SBS. Although general indicators have been identified,there is still much controversy surrounding the exact in-juries that SBS causes. As a result of this, rigid body mod-elling was used to assess the impact shaking had on aninfant (Wolfson et al., 2005). Realistic shaking was simu-lated on a test dummy, and data were obtained; however,it was determined that much more investigation needs tobe completed in order to obtain any significant evidence(Wolfson et al., 2005). This is where the research and in-vestigation is heading. It is important for forensic nursesto stay abreast or even become involved in this type ofresearch.

Education

Because forensic nurses are well versed in the patho-physiology of abuse and are inherent patient advocates,they have the responsibility to share their expertise withother healthcare professionals. One example of a forensicnurse educating a local community was when an unre-sponsive two-and-a-half-year-old girl was brought to alocal trauma hospital. She died within 24 hours of admis-sion. The father was charged with child abuse by shak-ing, but pled not guilty. The defense attorney contactedthe local IAFN chapter to inquire about a forensic nursewho would be willing to lend expertise. As the case pro-gressed, the forensic nurse found that the probable causeof death was septicemia. The forensic nurse educated theattorney about both SBS as well as septicemia, and wentto the local hospital and presented a conference to thestaff regarding SBS and other diagnosis. It was the furtherinvestigation into the presenting physical symptoms thattriggered the forensic nurse to solve this mystery. The ac-cused was found not guilty as a direct result of the astuteinvestigation by the forensic nurse and her ability to ed-ucate the attorneys and jury about her findings. Foren-sic nurses have the ability to see cases from varying per-spectives. Because of this ability, forensic nurses have theresponsibility to educate medical and other professionalstaff on matters such as SBS.

Additionally, forensic nurses must educate the treat-ment staff of the importance of accurate and thor-ough documentation. Many times abusers are acquit-ted secondary to inadequate documentation; conversely,

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innocent caregivers are convicted for the very same rea-sons. It is for these reasons that documentation on all ac-counts is essential.

Prevention

In a research study conducted by Kemp and Coles (2003),60% of all child abuse cases have presented to the hospi-tal or doctors office prior to sustaining admitable injury.This reflects a clear need for child abuse prevention ser-vices within the healthcare system. Forensic nurses mustfocus on primary prevention. This could include seminarsfor daycare providers, classes for new parents as well asfoster parents, and interventions for vulnerable popula-tions such as adolescent parents. Finally, forensic nursesmust lobby for more stringent federal guidelines regard-ing abuse prevention. It is not enough to give a pamphletto a new mother hours after her child is born, when thepost-partum nurses are still caring for the baby. This isthe federally accepted form of prevention for SBS today.There should be discussions during prenatal visits andprenatal classes. Also, there should be discussion duringthe post-partum period as well as prevention discussionduring well baby home health visits. Education on SBSshould be available at pediatricians’ offices and clinicsas well.

Conclusion

SBS is a form of abuse ever prevalent in today’s society.Additionally, it is a syndrome that is 100% preventable.Forensic nurses are dedicated to the eradication of abuseas well as advocacy for the vulnerable. A helpless childis amongst one of the most vulnerable populations. SBScan occur secondary to frustration or sheer ignorance.Regardless of the pre-existing conditions, forensic nursesshould understand the history of SBS and the physicalmanifestations that may be caused by shaking. Forensicnurses should educate medical staff on the physical man-ifestations that can ensue from SBS, educate parents onthe effects shaking can have on their child, and continueresearch and investigation into the various injuries thatare caused by shaking a baby.

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