~D

i84i i

t

Shaken Baby Syndrome:
Identification and Prevention
9 for Nurse Practitioners 9
Deborah Coody, MSN, RN, CPNP, Mary Brown, MSN, RN, CPNP,
Diane Montgomery, MSN, RN, CPNP, Abbie Flynn, MSN, RN-C, NNP, and
Robert Yetman, MD
Shaken baby syndrome is a less widely recognized form of physical child abuse. It is
defined as vigorous manual shaking of an infant who is being held by the extremities or
shoulders, leading to whiplash-induced intracranial and intraocular bleeding and no
external signs of head trauma; often identifying shaken baby syndrome is difficult
because of the lack of obvious external signs. Shaken baby syndrome should be
considered in infants with seizures, failure to thrive, vomiting associated with lethargy or
drowsiness, respiratory irregularities, coma, or death. With the increased awareness of
child abuse, more attention has been focused on morbidity and death caused by the
violent shaking of infants. This article describes the clinical findings of shaken baby
syndrome, explores the characteristics of families al risk for abuse, and discusses
implications for nurse practitioners, l PEDIATRHEA~tUCARE.(1994). 8, 50-56

H e a d injury is a leading cause of morbidity and death
among children (Gordon, 1989); it is the most frequent
cause of morbidity and death in abused children (Billmire & Meyers, 1985). An estimated 2.7 million children in the United States were the victims of child abuse
in 1991, and at least 1,033 of these children died of
abuse (National Coalition for the Prevention of Child
Abuse, 1991). O f the child abuse victims, 55% were 1
year of age or younger. With the increased awareness
and reporting of child abuse, more attention has been
tocused on the damage caused by the violent shaking
,,:)t"infants, a previously less widely recognized form of
physical abuse.

)eborah Coody, MSN, RN, CPNP, is an assistant professor of pediatrk s at the,
~iversitv of Texas Medical S(hool at Houston
Z , r v grown, MSN, RN, CPNP is a (lini(al instructor at the University ol
<a~ S(hool of Nursing at ~touston
}~ane Montgomery, MSN, RN, CPNP, is a (~[inical instructor at the University
i !exas Medical School at Iqouston.
9~::bie Eiynn, MSN, RN-C, NNP, i,, a d i n i ( a l instructor at the University of
~ -as Medical School at Houslou
~:t:bert Yetman, MD, is an associate professor of pediatrks at the University
Texas Medical School at 14oustor~
~. ~rint requests: Deborah Loody, MSN, RN, CPNP, Assistant Pro|essor, De~ :tment of Pediatrics, University of ]exas Medical School at Houston, 64~1
rain. ~.020 MSB, Houston~ TX 77030
pyright 9 1994 bv the Nationat Association of Pediatric Nurse Associates
>ractitioners
~!~5245/94/$~l)0

~ 0

25/1/47066

The first article describing infantile whiplash injuries
was published by Guthkelch in 1971; the term "whiplash shaken baby syndrome" was established by John
Caffey in 1972. This syndrome, which is now commonly referred to as "shaken baby syndrome," or SBS,
involves vigorous manual shaking of infants who arc
being held by the extremities or shoulders, with whiplash-induced intracranial and intraocular bleeding, but
with no external signs of head trauma.
s CASE STUDY

],.I). is a 6-month-okt fcmalc who was brought to a
pediatric emergency center by her parents after she had
a seizure at a day care center. She had no previous
history of seizures and was ati:brile. Her parents reported that she had been in good health except for
requiring treatment for an arm fracturc at 4 months
after she had "rolled over on her arm the wrong way."
The parents were both 19 years of age, and I,.D. was
their only child. L.D. recently started attending a statesubsidized day-care pr~,gram on her mother:s return to
work. Both parents dcscribcd L.D, as "filssy all the time;
she cries no matter what ~e de," ilnidal physical examination revealed a l::tilargic vet irritable infant with
decreased tone throughout the body qhe ~la<t t ~el~sc
anterior fontanelle and sight suturTcs 3u~ nc cx idcJlce ,'f
external trauma to th,,. ~1c~cl ~nd nc&,. l~:cr head circtm'ikrencc measured 46.f, ,, -~, g;'catcr l:har~ th: ;'(Ida pvtcentile for her age. !:~1 :,~:ra,,ctflar llOVCi-qcllls w'2rc

Journal of Pediatric Health Care
March-April 1994

C o o d y et al.

i:

51

i

t
u

9 FIGURE 1 Vigorous shaking produces acceleration-deceleration of the infant's head and results in
the whiplash injury.

noted on the right, but no extraocular movements were
detected on the left. Funduscopic examination showed
massive retinal hemorrhages bilaterally. Dark red ecchymotic areas were found on both upper arms, and
yellowish-green ecchymoses were noted on her abdomen and posterior thighs. The remainder of the physical
examination was normal.
Liver and coagulation studies were normal. Lumbar
puncture produced xanthochromic fluid with 40,000
red blood cells, 850 white blood cells (80% polymorphonudear, 20% lymphocyte), protein of 38 mg/dl and
glucose of 76 mg/dl. Blood and cerebrospinal fluid cultures were negative. Skull radiographs showed widened
coronal and sagittal sutures but no fracture; no fractures
were evident on radiographs of ribs, yet a calcified area
of healing was noted on the right proximal humerus.
Computerized tomography (CT) showed diffuse cerebral edema and reduced ventricular size with some enlargement of the subarachnoid space. Seizures contin-

ued for 2 days and were treated with phenobarbital,
hydantoin, and valproate sodium. The patient regained
consciousness over a period of 2 weeks but remained
in a vegetative state, opening and closing her eyes but
not responding meaningfully to any stimuli. The ocular
hemorrhages disappeared and were replaced by a pale
yellow disc, still present i year after her admission. She
remained retarded, quadriplegic, and blind.
9 THE WHIPLASH INJURY

When a baby is shaken, the shaker usually grabs the
child around the thorax. The pressure that is applied
around the chest inhibits venous return, causing the
blood to pool in larger vessels including those that drain
the blood from the head. An infant's head is relatively
larger and heavier than the older child's head, and it is
supported by weaker neck muscles (Dykes, 1986). Vigorous shaking of an infant produces acceleration-deceleration of the infant's head. Because of the time lag

52

loumal of Pediatric Health Care
Volume 8, Number 2

Coodv e! a [

II FIGURE 2 Scattered dome-shaped retinal hemorrhages. Note. From "Shaken baby syndrome" by R.F.
Swengel, D.W. Scharre, & C.E. Mein, 1990, Ameri(an t-amily Physician, 41, pp. 1145-1152.
Copyright 1990 by the American Academy of Family Physicians. Reprinted by permission.

between movement of the skull and movement of its
contents during a shaking episode, rotational forces lead
to shearing and tensile stress on the bridging cortical
veins (Figure 1 ). This stress on thc attachments between
the outer surlhces of the brain and inner surfitces of the
skull can cause tearing of the cortical veins, resulting iI:
subdural hematomas. Cerebral inju O, in children causes
increased cerebral blood volume; thus the blood vessels
of the head contain an increased amount ofbk)od under
increased pressure. Because wall tension in a cylindrical
structure increases as the product of pressure and radius
(Spaide, Swengel, Scharrc, & Mcin, 1990)~ blood vessels m the head are more likely to rupture from the
trauma caused bv shaking. Intracranial hemorrhages,
cerebral hyperemia, and edema increase intracraniai
pressure. Transmitted by the optic nerve sheaths, this
pressure can reduce venous outflow from the eve. Sudden distention of the sheaths may bc the cause of the
optic nerve sheath hemorrhages seen in SBS. Retinal
hemorrhages in SBS result fi'om compression of the
thorax, high intracranial pressure secondary to hemorrhage and edema, and blood acceleration backward
through venous channels into the retinal vascular tree
(Spaide, 1987).
Intracraniat injm y is the major cause of death and
morbidiD; in SBS. Subdural hematomas are the most
common intracranial lesions seen, tbllowed bv subarachnoid hemorrhages, cerebral contusions, and acute intcrhemispheric subdural hematomas.
m CLINICAL PRESENTATION

SBS is difficult to diagnose because the child usually has
little or no external evidence of trauma and parents do
not voluntarily give a history of abuse. A complete his-

tory and a thorough physical examination are necessary
to make the diagnosis. These children arc generally under the age of 1 year, and most arc less than 6 months
old (Spaidc ctal., 1990). They usually have vague symptoms similar to those of infectious processes commonly
associated with int)nts and children. For this reason,
SBS is often not considered in the diagnosis. The most
common symptoms include vomiting, irritabiliD,, listlessness, lethargy., bradycardia, apnea, seizures, coma,
bulging or full fontanels, large head circumfkrence, hvpothermia, poor feeding response, failure to thrive, or
other vague symptoms indicative of other conditions
(Brenner, Fischer, & Mann-Gray, 1988; Dykes, 1986;
I.udwig & Warman. 1984; Spaide et al., 1990).

Although

ocular findings may be present,
they are often missed.
ii

Although ocular findings may be present, they arc
often missed. These findings include orbital and lid ccchymosis, hyphema, subconjunctival hemorrhage,
anisocoria, disconjugate eye movement, papilledema,
sixth-nerve palsy, and retinal detachment (Dykes,
1986). The most classic finding of SBS, however, is
retinal hemorrhages, which are bilateral in most cases
(Figure 2). Newborns commonly have retinal hemorrhages from birth trauma, which usually resolve within
1 month of birth. The presence o f retinal hemorrhages
in children under 4 years of age, with the possible exception of the first month of life, is highly suggestive
of SBS (Carter & McCormick, 1983). SBS is also charactcrized by subdural and/or subarachnoid hemor-

Journal of Pediatric Health Care

March-April t994

Coody et al.

,53

9 FIGURE 3 Computerized tomography scan on the day of admission in a 2-month-old girl with
seizures and bilateral retinal hemorrhages. Subdural hematomas are seen in the frontal and temporal
regions. Note. From "Shaken baby syndrome" by R.F. Spaide, R.M. Swengel, D.W. Scharre, & C.E.
Mein, 1990, American Family Physician, 41, pp. 1145-1152. Copyright 1990 by the American
Academy of Family Physicians. Reprinted by permission.

rhages with minimal or absent signs of external craniofacial trauma (Hadley, Sonntag, Rekate, & Murphy,
1989). Occasionally evidence of ecchymotic grip marks
are found on the child's shoulders, upper arms, or thorax
from the infant being grasped firmly for shaking.
9 DIAGNOSTIC EVALUATION

The diagnostic evaluation for SBS is based on signs and
symptoms observed at examination. The practitioner
who initially evaluates the young child with common
symptoms of SBS may not initially order complete
ophthalmologic examinations, skull radiography, CT,
or magnetic resonance imaging (MRI). Differential diagnoses of SBS include seizure disorder, meningitis,
failure to thrive, viral syndromes, shock, apnea episode,
sudden infant death syndrome, hydrocephalus, or rupture of a congenital aneurysm. After screening blood
and urine studies show no evidence of infection or metabolic problems, further investigations are warranted.
Unfortunately, the condition of many children remains
undiagnosed because the children have signs that do
not appear to originate from trauma.
Any child who has unexplained lethargy or seizures
should immediately have an ophthalmologic examination to rule out abuse. Although retinal hemorrhages
are common from birth trauma, after the neonatal period retinal hemorrhages in infants should be considered
to be caused by child abuse unless proved otherwise
(Kessler & Siegel-Stein, 1984). A lumbar puncture is
performed very carefully in children with symptoms of
seizures or vomiting associated with lethargy or drows-

iness. Blood-contaminated cerebrospinal fluid, or a
"bloody tap," is difficult to interpret. The needle tip can
easily enter the anterior internal venous plexus, causing
venous blood to exude from the needle hub. When
cerebrospinal fluid collected in three or four tubes becomes progressively clearer, this is good indication that
the lumbar puncture has been "traumatic" or caused by
the procedure itself. Grossly bloody fluid that does not
clear can be a manifestation of a subarachnoid hemorrhage (Apolo, 1987).
Diagnostic radiologic studies include radiographs,
CT scan, and MRI. A skull fracture, which may or may
not be found on radiologic studies, is usually in the
occipital or parietal regions and is the result of direct
trauma (Spaide et al., 1990). Associated radiologic findings that may be found include broken ribs, chest
bruises, spiral fracture of extremities, metaphyseal lesions, and epiphyseal separation (Spaide et al., 1990).
The CT scan, an extremely sensitive and relatively noninvasive technique to assess intracranial pathologic condition, has been used as a key diagnostic study in identifying SBS. CT is used initially because it is usually
obtained more quickly and is less expensive than MRI.
The CT scan shows intracranial hemorrhages associated
with vigorous shaking or blunt trauma with or without
skull fracture (Alexander, Sato, Smith, & Bennett,
1990), and it is superior to skull radiography in diagnosing depressed skull fractures, hairline fractures, and
mild compression fractures often missed on plain radiography (Figure 3). The CT is effective in exhibiting
a combination of cerebral edema and contusional hem-

54

Journal of Pediatric Health Care
Volume 8, Number 2

C o o d y et al.

m TABLE

1 Families at risk f o r a b u s e

Characterislics e f ~

Poor nurturing/M:mseduring
child hood
Low self esteem/depression
Social isolation
Inadequate knowledge of normal
developmental behavior
Free expression of violence; difficulty controlling impulses
Substance abuse

Characteristics of child

Environmental and other
factors

Physical anomalies

Financial difficulties

Developmentally delayed
Physically delayed
"Difficult" temperament, as
described by parent
Does not meet expectations of parent(s)
May remind parent of
someone else

Unemployment
Illness
Divorce or relationship
difficulties
Housing problems
Lack of family support

Compiled from Heindl, K., Krall, C., Salus, M., & Broadhurst, D. (1979); Kernpe, ( H . , & Heifer, R.E. (1980);: Kessler, D.B., & Hyden, P. (1991); Whaley, L.F.,
& Wong, D.L. (1991); Wissow, L.S. (1990).

orrhages (Ellison, Tsai, & Largent, 1978). The most
common finding of SBS on the CT is subdural hematoma, a lesion almost always traumatic in origin. Other
findings include cerebral contusion and subarachnoid
hemorrhages. In a follow-up CT, the brain may show
atrophy, multiple hypodense areas, and ventricular enlargement (Alexander et al., 1990). A normal CT scan
does not eliminate the diagnosis of SBS if other signs
of abuse are also present (Bennett & French, 1980).
The MR3 offers an even more detailed study than does
the CT scan. It offers better contrast sensitivi~ and
clari~ and obtains more vivid evidence of injury. Disadvantages of the MRI include its high cost, lack of
availability, and the requirement for sedation in a child
already compromised with intracranial injuries.
m SEQUELAE

risk for child abuse (Table 1), the determination has
not yet been made whether these risks are exactly the
same for infants of SBS. However, it is reasonable to
infer that these risk factors may be similar for SBS.
Spaide et al. (1990) recognized the following three factors that contribute to the impairment of the parentchild relationship in SBS:
a. Behavioral difficulties of the parent;
b. Social and stress management problems in the
family;
c. The child's behavior leading to the abuse.
The parent may have an unconscious desire to be
nurtured by the child, because the parent may not have
received adequate nurturing experiences during childhood (Whaley & Wong, 1991). Young infants who
sleep most of the time and cry often while awake, such
as the 20% to 30% of infants in whom colic develops,

SBS may cause death, permanent brain damage, or longterm disabiliF. Developmental delay, spasticity, qua&
raparesis, hearing loss, hydrocephalus, seizure disorder,
microcephaly, and blindness are frequently seen results
ofSBS (Spaide, Swengel, Scharre, & Mein, 1990). Less
severe cases may result in chronic brain damage. Mild
to moderate mental retardation and developmental delay with no apparent cause may not be found until the
child enters school (Caffey, 1974). Possibly some children with mental retardation were actually undiagnosed
SBS victims. Developmental delay can also be associated
with SBS where the increased intracranial pressure interfered with the blood supply to the pituitary gland
(Dykes, 1986). Therefore the practitioner should consider SBS in children with impaired growth and hypopituitarism,

give very little "nurturing" to the needy parent (Spaide
et al., 1990). If the parent's expectations of a submissive,
nurturing infant are not met, the parent may feel rejected, leading to further breakdown of the parent-child
relationship and increasing the likelihood of shaking
secondary to frustration. Many parents who would
never consider striking their child may resort to shaking
their child as a less violent approach, not knowing the
possible sequelae of the event.

m FAMILIES AT RISK FOR ABUSE

m IMPLICATIONS FOR NURSE PRACTITIONERS

Although nursing, medical, and behavioral scientists
have identified numerous factors that place children at

Pediatric nurse practitioners (PNPs) are in a strategic
position to offer primary and secondary prevention in-

A ny child who has unexplained lethargy or
seizures should immediately have an
ophthalmologic examination to rule out abuse.

Journal of Pediatric Health Care
March-April 1994

Coody et al.

55

9 TABLE 2 Educational materials
lri~

"Never Shake a Baby"
Media campaign
"Crying-What Can I Do?"
"Discipline and Child
Abuse"
"The Parents' Cheeklist"
"About Preventing Child
Abuse"
"]'he First Five Years"
"The First Year-Caring for
Your Baby"
"Your Baby and Crying"
"You and Your Baby-The
Phenomenon of Early
Development"
"Brazelton on Parenting:

ment Ruler
Various child abuse
topics

Oescription

16 x 20-inch poster
8 1/2 x 11-inch poster
7-minute video

Ohio Institute on Child Abuse
Prevention

Guides for parents in preventing
child abuse

Kidsrights Catalogue

Parent information booklet

Scriptographic Publications
I~800-628-7733
American Academy of Pediatrics

Book for new parents; anticipatory guidance
Booklets for new parents; anticipatory guidance

Videotapes for health professionals
Quick-check for developmental
milestones-birth to 24
months
Pamphlets/booklets

terventions, to identify the family at risk, and to recognize victims of SBS. Primary prevention interventions, taken to ensure that child abuse will never occur,
begin with teaching all new parents, potential parents
and caretakers, and the general public about SBS and
the mechanism of injury involved (Table 2). PNPs in
hospital nurseries and outpatient settings have a responsibility to educate new parents about normal child
development and the danger of shaking infants, to foster
bonding, and to assess families for risk of abuse. Secondary prevention interventions, provided to families
identified to be at risk for abuse, are based on information that these parents have a lack of knowledge of
normal child development and have unrealistic expectations of their children. PNPs have the appropriate
background and training to offer instruction, anticipatory guidance, and education in these areas. In the office
setting, PNPs have the critical oppommity to assess the
quality of interactions between parent and child and to
intervene or refer families at risk for abuse. The PNP
should discuss effective discipline techniques and techniques that do not work and should not be used. The
PNP can model appropriate interactive behavior during
the examination, teaching by example. The office setting
also provides an ideal opportunity to offer parenting
classes about normal developmental stages of infants,

1-800-858-5222
1-800-892-KIDS

1-800-433-9016

Ross Laboratories (free)

Pipher Films, Inc.
Ross Laboratories (free)
Houston Area Chapter of

NAPNAP--Mary Brown
(713)792-7824
National Committee for Prevention of ChiM Abuse
(3121663-3520

common problem areas such as cuing and colic, and
dealing with difficult situations effectively. Tertiary prevention interventions, taken after abuse has already occurred in an effort to prevent further abuse (Kessler &
Hyden, 1991), include referrals to child protective services, legal indictments, and rehabilitative measures.
Unfommately, tertiary prevention has been the main
focus within health care systems for much too long.
PNPs must make a concerted effort to prevent child
abuse and/or identify and intervene in the early stages
in a way that causes the least trauma to the child. A
coordinated effort needs to be established to develop
programs that provide anticipatory guidance to parents
and prevention programs and treatment for children and
their families (National Association of Pediatric Nurse
Associates and Practitioners, 1992).

REFERENCES

Alexander, R. A, Sato, Y., Smith, W., & Bennett, T. (1990). Incidence of impact trauma with cranial injuries ascribedto shaking.
American Journal of Diseases of Children, 144, 724-726.
Apolo, J. O. (1987). Bloodycerebrospinal fluid: Traumatic tap or
child abuse?Pediatric Emergency Care, 3, 93-95.
Bennett, H. S., & French, J. H. (1980). Elevatedintracranial pressure
in whiplash shaken infant syndrome detectedwith normal cornputerized tomography. Clinical Pediatrics, 19, 633-634.

'~6

C~)odv et a[.

gillmire, M. E., & Phillips, T. J. (1985). Serious head injury in infants:
Accident or abuse? Pediatrics, 75, 340-342.
Brenner, S. L., Fischer, H., & Mann-Gray, S. (1988). Race and the
shaken baby syndrome: Experience at one hospital. Journal of the
National Medical Association, 81, 183-184.
Caf[~y, 1. (1972). On the theory and practice of shaking infants, its
potential residual effects of permanent brain damage and mental
retardation. American Journal ofDiseases of Children, 124, 161-169.
Caffey; J. (1974). The whiplash shaken baby syndrome: manual shaking by the extremities with whiplash-induced intracranial and intraocular bleedings, linked with residual permanent brain danaagc
and mental retardation. Pediatrics, 54, 396-403.
Carter, 1- E., & McCormick, A. Q. (1983). Whiplash shaking syndrome: Retinal hemorrhages and computerized axial tomography
of the brain. Child Abuse and Neglect, 7, 27%286.
Dykes, L. J. (1986). The whiplash shaken infaat syndrome: What
has been learned? Child Abuse and Neglect, 10, 211-221.
Et[ison, P. H., Tsai, F. Y., & Largent, I. A. (1978). Computerized
tomography in child abuse and cerebral contusion. Pediatrics, 62,
151-154.
Gordon, V. L. (1989). Recovery from a head injury: A family process.
Pediatric Nursing, 15, 131 - 133.
Guthkelch, A. N. (1971). Infantile subdural haematoma and its relationship to whiplash injuries. British Medical Journal, 2, 430431.
Hadley, M. N., Sonntag, V. K., Rekate, H. L., &Murphy, A. (1989).
The infant whiplash-shaken injury syndrome: A clinical and pathological study. Neurosurgoy, 24, 536-540.

Iournal of Pediatric Health Care
Volume 8, Number 2

Heindl, K., Krall, C., Salus, M., & Broadhurst, D. (1979). The nurse's
role in prevention and treatment of child abuse and neglect (Publication # H D S 7930202). Washington, DC: National Center on
Child Abuse and Neglect, Department of Health, Education and
Welfare.
Kempe, C. H., & Heifer, R. E. (1980). The battered child (3rd ed.).
Chicago: University of Chicago Press.
Kessler, D. B., & Hyden, P. (1991). Physical, sexual and emotional
abuse of children. Clinical Symposia, 43, 2-3, 31-32.
Kessler, D. B., & Siegel-Stein, F, (1984). Retinal hemorrhage, meningitis, and child abuse. New York State Journal of Medicine, 5960.
Ludwig, S., & Warrnan, M. (1984). Shaken baby syndrome: A review
of 20 cases. Annals of Emergency Medicine, 13, 104-107.
National Association of Pediatric Nurse Associates and Practitioners,
1992, Position Statement on ChildAbuse, Cherry Hills, NJ: Author.
National Coalition for the Prevention of Child Abuse, 1991, 1991
statistics, Chicago: Author.
Spalde, R. F. (1987). Shaken baby syndrome: Ocular and computed
tomographic findings. Journal of Clinical Neuro-ophthalmology, 7,
108-111.
Spaide, R. F., Swengel, R. M., Scharre, D. W., & Meine, C. E.
(1990). Shaken baby syndrome. American Family Physician, 41,
1145-I152.
Whaley, L. F., & Wong, D. L. (1991) Nursing care of infants and
children (4th ed.). Chicago: Mosby-Year Book, Inc.
Wissow, L. S. (1990). Child advocacyfor the clinician: An approach to
child abuse and neglect. Baltimore: Williams and Wilkins.

Fhc lot gYAl. is abstracted and / or indexed in the InternationalNursinglndev, the Cunmlativclndav to Nursing&AlliedHealth Literature, and MEDLINE.
This JOURXALhas been registered with Copyright Clearance (;enter, Inc., 222 Rosewood Dr., Danvers, MA 01923. Consent is given for the copying
of articles for personal or internal use of specificclients. This consent is given on the condition that the copier pay directly to the Center the per-copy
fee stated on the first page of each article for copying beyond that permitted by U.S. Copyright Law. This consent does not extend to other kinds of
copying, such as fbr general distribution, resale, advertising and promotional purposes, or for creating new collectiveworks. All inquiries regarding
copyrighted material fi'om this publication other than those that can be handled through Copyright ClearanceCenter should be directed to the Associate
lournat Publisher, Mosby-Year B(x~k,Inc., t 1830 Westline Industrial Dr., St. Louis~MO 63146, phone (314)579-2808; fax (314)432-1380.