The NYTimes has a headline that questions if “Shaken Baby Syndrome” exists. Actually, the article is better than the headlines, but I worry that by trying to absolve the guilt of the perpetrator by showing the problems in diagnosing when and how the child was injured, they are missing a  teaching moment.

What you need to know: Don’t shake the baby. If he is crying, let him cry. Don’t ever ever shake the kid to get him to stop. It’s just so easy to hurt a baby, even when you don’t mean to do harm.

How easy it it?

From the National Library of Medicine:

Shaken baby syndrome can occur from as little as 5 seconds of shaking…

When an infant or toddler is shaken, the brain bounces back and forth against the skull. This can cause bruising of the brain (cerebral contusion), swelling, pressure, and bleeding in the brain. The large veins along the outside of the brain may tear, leading to further bleeding, swelling, and increased pressure. This can easily cause permanent brain damage or death…

In most cases, an angry parent or caregiver shakes the baby to punish or quiet the child. Such shaking usually takes place when the infant is crying inconsolably and the frustrated caregiver loses control. Many times the caregiver did not intend to harm the baby. Still, it is a form of child abuse.

Injuries are most likely to happen when the baby is shaken and then the baby’s head hits something. Even hitting a soft object, such as a mattress or pillow, may be enough to injure newborns and small infants. Children’s brains are softer, their neck muscles and ligaments are weak, and their heads are large and heavy in proportion to their bodies. The result is a type of whiplash, similar to what occurs in some auto accidents.

In other words, usually the injury is an accident. But not always. And the bad news is that probably most cases, especially mild cases, may not be recognized by the physician.

Before “shaken baby syndrome” was commonly recognized as a diagnosis to explain why babies suddenly went into a coma, I had two patients who probably had the syndrome but didn’t recognize it then. (I should note that I trained in the 1960’s, and child abuse syndromes were only widely recognized in the 1970’s).

One, a baby whose parents left her with their younger brother when they went out to a local rodeo. The brother and two friends brought he comatose baby to the ER, pale, and unconscious. The baby “died” stopped breathing  and lost her heart beat, but (alas) we managed to do CPR and resuscitate her. We transferred her by ground ambulance to the local hospital (90 miles away) and they arranged air transfer to the university for treatment (300 miles away). She lived, but severely brain damaged. They tried to point to the babysitter, a teen ager, as causing the problem, but since the syndrome wasn’t well known back then, and there were no bruises, no case came to court.

The second was a baby who similarly was brought in with severe lethargy, and a history of an ear infection. Again, he had been left in care of his non custodial parent, a young man. We didn’t have CT scans back then so we started treatment for meningitis (presuming the infection had spread from the ear to the brain). The Spinal tap however showed only a little blood and  no pus. So the next day we arranged transfer 200 miles to a larger hospital with specialists, where the case was recognized as shaken baby syndrome. A court case was attempted, but I never testified so presumably the father was never tried after his arrest.

I had several later cases too, after Shaken Baby syndrome had been better recognized and we had CT scans to verify what was going on.

The third case was a child again brought into the ER with the history that she “had a seizure” in the car. Again, no bruising. We started treatment for epilepsy and arranged a CT scan (the nearest one was 35 miles away) the next day. The CT scan showed a subdural, and when we transferred the child, the “retinal hemorrhages” that suggest shaken baby syndrome were found, and the father charged.

In this case, we were pretty sure of the diagnosis, not only because by this time the diagnosis was better understood, but because two months earlier the child had been found to have some broken ribs by the chiropractor, and we had a civil hearing on whether or not the father should be charged.  But we couldn’t “prove” who did the injury, and he blamed the chiropractor. Since he had beaten the mother, a compromise was reached: separate from mom, get anger management treatment, and legally he could not be left alone with the child. Alas, his wife was young and needed to shop, so she asked daddy to babysit.

This father did go to court, ended up in jail, and the child was taken from mom’s custody to be raised by a relative in another state.

Case number four was a baby whose mom left him with the boyfriend/father to shop. On arriving home, she couldn’t wake the baby, but father said the child was well when he left the house. Mom brought child came to the ER, to our rural hospital without a CT scan. We called to air evac the child to the nearest children’s hospital (which was 200 miles away). Again, there were no bruises or signs of trauma, but there were retinal hemorrhages suggesting that he had been shaken. . By the time the helicopter arrived, the kid was anemic and in shock from an expanding subdural hematoma and probably internal bleeding, and we soon had to intubate him to keep him alive and start a blood transfusion. The weather turned bad, too bad for the visual flight rules that our heliport needed, so we had to arrange a “fixed wing” plane to come to the nearest airport that had instrument flight rules. By the time it arrived, the child died.

In this case, the father denied harming the baby but finally he admitted to the shaking to get  a plea bargain.

Mom (as is common in these cases) defended the boyfriend as not being violent, but the grandmom later admitted to me that he took drugs and had hit her daughter several times.

So how common is shaken baby syndrome? Too common I suspect. Probably a lot of cases in the past were attributed to crib deaths or fevers.

Yet when the NYTimes has an article questioning if the diagnosis exists, I wonder if it is because the perpetrator is an attractive young woman, not a drug taking young man with a temper.

This manipulation of sympathy is not new: the notorious Boston Nanny case brought the problem a lot of publicity. The young, attractive girl charged had a lawyer who decided the best way to get her off was to limit the charges to “all or nothing”: Either first degree murder, or let her go free.

(There is more legal maneuvering to this: if she pleaded involuntary manslaughter or a lesser charge, the employment agency could have been charged as negligent for not screening her for a bad temper).

The jury, however, must have been working class, and called their bluff, and gave her the stiff sentence, which later was overturned by another court and the time in jail cut to the time she already spent in jail.

To this day, she denies shaking the child, yet I wonder: is she being honest? Did she misjudge the strength used to shake him, or did she block out the memory? Could it be that she shook the kid but didn’t realize how hard she shook him?

Most of the cases above that I was involved with had a suspect that was known to be violent, and in one case, there was evidence of child abuse before the incident occurred.

The real problem is not that the “shaken baby ” syndrome doesn’t exist, it is that it doesn’t take much shaking to cause it. babies are very vulnerable. And no, you usually don’t see bruising. You may not even get a skull fracture: if the child wasn’t slammed against an object, you still can rip the veins in the brain to cause problems.

And that information needs to be given more publicity to the public, In our clinic, we had “don’t shake the baby” posters on our walls, but how many lay people are aware of how easily shaking a kid can result in injury?

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Nancy Reyes is a retired physician living in the rural Philippines. She blogs at Finest Kind Clinic and Fishmarket, and writes on medical matters at HeyDoc Xanga blog.

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