ORIGINAL ARTICLE

The physical manifestations of shaken baby syndrome
Megan A. Mraz, MSN, RN
Duquesne University (Doctoral...
M. A. Mraz                                                                                         The physical manifestat...
The physical manifestations                                                                                        M. A. M...
M. A. Mraz                                                                                          The physical manifesta...
The physical manifestations                                                                                         M. A. ...
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The physical manifestations of shaken baby syndrome. journal of forensic nursing

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The physical manifestations of shaken baby syndrome. journal of forensic nursing

  1. 1. ORIGINAL ARTICLE The physical manifestations of shaken baby syndrome Megan A. Mraz, MSN, RN Duquesne University (Doctoral Student), Pittsburgh, Pennsylvania; West Chester University (Instructor), West Chester, Pennsylvania; Alfred I. duPont Hospital for Children (Staff Nurse), Wilmington, Delaware Keywords Abstract Abuse; forensic nursing; nursing intervention; shaken baby syndrome. Shaken baby syndrome (SBS) is a great concern for forensic nurses. Accurate diagnosis and treatment is essential. The purpose of this report is to review Correspondence the history of SBS, as well as the physical symptoms of a patient suspected of Megan A. Mraz, MSN, RN, 222 K Sturzebecker suffering from this form of abuse. Implications of SBS for the forensic nurse Health Science Center, West Chester University, West Chester, PA 19383. Tel: 610-436-4408; will be presented; this will include the education of families and caregivers and E-mail: meganmraz@comcast.net methods of prevention. Received: May 29, 2007; accepted: October 11, 2007 doi: 10.1111/j.1939-3938.2009.01027.x cerebral edema; retinal and cerebral hemorrhaging; bone Introduction fractures, both old and new; cerebral atrophy; hydro- Shaken baby syndrome (SBS) is an infliction of trauma cephalus; papilledema; and cervical spine injury (Miehl, onto a younger child when he or she is violently shaken. 2005). For example, how does the physical presentation This act initiates traumatic brain injury, as well as other of a 2-year-old who was shaken differ from that of a 2- physical devastation (Geddes & Plunkett, 2004). The year-old who has sustained injury from falling off a set anatomy of a young child is that of a large head and of monkey bars? This question is imperative to research weak neck muscles. The rigorous shaking back and forth and investigation in the healthcare arena. Forensic nurses causes the brain to bounce against the skull. This results have the educational background as well as the clinical in swelling and bruising of the brain. The outcomes of expertise to provide vital input into this inquiry. Addi- these cases range from complete recovery, to permanent tionally, forensic nurses have an obligation to be abreast damage, and even death in severe cases. of the most current research in order to provide thorough In 2001, an estimated 903,000 children were victims and accurate participation as part of the multidisciplinary of SBS. Additionally, 1,300 children were fatally injured team that will help these victims. Presentation of SBS is from SBS the same year (Miehl, 2005). Although inci- based on injuries sustained and caregiver reports of the dences per year vary, it is estimated that 19% to 30% of precipitating events. The purpose of this report is to detail child fatalities are a result of intentional injury. The abil- the evolution of SBS and current day research. Through- ity to detect SBS is difficult secondary to under reporting out the history of SBS, medicine has been able to more and misdiagnosis. There is no established set of symptoms clearly identify the various symptoms and physical pre- that indicate SBS; consequentially, many children who sentation of these victims. Finally, the forensic nurse’s are abused are inaccurately diagnosed with a bacterial or role should come to include investigation, education, and viral infection. efforts toward prevention of this form of abuse. If the obvious signs of abuse are not present, then what do healthcare providers assess when abuse is suspected? History While the infant may not have outward bruising and swelling, there are substantial internal injuries that may Child abuse was first introduced to America through a be present and should be assessed for. Some examples are young 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
  2. 2. M. A. Mraz The physical manifestations 2004). In 1864, Mary Ellen died and a review of her case nation and impeccable history of events leading up to the indicated that New York City police had encountered her victim’s admission. on a number of occasions. However, during all these in- Retinal hemorrhages are present in approximately stances, a medical consult was never initiated. During this 75% of all SBS cases (Bechtel et al., 2004). In a recent period in history, child abuse was regarded as a societal study, it was concluded that retinal hemorrhages in an problem, not a medical concern. It was not until 1962 infant should be considered a sign of child abuse until that the notion of child abuse as a medical concern was proven otherwise. These researchers studied the medi- addressed. cal records of 100 infants with medical diagnosis of hy- In 1946 a pediatric radiologist by the name of Dr. John poxia and hypertrophic pyloric stenosis, and in all cases Caffey introduced the concept of SBS, and termed it not one infant had retinal bleeding (Herr, 2004). A study “whiplash shaken baby syndrome” (Miehl, 2005). He no- conducted by Keenan, Runyan, Marshall, Nocera, and ticed that a series of internal injuries such as subdural and Merten, compared the incidence of retinal hemorrhage subarachnoid hematoma and retinal hemorrhage were between children with inflicted versus non-inflicted in- consistently present in these patients; however, Dr. Caf- jury. It was determined that 76.3% of children sustained fey did not observe any evidence of external injury. He retinal hemorrhages secondary to inflicted trauma as op- believed it was the anatomical proportions of the infant, posed to 8.3% of children who sustained retinal hemor- as compared to the adult, that attributed to the sever- rhages from non-inflicted trauma. ity of these injuries. He proposed that the size of the in- Finally, researchers Bonnier, Mesples, and Gressens fant head, 25% of the total body weight as opposed to looked at the pathophysiology of sustained injury post the 10% of an adult, in addition to the weak neck mus- shaking of animal subjects (2004). The researchers ac- cles, poor motor control, and higher concentration of wa- quired a cohort of mice that were 8 days post-natal and ter in the cranial cavity, contributed to the nature of this divided them into three groups: a control group, a shaken injury. group, and a shaken group that had been pre-medicated. The group of mice, who were shaken, were shaken for 15 seconds on a rotating shaker. During the shaking there Current day research was no evidence of hypoxia, such as changes in color or As more research is conducted, healthcare providers have breathing patterns. As expected, no mice in the control better guidelines on the clinical presentation of SBS. group sustained retinal hemorrhage. Of the group mice In addition to caregiver reports of precipitating events who were shaken, 33% sustained retinal hemorrhage. that are inconsistent or unreasonable, as well as a de- As forensic nurses, it is essential that a medical exami- lay in seeking medical attention, there are some spe- nation is conducted in all instances of suspected abuse or cific physical characteristics that are consistent with SBS. sudden onset trauma. Presence of retinal hemorrhage is The hallmark of these manifestations is lack of external one of the first and earliest signs of inflicted intracranial injury. Additionally, healthcare providers should assess injury (Smith, 2004). Consequentially, early diagnosis for bradypnea or apnea, changes in level of conscious- of retinal hemorrhage may prevent further unnecessary ness, bradycardia, bulging fontanels, and seizure activity injury and initiate early investigation into precipitating (Miehl, 2005). events. These initial symptoms should alert the healthcare Hematomas are the most common injury sustained in provider to further investigate for SBS. Various physi- SBS (Keenan et al., 2001). When an infant is shaken, cal manifestations should be examined in order to appro- the forced movement of the brain within and against the priately diagnose SBS. The exploration of these physical skull can tear the vessels, resulting in a hematoma. Ad- manifestations and a thorough history of the events prior ditionally, these forces develop injury of the nerve axons to injury will enable the health care professionals to as- throughout the brain resulting in diffuse axonal injury. certain the most accurate diagnosis. Hematomas can result in cerebral hypoxia, edema, and vasoocclusion (Zenel & Goldstein, 2002). This type of injury requires accurate and immediate di- Physical manifestations agnosis and intervention. Diagnosis is made via radiologic While reviewing the various physical manifestations of imaging such as CT scans and magnetic resonance imag- SBS, it is important to remember there is no one defin- ing (MRI). Intervention may include surgical evacuation ing characteristic. Typically, many of these manifestations of the hematoma, ICP monitoring, and external ventric- present in the victim. Healthcare professionals cannot dis- ular draining. regard other potential causes of these symptoms. SBS is Cerebral atrophy, one of the possible outcomes caused most often identified through a thorough physical exami- by hematomas, is a degeneration of cells within the brain. 27
  3. 3. The physical manifestations M. A. Mraz Moreover, it is a loss of neurons within the brain. Lo et al. It is believed an infant can fracture, possibly even (2003) found that 93.75% of their research sample, a co- break, his or her cervical spine. This injury is secondary hort of children who had been admitted to a Pennsyl- to the whiplash type of motion that SBS demonstrates. vania hospital for suspected intentional injury, suffered C-spine injury can be diagnosed from an X-ray, and c- from cerebral atrophy. Using MRI, the researchers ob- spine injury typically results in varying levels of paresis served 15 of their 16 participants developing cerebral at- and plegia. rophy as early as 9 days post presentation (Lo et al., In 1968, a researcher by the name of Ommaya at- 2003). The incidence of cerebral atrophy is not docu- tempted to establish whether intracranial and neck in- mented; this may be secondary to the poor prognosis as- juries could, in fact, be caused by whiplash. He took 19 sociated with the severity of this injury. monkeys, secured them in a fiberglass carriage, and simu- Hydrocephalus is the abnormal accumulation of cere- lated an instant force of whiplash, comparable to the force bral spinal fluid in the ventricles of the brain and occurs exerted on an infant when shaken, as well as injuries sus- in two forms: communicating and non-communicating. tained during a motor vehicle collision. Findings showed For infants who have suffered brain trauma, it is com- that 11 of the 19 monkeys suffered c-spine injury. municating hydrocephalus that incurs; this is caused by It was not until 2002 when a researcher by the name inadequate absorption of cerebral spinal fluid when the of Uscinski completed a retrospective analysis of Om- ventricular pathways are not obstructed (Ogershok et al., maya’s study and confirmed these results can be applied 2001). to injuries suffered in SBS. He formulated his confirma- Hydrocephalus is another complication of SBS that tion by applying the principles of Newtonian physics to forensic nurses should be aware of. According to Oger- Ommaya’s study (Uscinski 2002). shok et al. (2003), hydrocephalus has been rarely asso- When forensic nurses are on the scene of a suspected ciated with SBS, yet frequently observed by physicians case of SBS, it is essential that they recall the possibility and nurses in caring for these patients. Treatment for hy- of c-spine injury and stabilize the neck with a collar. Fur- drocephalus requires a surgically placed external ventric- ther injury to the c-spine while treating a patient may ular drain during the immediate post-injury phase. This cause greater injury. The collar can be removed once the will allow for normal levels of intracranial pressure. As c-spine has been cleared. This usually occurs once the the recovery process continues, the patient will be trialed patient has become neurologically and hemodynamically without drainage support. Failure of the patient to absorb stable. and drain their own Cerebrospinal fluid (CSF) will result Lack of external injury is one of the three classic signs in a permanent ventricular drain, or shunt. of SBS (Smith, 2003). Lack of external injury may be Additional injury differs among infants who suffer in- present for initial responders. However, their treatment flicted injury as opposed to those who suffer non-inflicted may cause external injuries to be present at subsequent injury. Research indicates that infants with inflicted in- evaluations. For example, the external injury observed jury are more likely to sustain rib fractures, long-bone by the forensic nurse who arrives at the scene may be far fractures, and metaphyseal fracture (Keenan et al., 2004). different from the injury observed by the forensic nurse For inflicted injury, 17.5% to 27.5% of infants suffer frac- who will assesses the patient three days after the initial ture as opposed to 2.8% to 6.9% of fractures sustained insult when multiple IV attempts have been made, many from non-inflicted injury. In matters of skull fractures, rounds of compressions have ensued, and a significant there seems to be no disparity amongst inflicted versus amount of generalized edema has developed. non-inflicted fractures. Two independent case studies were presented by Ori- If SBS is suspected, possible bone fractures should be ent (2005) and Asamura (2003). In both cases, the vic- investigated as soon as the patient is medically stable. tims suffered no external injury. In Orient’s case report This may not seem imperative as no external injury an unresponsive 2-month-old infant presented to the may be observed. However, bone fractures may be key emergency department with his father. The infant was di- in determining the cause of injury. Radiologic examina- agnosed with multiple cerebral hematomas, bilateral reti- tion such as bone scans and skeletal surveys will allow nal hemorrhages, and rib fractures. No external injury the medical staff to establish sites of injury as well as was observed (Orient, 2005). The second case report was prevent further injury (Miehl, 2005). Prior to the diag- about a 3-month-old infant in Japan, where SBS is rela- nosis of fracture, injury should be suspected and mea- tively unknown. The father indicated he would shake the sures should be initiated to decrease further damage to baby while playing with him. The external examination the bones. Some measures may include stabilization of revealed no injury. The internal examination revealed long bones and adhering to log rolling while turning the various subdural and subarachnoid hematomas, cerebral patient. edema, and old bone fractures. The medical staff did not 28
  4. 4. M. A. Mraz The physical manifestations assess for retinal hemorrhage (Asamura et al., 2003). In forms of injury, prevention is vital. Forensic nurses must both instances, the infants were diagnosed SBS, and both perpetuate their knowledge to high-risk families and sit- cases lacked external injury. uations. This can be achieved through ongoing research, A retrospective chart review was conducted by King, presentations, and seminars. MacKay, and Sirnick to evaluate the presence of external injury in infants with diagnosed SBS (2003). A total of Investigation 364 charts were reviewed, all charts were of patients with Currently, in order to further understand the implications SBS as the diagnosis (King et al., 2003). This review indi- of shaking, researchers are testing the concept of rigid- cated that 40% of all cases displayed no signs of external body modelling for identification of physical symptoms injury (King et al., 2003). This leaves 60% that did exhibit of SBS. Although general indicators have been identified, signs of injury; however, because this was a retrospective there is still much controversy surrounding the exact in- study, the authors acknowledged that hospital-inflicted juries that SBS causes. As a result of this, rigid body mod- injury may have served as a reason for this statistic. This elling was used to assess the impact shaking had on an lack of knowledge secondary to the retrospective analy- infant (Wolfson et al., 2005). Realistic shaking was simu- sis was regarded as a limitation to the study (King et al., lated on a test dummy, and data were obtained; however, 2003). it was determined that much more investigation needs to Papilledema is the swelling of the optic disc. This type be completed in order to obtain any significant evidence of injury is usually secondary to increased intracranial (Wolfson et al., 2005). This is where the research and in- pressure. A study conducted by Ogershok, Haynes, and vestigation is heading. It is important for forensic nurses Hogg reviewed cases of known SBS; follow-ups of these to stay abreast or even become involved in this type of cases showed evidence of papilledema. The aftermath of research. papilledema has rarely been documented in other disease processes where increased intracranial pressure is ob- Education served, such as a brain tumor. In terms of follow through, this injury is essential to assess for as well as continue re- Because forensic nurses are well versed in the patho- search on (Ogershok et al., 2001). Forensic analysis of physiology of abuse and are inherent patient advocates, long-term effects is crucial to these types of injury. The they have the responsibility to share their expertise with long-term outcomes of SBS have been difficult, at best, other healthcare professionals. One example of a forensic to research. There must be more emphasis placed on the nurse educating a local community was when an unre- sequelae to better understand the implications of SBS. sponsive two-and-a-half-year-old girl was brought to a In addition to papilledema, there are countless other local trauma hospital. She died within 24 hours of admis- long-term outcomes associated with SBS. These include, sion. The father was charged with child abuse by shak- but are not limited to, microcephaly, hemiparesis, ataxia, ing, but pled not guilty. The defense attorney contacted cerebral palsy, cortical blindness, epilepsy and other the local IAFN chapter to inquire about a forensic nurse seizure disorders, speech and language delays, global de- who would be willing to lend expertise. As the case pro- velopmental delay, and behavioral dysfunction (Barlow gressed, the forensic nurse found that the probable cause et al., 2005). of death was septicemia. The forensic nurse educated the attorney about both SBS as well as septicemia, and went to the local hospital and presented a conference to the Implications for forensic nursing staff regarding SBS and other diagnosis. It was the further One of the key responsibilities of a forensic nurse is investigation into the presenting physical symptoms that to provide care to victims of crime through investi- triggered the forensic nurse to solve this mystery. The ac- gation, education, and prevention. All three of these cused was found not guilty as a direct result of the astute initiatives include a sophisticated understanding of the investigation by the forensic nurse and her ability to ed- physical manifestations of SBS. Because the physical ucate the attorneys and jury about her findings. Foren- manifestations of SBS are not always clear, a great deal of sic nurses have the ability to see cases from varying per- investigation is required for all possible presenting symp- spectives. Because of this ability, forensic nurses have the toms. Forensic nurses must be well versed in the poten- responsibility to educate medical and other professional tial injuries that may be sustained secondary to shaking. staff on matters such as SBS. With this understanding, forensic nurses must dissemi- Additionally, forensic nurses must educate the treat- nate this knowledge to various health care providers, doc- ment staff of the importance of accurate and thor- tors, nurses, social workers, pathologists, and child abuse ough documentation. Many times abusers are acquit- consultants, as well as attorneys. Finally, as with many ted secondary to inadequate documentation; conversely, 29
  5. 5. The physical manifestations M. A. Mraz innocent caregivers are convicted for the very same rea- traumatic brain injury in infancy. Pediatrics, 116(2), sons. It is for these reasons that documentation on all ac- 174–185. counts is essential. Bechtel, K., Stoessel, K., Leventhal, J., Ogle, E., Teague, B., Lavietes, S., Banyas, B., Allen, K., Dziura, J., & Duncan, C. Prevention (2004). Characteristics that distinguish accidental from abusive injury in hospitalized young children with head In a research study conducted by Kemp and Coles (2003), trauma. Pediatrics, 114(1), 165–168. 60% of all child abuse cases have presented to the hospi- Bonnier, C., Mesples, B., & Gressens, P. (2004). Animal tal or doctors office prior to sustaining admitable injury. models of shaken baby syndrome: Revisiting the This reflects a clear need for child abuse prevention ser- pathophysiology of this devastating injury. Pediatric vices within the healthcare system. Forensic nurses must Rehabilitation, 7(3), 165–171. focus on primary prevention. This could include seminars Evans, H. (2004). The medical discovery of shaken baby for daycare providers, classes for new parents as well as syndrome and child physical abuse. Pediatric Rehabilitation, foster parents, and interventions for vulnerable popula- 7(3), 161–163. tions such as adolescent parents. Finally, forensic nurses Geddes, J., & Plunkett, J. (2004). The evidence base for must lobby for more stringent federal guidelines regard- shaken baby syndrome. British Journal of Medicine, ing abuse prevention. It is not enough to give a pamphlet 328(7451), 719–720. Herr, S. (2004). Does valsalva retinopathy occur in infants? to a new mother hours after her child is born, when the An initial investigation in infants with vomiting caused by post-partum nurses are still caring for the baby. This is pyloric stenosis. Pediatrics, 113(6), 1733–1734. the federally accepted form of prevention for SBS today. Keenan, H., Runyan, D., Marshall, S., Nocera, M., & Merten, There should be discussions during prenatal visits and D. (2004). A population based comparison of clinical and prenatal classes. Also, there should be discussion during outcome characteristics of young children with serious the post-partum period as well as prevention discussion inflicted and noninflicted brain injury. Pediatrics, 114(3), during well baby home health visits. Education on SBS 633–639. should be available at pediatricians’ offices and clinics Kemp, A., & Coles, L. (2003). The role of health professionals as well. in preventing non-accidental head injury. Child Abuse Review, 12(6), 374–383. Conclusion King, W., MacKay, M., & Sirnick, A. (2003). Shaken baby syndrome in Canada: Clinical characteristics and outcomes SBS is a form of abuse ever prevalent in today’s society. of hospital cases. Canadian Medical Association Journal, Additionally, it is a syndrome that is 100% preventable. 168(2), 155–159. Forensic nurses are dedicated to the eradication of abuse Lo, T., McPhillips, M., Minns, A., & Gibson, R. (2003). as well as advocacy for the vulnerable. A helpless child Cerebral atrophy following shaken impact syndrome and is amongst one of the most vulnerable populations. SBS other non-accidental head injury. Pediatric Rehabilitation, can occur secondary to frustration or sheer ignorance. 6(1), 47–55. Regardless of the pre-existing conditions, forensic nurses Miehl, N. (2005). Shaken baby syndrome. Journal of Forensic should understand the history of SBS and the physical Nursing, 1(3), 111–117. manifestations that may be caused by shaking. Forensic Ogershok, P., Jaynes, M., & Hogg, J. (2001). Delayed nurses should educate medical staff on the physical man- papilledema and hydrocephalus associated with shaking ifestations that can ensue from SBS, educate parents on impact syndrome. Clinical Pediatrics, 40(6), 351–354. the effects shaking can have on their child, and continue Orient, J. (2005). Reflections on shaken baby syndrome: A research and investigation into the various injuries that case report. Journal of American Physicians and Surgeons, are caused by shaking a baby. 10(2), 45–50. Smith, J. (2003). Shaken baby syndrome. Orthopaedic Nursing, 22(3), 196–203. References Uscinski, R. (2002). Shaken baby syndrome, fundamental Asamura, H., Yamazaki, K., Mukai, T., Ito, M., Takayanagi, questions. British Journal of Neurosurgery, 16(3), 217–219. K., Ota, M., & Fukushima, H. (2003). Case of shaken baby Wolfson, D., McNally, D., Clifford, M., & Vloeberghs, M. syndrome in Japan caused by shaking alone. Pediatrics (2005). Rigid body modelling of shaken baby syndrome. International, 45(1), 117–119. Journal of Engineering in Medicine, 219(1), 63–70. Barlow, K., Thomson, E., Johnson, D., & Minns, R. (2005). Zenel, J., & Goldstein, B. (2002). Child abuse in the pediatric Late neurologic and cognitive sequelae of inflicted intensive care unit. Critical Care Medicine, 30(11), 515–523. 30

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