The physical manifestations of shaken baby syndrome can include: 1) Internal injuries like cerebral edema, retinal and cerebral hemorrhaging, bone fractures both old and new, cerebral atrophy, hydrocephalus, and cervical spine injury despite a lack of external injuries. 2) Hallmark symptoms include lack of external injury, bradypnea or apnea, changes in level of consciousness, bradycardia, bulging fontanels, and seizure activity. 3) Common physical findings that can help diagnose shaken baby syndrome include retinal hemorrhages present in 75% of cases, hematomas which are the most common injury, and cerebral atrophy found in over 90% of suspected intentional injury cases. Accurate

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. 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. 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. 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. 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.
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K., Ota, M., & Fukushima, H. (2003). Case of shaken baby Wolfson, D., McNally, D., Clifford, M., & Vloeberghs, M.
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Barlow, K., Thomson, E., Johnson, D., & Minns, R. (2005). Zenel, J., & Goldstein, B. (2002). Child abuse in the pediatric
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30