Sunday, December 28, 2008

Well, it being the season to look over the year past and compile lists, I visited to see what a search for "shaken baby" and 2008 would find.

Of 68 articles and letters in their database, I found the 26 (ranked in publication order) of interest:

1: J Emerg Med. 2008 Dec 10.
Retinal hemorrhages and shaken baby syndrome: An evidence-based review.
Togioka BM, Arnold MA, Bathurst MA, Ziegfeld SM, Nabaweesi R, Colombani PM, Chang DC, Abdullah F.
Center for Pediatric Surgical Trials and Outcomes Research, Division of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: Among the causes of non-accidental head injury (NAHI), shaken baby syndrome (SBS) is difficult to diagnose and is associated with retinal hemorrhages (RH). Description: To identify findings and patterns of RH specific to SBS, a PubMed search using the keywords "shaken baby syndrome" or "child abuse" and "retinal hemorrhage" was conducted; 66 articles met the inclusion criteria. The published data address the utility of RH in three categories: 1) in diagnosing SBS; 2) as correlated to intracranial pathology; and 3) in prognosticating SBS. The present review aimed to summarize studies in a way that facilitates clinical decision-making.
RESULTS: Studies found a 53-80% incidence of RH with abusive head injury and a 0-10% incidence with proven severe accidental trauma. RHs are found bilaterally 62.5-100% of the time in SBS cases, and flame-shaped hemorrhages are the most common. The incidence of RH from convulsions, chest compressions, forceful vomiting, and severe persistent coughing in the absence of another condition known to cause RH is 0.7%, 0-2.3%, 0%, and 0%, respectively.
CONCLUSION: SBS remains a difficult cause of NAHI to diagnose. Ophthalmologic examination can provide critical diagnostic and prognostic information in cases of suspected SBS. Child abuse should be highly suspect in children with RH and a parental explanation of accidental head injury, especially if the RHs are found to be bilateral, flame-shaped, or to extend through to all layers of the retina.
Related Articles
Postmortem orbital findings in shaken baby syndrome. [Am J Ophthalmol. 2006]
Correlation between retinal abnormalities and intracranial abnormalities in
the shaken baby syndrome. [Am J Ophthalmol. 2002]
Findings in older children with abusive head injury: does shaken-child syndrome exist? [Pediatrics. 2006]
Review Shaken baby syndrome. [Crit Care Nurs Q. 2000]
Review Shaken baby syndrome: identification, intervention, and prevention. [Clin Excell Nurse
Pract. 1999]

2: Graefes Arch Clin Exp Ophthalmol. 2008 Dec 4.
A finite element infant eye model to investigate retinal forces in shaken baby syndrome.
Hans SA, Bawab SY, Woodhouse ML.
Department of Mechanical Engineering, Old Dominion University, 238 Kaufman Hall, Norfolk, VA, 23529-0247, USA,

BACKGROUND: Shaken baby syndrome (SBS) is a form of abuse in which an infant, typically 6 months or less, is held and submitted to repeated acceleration-deceleration forces. One of the indicators of abuse is bilateral retinal hemorrhaging. A computational model of an infant eye, using the finite element method, is built in order to assess forces at the posterior retina for a shaking and an impact motions.
METHOD: The eye model is based on histological studies, diagrams, and materials from previous literature. Motions are applied to the model to simulate a four-cycle shaking motion in 1 second with maximum extension/flexion of the neck. The retinal forces of the shaking motion, at the posterior eye, are compared to an impact pulse (60G) simulating a fall for a total duration of 100 ms.
RESULTS: The shaking motion, for the first cycle, shows retinal force means at the posterior eye to be around 0.08 N sustained from the time range of 50 to 200 ms, into the shake, with a peak in excess of 0.2 N. The impulse, area under the curve, is 15 N-ms for 250 msec for the first cycle. The impact simulation reveals a mean retinal force around 0.025 N for a time range of 0 to 26 ms, with a peak force around 0.11 N. Moreover, the impulse for the impact simulation is 13 times lower than the shaking motion.
CONCLUSION: The results suggest that shaking alone may be enough to cause retinal hemorrhaging, as there are more sustained and higher forces in the posterior retina, compared to an impact due to a fall. This is in part due to the optic nerve causing more localized stresses in a shaking motion than an impact.
Related Articles
Can shaking alone cause fatal brain injury? A biomechanical assessment of the Duhaime shaken baby syndrome model. [Med Sci Law. 2003]
Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome. [Am J Ophthalmol. 2002]
Review Update on shaken baby syndrome: ophthalmology. [Curr Opin Ophthalmol. 2007] Review Shaken baby syndrome. [Postgrad Med J. 2002]

3: J Dev Behav Pediatr. 2008 Dec;29(6):508-11.
Getting the word out: advice on crying and colic in popular parenting magazines.
Catherine NL, Ko JJ, Barr RG.
Centre for Community Child Health Research, Child and Family Research Institute, Vancouver, BC, Canada.

The objective of this study is to determine whether advice in parenting magazines reflects current evidence-based understanding of early infant crying and colic, where (1) "colic" is the upper end of a spectrum of crying behavior reflective of normal infant development, and (2) physical abuse--in particular, shaken baby syndrome (SBS)--is a serious medical consequence of early crying. All available issues of 11 popular Canadian parenting magazines published between January 2000 and December 2004 were hand-searched and systematically reviewed. Fifty-one articles were found with information on: (1) causes of, (2) responses to, and/or (3) mention of SBS or abuse as a consequence of crying and/or colic. There were 105 specific causes suggested, but almost no agreement concerning the causes of crying and colic. Similarly, there were 231 specific responses to crying and colic mentioned, but little agreement among the suggested responses. For both crying and colic together, the consequence of abuse was mentioned only 7 times, and SBS only twice. Making the advice literature a truly helpful vehicle for parents concerning normal behavioral development and its consequences for their new infant seems to be a significant challenge. Arguably, this is an important shared responsibility of physicians, researchers, and journalists.
Related Articles
Age-related incidence curve of hospitalized Shaken Baby Syndrome cases: convergent evidence for crying as a trigger to shaking. [Child Abuse Negl. 2006]
Differential calming responses to sucrose taste in crying infants with and without colic. [Pediatrics. 1999]
ReviewInfantile colic. [Am Fam Physician. 2004]
Age-related incidence of publicly reported shaken baby syndrome cases: is crying a trigger for shaking? [J Dev Behav Pediatr. 2007]

4: Child Abuse Negl. 2008 Nov;32(11):1017-25.
Secondary analysis of the "Love Me...Never Shake Me" SBS education program.
Deyo G, Skybo T, Carroll A.
College of Nursing, The Ohio State University, Columbus, OH, USA.

OBJECTIVE: Shaken baby syndrome (SBS) is preventable; however, an estimated 21-74 per 100,000 children worldwide are victims annually. This study examined the effectiveness of an SBS prevention program in the US.
METHODS: A descriptive, secondary analysis of the Prevent Child Abuse Ohio (PCAO) "Love Me...Never Shake Me" SBS education program database included 7,051 women who completed a commitment statement, pre and post-test, and follow-up survey.
RESULTS: Participants were mostly White (76%), had at least some college education (62%), were privately insured (62%), and lived with the father and infant (63%). Mothers knew of the dangers of shaking (96%) and recommended SBS education for all parents (98%) because they found it helpful (97%). Scores on the pre and post-tests were significantly different, but there was no difference based on education site or demographics. There was a significant increase in a pre/post-test item pertaining to infant crying. At follow-up, participants remembered postpartum SBS education (98%), but post-discharge did not receive SBS education from their primary care provider (62%). Most mothers practiced infant soothing techniques (79%) provided in the education; however, few women practiced self-coping techniques (36%) and accessed community support services (9%).
CONCLUSIONS: Postpartum SBS prevention education should continue. Development of SBS programs should result from these study findings focusing on education content and program evaluation.
PRACTICE IMPLICATIONS: Mothers report that shaken baby syndrome education is important for all parents and memorable at follow-up. Postpartum SBS education should continue because the hospital is the primary place they receive education. Mothers' report they less frequently receive education from healthcare sources post-discharge. Diligence of primary care providers to incorporate SBS prevention education in well child visits will increase parental exposure to this information. Education may need to place greater emphasis on infant crying and soothing, as well as parent support and self-coping techniques versus the dangers of shaking.

Related Articles
Preventing abusive head trauma among infants and young
children: a hospital-based, parent education program. [Pediatrics. 2005]
Creating opportunities for parent empowerment: program effects on the mental
health/coping outcomes of critically ill young children and their mothers.
[Pediatrics. 2004]
Review Shaken baby syndrome: identification, intervention, and
prevention. [Clin Excell Nurse Pract. 1999]

5: MCN Am J Matern Child Nurs. 2008 Nov-Dec;33(6):371-5.
Shaken baby syndrome education program: nurses making a difference.
Smith KM, deGuehery KA.
Shaken Baby Syndrome Education Program, Kaleida Health Women and Children's Hospital of Buffalo, Buffalo, NY, USA.

This article describes the nursing role in the Upstate New York Shaken Baby Syndrome (SBS) Education Program, an effort to educate parents of all hospital-born infants in the eight-county region of Western New York about the dangers of violent infant shaking. This program has now been expanded to include hospitals in 17 counties in Upstate New York. The major intervention is an educational program administered by nurses. These nurses describe the challenges and opportunities they faced in implementing a large community health program.
Related Articles
Preventing abusive head trauma among infants and young children: a hospital-based, parent education program. [Pediatrics. 2005]
Review Understanding shaken baby syndrome. [Adv Neonatal Care. 2004]
Review Shaken baby syndrome: identification, intervention, and prevention. [Clin Excell Nurse Pract. 1999]
6: W V Med J. 2008 Nov-Dec;104(6):22-3.
Testing educational strategies for Shaken Baby Syndrome.
Bailey M, Gress T, Bolden D, Pfitzer L.
Marshall University School of Medicine, Department of Pediatrics, Huntington, USA.

Shaken Baby Syndrome (SBS) occurs from the violent shaking of an infant, which may lead to brain damage or death. The goal of this study was to assess educational methods used to teach new mothers about SBS.
METHODS: Forty six parents at a community hospital were selected and randomly divided into three groups. Group 1 received a short lesson about SBS. Group 2 received the lesson and watched a locally developed SBS video. Group 3 received the lesson and watched a true dramatization of SBS created by a national organization. Pre and post surveys were administered.
RESULTS: Study groups were similar in regard to age, marital status, socioeconomic status and education. Group 1 parents showed no differences in scoring. Group 2 parents showed a significant increase in defining SBS and what to do for persistent infant crying. Group 3 parents scored significantly higher in defining SBS. CONCLUSION: Both video presentations improved scoring on understanding SBS but only the local video presentation increased scores in the management of persistent infant crying.
Related Articles
Shaken baby syndrome and a baby's cry. [Acta Paediatr. 2008]
Age-related incidence curve of hospitalized Shaken Baby Syndrome cases: convergent evidence for crying as a trigger to shaking. [Child Abuse Negl. 2006]
Review Understanding shaken baby syndrome. [Adv Neonatal Care. 2004]
Review Shaken baby syndrome: identification, intervention, and prevention. [Clin Excell Nurse Pract. 1999]

7: Child Abuse Negl. 2008 Oct;32(10):949-57.
Intervention type matters in primary prevention of abusive head injury: event history analysis results.
Russell BS, Trudeau J, Britner PA.
Worcester State College, Department of Psychology, Worcester, MA 01602, USA.

PURPOSE: The current study sought to compare interventional materials intended to raise public awareness of the caregiving practices connected to Shaken Baby Syndrome (SBS). Two hundred and sixty four adults (mean age 32 years) were recruited for participation through convenience sampling at a large Northeastern university. Participants fell into two groups-those who regularly cared for children (46%) and those who did not (54%).
METHODS: SBS awareness was surveyed prior to an educational intervention and at three times points (2, 6, and 12 weeks post-intervention) longitudinally. Three intervention levels were used: Two different video conditions, each with an informational brochure, and the brochure-only condition. Survey responses were combined into five factor scores. Changes in factor score over time were modeled using event history analysis to predict the conditional probability of change in awareness as a discreet event.
RESULTS: The resulting models show consistent results for three of the five factors, predicting the highest likelihood of increased awareness for a teaching video intervention, followed by a testimonial video, and the lowest probability for increased awareness for the use of an intervention using only a brochure. Negative change, or decreased awareness, was not predicted by the type of intervention materials. Demographic variables were not significant predictors of either positive or negative change.
CONCLUSION: The results indicate that the addition of video materials, and in particular material focusing on teaching alternative behaviors, significantly increases the likelihood of positive changes in SBS awareness over interventions which use only a brochure.
IMPLICATIONS FOR PRACTICE OR RESEARCH: The present study uses a two by three design to describe levels of improved awareness of Shaken Baby Syndrome across two groups of participants (those who regularly care for children and those who do not) and type of educational material (a brochure versus two different videos each in combination with the brochure). Results show a differential effect for each intervention level, and indicate a need for careful selection of educational materials for intervention programs concerned with preventing SBS through public awareness.
Related Articles
A family-based approach to the prevention of depressive symptoms in children at risk: evidence of parental and child change. [Pediatrics. 2003]
Review Psychological and/or educational interventions for the prevention of depression in children and adolescents. [Cochrane Database Syst Rev. 2004]

8: Med Sci Law. 2008 Oct;48(4):346-9
Cervical soft tissue lesions in the shaken infant syndrome: a case report.
Porzionato A, Macchi V, Aprile A, De Caro R.
Section of Anatomy, Department of Human Anatomy and Physiology, University of Padova, Italy.

Cervical soft tissue lesions have rarely been described in the shaken baby syndrome; they include ruptures of intervertebral discs and haemorrhages in the ligamenta flava, and in the interspinal and sternocleidomastoid muscles. We present here the autopsy case of a 30-month old girl who suffered an assault with multiple injury mechanisms, i.e., beating, sexual abuse and shaking trauma. External examination of the neck did not reveal bruises or excoriations, but cervical dissection showed haemorrhagic infiltration of the clavicular head of the sternocleidomastoid muscle, carotid region, posterior musculature of the pharynx and oesophagus, and retro-pharyngeal/oesophageal spaces. These findings were ascribed to the repeated violent movements of shaking trauma. The case presented confirms the occurrence of cervical soft tissue lesions in the shaken baby syndrome and reports injuries which have not previously been described. In suspected cases of shaken baby syndrome, particular attention must be paid to the examination of cervical soft tissue structures.
Related Articles
Incidence of impact trauma with cranial injuries ascribed to shaking. [Am J Dis Child. 1990]
Optic nerve damage in shaken baby syndrome: detection by beta-amyloid precursor protein immunohistochemistry. [Arch Pathol Lab Med. 2000]
Review Anatomy of the shaken baby syndrome. [Anat Rec. 1998]
Review Fall or shaken: traumatic brain injury in children caused by falls or abuse at home - a review on biomechanics and diagnosis. [Neuropediatrics. 2005]

9: Acta Neuropathol. 2008 Sep;116(3):317-29. Epub 2008 Mar 26.
Shaken baby syndrome: re-examination of diffuse axonal injury as cause of death.
Oehmichen M, Schleiss D, Pedal I, Saternus KS, Gerling I, Meissner C.
Institute of Legal Medicine, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany.

The discussion surrounding shaken baby syndrome (SBS) arose from the lack of evidence implicating diffuse axonal injury (DAI) as a cause of death. It was assumed instead that injury to the cervical cord, medulla, and nerve roots played a causal role. The present pathomorphological study examines 18 selected infants (<1-year-old)>
Related Articles
Postmortem orbital findings in shaken baby syndrome. [Am J Ophthalmol. 2006]
Axonal injury and the neuropathology of shaken baby syndrome. [Acta Neuropathol. 1998]
Findings in older children with abusive head injury: does shaken-child syndrome exist? [Pediatrics. 2006]
Review Shaken baby syndrome: the quest for evidence. [Dev Med Child Neurol. 2008]
Review Shaken baby syndrome. [Crit Care Nurs Q. 2000]

10: Acta Paediatr. 2008 Jun;97(6):782-5
Shaken baby syndrome and a baby's cry.
Talvik I, Alexander RC, Talvik T.
Children's Clinic of Tartu University Hospital, Tartu, Estonia.

The aim of this study was to investigate the relationship between crying of an infant and inflicted head injury by shaking and/or impact. During the period between January 1, 1997 and December 31, 2003, 26 cases of shaken baby syndrome (SBS) were identified in Estonia. The incidence of SBS was 28.7 per 100,000 children under 1 year of age during the whole study period. In this group there were four children from twin pairs: two twin boys and a girl from a twin pair and a boy from another twin pair. This represents 15.4% of the 26 cases. Twins in Estonia represent 2.12% of infant births. The mean age on admission was 3.9 months. According to outpatient records almost all parents (88.5%) in the study group (23/26) had contacted their family physicians and other specialists because of excessive crying or irritability of the baby prior to the admission to the hospital with SBS or death. We found that the time curve of crying was similar to the curve of highest incidence of cases of SBS except the crying curve began earlier.
CONCLUSION. Our data confirm that the families with twins are at additional risk for SBS and parent's complaints of excessive crying of their infants should be taken as signal that parents need to be carefully counselled.
Related Articles
Age-related incidence curve of hospitalized Shaken Baby Syndrome cases: convergent evidence for crying as a trigger to shaking. [Child Abuse Negl. 2006]
Age-related incidence of publicly reported shaken baby syndrome cases: is crying a trigger for shaking? [J Dev Behav Pediatr. 2007] Inflicted traumatic brain injury (ITBI) or shaken baby syndrome (SBS) in Estonia. [Acta Paediatr. 2006]
Review Shaken baby syndrome education: a role for nurse practitioners working with families of small children. [J Pediatr Health Care. 2006]
Review Understanding shaken baby syndrome. [Adv Neonatal Care. 2004]
11: Nurs Womens Health. 2008 Jun;12(3):235-9.
Shaken baby syndrome: facts, education, and advocacy.
Lewin L.
Case Western Reserve University, Frances Payne Bolton School of Nursing, Cleveland, OH, USA.
Related Articles
Review Shaken baby syndrome. [J Perinat Neonatal Nurs. 2008]
Shaken baby syndrome: assessment, intervention, & prevention. [J Psychosoc Nurs Ment Health Serv. 2004] ReviewShaken baby syndrome. [Crit Care Nurs Clin North Am. 2006] Myths and facts...About shaken baby syndrome. [Nursing. 2008]
12: Eye. 2008 May;22(5):715-7. Epub 2008 Feb 8.
Natural animal shaking: a model for non-accidental head injury in children?
Serbanescu I, Brown SM, Ramsay D, Levin AV.
Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, Ontaria, Canada.

BACKGROUND: Non-accidental head injury (NAHI) is a form of child abuse where a perpetrator may violently subject an infant to repeated acceleration-deceleration forces with or without head impact, producing injuries including retinal haemorrhages in most cases. Animal models have included laboratory shaking of mice and rats, but only a small fraction develop retinal haemorrhages presumably due to the small eyes, which would require unattainable force levels to mimic that sustained by the infant eye. Animal models are also problematic due to ethical issues raised by subjecting even anaesthetized animals to abusive injury.
METHODS: We investigated a naturally occurring event, where three animal victims were shaken by a canine. The eyes were harvested and examined histologically. RESULTS: The victims' eyes showed no haemorrhage or retinoschisis.
CONCLUSIONS: Our model may not be a complete NAHI mimic. The discrepancies may ensue from anatomical and mechanical differences in the injury mechanism. Other models must be sought to further study this form of abusive eye injury.
Related Articles
Postmortem orbital findings in shaken baby syndrome. [Am J Ophthalmol. 2006]
Findings in older children with abusive head injury: does shaken-child syndrome exist? [Pediatrics. 2006]
Perpetrator accounts in infant abusive head trauma brought about by a shaking event. [Child Abuse Negl. 2005]
Review Non-accidental head injury--the evidence. [Pediatr Radiol. 2008]
13: Am J Prev Med. 2008 Apr;34(4 Suppl):S143-7
Evaluating the epidemiology of inflicted traumatic brain injury in infants of U.S. military families.
Ryan MA, Lloyd DW, Conlin AM, Gumbs GR, Keenan HT.
Department of Defense Center for Deployment Health Research, Naval Health Research Center, San Diego, California 92106, USA.

BACKGROUND: Evaluating the incidence of inflicted traumatic brain injuries (inflicted TBI) in young children, and encompassing shaken baby syndrome (SBS) and related injuries, is an epidemiologic challenge. Data available regarding military families in the U.S. may complement other national surveillance efforts.
METHODS: A protocol was developed to assess the epidemiology of inflicted TBI among infants of U.S. military families, integrating data from the Department of Defense Birth and Infant Health Registry, healthcare utilization databases, child abuse reporting systems, and military personnel databases. The in-progress protocol, and its inherent strengths and limitations, are described here.
DISCUSSION: The primary strengths of data from U.S. military families are related to the full characterization of the denominator, such that analyses are person-time and population based. Unique data are available to describe the full population of military parents, including occupational, geographic, and socioeconomic factors, as well as deployment-related potential stressors. The limitations of military data are similar to many other child abuse surveillance systems in that cases are underreported and not fully characterized. Linking abuse reports and medical utilization data to population data, however, will allow unique analyses of "probable" and "possible" cases of inflicted TBI in infants of military families.
CONCLUSIONS: Data from the U.S. military, when appropriately linked and analyzed, provide opportunities to evaluate important risk factors for inflicted TBI in infants. Although epidemiologic challenges may make incidence rates using military data noncomparable to rates using other data sources, multivariate analyses can evaluate critical and unique risk factors, as well as the effectiveness of prevention initiatives.

Related Articles
Review The epidemiology of traumatic brain
injury: a review. [Epilepsia. 2003] Surveillance for traumatic brain injury deaths--United States, 1989-1998. [MMWR Surveill Summ. 2002]

14: Am J Prev Med. 2008 Apr;34(4 Suppl):S134-9
Passive surveillance of shaken baby syndrome using hospital inpatient data.
Wirtz SJ, Trent RB.
Epidemiology and Prevention for Injury Control Branch, California Department of Public Health, Sacramento, California 95899-7377, USA.

BACKGROUND: The conference from which these articles came addressed the question of public health surveillance for shaken baby syndrome (SBS) and explores one component of a comprehensive SBS surveillance system that would be relatively easy to implement and maintain: passive surveillance based on hospital inpatient data. Provisional exclusion and inclusion criteria are proposed for a two-level case definition of diagnosed SBS (strict definition) and cases presumed to be SBS (broad definition). The strict SBS definition is based on the single SBS code in the ICD-9-CM (995.55). The broader presumptive SBS definition is based on research studies that have identified a pattern of diagnostic codes often considered part of the clinical diagnosis of SBS.
RESULTS: Based on 2006 analyses, California inpatient data are presented for 1998-2004. The strict SBS definition identified 366 cases over the 7 years, whereas the broader definition captured nearly 1000 cases. Annual rates show little fluctuation from the overall rate of 5.1 for strict SBS and 14.0 for broad SBS (per 100,000 children aged
Related Articles
Age-related incidence curve of hospitalized Shaken Baby
Syndrome cases: convergent evidence for crying as a trigger to shaking. [Child
Abuse Negl. 2006]

15: Am J Prev Med. 2008 Apr;34(4 Suppl):S126-33
Incidence and demography of non-accidental head injury in southeast Scotland from a national database.
Minns RA, Jones PA, Mok JY.
Department of Child Life and Health, University of Edinburgh, Edinburgh, Scotland, United Kingdom.

BACKGROUND: This study utilized an existing national database of cases of non-accidental head injury (NAHI; also called inflicted traumatic brain injury [inflicted TBI] and shaken baby syndrome [SBS]) in Scotland to report the incidence, confidence intervals, and demography of such cases in Southeast Scotland.
METHODS: This prospective population-based study was conducted from January 1998 to September 2006. Data from the Lothian region of Scotland, where there is known full ascertainment of infant head injuries, including NAHI, have been used to calculate the incidence rate for this region of Scotland, with government statistics providing the normal annual infant population as the denominator. A new Scottish Index of Multiple Deprivation (SIMD), which assesses a very focused area (data zone population size=750) and provides novel information about social demography for education, housing, employment, health, crime, income, and geographic accessibility to services, was applied to the identified cases of NAHI during this study period. RESULTS: The mean incidence of NAHI in southeast Scotland for 8.75 years was 33.8/100,000 infants per year. The cases of NAHI were mostly located in the lowest 1 (or 2) quintiles for all SIMD domains (education, housing, employment, health, crime, income), although they had good accessibility to medical and other community services.
CONCLUSIONS: The incidence rates from this prospective study for NAHI are considerably higher than other published UK surveys and are not considered to reflect a cluster effect. The perpetrators in this study fit a strongly skewed profile aggregating to the lowest socioeconomic groups in the community.
Related Articles
A retrospective epidemiological analysis of non-accidental
head injury in children in Scotland over a 15 year period. [Scott Med J. 1998]
Annual incidence of shaken impact syndrome in young children. [Lancet. 2000]

16: Am J Prev Med. 2008 Apr;34(4 Suppl):S116-9
What are we trying to measure? The problems of case ascertainment.
Reece RM.
Department of Pediatrics, Tufts University School of Medicine, Boston, Massachusetts 02556, USA.

To determine the incidence of a particular phenomenon, one has to know how that phenomenon is defined. The term "shaken baby syndrome" (SBS) came into general usage in the 1980s, followed by shaken impact syndrome (SIS), inflicted childhood neurotrauma, abusive head trauma (AHT), inflicted traumatic brain injury (inflicted TBI), non-accidental head injury (NAHI), and others. Several means of defining this clinical syndrome have been suggested. Keenan has proposed a research definition. Minns has offered a pure clinical definition, and Livingston and Childs suggest a definition that combines the clinical and radiologic features with the history of events leading to the condition. By using these definitions, eight articles describing SBS, published in the last 20 years, were analyzed for these characteristics. A definition of shaken baby syndrome reflecting the common themes in these clinical reports is offered.
Related Articles
Postmortem orbital findings in shaken baby syndrome. [Am J Ophthalmol. 2006]
17: Am J Prev Med. 2008 Apr;34(4 Suppl):S112-5
The challenges of assessing the incidence of inflicted traumatic brain injury: a world perspective.
Runyan DK.
Department of Social Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7240, USA.

OBJECTIVE: Commentary on the methods available for ascertaining the incidence of inflicted traumatic brain injury (inflicted TBI) and the difficulties involved in defining and measuring this condition in young children.
DESIGN: Review of published and unpublished international data regarding parental shaking of infants compared to studies assessing incidence.
RESULTS: Review of parental report data reveal that the shaking of young children is a surprisingly common act in a wide variety of countries and cultures. While 2.6% of parents of children aged under 2 years in the U.S. report shaking their child as an act of "discipline," survey data from lesser-developed countries on four continents indicate that shaking, as a form of discipline, may be many times more common among infants in their countries and that the consequences, short of hospitalization or death, are inadequately studied. Methodologic challenges to epidemiologic work to develop better estimates are discussed.
CONCLUSIONS: These data highlight the challenges faced in ascertaining the epidemiology of inflicted TBI in young children. While there is scientific evidence that the shaking of young children can produce profound destruction of children's brains and lives, these data reveal that there are many other children who are shaken by their caregivers but escape the acute clinical presentation of "shaken baby syndrome" or for whom the injuries are not recognized as due to inflicted TBI. The impact of these private acts must be further studied as there may be other long-lasting and serious intracranial impacts that have not been characterized.

Related Articles
A population-based study of inflicted traumatic brain injury in young children. [JAMA. 2003]
Analysis of perpetrator admissions to inflicted traumatic brain injury in children. [Arch Pediatr Adolesc Med. 2004]
Review Biochemical markers of brain injury: could they be used as diagnostic adjuncts in cases of inflicted traumatic brain injury? [Child Abuse Negl. 2004]
Review Rehabilitation of persons with traumatic brain injury. [NIH Consens Statement. 1998]
18: Am J Prev Med. 2008 Apr;34(4 Suppl):S103-5
Epidemiology the major missing element in the global response to child maltreatment?
Butchart A.
Department of Injuries and Violence Prevention, Noncommunicable Diseases, and Mental Health, World Health Organization, Geneva, Switzerland.
Related Articles
Review Update on child maltreatment with a special focus on shaken baby syndrome. [Curr Opin Pediatr. 2005]
How to recognize shaken baby syndrome (SBS). [J Okla State Med Assoc. 2004]
Shaken baby syndrome: assessment, intervention, & prevention. [J Psychosoc Nurs Ment Health Serv. 2004]
Review Update on child maltreatment. [Curr Opin Pediatr. 2008]
19: ANS Adv Nurs Sci. 2008 Apr-Jun;31(2):E1-8
Inflicted childhood neurotrauma.
Fiske EA, Hall JM.
Carson-Newman College, Jefferson City, Tennessee 37760, USA.

In this article, we review literature related to inflicted childhood neurotrauma (ICN). We discuss the rationale for use of the term "ICN," rather than the more benign, commonly used "shaken baby syndrome." The change in language alters the discourse about a potentially lethal outcome or lifelong problem for survivors. A description of ICN is followed by a discussion of ethical parameters and obligations of those who care for infants and children and professionals who are sentinels to these events such as law enforcement officials, nurses, physicians, and social workers.
Related Articles
Shaken baby syndrome: assessment, intervention, & prevention. [J Psychosoc Nurs Ment Health Serv. 2004]
20: Biomech Model Mechanobiol. 2008 Apr;7(2):105-25. Epub 2007 Mar 2
Infant brain subjected to oscillatory loading: material differentiation, properties, and interface conditions.
Couper Z, Albermani F.
School of Engineering, University of Queensland, Brisbane 4072, Australia.

Past research into brain injury biomechanics has focussed on short duration impulsive events as opposed to the oscillatory loadings associated with Shaken Baby Syndrome (SBS). A series of 2D finite element models of an axial slice of the infant head were created to provide qualitative information on the behaviour of the brain during shaking. The test series explored variations in subarachnoid cerebrospinal fluid (CSF) representation, brain matter stiffness, dissipation, and nonlinearity, and differentiation of brain matter type. A new method of CSF modelling based on Reynolds lubrication theory was included to provide a more realistic brain-CSF interaction. The results indicate that solid CSF representation for this load regime misrepresents the phase lag of displacement, and that the volume of subarachnoid CSF, and inclusion of thickness variations due to gyri, are important to the resultant behavior. Stress concentrations in the deep brain are reduced by fluid redistribution and gyral contact, while inclusion of the pia mater significantly reduces cortex contact strains. These results provide direction for future modelling of SBS.
Related Articles
Rigid-body modelling of shaken baby syndrome. [Proc Inst Mech Eng [H]. 2005]
Can shaking alone cause fatal brain injury? A biomechanical assessment of the Duhaime shaken baby syndrome model. [Med Sci Law. 2003]
Shaken baby syndrome: a biomechanics analysis of injury mechanisms. [Forensic Sci Int. 2005]
Review Case analysis of brain-injured admittedly shaken infants: 54 cases, 1969-2001 [Am J Forensic Med Pathol. 2005]
21: Curr Opin Pediatr. 2008 Apr;20(2):205-12
Update on child maltreatment.
Newton AW, Vandeven AM.
Department of Pediatrics, Harvard Medical School, Child Protection Program, Children's Hospital, Child Protection Consultation Program, Massachusetts General Hospital, Boston, Massachusetts 02115, USA.

PURPOSE OF REVIEW: The authors discuss the significance of studies published over the previous year regarding assessment and treatment and prevention of child maltreatment, including physical and sexual abuse, inflicted traumatic brain injury, and child neglect.
RECENT FINDINGS: The evidence base for many forms of child abuse is growing. As clinicians begin to understand the factors which may increase child vulnerability to abuse, more sophisticated and focused prevention efforts are being implemented. In response to a very public reprimand by the General Medical Council of two child abuse pediatricians, which was felt by many to be unwarranted, the UK government re-emphasized its commitment to the protection of children. In the US, this well-publicized set of events has renewed the medical community's commitment to the recognition of child abuse pediatrics as a formal subspecialty. Several authors detail the short-term and long-term outcome of varying forms of abuse for children as they grow into adults, reinforcing the importance of community efforts to prevent abuse and support families during times of heightened stress such as the current war in Iraq.
SUMMARY: The short-term and long-term impact of child maltreatment is significant not only for individuals, but for families and communities where abuse is taking place. General pediatricians have an important role to play with families and in the community as advocates for the protection of children.
Related Articles
Review Update on child maltreatment. [Curr Opin Pediatr. 2007]
Review Update on child maltreatment with a special focus on shaken baby syndrome. [Curr Opin Pediatr. 2005]
Family pediatrics: report of the Task Force on the Family. [Pediatrics. 2003] Preventive health care, 2000 update: prevention of child maltreatment. [CMAJ. 2000] Review An update on child abuse and neglect. [Curr Opin Pediatr. 2004]
22: Child Abuse Negl. 2008 Mar;32(3):415-28
Comparative study of the cognitive sequelae of school-aged victims of Shaken Baby Syndrome.
Stipanicic A, Nolin P, Fortin G, Gobeil MF.
Department of Psychology, University of Quebec at Trois-Rivières, Child and Family Development Research Unit, Quebec, Canada.

OBJECTIVE: Shaken Baby Syndrome (SBS) is now recognized as being the main cause of severe traumatic brain injury in infancy. However, our understanding of the impact of this type of abuse on child development remains sketchy. The main objective of the current study was therefore to shed light on the cognitive dysfunctions that are particular to SBS victims once they are school-aged.
METHOD: A clinical group was formed of 11 children diagnosed with SBS who had been admitted between 1988 and 1999 to a tertiary pediatric hospital in Quebec, Canada. The children were matched for age, gender, socio-economic status, and family composition to 11 healthy Quebec children, who made up the control group. A battery of composite tests was developed to assess the children's main cognitive functions and was administered individually to the 22 children. A univariate t-test was used to compare the performances of the two groups.
RESULTS: The mean age of the children in the clinical and control groups at the time of the assessment was 87.64 months and 90.18 months, respectively. Pairing and birth data were equivalent for both groups. Significant weaknesses were noted in the clinical group for intelligence quotient (IQ), working memory, mental organization, alternation, and inhibition. These deficits seemed to have a greater impact on the verbal sphere of the children's mental functioning.
CONCLUSION: Primary results point to the anterior cerebral regions of the brain as the principal site of dysfunctions that persist years post-trauma. It is important to consider these results longitudinally, even in children apparently less extensively affected, since the frontal regions only reach maturity at the end of adolescence.
Related Articles
Medical and cognitive outcome in children with traumatic brain injury. [Can J Neurol Sci. 2004]
Late neurologic and cognitive sequelae of inflicted traumatic brain injury in infancy. [Pediatrics. 2005]
Shaken baby syndrome in Canada: clinical characteristics and outcomes of hospital cases. [CMAJ. 2003]
23: J Neurotrauma. 2008 Mar;25(3):205-13
Traumatic axonal injury in the spinal cord evoked by traumatic brain injury.
Czeiter E, Pal J, Kovesdi E, Bukovics P, Luckl J, Doczi T, Buki A.
Department of Neurosurgery, University of Pécs, Pécs, Hungary.

Although it is well known that traumatic brain injury (TBI) evokes traumatic axonal injury (TAI) within the brain, TBI-induced axonal damage in the spinal cord (SC) has been less extensively investigated. Detection of such axonal injury in the spinal cord would further the complexity of TBI while also challenging some functional neurobehavioral endpoints frequently used to assess recovery in various models of TBI. To assess TAI in the spinal cord associated with TBI, we analyzed the craniocervical junction (CCJ), cervico-thoracic (CT), and thoraco-lumber (ThL) spinal cord in a rodent model of impact acceleration of TBI of varying severities. Rats were transcardially fixed with aldehydes at 2, 6, and 24 h post-injury (n = 36); each group included on sham-injured rodent. Semi-serial vibratome sections were reacted with antibodies targeting TAI via alteration in cytoskeletal integrity or impaired axonal transport. Consistent with previous observations in this model, the CCJ contained numerous injured axons. Immunoreactive, damaged axonal profiles were also detected as caudal, as the ThL spinal cord displayed morphological characteristics entirely consistent with those described in the brainstem and the CCJ. Quantitative analyses demonstrated that the occurrence and extent of TAI is positively associated with the impact/energy of injury and negatively with the distance from the brainstem. These observations show that TBI can evoke TAI in regions remote from the injury site, including the spinal cord itself. This finding is relevant to shaken baby syndrome as well as during the analysis of data in functional recovery in various models of TBI.

Related Articles
Impaired axonal transport and altered axolemmal permeability occur in distinct populations of damaged axons following traumatic brain injury. [Exp Neurol. 2004] Review All roads lead to disconnection?--Traumatic axonal injury revisited. [Acta Neurochir (Wien). 2006]

24: Childs Nerv Syst. 2008 Feb;24(2):169-72; discussion 173
Epilepsy associated with shaken baby syndrome.
Bourgeois M, Di Rocco F, Garnett M, Charron B, Boddaert N, Soufflet C, Roujeau T, Zerah M, Sainte-Rose C, Plouin P, Renier D.
Department of Pediatric Neurosurgery, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015, Paris, France.

OBJECT: The shaken baby syndrome (SBS) is an important cause of developmental delay in infants. Epileptic seizures are a common feature of this syndrome. The aim if this study is to analyse the impact of the early and late seizures disorder.
MATERIALS AND METHODS: We have retrospectively reviewed the clinical and electrophysiological findings in a series of 404 children hospitalised with SBS.
RESULTS: In the acute phase, clinical epileptic seizures of various semiologies were found in 73% of the infants. Only 11% of the children had a normal EEG on admission. A poor outcome was found in 88% of the children in case of persisting EEG anomalies despite anti-epileptic treatment with 48% mortality in these patients. The development of refractory epilepsy was also associated with a poor outcome in this series. In fact 96% of the children with seizure recurrence had behavioural problems.
CONCLUSIONS: The early recognition and subsequent management of these seizures is vital to prevent further neurological injury. Delayed or recurrent epileptic seizures may occur with a different semiology to the seizures in the acute phase and are also associated with a poor prognosis.

25: J Perinat Neonatal Nurs. 2008 Jan-Mar;22(1):68-76
Shaken baby syndrome.
Altimier L.
Mercy Anderson Hospital, Cincinnati, Ohio 45255, USA.

Non-accidental head trauma in infants is the leading cause of infant death from injury. Clinical features that suggest head trauma (also known as shaken baby syndrome or shaken impact syndrome) include the triad consisting of retinal hemorrhage, subdural, and/or subarachnoid hemorrhage in an infant with little signs of external trauma. Abusive head injuries are among the most common causes of serious and lethal injuries in children. These injuries may result from impact or shaking or a combination of these mechanisms. These mechanisms cause the child's head to undergo acceleration/ deceleration movements, which may create inertial movement of the brain within the cranial compartment.
Related Articles
Review Shaken baby syndrome. [Orthop Nurs. 2003]
Review Nonaccidental head trauma in infants. [Childs Nerv Syst. 2007]
Review Shaken baby syndrome education: a role for nurse practitioners working with families of small children. [J Pediatr Health Care. 2006]
Shaken baby syndrome: assessment, intervention, & prevention. [J Psychosoc Nurs Ment Health Serv. 2004]
26: Med Hypotheses. 2008;71(1):117-21. Epub 2008 Mar 25
The nature of shaken baby syndrome injuries and the significance of a "Lucid Interval".
Talbert D.
Institute of Reproductive and Developmental Biology, Imperial College School of Medicine, Du Cane Road, London, England, United Kingdom.

BACKGROUND: The possibility of shaking an infant sufficiently violently to cause brain damage by head rotational acceleration remains controversial and the nature of the anticipated injuries poorly defined. Animal studies of whiplash injuries have revealed two modes of injury; subdural haemorrhage (SDH) and cortex surface injury (CSI). CSI can be induced without SDH with a suitable whiplash impulse, suggesting independent mechanisms. Experimental whiplash injury has been found to bring an immediate cessation of cerebral function (coma) with a threshold approximating to peak velocity (applied accelerationxapplied time). Tangential forces producing brain acceleration are transferred across the subarachnoid space by trabeculae. Their total cross-sectional area is much less than that of the arachnoid and pia surfaces, producing high stress concentrations where trabeculae bond with the pia mater.
HYPOTHESIS: That CSI occurs within the pia-glia formation when astrocytes linking the pia below trabeculae to the cortex fail under the high local stress concentrations. The pia may be locally pulled off the neural tissue, dragging neural tissue with it. Axons will be stretched or broken, thereby immediately disrupting interneuron communications (coma).
CONCLUSION: In contrast to such immediate mechanical injuries, chemical (e.g. hypoxic) insults take time to develop, described as a "lucid interval". Crying requires recognition of a noxious stimulus, and coordination of respiratory and vocal muscles, showing that the infant is not in a coma but in a lucid interval. Therefore, when crying can be heard on 999 or 911 tape recordings the initial event could not have been shaking.
Related Articles
Review Shaken baby syndrome: the quest for evidence. [Dev Med Child Neurol. 2008] Review Shaken baby syndrome. [Postgrad Med J. 2002]
Review Shaken baby syndrome. [J Perinat Neonatal Nurs. 2008]

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