Shaken Baby Syndrome - CDC

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A Journalist’s Guide toShaken Baby Syndrome:A Preventable TragedyA part of CDC’s “Heads Up” SeriesU.S. Department of Health and Human ServicesCenters for Disease Control and Prevention

Table of ContentsA Journalist’s “Five Ws”The What: Shaken Baby Syndrome2The Who: Facts & Figures3The Why: Triggers & Risk Factors4The When (& How): Tips for Accurate Reporting5The Where: CDC Experts & Other Sources8For more information-—as well as radio PSAs and broadcast-quality video thatincludes B-Roll, full-screen tips, and downloadable scenarios—please visit:www.cdc.gov/TraumaticBrainInjury.To access radio PSAs that offer tips for coping with a crying baby, please visit:www.cdc.gov and click on Podcasts.

The What:there are no obvious external physicalsigns, such as bruising or bleeding, toindicate an injury.Shaken Baby Syndrome (SBS) is apreventable, severe form of physicalchild abuse resulting from violently shakingan infant by the shoulders, arms, or legs.SBS may result from both shaking aloneor from shaking with impact.In more severe cases of SBS, babies mayexhibit the following:3, 4 UnresponsivenessSBS is not just a crime—it is a publichealth issue. SBS resulting in head injuryis a leading cause of child abuse deathin the United States. Nearly all victims ofSBS suffer serious health consequencesand at least one of every four babies whoare violently shaken dies from this form ofchild maltreatment.1Shaken Baby Syndrome Loss of consciousness Breathing problems (irregular breathingor not breathing) No pulseBabies suffering lesser damage from SBSmay exhibit some of the following:5, 6 Change in sleeping pattern or inability tobe awakenedFrom a public health perspective, creatinggreater awareness about SBS is important.Helping people understand the dangersof violently shaking a baby; the risk factorsassociated with SBS; the triggers for it;and ways to prevent it may help reducethe number of babies affected by SBS.Everyone, from caregivers to bystanders,can do something to help. Vomiting Convulsions or seizures Irritability Uncontrollable crying Inability to be consoled Inability to nurse or eatSBS can potentially result in the followingconsequences: DeathThe bottom line is that vigorouslyshaking a baby can be fatal or result ina permanent disability. Shaking mostoften occurs in response to a baby crying,or other factors that can lead the personcaring for a baby to become frustrated orangry. All babies cry and do things thatcan frustrate caregivers; however, not allcaregivers are prepared to care for a baby.Babies, newborn to one year (especiallybabies ages 2 to 4 months), are at greatestrisk of injury from shaking. Shaking themviolently can trigger a “whiplash” effectthat can lead to internal injuries—includingbleeding in the brain or in the eyes. Often1 Blindness Mental retardation or developmentaldelays (any significant lags in a child’sphysical, cognitive, behavioral, emotional,or social development, in comparisonwith norms)7 and learning disabilities Cerebral palsy Severe motor dysfunction (muscleweakness or paralysis) Spasticity (a condition in which certainmuscles are continuously contracted—this contraction causes stiffness ortightness of the muscles and mayinterfere with movement, speech, andmanner of walking)8 SeizuresCarbaugh SF. Understanding shaken baby syndrome. Adv Neonatal Care 2004;4(2):105–16.Lee C, Barr RG, Catherine NM, Wicks A. Age-related incidence of publicly-reported shaken baby syndrome cases: Is crying a triggerfor shaking? J Dev Behav Pediatr 2007;28(4):288–93.3Miehl NJ. Shaken baby syndrome. J Forensic Nurs 2005;1(3):111–7.4Carbaugh SF. Understanding shaken baby syndrome. Adv Neonatal Care 2004;4(2):105–16.5Ibid.6Miehl NJ. Shaken baby syndrome. J Forensic Nurs 2005;1(3):111–7.7Encyclopedia of Children’s Health. Developmental delay [online]. [cited 2008 Oct 16.] Available from URL: lay.html.8National Institutes of Health, National Institute of Neurological Disorders and Stroke. NINDS spasticity information page [online]. 2007.[cited 2008 Oct 16.] Available from URL: ticity.htm.22

like an adult may sustain in repeatedcar crashes. It is child abuse, not play.This is why claims by perpetrators thatthe highly traumatic internal injuriesthat characterize SBS resulted frommerely “playing with the baby” are false.While jogging an infant on your knee ortossing him or her in the air can be veryrisky, the injuries that result from SBS arenot caused by these types of activities.13The Who:Facts & Figures It is difficult to know the exact numberof SBS cases per year because manycases of SBS are underreported and/or never receive a diagnosis. However,a study of North Carolina SBS casessuggests that as many as three to fourchildren a day experience severe orfatal head injury from child abuse in theUnited States.9Babies less than 1 year of age10 (withthe highest risk period at 2 to 4 months)are at greatest risk for SBS becausethey cry longer and more frequently,and are easier to shake than older andlarger children.11SBS injuries have been reported inchildren up to age 5.12SBS is the result of violent shaking thatleads to a brain injury, which is much The most common trigger for shakinga baby is inconsolable or excessivecrying—a normal phase in infantdevelopment.14, 15, 16 Parents and their partners account forthe majority of perpetrators. Biologicalfathers, stepfathers, and mothers’boyfriends are responsible for themajority of cases, followed by mothers.17 In most SBS cases there is evidenceof some form of prior physical abuse,including prior shaking.18, 199Keenan HT, Runyan DK, Marshall SW, Nocera MA, Merten DF. A population-based comparison of clinical and outcome characteristicsof young children with serious inflicted and noninflicted traumatic brain injury. Pediatrics 2004;114(3):633–9.10Dias MS, Smith K, deGuehery K, Mazur P, Li V, Shaffer ML. Preventing abusive head trauma among infants and young children: Ahospital-based, parent education program. Pediatrics 2005;115(4):e470–7.11Miehl NJ. Shaken baby syndrome. J Forensic Nurs 2005;1(3):111–7.12American Academy of Pediatrics Committee on Child Abuse and Neglect. Shaken baby syndrome: Rotational cranial injuries—technical report. Pediatrics 2001;108(1):206–10.13Hoffman JM. A case of shaken baby syndrome after discharge from the newborn intensive care unit. Adv Neonatal Care2005;5(3):135–46.14Ibid.15Miehl NJ. Shaken baby syndrome. J Forensic Nurs 2005;1(3):111–7.16Carbaugh SF. Understanding shaken baby syndrome. Adv Neonatal Care 2004; 4(2):105–16.17Keenan HT, Runyan DK, Marshall SW, Nocera MA, Merten DF. A population-based comparison of clinical and outcome characteristicsof young children with serious inflicted and noninflicted traumatic brain injury. Pediatrics 2004;114(3):633–9.18Alexander R, Crabbe L, Sato Y, Smith W, Bennett T. Serial abuse in children who are shaken. Am J Dis Child 1990;144(1):58–60.19Ewing-Cobbs L, Kramer L, Prasad M, Niles Canales D, Louis PT, Fletcher JM, et al. Neuroimaging, physical, and developmental findingsafter inflicted and non-inflicted traumatic brain injury in young children. Pediatrics 1998;102(2):300–7.3

The Why:Triggers & Risk FactorsThe crying.the late-night feedings.theconstant changing of diapers.the resultingexhaustion.The fact is that many new parents andcaregivers find themselves unpreparedfor the realities of caring for a baby andthe stress and aggravation that canaccompany those realities.Add to these stresses at home, the outsidestressors created by work, social, and/or financial challenges, and you have apotentially combustible combination. It’s amix that in some situations leads to violentbehavior by the caregiver and can result infatal or debilitating injuries for a baby.What most people don’t realize is thatthere is a normal crying curve for babies.Recent studies show that crying begins toincrease around 2 to 3 weeks of age, andpeaks around 6 to 8 weeks of age, asillustrated above. It then tapers off, andusually ends, when the baby is 3 to 4months old.21Following is a brief discussion ofinconsolable crying, the primary triggerfor SBS and risk factors for SBSperpetrators and victims.Inconsolable CryingIf you’ve ever been around a baby whowon’t stop crying, you likely know thatthere is potential to get frustrated.The key here is that crying is normal andis not the problem.The problem is how caregivers respond toa baby’s cry.The fact is that crying—includingprolonged bouts of inconsolable crying—is normal developmental behavior in babies.It helps to think of crying as one of the waysbabies communicate. Research also showsthat most babies who cry a great deal arehealthy and stop crying for prolongedperiods of time after 4 months of age.20Picking up a baby and shaking, throwing,hitting, or hurting him/her is never anappropriate response. It is important forparents and caregivers to know how theycan cope if they find themselves becomingfrustrated (see tips on page 6).20St. James-Roberts, I. Effective services for managing infant crying disorders and their impact on the social and emotional developmentof young Children. In: Tremblay RE, Barr RG, Peters RDeV, eds. Encyclopedia on Early Childhood Development [online]. 2004:1-6.Available at: s-RobertANGxp.pdf.21Lee C, Barr RG, Catherine NM, Wicks A. Age-related incidence of publicly-reported shaken baby syndrome cases: Is crying a triggerfor shaking? J Dev Behav Pediatr 2007;28(4):288–93.22Hoffman JM. A case of shaken baby syndrome after discharge from the newborn intensive care unit. Adv Neonatal Care2005;5(3):135–46.23Black DA, Heyman RE, Smith Slep AM. Risk factors for child physical abuse. Aggress Violent Behav 2001;6(2–3):121–88.24Keenan HT, Runyan DK, Marshall SW, Nocera MA, Merten DF, Sinal SH. A population-based study of inflicted traumatic brain injury inyoung children. JAMA 2003;290(5):621–6.25Hoffman JM. A case of shaken baby syndrome after discharge from the newborn intensive care unit. Adv Neonatal Care2005;5(3):135–46.26Black DA, Heyman RE, Smith Slep AM. Risk factors for child physical abuse. Aggress Violent Behav 2001;6(2–3):121-8827Keenan HT, Runyan DK, Marshall SW, Nocera MA, Merten DF, Sinal SH. A population-based study of inflicted traumatic brain injury inyoung children. JAMA 2003;290(5):621–6.4

The When (& How):While no one wakes up and says,“Today I plan to shake or harm ababy,” excessive frustration andexhaustion can lead individuals to abreaking point. However, there areother factors that can also increasethe risk for an action that can harma baby. These factors include:22, 23, 24 Having unrealistic expectationsabout child development andchild-rearing Having been abused orneglected as a child Being a victim or witness todomestic violence Being a single parentTips for AccurateReportingSBS is more than a story for the Metrosection editor or crime reporter—it’s ahealth story about a tragedy that canbe prevented by greater communityawareness. Prevention is a communityeffort that includes recognizing andcommunicating the risk factors and commoncharacteristics of perpetrators and victims,and also sharing ways to lessen the loadon stressed out parents and caregivers.Following are tips and recommendations toconsider as you craft your story.The following increases aninfant’s risk for being shaken25, 26, 27particularly when combined witha parent or caregiver who’s notprepared to cope with caring fora baby: A history of previous child abuse Infant prematurity or disability Being one of a multiple birth Being less than 6 months of age Inconsolable and/or frequentcryingTips Examine SBS as a public health issueversus solely reporting it from a criminalperspective. Reinforce prevention messages for parentsand caregivers (see tips on page 6). Connect the dots between a parent’sor caregiver’s loss of control and otherfactors in his/her life and/or communitythat increase risk or build protection(include history of abuse in the familyor lack of support or isolation). Alsooutline the types of stressors that triggerbehavior that can lead to SBS. Emphasize that everyone has a rolein preventing SBS through bettereducation, awareness within thecommunity, and better support forparents and caregivers. Provide your audience with resourcesfor additional information to help themprevent SBS. Promote local parenting helplines Highlight child maltreatment programsin your communityA list of tips for parents and other caregiversfollows. Also see the list of resources in thenext section—The Where: CDC Experts &Other Sources.5

Recommendations forYour Readers/Viewers:Pain-like Look on Face.Long Bouts of Crying: Crying can go onfor hours.If you are the parent or caregiver of a baby: Babies can cry a lot in the first fewmonths of life and this can be frustrating.But it will get better. Evening Crying: Baby cries more in theafternoon and evening.For more information about the Periodof PURPLE Crying and NCBS, visit:www.dontshake.org.Remember, you are not a bad parent orcaregiver if your baby continues to cryafter you have done all you can to calmhim/her.You can try to calm your crying baby by: Rubbing his/her back Gently rocking Offering a pacifier Singing or talking Taking a walk using a stroller or a drivewith the baby in a properly-securedcar seat.If you have tried various ways to calmyour baby and he/she won’t stop crying,do the following: Check for signs of illness or discomfortlike diaper rash, teething, or tight clothing Call the doctor if you suspect yourchild is injured or ill Assess whether he/she is hungry orneeds to be burped Tell everyone who cares for your babyabout the dangers of shaking a babyand what to do if they become angry,frustrated, or upset when your baby hasan episode of inconsolable crying ordoes other things that caregivers mayfind annoying, such as interruptingtelevision, video games, sleep time, etc. Be aware of signs of frustration andanger among others caring for yourbaby. Let them know that crying isnormal, and that it will get better. See a health care professional if youhave anger management or otherbehavioral concerns.If you are a friend, family member, healthcare professional or observer of a parentor other caregiver: Be aware of new parents in your familyand community who may need help orsupport.If you find yourself pushed to the limitby a crying baby, you may need to focuson calming yourself. Put your baby in acrib on his/her back, make sure he/sheis safe, and then walk away for a bit andcall a friend, relative, neighbor, or parenthelpline for support. Check on him/herevery 5 to 10 minutes.Understand that you may not be ableto calm your baby and that it is not yourfault, nor your baby’s. It is normal forhealthy babies to cry much more inthe first 4 months of life. It may help tothink of this as the Period of PURPLECrying as defined by the NationalCenter for Shaken Baby Syndrome(NCSBS). PURPLE, stands for:Peak Pattern: Crying peaks around 2months, then decreases.Unpredictable: Crying for long periods cancome and go for no reason.Resistant to Soothing: The baby may keepcrying for long periods.6 Provide support by offering to givethem a break, sharing a parent helplinenumber, or simply being a friend. Let the parent know that the cryingcan be very frustrating, especially whenthey’re tired and stressed. Reinforcethat crying is normal and that it willget better. Tell the parent how to leave his or herbaby in a safe place while he or shetakes a break. Be sensitive and supportive in situationswhen parents are trying to calm a cryingbaby. Think about policies or services thatcould be resources for new parents inyour community—advocate for thosethat don’t exist.

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The Where:CDC Experts & Other SourcesCDC encourages you to contact its National Center for Injury Prevention and Control(Injury Center) if you have any questions about SBS or would like to interview one of itsexperts. The Injury Center Press Officer can be contacted at (770) 488-4902 between9:00 am and 5:00 pm EST. If there is an after-hours emergency, please call (404) 639-2888to contact the on-call press officer.Other Sources:American Academy of PediatricsPhone: (847) 434-4000Fax: (847) 434-8000www.aap.orgPeriod of PURPLE Crying : KeepingBabies Safe in North CarolinaPhone: 919-419-3474Fax: 919-419-9353www.purplecrying.infoNational Center onShaken Baby SyndromePhone: 801-627-3399Toll Free: 888-273-0071Fax: 801-627-3321www.dontshake.orgPrevent Child Abuse AmericaPhone: 312-663-3520Fax: 312-939-8962www.preventchildabuse.orgYour state or local health department andcommunity organizations can also serve asgood resources.Pennsylvania Shaken Baby Preventionand Awareness ProgramPhone: 717-531-7498Fax: htmFor more information on SBS and ChildMaltreatment, visit: www.cdc.gov/injury.8

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Helping All People Live toTheir Full PotentialU.S. Department of Health and Human ServicesCenters for Disease Control and Prevention

The fact is that many new parents and caregivers find themselves unprepared for the realities of caring for a baby and the stress and aggravation that can accompany those realities. Add to these stresses at home, the outside stressors created by work, social, and/ or financial challe