The month-old baby boy who slipped into a coma last month, is still fighting for his life at Kuala Lumpur Hospital. He is believed to have been abused. Every month, there are reports of abuse, especially those involving caretakers and teams of doctors are battling to save the lives of these young victims. In many cases, these are found to be victims of Shaken Baby Syndrome (SBS), says Kuala Lumpur Hospital consultant paediatrician Dr Irene Cheah. They will require medical attention for the rest of their short lives. SBS occurs when the person caring for the child becomes frustrated and angry, perhaps due to incessant crying, and shakes a child violently. Dr Cheah says there has been an increase in SBS cases of late. "Shaking a young child will result in head injury or traumatic brain injury." She said when someone forcefully shakes a baby, the child´s head moves uncontrollably because the neck muscles aren´t well developed and provide little support. "This violent movement pitches the infant´s brain back and forth inside the skull, sometimes rupturing blood vessels and nerves and tearing brain tissue because the blood vessels connecting the skull to the brain are fragile and immature. The brain may strike the inside of the skull, leading to bruising and bleeding which causes subdural haemorrhage and subarachnoid haemorrhage, parenchymal contusion, vascular infarction and global hypoxic injury. Dr Cheah says it´s never okay to shake a baby. "A child can have a skull fracture, skull swelling, contact subdural haemorrhage and retinal haemorrhages or ocular injury," she says. The injuries may cause permanent disabilities such as blindness, seizures, mental retardation and cerebral palsy. Even if the shaking was not intended to injure the baby, it is child abuse. Also, when a baby is shaken its head may hit an object. Even a soft object can cause injury to newborns and small infants. Since their heads are large and heavy in proportion to their bodies and the skulls fragile, the shaking also causes whiplash. Dr Cheah says that in more than 60 per cent of these cases the victims are boys. The perpetrators are more likely to be men, either the caregiver or boyfriend of the mother. Often, she adds, parents are not aware that their child has been abused and seek help only when they notice mild or severe symptoms such as decreased alertness, extreme irritability, lethargy, poor feeding, vomiting, loss of vision, seizures, and pale or bluish skin. Since there are no visible signs of injury the condition can be difficult to diagnose and may not be identified during a visit to a doctor. Injuries such as rib fractures however, can be seen with an X-ray. An estimated 1,200 to 1,400 cases of SBS occur each year in the United States. Some of these involve young, unmarried mothers with little education and who come from unstable family situations, or mothers who have had multiple pregnancies. In view of the rising incidences of SBS, the Suspected Child Abuse and Neglect Team (Scan Team) of which Dr Cheah is chairman, is on an awareness drive with the Health Ministry to educate parents on the dangers and consequences of SBS, through the media, Antenatal Clinics and pre-discharged Neonatal Intensive Care Units. "We plan to send trained maternal and child health nurses on home visits besides encouraging frequent parent-infant contact if the baby is a pre-term or has had prolonged hospitalisation," she says. Caregivers will be educated on ways to cope with incessant crying and encouraged to disclose their fears and frustrations, which are expected in such situations. "It´s important that caregivers are properly trained to care for infants and children of all ages. Its equally crucial that caregivers take care of themselves and get enough rest, have a balanced routine, adequate nutrition and exercise. It´s learned that the health authorities and the Scan team are also looking into teaching schoolchildren about SBS and anger management skills. Stay alert for SBS CONSULTANT neurosurgeon Dr Azmi Alias has his hands full whenever an infant is brought to his attention suffering from brain injuries due to Shaken Baby Syndrome. "I see children being brought to hospital for brain injury due to falls, accidents involving motor vehicles, the TV, fan blades, swings. Then there are the non-accidental injuries, such as Shaken Baby Syndrome and child abuse," he says. SBS is serious child abuse. A parent or other caregiver may shake a baby out of anger or frustration, often because the baby will not stop crying. But because babies have very weak neck muscles that cannot fully support their proportionately large heads, "severe shaking causes serious and sometimes fatal brain injuries," says Dr Azmi. "These forces are exaggerated if the baby´s head hits a surface." This syndrome is primarily seen in children younger than two years. The average victim is between three and eight months. Parents experiencing stress as a result of environmental, social, biological or financial situations may be more prone to impulsive and violent behaviour. Those involved with domestic violence and/or substance abuse may be at higher risk of inflicting this abuse. Dr Azmi says there is often no obvious external evidence of injury or physical signs of violence, resulting in underdiagnosis of this syndrome. It´s learnt that even physicians who are not aware of what has happened to a baby, may not detect injuries that are primarily internal. Instead, they attribute a baby´s fussiness to an underlying cause such as a virus. Symptoms of SBS may appear immediately after the shaking, and usually reach a peak within 4-6 hours. The prognosis for victims varies with the severity of the injury, but generally is poor. Many cases are fatal or lead to severe neurological deficits. Death is usually caused by uncontrollable increased intracranial pressure from cerebral oedema, bleeding within the brain, or tears in the brain tissue. However, even babies with injuries that appear to be mild may show developmental difficulties. Typically, surviving babies with this syndrome may develop any of the following disabilities: - Cerebral palsy
- Paralysis
- Vision loss or blindness
- Mental retardation
- Epilepsy
- Seizures
Dr Azmi says SBS is completely preventable and parents and care givers must even be careful not to shake the baby too much while attempting to burp them. Situations that may suggest child abuse
Child and family characteristics- premature, handicapped and crying babies
- younger infants are more frequently abused than older ones
- parents are drug or alcohol abusers
- families frequently at A&E department
- families who employ babysitters
Presenting situations- injuries of different stages of healing
- lack of parental concern
- delay in seeking medical advice
- injuries occurring at night
Injury types - head injuries in infants
- subdural or subarachnoid haemorrhages
- human bite marks or fingerprint bruising
- cigarette burns, especially if multiple
- retinal haemorrhages
- unusual fractures such as ribs
- bruising in inaccessible sites or unusual cuts or marks
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