Incidence of impact trauma with cranial injuries ascribed to shaking

Shaking as a mechanism of severe brain injury in infants has been challenged on a theoretical basis as insufficient to explain the magnitude of observed injuries. Computed tomography and magnetic resonance imaging, developed since shaken baby syndrome was first described, are helpful in establishing whether external trauma occurred for infants thought to have been shaken. We compiled data from 24 infants initially diagnosed as having shaken baby syndrome, including physical examination, roentgenograms, computed tomography or magnetic resonance imaging, and autopsy (when applicable). Half of the patients showed no evidence of direct impact, and evidence of external trauma was not predictive of a fatal outcome. These findings indicate that shaking by itself is sufficient to cause severe or fatal intracranial injury and that the shaken baby syndrome reflects a spectrum of such child abuse injuries that may include direct trauma or only shaking.     

Bloody cerebrospinal fluid: traumatic tap or child abuse?

A central nervous system dysfunction of nontraumatic etiology was initially suspected in three cases of shaken baby syndrome. Blood contaminating the cerebrospinal fluid was attributed to a traumatic lumbar puncture. Failure to detect retinal hemorrhages contributed to the misdiagnosis. Emergency physicians must consider the diagnosis of shaken baby syndrome in a critically ill infant with bloody cerebrospinal fluid. Ophthalmoscopy should be done routinely in these patients.     

Quality of interaction between at‐risk infants and caregiver at 12–15 months is associated with 3‐year autism outcome

Background: Recent models of the early emergence of autism spectrum disorder (ASD) propose that infant intrinsic risk susceptibilities in behaviour may be amplified by interaction within the early social environment into an increasingly atypical developmental trajectory. This study examines whether 6‐ and 12‐month parent–infant interactions in at‐risk siblings differ from those with low‐risk and whether – in at‐risk siblings – such interactions predict later 3‐year classification of ASD or no ASD. Method: Within the British Autism Study of Infant Siblings (BASIS), 6‐min videotaped episodes of parent–infant free play in infants at 6–10 months (45 at‐risk siblings and 47 low‐risk siblings) and 12–15 months (43 at‐risk siblings and 48 low‐risk siblings) in a laboratory setting were rated on the Manchester Assessment of Caregiver‐Infant Interaction (MACI), blind to participant information. Standard tests were administered for concurrent behavioural signs of ASD features and developmental level. Systematic consensus diagnostic classification of ASD was made at 3 years for the at‐risk siblings. Results: Parent nondirectiveness and sensitive responsiveness differed in relation to ASD/risk status (at‐risk ASD, at‐risk no‐ASD and low‐risk) at both 6 and 12 months. At 6 months, infant liveliness was lower in the at‐risk groups; at 12 months, infant attentiveness to parent and positive affect were lower in the at‐risk group later diagnosed with ASD. Dyadic mutuality and intensity of engagement showed a group effect at 12 months. Dyadic mutuality, infant positive affect and infant attentiveness to parent at 12 months (but not 6 months) predicted 3‐year ASD outcome, whereas infant ASD‐related behavioural atypicality did not. Conclusions: This is the first prospective evidence that early dyadic interaction between at‐risk infants and their parents is associated with later diagnostic outcome in ASD. Possible explanations for these findings and their theoretical implications are considered.     

A witnessed short fall mimicking presumed shaken baby syndrome (inflicted childhood neurotrauma)

A witnessed fall backwards of an infant from a sitting position resulted in the subdural hematoma and retinal hemorrhages characteristic of presumed shaken baby syndrome. Violent shaking is not necessary to produce these findings.     

Shaken baby syndrome and a baby's cry

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.     

Minimally invasive management of a traumatic artery aneurysm resulting from shaken baby syndrome

Based on our review of the literature, we present the first use of coiling in an infant with a traumatic artery aneurysm that resulted from shaken baby syndrome. Computed tomography (CT) scans showed a skull fracture, hemorrhagic subdural collections, multiple parenchymal contusions, and intraventricular and subarachnoid hemorrhages in a 3-week-old infant who presented with lethargy, poor feeding, and seizure. These multiple injuries were consistent with shaken baby syndrome. After closed-head injury medical management, including subdural taps, the baby was discharged home. When increasing seizures and hydrocephalus developed 8 months later, CT angiographic scans showed a pseudoaneurysm of the anterior cerebral artery. We successfully occluded the aneurysm with pushable coils placed via a microcatheter and treated the obstructive hydrocephalus with endoscopic third ventriculostomy. We show that minimally invasive radiological and surgical techniques may be effective in managing the sequelae of trauma in children.     

Nichtakzidentelle Kopfverletzungen und Schütteltrauma-Syndrom

Inflicted traumatic brain injury, in particular the shaken baby syndrome, leads to significant neurological disability in more than two-thirds of surviving victims, and is fatal in 12–27% of cases. It is characterized by a constellation of subdural hematoma and mostly marked retinal hemorrhages with severe diffuse brain injury, usually without external injuries. Shaken baby syndrome resulting in significant brain damage requires extensive, violent shaking of a child leading to uncontrolled rotation of the head. The resulting subdural and retinal hemorrhages are, however, not important for the prognosis. The combination of diffuse axonal injury and initial traumatic apnea leading to hypoxia, ischemia and intracranial hypertension is assumed to be responsible for the marked brain damage. Clinical symptoms are irritability, feeding problems, somnolence, apathy, cerebral convulsions, vomiting, apnea, coma and death. Shaking injury is a syndromic diagnosis dependant on the total picture of clinical, ophthalmological, radiological and brain imaging features.     

G × E interaction in the organization of attachment: mothers’ responsiveness as a moderator of children’s genotypes

Background: Scholars acknowledge that both biologically‐founded child temperament and environmental factors are influential in determining the quality of infant–mother attachment. We present evidence for gene by environment (G × E) interaction in the organization of attachment. Methods: Participants were 88 typically developing infants and their mothers. Molecular genetic measures of the infants focused on the polymorphism in the serotonin transporter gene (5‐HTTLPR, ss/sl vs. ll genotype). Mothers’ responsiveness to their infants at 7 months was observed in lengthy naturalistic interactions, and was conceptualized as the environmental influence. Results: For infants with a short allele (ss/sl ), variation in mothers’ responsiveness was significantly associated with attachment security, assessed at 15 months in the Strange Situation. For those infants, low responsiveness predicted particularly high risk for insecure attachment, and high responsiveness offset that risk. For infants homozygous for the long allele (ll ), there was no association between responsiveness and attachment organization. Conclusions: The findings show that the quality of early care serves to amplify or offset the risk conferred by genotype.     

Abusive head trauma in children: a literature review

ObjectiveTo review the scientific literature on pediatric abusive head trauma as a form of physical abuse against infants and young children, highlighting the prevalence, signs and symptoms, consequences, risk factors for its occurrence, and prevention strategies.Data sourceThe MEDLINE, SciELO, LILACS, and Web of Science databases from 2001 to 2012 were reviewed, using the terms “shaken baby syndrome” and “abusive head trauma” in English, Spanish, and Portuguese.Data synthesisPediatric abusive head trauma is defined as injury to the skull or intracranial contents of a infant or child younger than 5 years due to intentional abrupt impact and/or violent shaking. It occurs mainly in infants and children under 1 year of age, and may result in severe consequences, from physical or mental disabilities to death. Although there are specific signs for this form of abuse, they can be mistaken for common illnesses in children or accidental head injury; thus, clinical training of professionals involved in the assessment of cases to attain the correct diagnosis is crucial. Prevention strategies should include early identification of cases, as well as parental education on child development, especially on the infant's crying pattern.ConclusionsConsidering the severity of abusive head trauma in children, it is critical that prevention strategies be implemented and evaluated in the Brazilian context. It is suggested that its incidence indicators be assessed at the national level.     

A case–control study to examine the association between breastfeeding during late pregnancy and risk of a small‐for‐gestational‐age birth in Lima,Peru

Excessive demands on maternal nutritional status may be a risk factor for poor birth outcomes. This study examined the association between breastfeeding during late pregnancy (≥28 weeks) and the risk of having a small‐for‐gestational‐age (SGA) newborn, using a matched case–control design (78 SGA cases: birthweight <10th percentile for gestational age; 150 non‐SGA controls: 50th percentile <birthweight <90th percentile for gestational age). Between March 2006 and April 2007, project midwives visited daily three government hospitals in Lima, Peru and identified cases and matched controls based on hospital, gestational age, and inter‐gestational period. Mothers were interviewed and clinical chart extractions were completed. Factors associated with risk of SGA were assessed by their adjusted odds ratios (aOR) from conditional logistic regression. Exposure to an overlap of breastfeeding during late pregnancy was not associated with an increased risk of having a SGA newborn [aOR = 0.58, 95% confidence interval (CI): 0.10–3.30]. However, increased risk was associated with having a previous low‐birthweight birth (aOR = 6.53; 95% CI: 1.43–29.70) and a low intake of animal source foods (<25th percentile; aOR = 2.26; 95% CI: 1.01–5.04), and tended to be associated with being short (<150 cm; aOR = 2.05; 95% CI: 0.92–4.54). This study found no evidence to support the hypothesis that breastfeeding during late pregnancy increases the risk for SGA; however, studies with greater statistical power are needed to definitively examine this possible association and clarify whether there are other risks to the new baby, the toddler and the pregnant woman.     

Practitioner Review: Beyond shaken baby syndrome: what influences the outcomes for infants following traumatic brain injury?

Background: Traumatic brain injury (TBI) in infancy is relatively common, and is likely to lead to poorer outcomes than injuries sustained later in childhood. While the headlines have been grabbed by infant TBI caused by abuse, often known as shaken baby syndrome, the evidence base for how to support children following TBI in infancy is thin. These children are likely to benefit from ongoing assessment and intervention, because brain injuries sustained in the first year of life can influence development in different ways over many years. Methods: A literature search was conducted and drawn together into a review aimed at informing practitioners working with children who had a brain injury in infancy. As there are so few evidence‐based studies specifically looking at children who have sustained a TBI in infancy, ideas are drawn from a range of studies, including different age ranges and difficulties other than traumatic brain injury. Results: This paper outlines the issues around measuring outcomes for children following TBI in the first year of life. An explanation of outcomes which are more likely for children following TBI in infancy is provided, in the areas of mortality; convulsions; endocrine problems; sensory and motor skills; cognitive processing; language; academic attainments; executive functions; and psychosocial difficulties. The key factors influencing these outcomes are then set out, including severity of injury; pre‐morbid situation; genetics; family factors and interventions. Conclusions: Practitioners need to take a long‐term, developmental view when assessing, understanding and supporting children who have sustained a TBI in their first year of life. The literature suggests some interventions which may be useful in prevention, acute care and longer‐term rehabilitation, and further research is needed to assess their effectiveness.     

‘The second mother’: How the baby food industry captures science,health professions and civil society in France

Most babies in France are fed with infant formula and then commercial complementary foods, many of which are ultra‐processed and harmful to health. Internationally, there is opposition by the baby food industry to the introduction of public health policies that would limit the marketing and consumption of such products. Our aim was to identify the key baby food industry actors, describe their history and corporate political activity (CPA) in France. We sourced publicly available information, which we triangulated with data from 10 semi‐structured interviews. Qualitative thematic analysis was undertaken simultaneously to data collection, guided by an existing classification of the CPA of the food industry. The baby food industry in France has shaped the science on infant and young child nutrition and nurtured long‐established relationships with health professionals. This corporate science and these relationships helped baby food companies to portray themselves as experts on child‐related topics. The baby food industry has also engaged with a broad range of civil society organisations, particularly through the concept of the first 1000 days of life, and during the covid‐19 pandemic. We found evidence, although limited, that the baby food industry directly lobbied the French government. Since its early development in France in the 19th century, the baby food industry used its CPA to promote its products and protect and sustain its market. Our findings can be used to recognise, anticipate and address the CPA of this industry, and to minimise any negative influence it may have on babies'' and mother''s health.     

When shared decision‐making and evidence based practice clash: Infant sleep practices

In complex decisions, there are times when there may be a conflict between the recommendations from clinical practice guidelines and the outcome of a shared decision‐making process between the clinician and the patient. Sticking rigidly to practice guidelines can be seen as paternalistic and even dismissive of a patient's specific circumstances and preferences; however, failing to adhere to such guidelines can be troubling for many doctors. In this article, we present and discuss this conflict using the common problem of how to provide family‐centred, yet evidence‐based guidance on infant sleep practices. Infant sleep practices are a common discussion topic at well‐baby visits, and family preferences for infant sleep practices are often at odds with national recommendations. With three cases as a backdrop, we discuss how cultural humility, complexity and trust can be key factors in how the clinician‐parent discussion on infant sleep can incorporate safe sleep guidelines into a family‐centred, culturally relevant discussion.     

Estimates of the quality of complementary feeding among Vietnamese infants aged 6−23 months varied by how commercial baby cereals were classified in 24‐h recalls

The World Health Organization's (WHO) standardized questionnaire for assessing infant and young child feeding practices does not include commercial baby cereals (CBC), which are derived from several food groups and are fortified with micronutrients. We examined how different scenarios for classifying CBC affect estimates of the quality of complementary feeding in children ages 6?23 months in Vietnam in 2014 (n = 4811). In addition to the WHO standardized 24‐h recall questionnaire for infant and young child feeding, we asked mothers about the consumption of CBC. The five resulting scenarios were S1 – omitted CBC; S2 – CBC classified as grains; S3 – as grains and dairy; S4 – as grains, dairy and fruit/vegetables; and S5 – as grains, dairy, fruit/vegetables and any others. Including CBC resulted in 4?11 percentage points higher in the prevalence of children who were fed each of the six food groups compared with what was reported in the WHO standardized questionnaire. Minimum dietary diversity (% fed ≥ 4 out of the 7 food groups) was higher in S5 (90%) than in S1 (84%), S2 (84%), S3 (85%) and S4 (86%). Minimum acceptable diet was also higher in scenarios S5 (80%) than in S1 (74%), S2 (75%), S3 (75%) and S4 (77%). Consumption of iron‐rich foods was 94% when CBC was accounted, which was higher than the alternative scenario (89%). In summary, when CBC were included, population‐level estimates of dietary quality were higher than when CBC were omitted. Guidance is required from the WHO about how to account for the consumption of CBC when estimating the quality of complementary feeding.     

Babies in boxes and the missing links on safe sleep: Human evolution and cultural revolution

Concerns about bedsharing as a risk for sudden infant death syndrome and other forms of sleep‐associated infant death have gained prominence as a public health issue. Cardboard “baby boxes” are increasingly promoted to prevent infant death through separate sleep, despite no proof of efficacy. However, baby boxes disrupt “breastsleeping” (breastfeeding with co‐sleeping) and may undermine breastfeeding. Recommendations enforcing separate sleep are based on 20th century Euro‐American social norms for solitary infant sleep and scheduled feedings via bottles of cow's milk‐based formula, in contrast to breastsleeping, an evolutionary adaptation facilitating the survival of mammalian infants for millennia. Interventions that aim to prevent bedsharing, such as the cardboard baby box, fail to consider the implications of evolutionary biology or of ethnocentrism in sleep guidance. Moreover, the focus on bedsharing neglects more potent risks such as smoking, drugs, alcohol, formula feeding, and poverty. Distribution of baby boxes may divert resources and attention away from addressing these other risk factors and lead to a false sense of security wherein we overlook that sudden unexplained infant deaths also occur in solitary sleep environments. Recognizing breastsleeping as the evolutionary and cross‐cultural norm entails re‐evaluating our research and policy priorities, such as providing greater structural support for families, supporting breastfeeding and safe co‐sleeping, investigating ways to safely minimize separation for formula‐fed infants, and mitigating the potential harms of mother–infant separation when breastsleeping is disrupted. Resources would be better spent addressing such questions rather than on a feel‐good solution such as the baby box.     

Serial abuse in children who are shaken

Serious injury can occur to children who are shaken, especially if the shaking is repeated or part of a pattern of abuse. Serial abuse in connection with children who are shaken and their siblings has important therapeutic and legal ramifications. From an ongoing study of child abuse and head trauma, 12 of 24 victims of shaking that resulted in intracranial injury were identified who had coexisting evidence of direct external trauma. Seventeen children (71%) had evidence of prior abuse, neglect, or both, including 8 who had multiple intracranial hemorrhages. Of the 21 families represented, 9 had more than one child, 3 (3%) of which had several siblings who had been victims of child abuse. Shaking of children usually is not an isolated event, as it frequently has been preceded by other types of abuse.     

Die nicht unfallbedingte Verletzung (battered child)

The recognition of a battered child represents a challenge for all groups of adults dealing with children. Radiology plays a special role in this setting. By detection typical injuries, imaging is able to confirm the suspicion of a battered child. Recognition of those injuries on films, taken for other reasons, gives the caretaker an important hint, thus maybe preventing a fatal outcome for the child. One of the most important injury types is represented by the so called “shakin baby syndrome”. The infant is held by the thorax and shaken. Thus causing a repetitive acceleration-deceleration trauma, which leads to the typical paravertebral rib fractures, intracranial bleeding and eye injuries. After shaking the child is thrown away, with subsequent injuries. The aim of this article is the presentation of an overview regarding the radiology of the battered child. Typical examples will be shown.     

Not-always-apparent abuse: the shaken baby syndrome

The authors report 3 cases of infants presenting with cerebral lesions related to violent head shaking. They emphasize the diagnostic difficulties when the classical signs of the battered child (marks of blows, fractures) are lacking. The traumatism is rarely recognized: only the negativity of the usual medical causes of subdural hematoma, meningeal or retinal hemorrhage and a peculiar familial history lead to the possible diagnosis of shaken baby syndrome. The value of skull CT-scan is major, showing intracranial lesions which could not be found before. Because of the observed lesions, evolution is often severe.     

Age-related incidence of publicly reported shaken baby syndrome cases: is crying a trigger for shaking?

OBJECTIVE:: This study aims to determine whether the age-specific incidences (1) of publicly reported cases of shaken baby syndrome (SBS) and (2) of publicly reported cases of SBS with crying as the stimulus have similar properties to the previously reported normal crying curve. METHODS:: The study reports cases of SBS by age of the child at the time of the inflicted trauma from the data set of the National Center on Shaken Baby Syndrome using cases entered between January 1, 2003 and August 31, 2004. RESULTS:: There were 591 cases of infants up to 1.5 years of age who had been reported to have been shaken or shaken and physically abused. Of these, crying was reported as the stimulus in 166 cases. In both samples, the curves of age-specific incidence started at 2-3 weeks, reached a clear peak at about 9-12 weeks of age, and declined to lower more stable levels by about 29-32 weeks of age, similar to the normal crying curve. These curves have similar onsets and shapes and a slightly later peak compared to the normal crying curve. CONCLUSIONS:: The findings provide convergent indirect evidence that crying, especially in the first 4 months of age, is an important stimulus for SBS.