In April a week is set aside to draw attention to a very serious problem—shaken baby syndrome. In the United States, of all forms of child abuse, shaken baby syndrome is most common cause of death and long-term disability in infants and young children. Resmiye Oral, MD pediatrician and clinical director of the Child Protection Program at University of Iowa Children's Hospitals, talks about child abuse and prevention:

What is shaken baby syndrome?

Shaken Baby Syndrome is a debilitating condition that is seen predominately in infants younger than two years of age.

How does it happen?

The majority of incidents occur when a caretaker is frustrated with a crying baby. The caretaker, not knowing how to calm down the baby, may grab the child by the chest, with the child and the caretaker facing one another, and the caretaker may start shaking the baby back and forth. The unsupported head then may move back and forth and sideways uncontrollably over a few seconds of shaking. Frequently the shaking comes to an end with slamming of the baby against a surface, which may be the crib, bed mattress, the floor, or a wall. Both shaking and slamming are very harmful to the baby's brain.

Can playful tossing or bouncing a baby cause shaken baby syndrome?

No, not at all. In order to cause the abusive head trauma, one needs to shake the baby violently, which any prudent neutral observer would recognize as potentially harmful.

What damage is caused when the shaking occurs?

The structures within the head have various densities and they are tightly attached to one another. Because of that, when a baby is shaken, the blood vessels, various layers of the brain, and membranes surrounding the brain all move at different paces. This leads to shearing forces, over-stretching the blood vessels, subsequent tears, and bleeding in the brain. Even the brain tissue may be torn, as well as nerves crossing various layers of the brain, interrupting certain vital functions. For instance, if the nerve fibers in the respiratory or circulatory center or the heart beat are interrupted, the baby's breathing or heart may stop beating, which may bring about severe lack of oxygen to the brain, or even imminent death if not intervened as soon as possible.

What are the symptoms of a baby that has been shaken violently?

The baby may become excessively sleepy, may go limp, and may develop extreme irritability, decreased appetite, poor feeding, or vomiting for no apparent reason. One may see grab marks on the arms or the chest, although these are relatively rare; the baby's interaction with the environment may change due to sleepiness; she may develop poor sucking or swallowing; head or forehead may appear larger than usual or the soft spots on the head may appear to be bulging; the baby may fail to lift the head, focus, or track movement. In most severe cases, muscles may get rigid and tense or he may start posturing and develop difficulty breathing, seizures, or unusual size of pupils.

What should be done if someone suspects that a baby has been shaken or is showing those symptoms?

Immediate treatment of Shaken Baby Syndrome is of paramount importance because it may prevent the severity of permanent brain damage and it may prevent death as well. Thus, contacting emergency medical services or the child's doctor immediately is very important. Anybody suspecting that a child might be shaken should inform the child's doctor of this concern so that the medical team can explore whether this is true and what the severity of impact is.

What medical care is provided for infants that have been shaken?

We should understand that Shaken Baby Syndrome may present to medical care at various levels of severity from mild and nonspecific to severe and immediately identifiable. So the cases that are mild and nonspecific may take some time for accurate diagnosis and the treatment for them may not necessarily be as intensive as the more severe cases. In the more severe cases, on the other hand, it is very important to address brain swelling so that it does not further harm the brain functions. Some of these infants may need support for breathing function. The prevention of seizures and/or immediate treatment of it is also very important. However, the most important intervention is prevention.

How can shaken baby syndrome be prevented?

Prevention can be done at various layers. First of all, primary prevention, which means the education of the entire population, is very important in the prevention of Shaken Baby Syndrome. These efforts should include high school students who may be baby sitters for young children and who are the prospective parents of the near future. Young individuals, including males, should learn about the normal development of infants, how to manage a crying baby, and the risks of shaking as a discipline method.

I stress the males since unfortunately 70 to 80 percent of abusive head trauma perpetrators are male, half of which are young, non-blood related, father figures. Because of that, young mothers who leave their young infants with their boyfriends should be especially careful in making that decision.

Secondly, the education of the population at large on these same topics using media resources such as radio, TV, newspapers, and magazines is very important as well.

Lastly, providing training to new parents before they are discharged from the hospital is very important.

It is also important to educate young parents that crying is the tool of communication for young infants and that they shouldn't be frustrated with a crying baby. Crying increases around two weeks of age when the baby starts being more awake. Young parents and everybody caring for infants should know that crying up to three or four hours a day is normal. When the baby starts crying, parents should make sure that the baby is not too hot or cold, he is not hungry, and his diaper is clean. After all these needs are met, if the baby continues to cry, it is OK to place the baby on his back in a safe place (a crib or playpen), and allow the baby to cry, and leave the room for a while so that you can take some time off. When you are frustrated, feel free to call a friend, relative, or even the child's physician or University of Iowa Hospitals and Clinics Call Center at 319-384-8008. It is also important for parents to inform the baby sitters, grandparents, aunts, neighbors, etc., on how to manage a crying baby, especially in case these individuals are going to take care of their baby, and the risks of Shaken Baby Syndrome, also should be discussed with these individuals.

I'm very happy to inform our community that at the UI Hospitals and Clinics Newborn Nursery, Neonatal Intensive Care Unit, and Pediatrics Clinic we offer parents the opportunity to observe a video clip on the prevention of Shaken Baby Syndrome as well as education on the issues. This will soon be expanded to include the UI Family Practice Clinic, as well.

And lastly, I'm also happy to announce that Iowa legislation is also working on the prevention of Shaken Baby Syndrome to allocate funding for those efforts through the Department of Public Health.

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Resmiye Oral, MD

Child Protection Program

University of Iowa Children's Hospitals