Journal Reading

Shaken Baby Syndrome

Maha Mian, Janki Shah, Amanda Dalpiaz, Richard Schwamb,
Yimei Miao, Kelly Warren, dan Sardar Khan
SUNY Stony Brook, Fisiologi dan Biofisika, Stony Brook, New York, AS; SUNY Stony
Fakultas Kedokteran Brook, Stony Brook, New York, AS

Oleh :
Muhammad Ridha Rifani, S.Ked
NIM. 1730912310073

Pembimbing:
Dr. dr. Kenanga Marwan S, Sp.An, KNA

Departemen Anestesiologi dan Terapi Intensif

Fakultas Kedokteran Universitas Lambung Mangkurat/RSUD ULIN
Banjarmasin
Juni, 2019
1
 Shaken Baby Syndrome
(SBS)
Introduction
Shaken Baby Syndrome (SBS) occurs in infants when subjected to excessive
acceleration–deceleration of the head

infants with subdural hematoma did not always have gross markings,
which signified the shaking of a baby as a possibility.
Rotational force pushes
the brain against the skull leading to various types of injuries to the
head and neck

β-amyloid precursor
protein (β-APP) immunohistochemical
staining and magnetic resonance imaging
(MRI) accurately identify brain injuries and
bleeding leading to a more accurate
diagnosis of SBS
Symptoms

• Brain swelling,
• Subdural hemorrhage (SDH) and
• Retinal hemorrhaging

Possible physical signs indicating SBS include paravertebral rib

fractures, or fractures in the femur or humerus contingent upon how
the infant was held . There is generally a very short interval of time
between whiplash and onset of symptoms due to the immature
growth. The immature growth of an infant’s neck, brain, and skull allow
for shaking to cause damage to the brain and its development.
 CLINICAL MANIFESTATION AND DIAGNOSIS

MRI scans of cranial lesions are able to show if any hemorrhaging has
occurred and to which extent. Generally, pre-retinal, intracranial, and
subretinual hemorrhages indicate some form of neurotrauma, including SBS.
Ophthalmologic examinations predict retinal hemorrhaging which is a good
indicator for the severity of the infants trauma

Togjoka et al. has shown that the incidence rate of retinal

hemorrhaging in infants with SBS is 53–80% [28]. In
absence of external signs of abuse, retinal hemorrhages
increase suspicion of SBS. Retinal folds and traumatic
retinoschisis are rare indicators of neurotrauma, but
particular to SBS

β-APP immunohistochemical staining is important in assessing

SBS injuries at a clinical and forensic level. The process detects
axonal injuries in the cranium and identifies immunoreactive
axons that aid in diagnosis of SBS. Although H&E staining is more
commonly used, β-APP is a great tool used in conjunction with
other tests
Brain MRI is supportive when diagnosis of SBS is unclear as it can reveal
contusions, hematomas, and hemorrhages. MRI has been proven to be more
sensitive in SBS diagnosis than computerized tomography.

Diffusion-weighted MRI provides even more

accurate results, as it can show cerebral parenchymal lesions that suggest
cerebral ischemia, a component of SBS.

Single proton emission computed tomography

(SPECT) can be used to reveal cerebral blood flowand to assess delays in
physical and
mental growth.
 SBS
CONTROVERSIES
Although certain indications create suspicion of SBS, it is still
difficult to confirm SBS,
since other pathologies share the same symptoms
vitamin D insufficiency during pregnancy can mimic the long bone
fracture that is commonly
experience trauma during delivery
associated with SBS

the subdural hemorrhages frequently seen

in SBS victims
accidental trauma, birth trauma, metabolic diseases, tumorous
conditions, genetic disorders, and autoimmune disorders

As SBS typically has no external appearance, accusations of child abusemust

be solely based upon the doctor who is treating the patient
SDH and retinal hemorrhaging are two of the major characteristics that point to
SBS and abuse of the infant. An article by Gabaeff aimed to challenge this belief.
The shaking of a baby’s head is the primary cause of SBS, Gabaeff argues that
humans can generate between 10 and 15 G’s of the brain with shaking.

The National Highway Traffic Safety Administration states injury to the brain is
typical at 80–100 G’s
Those who specialize in pediatrics have acknowledged that when a child falls,
1 in one million experience a serious or fatal injury.

Infants who experience SDH as a result of their fall and are taken to the hospital,
their parents may be accused of SBS
An area of further research is the mechanism of encephalopathy by which SBS
impairs
development. The shaking of the brain associated with SBS is believed to cause
diffuse axonal injury (DAI).

DAI causes tears in tissues and damage in axons (A1).

An alternative view is that infants suffer from hypoxic-ischemic injury.
Hypoxia damages small, intracranial vessels and can explain thin subdural
hemorrhages that
are not consistent with the thick subdural hemorrhages attributed to SBS.

Two different studies, one by Bonnier et al. and another by Bittigau et al., showed that
different animal models respond differently to inertial brain injury. Mice in one study
experienced axonal damage, while rats in the other experienced neuronal damage.
Such differences could result from differences inmodels such as hemorrhage type and
number Biochemical models have failed to completely recreate the shaking sensation
of shakes inflicted
of
SBS, but have provided insights into skull, body, and depression fractures, as
well as
intracranial hemorrhages.The model designed is inadequate at recreating
features
of infant brains and forces involved in the shaking process. Also, the model
does not prove that shaking in the absence of significant neck injury can caus
 TREATMENT OF SBS

Treatment for SBS is similar to that of general cranial hemorrhages. Subdural

hemorrhage (SDH) and evacuation surgery and the Burr hole craniotomy are two
known surgical drainage procedures for SBS. Subdural hemorrhages caused by SBS
can be treated through drainage and streptokinase (SK) lavage for lysis. Monitoring
the relationship between intracranial pressure and retinal hemorrhage can reveal the
extent of trauma, but does not necessarily diagnose SBS.
PROGNOSIS OF SBS

Prognosis for SBS is generally poor, resulting in a growth retardation or fatality in

severe
cases. Each clinical case of SBS has different prognosis outcomes, but there is a
trend of mortality and growth retardation in all. SBS has a mortality rate of
approximately
15–23% and affects about 14–40 per 100,000 infants younger than 12 months.
For those that survive, 5–10% exist in a vegetative state, 30–40% suffer visual
impairment, 30% suffer epileptic episodes, and 30–50% experience paralysis or
developmental retardation.
A neuroimage taken of intraparenchymal lesions helps doctors predict
neurodevelopmental outcomes. Presence of lesions indicates neurodevelopmental
injury
and the extent of the lesion correlates with the severity of impairment [24].Ocular
and
nonocular examinations can create an outcome for SBS victims. It is concluded that
nonreactive pupils and midline shifts in the brain are indicative of mortality. Ventilatory
requirement is a prognostic indicator for visual functions
 PREVENTION OF SBS

An infant’s headmakes up 10 to 15% of its bodyweight, compared to an average adult’s

head, which contributes 2–3%. The disproportionate head to body weight ratio
contributes
to why SBS is severe formany infants.

Prevention falls to physicians and nurses. Professional guidance from physicians and
nurses to the parents of infants with suspected SBS can prevent recurrence. It is
important to educate high-risk populations about consequences of SBS and the fact that
new parents are more susceptible to shaking infants.

Pediatricians are in a position to recognize and prevent SBS. Likewise, nurse

practitioners come in contact with both infants and caregivers, and can be useful in
recognizing SBS.

There are several centers and organizations established for SBS prevention, including
the National Center on Shaken Baby Syndrome.
By educating new parents about the danger of SBS, it is possible to decrease the
incidence of
SBS.

To prevent further damage to the infant’smental and physical health, it is vital that
the caregiver contacts a medical care center and discloses the incident as soon as
LEGAL AND SOCIAL IMPLICATIONS

SBS has a number of social and legal implications. Child abuse is a punishable
crime,
yet caregivers are not charged because they cite SBS cannot be diagnosed with
absolute certainty. It is rare for parents or caregivers to confess voluntarily.

Caregivers accused of inflicting SBS often claim that the infant fell or hit his/her
head during play.
It is unlikely that a fall or hit during play would result in the same injuries as a
case of
SBS. In some cases, both the abuser and the infant become victims.

Several programs have been established to prevent SBS and provide

communities with tools to seek out potential abusers as well as aid families
affected by child abuse.
Race, social-economic status or ethnicity do not play a significant role in
incidences of SBS

.The psychological state of the parent and caregiver plays a significantly more
important role in the incidence of SBS. Additionally, offenders of SBS are more
likely
to be male
SUMMARY

SBS is a clinical disorder and a form of abuse.

The violent shaking of an infant by a caregiver causes retinal and subdural
hemorrhages, subdural hematomas, and the onslaught of other less defined
symptoms. When diagnosing SBS, physicians must consider all symptoms and
employ the most accurate and efficient method, including β-amyloid precursor
protein immunohistochemical staining, SPECT, and MRI.

Physicians must consider factors such as time and infant neurodevelopment in

diagnosis and treatment. It is possible for symptoms of SBS to be diagnosed for a
disorder outside of abuse. There are no biomechanical models accurate enough to
recreate SBS completely.
Treatment of SBS includes drainage and SK lavage and other surgical
procedures. SBS prognosis is especially poor, leaving most infants with either fatal
or developmentally impaired outcomes.
Prevention of SBS can only come through
education of parents, and through the watchful eyes of clinical staff.
Declaration of Interest

The authors report no conflicts of interest.

The authors alone are responsible for the
content and writing of the article.
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