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Nursing Care Plan | NCP Shaken Baby Syndrome

Shaken baby syndrome (SBS) is a form of child abuse in which an adult forcefully shakes a baby or toddler by the arms, chest, or shoulders, causing the head to whiplash back and forth on the neck and leading to bleeding inside the skull from broken blood vessels. The syndrome was first identified by Dr. John Caffey (1895–1978), a pediatric radiologist, who published a landmark paper on it in 1972.

Shaken baby syndrome is a type of traumatic brain injury that results when a baby or young child is grasped by the upper body and shaken back and forth by a teenager or adult. A baby has a relatively large and heavy head in comparison to the rest of its body, and it has weaker neck muscles than older children or adults. When the baby is shaken, or its head is struck against a wall or other hard surface, its brain moves back and forth inside the skull, causing tissue to bruise and small blood vessels to break. Blood can collect inside the skull and put pressure on the brain, leading to permanent brain damage, seizures, or death.

The American Academy of Pediatrics (AAP) estimates that there are between 600 and 1,400 cases of SBS in the United States each year, though it is possible that the true number is higher because some cases are misdiagnosed as the result of accidental falls or auto accidents. What is known is that shaken baby syndrome is the most common cause of mortality and long-term disability in infants and young children due to physical abuse. The syndrome has been reported in infants as young as five days and children as old as five years, but most victims are two years of age or younger. SBS occurs in all racial groups in the United States but is more likely to be caused by males than by females. Adult males in their early twenties are the perpetrators in 65 to 90 percent of cases; most often they are the baby’s father or the mother’s boyfriend. Female perpetrators are more likely to be a teenage babysitter or nanny than the baby’s mother. The usual trigger for the abuse is crying lasting for several hours or repeated diaper soiling, although in some cases involving men, the abuser is angry because he is jealous of the attention the baby receives from its mother.

Nursing Care Plan Signs and Symptoms

The cause of SBS is brain damage resulting from bleeding beneath the skull and bruising of brain tissue due to the brain’s moving up against the inside of the skull during shaking. In some cases the brain is also damaged by loss of its oxygen supply.

The symptoms of severe SBS include:
• Bleeding into the retina of the eye
• Bleeding into the space between the brain and the layers of tissue that cover the brain
• Swelling of the head from fluid accumulating in the tissues of the brain
• Damage to the spinal cord and soft tissues of the neck
• Fractures of the ribs or other bones
• Convulsions
• Loss of consciousness

Babies who are less severely injured when shaken may have symptoms that are easy to confuse with the symptoms of flu:
• Vomiting or other flu-like symptoms without fever or diarrhea
• Crankiness and irritability over a period of time
• Poor feeding, loss of appetite
• Breathing problems
• Unusual drowsiness

Nursing Care Plan Diagnosis

The doctor’s greatest help in making a correct diagnosis of shaken baby syndrome is a description of what happened by the perpetrator or a witness. In many cases an abuser will tell the doctor that the child fell or was in a car accident, or that the abuser shook the baby trying to revive it. One important clue is that the injuries caused by SBS are usually much more severe than would be caused by a fall or other accidental head injury. The doctor can tell that a shaken baby has a closed-head injury by taking imaging studies, usually a CT scan or an MRI. X-ray studies will reveal broken ribs or other bones. Bleeding into the retina of the eye can be detected by an ophthalmologist (doctor who specializes in eye disorders). In some cases, the doctormay order laboratory tests to rule out meningitis and other infectious diseases that can affect the brain and cause a seizure or coma.

Nursing Care Plan Treatment

Children with severe injuries from shaken baby syndrome require emergency treatment, usually brain surgery to relieve pressure on the brain and respiratory support to help them breathe. Treatment of the blindness, learning disorders, mental retardation, and other long-term consequences of SBS may last for the rest of the child’s life. These children often need special education services, physical therapy, speech therapy, eye treatment, psychotherapy, and occupational therapy.

Prognosis
SBS has a high mortality rate. It is estimated that a third of the babies who are abused in this way will die; another third will suffer severe permanent injuries; and the remaining third will recover.

Nursing Care Plan Prevention

Dr. Caffey believed in the value of education to prevent at least some instances of SBS. While some abusers are people with a history of substance abuse or poor impulse control, others do not understand how much an angry adolescent or adult can harm a baby by shaking it. Various prevention strategies that are used include showing videos about SBS to new parents; encouraging pediatricians to discuss the stresses of childrearing with parents and teach them some ways to soothe a crying child; asking social workers to help identify families at risk of child abuse; instructing workers in day care centers and others who work with small children about the syndrome; and advising parents to screen babysitters or nannies very carefully before hiring them for child care responsibilities. Specific tips for managing the stress of caring for a crying infant are described in the sidebar.

The Future
It is difficult to tell whether the various preventive strategies for lowering the rate of shaken baby syndrome will have a significant effect in the years to come, as many abusive, addicted, or mentally disturbed people cannot be reached by educational measures. One hopeful development is that more doctors and nurses are aware of the syndrome and better able to diagnose it quickly.
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