SQU Med J, August 2011, Vol. 11, Iss. 3, pp. 322-327, Epub. 15th Aug 11
Submitted 18th Jan 11
Revision ReQ. 5th Mar 11, Revision recd. 4th Apr 11
Accepted 4th May 11

Child abuse is a global problem that presents in the forms of physical abuse, sexual abuse, neglect, and emotional 
abuse.1 Children subjected to various form of abuses 
can develop emotional, cognitive and physical 
conditions. The magnitude of abuse in children is 
often underestimated either because the sequelae 
of the abuse, or their young age, makes the victims 
incapable of articulating what happened to them.2

Shaken baby syndrome (SBS) is one form of 
abuse that predominantly impacts neurological 
functioning, but it can also have multiple impacts 
on neurocognitive functioning. SBS is a relatively 
new diagnosis that was first described by Guthkelch 
in 1971.3 The first name used to describe it was 

'whiplash˗shaken infant syndrome'. Other terms 
used were ‘shaken infant syndrome’, ‘shaken impact 
syndrome’, ‘infant whiplash˗shake syndrome’, 
‘abusive head trauma’, and ‘inflicted/non˗accidental’ 
or ‘intentional head injury’. In medical literature, 
SBS is the most widely used and recognised term;4 

however, the term is not widely accepted. For 
example, the American Academy of Pediatrics 
prefer ‘abusive head trauma’ which is broad and 
inclusive of all mechanisms of injury.5 

The number of articles on SBS has significantly 
increased in recent years.1 It is evident from the 
literature review that no publications on SBS have 
emerged from Arabian Gulf states. This region has 
a population structure with a large proportion of 

1Department of Child Health, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman; Departments of 1Child 
Health and 2Ophthalmology, Sultan Qaboos University Hopsital, Muscat, Oman.
*Corresponding Author email: munasa@squ.edu.om

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:مفتاح الكلمات

aBstract: Shaken baby syndrome (SBS) is a form of abuse that is characterised by brain injury. Because of the 
subtle and yet debilitating neurobehavioural impairment which ensues, SBS represents a diagnostic dilemma for 
attending clinicians. The situation is made worse by the young age of the affected child who may not be capable 
of explaining what happened. SBS has been reported in many parts of the world. To our knowledge, there is a 
dearth of literature on the topic from Arab/Islamic countries. This article attempts to shed light on the syndrome 
by reviewing information on the aetiology of SBS, as well as on its diagnosis and the reasons for delayed diagnosis. 
The central aim of this review is to increase awareness of SBS so that enlightened policies for prevention and 
intervention could be developed in the region and particularly in Oman.

Keywords: Shaken baby syndrome; Child abuse

REVIEW

Shaken Baby Syndrome as a Form of Abusive 
Head Trauma

*Muna Al-Saadoon,1 Ibtisam B. Elnour,1 Anuradha Ganesh2



Muna Al-Saadoon, Ibtisam B. Elnour, Anuradha Ganesh

review | 323

children and adolescents; however, despite rapid 
economic growth in the region, no child protection 
agencies have been established. Anecdotal and 
impressionistic observations reveal that something 
akin to SBS is seen in the region. The aim of this 
article is to synthesise some of the relevant literature 
and shed light on the intricacies of SBS.

r i s k fa c t o r s a n d c a u s e s 
The victims of SBS are usually under one year-
old and thus helpless and unable to protect 
themselves.6 However, there are a few case reports 
of older children with closed head injury with 
severe neurologic impairment and ophthalmic 
findings suggestive of a shaking injury.7 Infants 
and children are particularly vulnerable to violent 
shaking because of their relatively large head and 
weak cervical musculature.8,9 These factors, together 
with the incompletely fused sutures and relatively 
large volumes of cerebrospinal fluid in young 
children, allow for greater movement within the 
cranial vault, resulting in potentially severe damage 
to the immature incompletely myelinated brain.8,9 
Perceived disruptive behavior such as unwarranted 
and unremitting crying spells have been suggested 
as being important precursors of abuse in the form 
of ‘shaking’ by significant figures in the child’s life.10

Perpetrators of SBS are often male with the 
biological father being the most common abuser.1 
The literature also suggests that stepfathers or male 
partners may also be involved in such heinous 
acts. Female babysitters are also known to be 
perpetrators of SBS, as well as biological mothers. 
Overall, the perpetrator was male in 72% of cases.1,11 
There is speculation that males, due to their greater 
physical power, are more likely to cause SBS when 
they ‘shake’ children.1 One might argue that females 
might be more tolerant to babies’ needs and 
demands. In contrast, males are perhaps more easily 
provoked by a crying baby. On the whole, there is 
evidence to suggest that both parties contribute to 
this abuse. The distressed child may cause stress to a 
significant figure thus provoking them into abusing 
the child. There is also evidence to suggest that 
individuals who are prone to anger and marked by 
explosive personality disorder are likely to commit 
such acts.10,12 

m e c h a n i s m o f i n j u r y
SBS is an extremely serious form of abusive head 

trauma that occurs when a child is held by the torso or 
the extremities and subjected to violent shaking that 
results in rapid head movements with acceleration, 
deceleration and rotational forces, with or without 
impact. It results in a unique constellation of 
intracranial, intraocular and skeletal injuries.7,13 The 
most common intracranial abnormality detected is 
subdural haematoma. Children with SBS are often 
found to have retinal haemorrhage.2,11,14 Fractures 
of the ribs where the child is grasped, or long bone 
fractures when child is held, might also be detected. 
Cervical spine injuries are rarely recorded in cases 
of SBS.11,13 

Diagnosis 
SBS is known to be difficult to detect and diagnose. 
Clinicians should use their own clinical judgment 
as each individual case is different and needs to be 
considered carefully on its own evidence. According 
to estimations from the World Health Organization 
(WHO), in 2002 almost 31,000 children aged <15 
years died worldwide as a result of homicide.15 

Despite advances in investigative neurology, abusive 
head trauma is commonly under-recognised and 
remains a diagnostic challenge. The diagnosis of 
SBS must be considered in any infant or young child 
who collapses with no obvious causes. Clinicians 
must maintain a low threshold of suspicion for 
considering this diagnosis.16 The diagnosis of SBS is 
usually made following a careful medical and social 
history taking. This ought to be supplemented by 
appropriate investigations. Children with SBS are 
often seen first at emergency departments (EDs). 
The incidence rates of child abuse at EDs ranges 
from 2–10%; the detection rate might increase 
if medical staff were systematically vigilant 
about the possibilities of abuse in each child they 
encountered.17 

A comprehensive history of the presenting 
complaints is an essential component of the 
diagnostic process. Infants with SBS present to 
hospital with a variety of symptoms ranging from 
vomiting, poor feeding and lethargy to convulsions, 
apnoea and death. Symptoms occur immediately 
after the insult, thus recording the timing of the 
symptoms is very important.18,19 Not all infants are 
acutely ill at presentation, and in some cases the 
absence of either a history or external signs of injury 
may delay diagnosis. It is also important to note that 



Shaken Baby Syndrome as a Form of Abusive Head Trauma

324 | SQU Medical Journal, August 2011, Volume 11, Issue 3

o p h t h a l m i c m a n i f e s tat i o n s o f 
s b s 
Ocular manifestations of SBS, characteristically 
retinal haemorrhages, are seen in 85% of cases 
and are bilateral, diffuse and multilayered.20  
A large study from the USA concluded that retinal 
haemorrhages in young children are associated 
with a high likelihood of abuse.21 Other ocular 
manifestations of SBS include blood-filled schisis 
cavities and circumlinear perimacular folds.22 

Papilloedema may also be noted. The anterior 
segments are usually unremarkable in SBS. The 
pathogenesis of the ocular findings is the same as 
the intracranial manifestations, namely repetitive, 
to and fro acceleration˗deceleration forces, that 
cause a displacement of vitreous volume and a 
resultant traction on the retina and retinal vessels 
resulting in rupture and haemorrhage. 

The presence of retinal haemorrhages implies 
a shaking aspect to the trauma; these are rarely 
seen in victims of road traffic accidents who have 
skull fractures and intracranial bleeding due to 
direct trauma.23 Minor falls and blows, so common 
in the domestic context, do not cause retinal 
haemorrhages. Seizures are also not known to result 
in retinal haemorrhages.14 Differential diagnoses of 
retinal haemorrhages in this age group of children 
includes birth trauma, severe life threatening 
accidental head injury, coagulopathies, sepsis and 
vasculitis. With the exception of birth trauma, 
retinal haemorrhages in the other conditions tend 
to be few and localised.14 

m a n a g e m e n t 
Where abusive head trauma is a possibility, a strategy 
discussion involving police and the children’s 
social carer should be held to decide whether to 
initiate enquiries and then a criminal investigation. 
Children are frequently referred to a specialist 
centre where paediatric neuroscience resources are 
available. It is important that such specialists are 
supported by general paediatricians who are able to 
liaise with the local and statutory child protection 
teams and participate fully in procedures for 
safeguarding the child. Laboratory investigations 
are necessary in order to exclude other medical 
conditions such as rare metabolic diseases (glutaric 
aciduria), coagulation disorders, and infective 
encephalopathy.24,25 Other investigations should 
include a septic screen to exclude infection—as 

shaking alone without impact injury can produce 
the symptoms seen in children with shaken baby 
syndrome.9 There are a number of features in the 
children and parents that may increase suspicion 
that harm has been done; these are triggering 
factors such as “crying, temperamental behaviour, 
toileting problems” and a history of previous 
or recent injury.19 Birth history, developmental 
milestones, and vitamin K status are also important 
to note. In most cases where a history of injury is 
given, it is reported to be of a minor nature and 
is not consistent with the severity of the infant’s 
condition. A review of checklists of risk indicators 
for child abuse in emergency departments, shows 
that three history items are worthwhile considering: 
delay in seeking medical advice, an inconsistent 
history, and clinical findings that are incongruent 
with the history narrated by the accompanying 
adult.17 

Physical examinations for SBS should include all 
of the body looking for signs of external injuries such 
as skin bruising, abdominal injuries and skeletal 
injury such as fractures of ribs or long bones.19 The 
child conscious level, neck and cervical spinal cord 
injuries should be evaluated together with the need 
for resuscitation. It is also necessary to look for 
signs of intracranial bleeding such as fullness of the 
fontanelle and increased head circumference. Fundi 
should be examined by the clinician/paediatrician, 
and as soon as possible by an experienced 
ophthalmologist, in order to exclude eye injury 
including retinal haemorrhage. Neuro-imaging is 
the definitive diagnostic investigation and should 
be performed whenever SBS is suspected. The 
first line investigation in suspected abusive head 
trauma is a computed tomography (CT) head scan 
followed by a magnetic resonance imaging (MRI) 
scan. MRI is a more sensitive method of detecting 
small intracranial collections, especially in areas less 
well seen on CT.4 Cerebral oedema and ischaemic 
changes are also well demonstrated by diffusion 
weighted MRI. A skeletal survey, including skull 
films, should be performed in all children less than 
three years old where physical abuse is suspected.19 

The clinical diagnosis is usually based on a patient 
history that does not explain the clinical features; 
it is supported by the findings of the physical and 
retinal examinations and the brain MRI.



Muna Al-Saadoon, Ibtisam B. Elnour, Anuradha Ganesh

review | 325

subdural collections could be associated with 
meningitis, urine screening for toxicology, and a 
metabolic screen. It is also important to do a full 
blood count, repeated after 24–48 hours, which may 
demonstrate a rapidly falling and low haemoglobin 
level.16 The role of the ophthalmologist is often to 
assist in the diagnosis of SBS by examining the child 
for retinal haemorrhages. Retinal haemorrhages 
often resolve spontaneously and do not require 
therapy; however, extensive, non˗resolving vitreous 
haemorrhage or retinal detachment might mandate 
surgical intervention. Careful follow˗up is desirable 
to document and treat sequelae which may be 
consequent to neurologic or ocular damage.26 

o u t c o m e 
The available evidence suggests that around one 
third of severely shaken infants subsequently die as 
the result of being shaken.1,4,26 This rate is 6% to 12% 
higher than that for accidental head injuries in a 
similar age range.26 The syndrome has an extremely 
high degree of morbidity with 60% of survivors 
having a moderate or greater degree of disability.11 
The victims of SBS display a wide range of 
neurological sequelae.26 These include cognitive and 
behavioral disturbances, cerebral palsy, blindness, 
and epilepsy.4 It is well known that outcomes due 
to head injury are more severe in abused children 
compared to injuries resulting from unintentional 
accidents.2,27 The functional prognosis of children 
marked by SBS is likely to be poor. This partly 
reflects the silence on the part of the parent who 
may conceal the shaking incident since this might 
lead to legal prosecution. The victim themselves 
are likely to be rendered incapable of ‘complaining’.  
The very fact that the incident is associated with 
neurological dysfunction, makes it likely that some 
residual though subtle impairment is likely to be 
chronic and have severe consequences in term of 
quality of life.28,29

b i o m a r k e r s a s t h e f u t u r e 
h o p e f o r r a p i d s c r e e n i n g o f 
n e u r o t r a u m a 
Many cases of brain injury can present with clinically 
non-specific symptoms such as vomiting, poor 
feeding and irritability.11 It is worthwhile noting that 
such a presentation may be indistinguishable from 
other childhood maladies such as gastroenteritis 
or respiratory tract infection.11 The history will be 

misleading and clues to the cause of the head injury 
will be omitted. All of these factors can contribute 
to a delayed/missed diagnosis. Many research 
studies are underway to find biological makers of 
SBS. Despite the importance of such biological 
markers, there is, as yet, no study supporting their 
validity and reliability.30 The clinician’s vigilance still 
remains the best option.

d i l e m m a o f s b s 
The diagnostic dilemma of this syndrome is three-
fold. The first is that the shaking is not witnessed 
and even when a perpetrator confesses the full truth 
of the incident most likely is not fully revealed. This 
results in questions about whether the shaking 
event is the cause of the clinical and pathological 
findings in the affected children.1,31,32 However, it is 
suggested that mechanical shaking is the primary 
reason for retinal bleeding as researchers found no 
difference in the extent, type, or frequency of retinal 
bleeding between patients diagnosed with SBS who 
exhibited signs of direct impact trauma versus those 
who did not.14 The finding of positive correlation 
between retinal haemorrhages and intracranial 
injury may support the theory that mechanical 
shaking and its direct effect on the globe and orbit 
has a major role in the pathogenesis of SBS.7,14 Such 
studies and other results support the view that 
shaking alone is able to produce the symptoms seen 
in inflicted traumatic brain injury.18 

The second factor is the possible medical 
conditions that could have similar presentations 
to abusive head trauma such as birth and 
other accidental injuries, brain congenital 
malformations, genetic and metabolic conditions, 
hematological disorders, infectious diseases, 
toxins, complications of surgical intervention, and 
nutritional deficiencies.19 Short falls are the primary 
cause of injury given by care providers in most of 
the cases of SBS. Studies found that minor falls  
(< 4 feet) do not cause serious injury in children, 
except for epidural haematoma whereas subdural 
and/or subarachnoid haemorrhage are seldom 
seen and retinal haemorrhage are virtually never 
seen in short falls.2 Such findings minimise the 
possibility of a short fall being the causative factor 
of the retinal and intracranial findings of SBS. The 
possibility of a neonate developing intracranial 
bleeding after normal delivery is not rare and the 
potential for serious injury following a fall from 



Shaken Baby Syndrome as a Form of Abusive Head Trauma

326 | SQU Medical Journal, August 2011, Volume 11, Issue 3

variant of non˗accidental head injury in infants. 
Dtsch Arztebl Int 2009; 106:211–7. 

7. Salehi˗Had H, Brandt JD, Rosas AJ, Rogers KK. 
Findings in older children with abusive head injury: 
Does shaken˗child syndrome exist? Pediatrics 2006; 
117:e1039–44. 

8. Case ME, Graham MA, Handy TC, Jentzen JM, 
Monteleone JA, National Association of Medical 
Examiners Ad Hoc Committee on Shaken Baby 
Syndrome. Position paper on fatal abusive head 
injuries in infants and young children. Am J Forensic 
Med Pathol 2001; 22:112–22.

9. Alexander R, Sato Y, Smith W, Bennet T. Incidence 
of impact trauma with cranial injuries ascribed to 
shaking. Am J Dis Child 1990; 144:724–6. 

10. Talvik I, Alexander RC, Talvik T. Shaken baby 
syndrome and a baby’s cry. Acta Paediatr 2008; 
97:782–5. 

11. King WJ, Mackay M, Sirnick A. Canadian Shaken 
Baby Study Group. Shaken baby syndrome in 
Canada: Clinical characteristics and outcomes of 
hospital cases. CMAJ 2003; 168:155–9.

12. Barr RG, Trent RB, Cross J. Age-related incidence 
curve incidence curve of hospitalized shaken baby 
syndrome cases: Convergent evidence for crying as 
a trigger to shaking. Child Abuse Negl 2006; 30:7–16.

13. Caffey J. On the theory and practice of shaking 
infants. Its potential residual effects of permanent 
brain damage and mental retardation. Am J Dis 
Child 1972; 124:161–9.

14. Morad Y, Kim YM, Armstrong DC, Huyer D, Main M, 
Levin AV. Correlation between retinal abnormalities 
and intracranial abnormalities in the shaken baby 
syndrome. Am J Opthalmol 2002; 134:354–9. 

15. Butchart A, Phinney HA, Main M, Fürniss T, Kahane 
T. Preventing Child Maltreatment: A guide to taking 
action and generating evidence. WHO: Geneva, 
2006. 

16. Royal College of Pediatrics and Child Health. Child 
Protection Companion.  London: RCPCH, 2006. 
From: www.rcpch/Child Protection Companion /1st 
Edition/April 2006 Accessed: Apr 2011.

17. Louwers EC, Affourtit MJ, Moll HA, de Koning HJ, 
Korfage IJ. Screening for child abuse at emergency 
departments: A systemic review. Arch Dis Child 
2010; 95:214–18. 

18. Starling SP, Patel S, Burke BL, Sirotnak AP, Stronks 
S, Rosquist P. Analysis of perpetrator admissions 
to inflicted traumatic brain injury in children. Arch 
Pediatr Adolesc Med 2004; 158:454–8. 

19. Chiesa A, Duhaime AC. Abusive head trauma. 
Pediatr Clin North Am 2009; 56:317–31.

20. Levin AV. Retinal haemorrhages and child abuse. 
In: David TJ, Ed. Recent Advances in Paediatrics. 
London: Churchill Livingstone, 2000. Pp. 151–219. 

21. Kivlin JD. A 12˗year ophthalmologic experience with 

a short distance is not common, but can happen. 
This necessitates consideration of these two 
possibilities when contemplating the diagnosis of 
abusive head trauma.11,33,34 Such medical mimics 
of SBS, compounded with an unreliable history, 
may make the diagnosis challenging, especially in 
children with absent external injuries as is the case 
in 40% of affected children.11 The third factor is the 
variable results of biomechanical studies of SBS 
injury which have to take into account the levels of 
rotational velocity, acceleration of the head, velocity 
from manual shaking, the presence of hypoxia and 
the associated potential injuries to the brain and 
cervical spine.35‒39

Conclusion 
It is important to raise awareness about abusive 
head trauma among paediatricians and general 
practitioners in Oman. Doctors providing health 
services to children should be alert to the non- 
specific symptoms of SBS in order to reach an 
early diagnosis. The importance of comprehensive 
history taking and complete physical examination 
in young children with suspected abusive head 
injury is vital. The multidisciplinary approach is a 
key issue in managing such cases in order to rule 
out medical mimics of abusive head injuries and 
better safeguard the child. Educational efforts to 
raise awareness about SBS should be instituted. 

References
1. World Health Organization. World Report on 

Violence and Health. Geneva: WHO, 2002. 

2. Reece RM, Sege R. Childhood head injury. Arch 
Pediatr Adolesc Med 2002; 154:11–15. 

3. Guthkelch AN. Infantile subdural haematoma and 
its relationship to whiplash injuries. BMJ 1971; 
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