Research in Child Abuse and Neglect: Shaken baby syndrome in Canada (2003)

Part of our ongoing survey of what the child abuse and neglect literature says about perpetrators. Perpetrator data is highlighted in bold.

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Shaken baby syndrome in Canada: Clinical characteristics and outcomes of hospital cases
W James King, Morag Mackay, Angela Sirnick. Canadian Medical Association. Journal. Ottawa: Jan 21, 2003. Vol. 168, Iss. 2; pg. 155, 5 pgs

Abstract (Summary)
BACKGROUND: Shaken baby syndrome is an extremely serious form of abusive head trauma, the extent of which is unknown in Canada. Our objective was to describe, from a national perspective, the clinical characteristics and outcome of children admitted to hospital with shaken baby syndrome.

METHODS: We performed a retrospective chart review, for the years 1988-1998, of the cases of shaken baby syndrome that were reported to the child protection teams of 11 pediatric tertiary care hospitals in Canada. Shaken baby syndrome was defined as any case reported at each institution of intracranial, intraocular or cervical spine injury resulting from a substantiated or suspected shaking, with or without impact, in children aged less than 5 years.

RESULTS: The median age of subjects was 4.6 months (range 7 days to 58 months), and 56% were boys. Presenting complaints for the 364 children identified as having shaken baby syndrome were nonspecific (seizure-like episode [45%], decreased level of consciousness [43%] and respiratory difficulty [34%]), though bruising was noted on examination in 46%. A history and/or clinical evidence of previous maltreatment was noted in 220 children (60%), and 80 families (22%) had had previous involvement with child welfare authorities. As a direct result of the shaking, 69 children died (19%) and, of those who survived, 162 (55%) had ongoing neurological injury and 192 (65%) had visual impairment. Only 65 (22%) of those who survived were considered to show no signs of health or developmental impairment at the time of discharge.

INTERPRETATION: Shaken baby syndrome results in an extremely high degree of mortality and morbidity. Ongoing care of these children places a substantial burden on the medical system, caregivers and society.

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Results

The 364 children identified with SBS (median age 4.6 months, range 7 days to 58 months), 56% of whom were male, are presented by pediatric centre in Table 1. Clinical features and past medical history (Table 2) revealed nonspecific presenting complaints (seizure-like episode, decreased level of consciousness or respiratory difficulty), and most of the children (95%) did not have an underlying chronic medical or physical problem. The 307 charts containing perinatal information (mean gestation 37 weeks, mean birth weight 2880 g) noted a difficulty with the pregnancy for 16% of the children (88% were born at < 36 weeks' gestation) and 17% were discharged from hospital after their mother.

Of the 364 children, 86% had subdural effusion, 42% had cerebral edema and 76% had retinal hemorrhages, of which 83% were bilateral (Table 3). Retinal hemorrhage was associated with more severe injury such as death (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.9-2.6), subdural hemorrhage (OR 3.2, 95 % CI 2.8-3.5) and neurological injury (OR 1.7, 95% CI 1.3-2.0). Cervical spine injuries were infrequently recorded (4%). The Glasgow Coma Scale on admission was documented for 86 (24%) children (median age 5.2 months, range 14 days to 38.6 months) with a median value of 6 (normal >=13 on a scale of 3-15). Imaging studies performed included CT scanning (96%) and MRI (24%). In 98% of cases, an abnormality was reported: subdural hemorrhage/effusion (CT: 79% of scans, MRI: 87% of images), subarachnoid hemorrhage/effusion (CT 32%, MRI 23%) and/or intracranial hemorrhage (CT 63%, MRI 44%). A skeletal survey, that is, a comprehensive radiographic evaluation, was performed in 301 children (82%) and a bone scan in 105 children (29%), as a result of which in 46% of cases and 51 % respectively an abnormality was reported.

The mean household size was 3.4 people, and the mean number of children per family was 1.7. The mean age of the primary caregiver was 23.7 years (range 15-40 years), with 68% of the parents being either married or living as common-law spouses. Incomplete chart documentation did not allow an estimate of socioeconomic status, employment history or level of education. The medical chart documented poverty (undefined) in 87 families (28%), and an unsafe or inappropriate environment was noted in 73 (20%). A past medical history and/or clinical evidence of previous maltreatment was noted in 220 children (60%), and 80 families (22%) had had previous involvement with child welfare authorities. The biological father (43%), followed by the biological mother (26%), was most often identified as the responsible caregiver with the child at the time of the injury, even though the primary caregiver was usually the biological mother (67%), followed by "other" (35%: 18% babysitter, 17% unknown) and then the biological father (18%).

The perpetrator was identified in 240 cases (66%), with the biological father being the most common (50%), followed by the stepfather/male partner (20%) and then the biological mother (12%). Overall, the perpetrator was male in 72% of the cases; 15% of perpetrators had a previous charge or suspicion for maltreatment of a child in their care. Although the degree of certainty about the perpetrator was considered definite in 96 (40%) cases (where the perpetrator was seen to shake the child or admitted to the assault), this was not associated with the presenting complaint, injury, previous maltreatment or outcome. In almost two-thirds of cases (64%), there was an ongoing police investigation, 26% of the perpetrators had criminal charges laid and 7% were convicted for the assault.

Sixty-nine children died (19%) as a direct result of the shaking injury. Children who died were slightly older than survivors (median age 7.8 v. 4.3 months), and death was associated with a decreased level of consciousness (OR 3.2, 95% CI 2.4-4.0) or respiratory difficulty (OR 2.5, 95% CI 1.8-3.2) on presentation; bruising (OR 2.3, 95% CI 1.5-3.1) on examination; and cerebral edema (OR 3.9, 95% CI 3.1-4.7) or subdural hematoma (OR 2.5; 95% CI 1.7-3.3) on imaging. Of the 295 survivors, only 65 (22%) were felt to be "well" (absence of health or developmental impairment) at the time of discharge, with 162 (55%) having a persistent neurological deficit and 192 (65%) having visual impairment. The PCPC scale, assessed at both the time of admission and at discharge, revealed that only 21 children (7%) were rated "normal," whereas 143 children (48%) had a moderate or severe degree of disability and 34 (12%) were in a coma or vegetative state. Of the survivors, 251 (85%) required ongoing multidisciplinary care. Review of placement at discharge revealed that 42 % of the children were taken into foster care, whereas 43% returned home with their biological parents) and a further 14% were placed with a close family member.