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Shaken Infant Syndrome

Shaken Infant Syndrome Shaken Infant Syndrome (also known as Shaken Baby Syndrome, SBS) is a relatively new term in the medical world. Simply put, it is the collective name of the symptoms produced when an infant is shaken violently or has sustained some type of head trauma. Any type of trauma to the head or cranial region results in some negative response to the body’s homeostatic system, in an infant or child this is especially true. An infant or child’s skull is disproportionately larger than that of a fully developed adult. This usually results in a higher susceptibility to head and neck injury. To understand how SBS effects the human body’s homeostatic system it must first be established what happens to be diagnosed with SBS. The majority of cases are a result from an infant or small child being shaken vigorously back and forth. Cases have been documented from falls or accidents ; however, it must be noted that this is a relatively small number. For the purposes of the scope of this paper, those results will be ignored. Shaken Baby Syndrome is a term used to describe the constellation of signs and symptoms resulting from violent shaking or shaking and impacting of the head of an infant or small child. When a small child or infant is shaken the head will act as a pendulum perched on the neck. The neck muscles are not fully developed yet so the head can not be held in place. The child’s skull is not yet fully developed at this point. The dura mater has not yet firmly attached itself to the skull since the sutures in the skull have not fully fused together. The skull is designed like this to allow for the future growth of the body and brain. When the head is snapped back and forth the brain can “rattle” inside the skull causing extradural, subdural, and subarachnoid hemorrhages that are sometimes referred to as extra-axial hemorrhages . Extra-axial hemorrhages indicate that these injuries occur outside the substance of the brain itself. Other injuries that can occur are damage to the neck, spine, and possible retinal hemorrhages or detachment. Extradural, subdural, and subarachnoid hemorrhages are best understood by reviewing the anatomy of the meninges. The meninges are divided into three layers: the dura mater, arachnoid layer, and pia mater. The dura mater lines the inner surfaces of the skull and forms partial divisions in the cortex of the brain. The dura mater is attached to the skull, particularly at the cranial sutures of the bones that make up the skull. In infants and small children this attachment has not yet taken place. The space between the skull and the dura mater is the extradural space. A hemorrhage into this space is referred to as an extradural hemorrhage. These hemorrhages are usually the result of a tear in a meningeal artery. An extradural hemorrhage is more prevalent in small children because the dura mater lining has not yet firmly attached itself to the junctures in the skull. When the head snaps back and forth the brain will bounce off the skull. This causes bruising or tearing to the dura mater or the meningeal artery. When the body recognizes that bruising has occurred the body’s natural healing abilities take effect. The first thing that the body will do will be to release histamines to increase to permeability of the capillaries in the area. This will cause the area to swell and attempt to repair itself. When the body does this the swelling creates pressure on the brain by pushing against the cortex since the skull is an unforgiving medium. When the meningeal artery is torn it releases a large about of blood into the space between the dura mater and skull. The body will react by releasing thromoboplastin from the damaged cells. This chemical starts the body’s chain reaction to clot the blood. In 30-60 minutes the blood clot is formed and begins to act as a biological stitch. The down side to this is there is a good possibility of parts of the blood clots breaking loose and causing arterial restriction in the achnoid layer leading to a possible subdural hemorrhage. An extradural hemorrhage by itself is a life threatening condition that is usually only treatable by immediate surgery to relieve the pressure on the brain. Even when the surgery is performed in time permanent brain damage can result. Seizures have been known to persist for up to six months after the injury or appear up to two years after surgery. The middle layer of the meninges is the arachnoid. It is a thin membrane similar in appearance to a spider's web. The potential space between the dura mater and the arachnoid is the subdural space. A hemorrhage into this space is referred to as a subdural hemorrhage. These hemorrhages are usually the result of a tear in one of the small veins, which traverses the space between the brain and the dura mater. Here the damage done is much the same as an extradural hemorrhage. The pia mater is the innermost layer. It is the most delicate and adhered directly to the surface of the brain. The space between the arachnoid and the pia mater is the subarachnoid space. A hemorrhage into this space is referred to as a subarachnoid hemorrhage. A hemorrhage in this area of the brain is not as severe as an extradural or subdural hemorrhage. When the bleeding occurs in this area the blood is released into the brain so there is not a much swelling. Increased activity can cause more bleeding if the hemorrhage has not been stopped. If left untreated this condition can result in permanent brain damage and possible stroke. Correction by surgery to drain the blood off the brain is usually required. Mentioned earlier was the possibility of spinal injury as a result of violently shaking a baby. The vertebrae that give flexibility to the neck are the top five in the spinal column, these are the cervical vertebrae. There are eight pairs of nerves in this region of the spine, called the cervical nerves. These nerves control facial muscles, eye movement, and most importantly breathing among other functions. When a child is shaken back and forth the cervical vertebrae are snapped and compressed against each other in rapid succession. During this action the intervertebral disc is compressed and sometimes crushed by the force of the vertebra pressing against it. When the disc is destroyed the vertebrae themselves absorb the impact. When vertebrae make contact in this manner there is a high probability that they will chip allowing bone fragments to penetrate the spinal column. Bleeding, or fluid accumulation and swelling, can occur within the spinal cord or outside the spinal cord but within the spine. The accumulation of blood or fluid can compress the spinal cord and damage it. When the spinal cord is damaged above the fifth cervical vertebrae all nervous functions below the injury site are effectively halted. The ventral and dorsal roots that control the reflexive action for breathing are located in this region. A retinal hemorrhage is the last type of injury related to shaken baby syndrome that will be discussed. This type of trauma is minor compared to the others discussed. If the child survives the other injuries this particular one will present its own host of problems later on in life. The retinal hemorrhage is caused when the head is jerked backwards after reaching full extension in a forward motion. When the head begins its movement back, following the laws of physics the eyeball tends to continue in a forward motion. A child’s muscle control of the eyeball is not as strong as an adult’s so the muscles can not keep the eyeball in place. The jerking motion tugs the optic nerve taut stressing the nerve and the blood vessels contained within it. The nerve may tear or separate under the stress, but more often the blood vessels within the nerve are torn. When torn they will bleed into the retina and the optic nerve. When the body sends in the clotting agents the will begin to clot the blood in the retina and the nerve. The clotting in the nerve can cause damage to the nerve leaving it permanently damaged. The clotting inside the retina will cause blind spots and possible total blindness. Shaken baby syndrome evokes the body’s homeostatic response system for injuries. In most cases the response to the injury from the body tends to upset the balance even more. The body’s healing system is primarily designed for healing external injuries or injuries to the extremities. It is in these cases that the body makes its own anatomical splint by causing a broken finger to swell to immobilize it. When the tissue in the cranium is swollen it results in crushing pressure on the brain causing the body to attempt to further supplement the injury site. The body will send in more of its healing resources further aggravating the problem. This is one of the few instances of when the body’s homeostatic system will defeat itself in almost every instance. Bibliography: Dr. John Lancon in response to questions posed by The National Center on Shaken Baby Syndrome Definition provided by Robert Reece, M.D., clinical professor of Pediatrics at the Tufts University School of Medicine Definition provided by John Lancon, M.D., Assistant Professor of Neurosurgery at the University of Mississippi Medical Center, Jackson, MS. Information provided by WebMD at http://webmd.lycos.com Chiras, Daniel D. Ph.D., University of Denver Human Biology Health, Homeostasis, and the Environment 3rd edition 1999 Peinkofer, Jim Pinekofer Associates http://members.aol.com/piney94/sis1.html Provider of all images American Academy Of Pediatrics Volume 108, Number 1 July 2001, pp 206-210 Shaken Baby Syndrome: Rotational Cranial Injuries—Technical Report (T0039)

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