Shaken Baby Syndrome

Nickolaus J. Miehl 
J Foren Nurs.  2005;1(3):111-117.  ©2005 International Association of Forensic Nurses

Abstract and Introduction

Abstract

haken baby syndrome (SBS) is a violent act of abuse that can cause myriad neurologic, cognitive, and other functional deficits. In the most serious cases, death can result. Health care practitioners, child care providers, and parents must be educated on the signs of SBS. Cases should be thoroughly reviewed and prevention strategies developed to prevent future incidents.

Introduction

The maltreatment of children, including nonaccidental trauma, continues to be problematic for children, families, and other care providers. Despite efforts of child protective services and health care providers alike, the maltreatment of children remains an all too common occurrence. According to Tenney-Soeiro and Wilson (2004), an estimated 903,000 children were victims of maltreatment in 2001. It is of particular concern when the maltreatment ends with a fatality; that same year, an estimated 1,300 child fatalities occurred as a direct result of maltreatment. Of these fatalities, 41% occurred in children under the age of 1 year, and 85% occurred in children under age 6. The best estimates on the incidence of physical abuse in the causation of child fatalities ranges from 19% to 30% (Tenney-Soeiro & Wilson, 2004; National Clearinghouse on Child Abuse and Neglect Information, 2004) (see Figure 1).

Figure 1. 

Child Abuse and Neglect Fatalities by Maltreatment Type, 2002
Reproduced with permission from the National Clearinghouse on Child Abuse and Neglect Information. (2004). Child abuse and neglect fatalities: Statistics and interventions.

Challenges in detecting and reporting SBS cases have been difficult to overcome, thus the true incidence rate is unclear. There is no centralized reporting system for SBS which can lead to the underreporting of this particularly severe form of maltreatment. Additionally, SBS is typically not an isolated event; rather it may be part of a more chronic pattern of maltreatment. SBS victims can present with a wide range of symptoms, from generalized flu-like symptoms to unresponsiveness with impending death.

Obvious signs of maltreatment may not be present. Detecting this type of maltreatment requires the careful attention of the health care practitioner in the community-based, primary care, and acute care settings to ensure the proper care of the victim, appropriate counseling for the family, reporting of correct information to law enforcement officials, and prevention of repeat occurrences.

History of Shaken Baby Syndrome

n 1946, Dr. John Caffey, a pediatric radiologist, first described what he termed "whiplash shaken-baby syndrome," a cluster of infantile subdural and subarachnoid hemorrhage, traction-type metaphyseal fractures, and retinal hemorrhage (Caffey, 1974). This cluster of injuries was noted in many infants despite the lack of any external injury. Dr. Caffey attributed these injuries to the developmental differences in the infants' heads as compared with adults' heads. In infancy the head comprises approximately 25% of the total body weight, as compared to approximately 10% of the total body weight in adults. Additionally, infants' weak neck muscles, poor motor control, and a higher concentration of water in the brain matter render them more susceptible to injury through violent shaking.

Epidemiology of Shaken Baby Syndrome

According to the American Academy of Pediatrics (AAP) Committee on Child Abuse and Neglect (2001), head injuries are the chief cause of traumatic death and the leading cause of child abuse fatalities. Additionally, homicide is the leading cause of injury-related fatalities in children under 4 years of age. Serious injuries in infants, notably those resulting in death, are rarely accidental unless there is a clear cause for the injuries, such as trauma resulting from a motor vehicle incident. When uncomplicated documented severe trauma (those resulting in skull fractures) were excluded, 95% of serious intracranial injuries and 64% of all head injuries in infants younger than 1 year were attributable to child abuse (Billmire & Meyers, 1985).

The majority of all cases of SBS are limited to children under 3 years of age (Duhaime, Christian, Rorke, & Zimmerman, 1998). Small children and infants are at a high risk due to their small size in comparison to the adult perpetrator. The act of shaking that can lead to SBS "is so violent that the individuals observing it would recognize it as dangerous and likely to kill the child" (AAP, 2001, p. 206). Shaking generally is attributed to the perpetrator's level of tension and frustration, often generated by an infant's crying or irritability.

Risk factors for nonaccidental injuries in children and infants include:

1. Young parental age
2. Unstable family environment
3. Low socioeconomic status
4. Infant prematurity or disability
5. Unrealistic child-rearing expectations
6. Rigid attitudes and impulsivity
7. Feelings of inadequacy, isolation, or depression
8. Negative childhood experiences including neglect or abuse

Additionally, parents or caretakers who have been involved with substance abuse and/or domestic violence may be at a higher risk for inflicting SBS. Societal factors, such as the general acceptance of violence on television, radio, and video games may also have a strong correlation with child maltreatment (Thomas, Leicht, Hughes, Madigan, & Dowell, 2003).

Parents may not be aware of the basic needs and normal development of their infant. This can lead to a role strain due to unrealistic expectations of the infant and a poor understanding of the infant's developmental level and abilities. Fulton (2000) notes that infants can spend up to 20% of their awake time crying. To the parents and caretakers of the infant, he or she may seem inconsolable, and frustration can quickly build. This may lead to the physical shaking of the infant in an attempt to calm the baby. Episodes of shaking are directly proportional to the degree of frustration felt by the parent or caretaker, and parents are often the perpetrators of abuse resulting in a child fatality (Tenney-Soeiro & Wilson, 2004). Men outnumber women as perpetrators of shaking by a 2:1 ratio, including fathers, step-fathers, and boyfriends (Keenan & Runyan, 2001). Caretakers, including babysitters, are now being examined as possible contributors to SBS (Fulton, 2000). Risk factors of caretakers contributing to SBS include immaturity, young age, and lack of life experience.

The basis for the diagnosis of inflicted injury is a physical examination that conflicts with the patient's history. The following situations should alert health care providers to the possibility of abuse:

1. Any infant or child who presents with a history that is not plausible or consistent
2. The presence of a new adult partner in the home
3. A history of delay in seeking medical attention
4. A previous history or suspicion of abuse
5. The absence of a primary caretaker at the onset of injury or illness
6. Physical evidence of multiple injuries at varying stages of healing
7. Unexplained changes in neurologic status, unexplained shock and/or cardiovascular collapse

Three categories are identified for caretaker explanations of the child's injuries (Coles & Kemp, 2003). The first category includes explanations of the child not being well including general malaise, fever, nausea, vomiting, having a fall, or being dropped. The second category consists of dangerous use of household objects, including appliances and toys; rough play; or no explanation of the events leading to the injury. Over time, the parent or caretaker may or may not offer an explanation and may have used the time to construct a fictitious explanation.

The final category is the admission of shaking. Very few caretakers do admit shaking, however when they do, they often cite a history of attempting to console the child or prevent the child from choking on an object. Two to three explanations or stories is not uncommon and underscores the need for health care providers to pay meticulous attention to caretakers' reports in addition to the clinical presentation of the child (Coles & Kemp, 2003).

Clinical Presentation of SBS

BS victims can present with a wide variety of symptoms ranging from the very mild to the most critical of states. In the less severe cases, the infant may present with the parents or caretaker relaying a history of poor feeding, vomiting, lethargy or irritability, hypothermia or chills, a generalized failure to thrive, increased sleeping, and a failure to smile or be verbal. These symptoms may persist for days to weeks and are apparent to any caretaker or parent as problematic and abnormal; however care at this stage may or may not be sought. These fairly nonspecific signs may be minimized by physicians or attributed to other causes of origin such as viral illness or colic and may resolve without the root cause being discovered.

In more severe SBS cases, the infant may exhibit more life-threatening signs and symptoms of neurologic impairment. Following a violent shaking, immediate medical attention may or may not be sought. The caretaker may put the infant to bed anticipating the child will recover. This leads to a missed opportunity for early intervention. Nevertheless, in these more severe cases, presentation to the hospital can reveal the following:

1. Respiratory difficulty including apnea
2. A decreased level of consciousness
3. Seizure activity
4. Bradycardia
5. Bulging fontanels indicative of increased intracranial pressure
6. Possible complete cardiovascular collapse requiring cardiopulmonary resuscitation (CPR)

One of the hallmark presentations of SBS is a lack of external injuries (Fulton, 2000). This may lead to a missed diagnosis even in the most severe SBS cases. The lack of obvious trauma may falsely minimize the health care provider's suspicion of possible maltreatment. In the event that external injuries are noted, however, they must be carefully documented. The use of forensic photography can aid in clear and accurate documentation of the injuries. Repeated physical examinations may also reveal further signs of trauma. Evidence of other injuries including bruises, rib fractures, long bone fractures, abdominal injuries, and retinal hemorrhage should be carefully assessed and accurately documented.

Retinal Hemorrhage

In SBS, the mechanism of injury resulting in retinal hemorrhage is not conclusively known, however several theories exist including rapid movement of the vitreous body combined with a sudden rise in intraocular pressure, increased intracranial pressure due to trauma (whether by impact or inertia), and extravasation of subarachnoid blood (Fulton, 2000; Munger, Peiffer, Boouldin, Kylstra, & Thompson, 1993). It is somewhat controversial whether retinal hemorrhage in children is a definitive sign of SBS. It has been noted, however, that large retinal hemorrhages are unusual in other forms of cerebral trauma, occurring in about 1% of children with serious head trauma (Keenan & Runyan, 2001). Furthermore, the AAP (2001) offers that retinal hemorrhage can be seen in 75-90% of all SBS cases. The number, location, size, and character of retinal hemorrhage varies with each case, however more severe hemorrhage can be associated with a more serious brain injury. In a similar fashion, a relationship can be drawn between the extent of the hemorrhage and the forcefulness of the shaking episode. This shaking can lead to permanent vision impairment and, in the more severe cases, blindness.

An accurate diagnosis of retinal hemorrhage in SBS is crucial for appropriate medical care and for legal reasons as well. The AAP (2001) suggests that where available, the child should be examined by an ophthalmologist, pediatric neurologist, pediatric neurosurgeon, or other experienced practitioner who is experienced with such hemorrhages and is equally familiar with the examination equipment and technique for this very reason. Furthermore, when the victim is examined for retinal hemorrhage by someone other than an ophthalmologist, up to 25% of the cases with injury may be missed (Santuci & Hsiao, 2003).

Orthopedic Injuries in SBS

While no apparent injury may exist, bone fractures can be found in half of all SBS cases (Zenel & Goldstein, 2002). These fractures may occur anywhere in the body; however the most common type of injury in SBS is the metaphyseal chip fracture. These fractures occur at the bone's growth plate as a result of the child's extremities flailing uncontrollably during the shaking episode. Rib fractures may also be noted. In fatally abused infants, the ribs are the most common site for fractures. Additionally, when an infant presents with fractured ribs, it is most often the result of physical abuse. Posterior rib fractures are often caused by anteroposterior thoracic compression such as that associated with a shaking episode (Bulloch et al., 2000; Kleinman & Schlesinger, 1997).

Radiologic examinations, including skeletal surveys, allow the health care practitioner to pinpoint sites of orthopedic injury (Zenel & Goldstein, 2002). A skeletal survey should include radiographs of the hands, feet, long bones, skull, spine, and ribs. This should be performed as soon as the child's medical condition permits. These films can be very useful in detecting both skull and rib fractures. A 2-week follow-up skeletal survey can greatly increase the diagnostic yield. Additionally, scintigraphy, a nuclear medicine test which detects areas of increased or decreased bone metabolism, has been demonstrated an increased sensitivity for detecting rib fractures. This technique may be of particular use if the child is to be discharged to a potentially unsafe environment prior to the 2-week skeletal survey follow up (Zenel & Goldstein, 2002).

Traumatic Brain Injury

raumatic brain injuries (TBI) occur when a sudden trauma, such as violent shaking, causes trauma to the brain. TBI symptoms can range from mild to severe depending on the extent of injury to the brain. Mild signs and symptoms include headache, lethargy, confusion, dizziness, blurred vision, and mood and memory changes. A child with a more severe TBI may exhibit these signs in addition to nausea and vomiting, seizures, inability to arouse from sleep, dilation of one or both pupils, loss of coordination, persistent crying, and a refusal to nurse or eat (Becker et al., 2002).

The key diagnostic feature of SBS is the presence of intracranial injury in an infant (Keenan & Runyan, 2001). The most common injury is a subdural hematoma; however epidural hematoma, subarachnoid bleeding and shearing injuries of the brain parenchyma can all occur. During the shaking episode, rotational forces and differential movement of the brain in relation to the surrounding tissues can tear the bridging vessels resulting in a subdural hematoma. Additionally, the rotational forces lead to strains on the nerve axons throughout the brain resulting in diffuse axonal injury (Keenan & Runyan, 2001). Inflicted head trauma seems to trigger a chain of events that result in cerebral hypoxia, cerebral edema, increased intracranial pressure (ICP), and vaso-occlusion (Zenel & Goldstein, 2002). The displacing effect of the subdural hematoma may lead to further ischemic compromise. Furthermore, cervical spine epidural hematoma may occur in a significant proportion of abused infants, in addition to focal axonal injury of the lower brainstem, superior spinal cord, and spinal nerve roots. It is also thought that the effect of stretching at the craniocervical junction during violent shaking may lead to apnea, which results in a diffuse hypoxic injury. In general, intracranial injury in the absence of significant accidental trauma is a significant indicator of inflicted injury (Blumenthal, 2002).

The onset of symptoms is useful both in understanding prognosis as well as determining a cause (Keenan & Runyan, 2001). Timing can best be established by synthesizing the history, clinical course, and results of diagnostic imaging studies. When accurate, the clinical history is the most precise means for establishing a timeline. Elapsed time from the onset of injury can be estimated through the breakdown of intracranial hemoglobin as seen on diagnostic radiological studies. Additionally, if a spinal tap is performed yielding bloody cerebrospinal fluid (CSF), a fluid which is xanthochromic should arouse suspicion that the cerebral trauma may be several hours old and the blood in the CSF is not from a traumatic spinal tap (Keenan & Runyan, 2001).

Radiologic imaging, including computed tomography (CT) scans and magnetic resonance imaging (MRI) is used to detect the presence of a traumatic brain injury. CT has the primary role in the imaging evaluation of a child with a TBI. The CT can detect injuries requiring immediate attention. Initial CT imaging should be performed without contrast and is the method of choice for demonstrating acute hemorrhage, including that involving the subarachoid space. The CT should be repeated after a period of time or if there is a rapid change in neurologic status. The use of the MRI optimizes detection and assessment of intracranial injury including intraparenchymal hemorrhage, contusions, shearing injuries, and edema. The MRI is also sensitive for detecting significant spinal injury and previous parenchymal hemorrhage. A posterior, intrahemispheric subdural hematoma as noted on either CT or MRI, in the absence of significant accidental trauma, is indicative of inflicted injury.

Clinical Management of SBS

Realizing that the final outcome stemming from inflicted injury is generally worse than accidental injury, clinicians must maintain a heightened index of suspicion for recognizing patterns of injury indicative of - or diagnostic for - physical abuse. Although the cause of injury may very greatly, there are no differences in the actual treatment of nonaccidental verses accidental injuries in children (Zenel & Goldstein, 2002).

Mandatory reporting laws for health care professionals have been enacted in all 50 states. Therefore, providers are required to notify state child protective services and law enforcement officials when they suspect abuse (Zenel & Goldstein, 2002). Likewise, suspicion of serious head injury as a result of abuse must be immediately reported to the proper authorities. Prompt notification facilitates a thorough investigation before the medical history becomes blurred by time or caretakers compare or collaborate on false explanations. Information regarding the onset of symptoms and chain of caretakers needs to be gathered and disseminated to law enforcement and child protective services. This allows law enforcement to promptly investigate allegations and elicit detailed information from caretakers. Also, a timely response may allow law enforcement officials to explore the scene where the injuries occurred. Child protective services can also begin an investigation into the alleged abuse. Early involvement of child protective services is also important for the protection of siblings and other children under the custody of the same caretakers.

The treatment team should consist of a health care practitioner who can immediately resuscitate and stabilize the victim while diagnostic examinations are being performed (AAP, 2001). Additionally, a diagnostic team consisting of specialists in pediatric radiology, pediatric neurology and neurosurgery, and ophthalmology, as well as a pediatrician specializing in abuse should be brought together to form the diagnostic team. In instances where these practitioners are not available, such as geographical isolation, a regional consultation system could be used. Follow-up examinations should also be performed by this same team (AAP, 2001).

Morbidity and Mortality

he morbidity and mortality of inflicted head injury is worse than accidental head injury (Blumenthal, 2002). Mortality rates range from 15% to 38% (AAP, 2001). The vast majority of survivors of inflicted head injury, including SBS, possess some degree of neurologic or cognitive impairment. Occipital lobe impairment can lead to blindness. Microcephaly is common, with head circumference measurements reflecting a change in brain growth as early as 2 months following the injury. Additionally, survivors may exhibit plasticity, seizure disorders, or have chronic subdural fluid collections, enlarging ventricles, cerebral atrophy, and encephalomacia. These injuries may later manifest through motor, cognitive, or learning disabilities. Children injured early in their course of growth and development are less likely to acquire the appropriate skills than are children who are injured later in life. Furthermore, it has been suggested that children who are severely brain-injured before age 6 do not catch up with their peers and have a lower rate of gaining new skills (Keenan & Runyan, 2001).

Long-term impairment can also occur in the form of:

1. Alzheimer's disease
2. Parkinson's disease
3. Dementia pugilistica
4. Posttraumatic dementia (Becker et al., 2002)

Alzheimer's disease (AD) is associated with a head injury early in life, with a more severe injury leading to an even greater risk of developing the disease. Parkinson's disease, as well as other movement disorders, may develop years after an injury as a result of damage to the basal ganglia. Dementia pugilistica, a structural brain abnormality also known as chronic traumatic encephalopathy, is characterized by dementia and Parkinson's. This results from suffering repeated blows to the head over a length of time, as can be seen with episodes of SBS.

Finally, the symptoms of posttraumatic dementia are similar to those of dementia pugilistica, however, patients may also have long-term memory problems. These problems in posttraumatic patients may have been caused by a single severe injury and in some cases involve a coma. Factors strongly related to poor outcome include young age, duration of unconsciousness, and low Glasgow coma scale (GCS) (Blumenthal, 2002).

Prevention Strategies

rimary prevention activities can be directed at the general population with the goal of ending child abuse and maltreatment (Thomas et al., 2003). These activities have a universal focus and seek to raise the awareness of the general public, service providers, and policy makers about the scope and problems associated with child abuse and maltreatment. Examples of primary prevention include public service announcements and awareness campaigns as well as family support and strengthening programs (Thomas et al., 2003).

Secondary prevention activities are targeted to those populations who possess one or more risk factors associated with abuse or maltreatment (Thomas et al., 2003). Programs may also be directed at specific communities or neighborhoods that have a high incidence of the risk factors. Programs for secondary prevention include parent education programs in a targeted area, home visitation programs, and family resource centers located in targeted neighborhoods or communities.

Tertiary prevention activities focus on families in which maltreatment or abuse has already been identified; these activities seek to reduce the negative consequences associated with abuse as well as prevent future episodes (Thomas et al., 2003). Programs for tertiary prevention include parent mentoring programs, intensive family preservation services, and mental health services to improve family functioning.

Home visitation programs, initially proposed in 1991, have demonstrated effectiveness in reducing the incidence of maltreatment and abuse. It is also noted that "providers of home visiting services were ... optimistic about their effectiveness and [United States Advising Board on Child Abuse and Neglect] Board members believed intuitively that home visitation makes good sense" (Krugman, 1993, p. 187). Additionally, the Board agreed that the primary goal of home visitation programs is to ensure that someone would always be available to the family. Therefore, rather than a specific program, home visitation programs have become a strategy for service delivery. These services include education, maternal/child health and mental health services geared toward strengthening and supporting families (Krugman, 1993).

Antenatal visits can provide valuable information on parental coping, assessment of strengths and needs, as well as screening for indications of postpartum depression. Home visitation programs have led to an improvement in the number of reports to child protective services and an improvement in both child and parenting behaviors (Nagler, 2002). Others report fewer health problems due to injury (Leventhal, 2001; Toomey & Bernstein, 2001), demonstrating the efficacy of home visitation programs in reducing the incidence of both accidental and nonaccidental injury. Other research shows that these outcomes are limited and not universal with regard to the population. The most notable impact is seen with populations who are more socially and economically disadvantaged (at risk), notably low-income unwed women (Olds et al., 1999).

Many prevention programs focus on education as a key to prevention. The primary goal is to teach parents and caregivers about the realities of parenting/caregiving and how to cope appropriately with crying children. Programs such as "Don't Shake the Baby" (Showers, 1992), provide information for parents including a crying card detailing why babies cry and what parents can do to soothe them. The card also describes the dangers of shaking and gives parents alternatives when they feel as if the crying cannot be tolerated for another moment.

In the evaluation of the initial program in which 3,293 new mothers were given a crying card, 95% of the mothers read the card. In addition, 75% stated the information was helpful to them and that they were much less likely to shake their babies after having read it. Many said they felt other parents needed this information (Showers, 1992).

Other hospital-based education programs attempt to teach all new parents about the dangers of shaking a child. Pennsylvania law mandated the implementation of the Shaken Baby Syndrome Education Act by the Department of Health. The Pennsylvania Shaken Baby Syndrome Education Program at Penn State Hershey Medical Center shares similar goals including:

1. Educating all parents about SBS, upon the birth of every child.
2. Confirming receipt of the education through the use of commitment statements that parents are asked to voluntarily sign.
3. Demonstrating a reduction in the incidence of SBS throughout the Commonwealth of Pennsylvania.

This program has been providing SBS education materials and training to obstetric, nursery, neonatal intensive care unit (NICU), and pediatric nurses and staff at 39 central Pennsylvania hospitals since May 2002. In September 2003, the Department of Health has joined the effort to expand the program to all Pennsylvania hospitals and to track the effectiveness of the program statewide. The program replicates the Upstate New York SBS prevention program, which has demonstrated a reduction in the incidence of SBS by nearly 50% in regions where the education is offered (Pennsylvania Shaken Baby Syndrome Education Program, 2004).

Education for day care providers is also an initiative that has been undertaken in several states. New York, Texas, and Utah have adopted regulations mandating that child care providers receive training on the dangers of shaking infants and children in order to maintain their license (National Center on Shaken Baby Syndrome [Legislation], n.d.). In New York, all child day care providers must be educated and informed on identifying, diagnosing, and preventing SBS. Texas has added the requirement that all child day care providers, as well as registered family homes providing day care for children under 24 months, must receive annual education on recognizing and preventing SBS and understanding early childhood brain development. Utah has also mandated annual education for all centers providing infant care services, including education on preventing SBS, learning about brain growth and development, and coping with crying babies.

The education of child care providers is twofold. First, the providers are exposed to crying infants and children on a continuous basis. Education is a means to aid these providers in developing appropriate coping skills to prevent episodes of shaking. Second, education on identifying and diagnosing SBS can better prepare the providers to spot possible abuse that may be ongoing and take the appropriate actions to protect the child (National Center on Shaken Baby Syndrome [Legislation], n.d.).

Other education programs also exist to teach the public in a variety of ways. "Dads 101" offers new fathers an opportunity to learn from experienced fathers the basics of raising a child, covering such tasks as changing a diaper and feeding to supporting the mother throughout pregnancy and delivery (National Center on Shaken Baby Syndrome [Dads 101], n.d.). A crucial element of Dads 101 is SBS prevention. Fathers are taught to understand the reality of infant crying and they also learn coping methods when the baby cries as well as effective ways to understand and deal with their own feelings of frustration when the baby won't stop crying. The Dads 101 program is currently used in hospitals, prisons, high schools, military bases, unwed parent groups, prenatal classes, and youth correctional facilities. School-based curricula are geared toward high school students. Viewed as potential parents and caregivers, students receive education on how to care for infants and young children, including the stress that may arise when a baby cries and the dangers of shaking a child.

Health care practitioners can also be instrumental in preventing child abuse and maltreatment, including SBS. Pediatric health care providers frequently have insight into family dynamics and witness family interactions. Additionally, they often are the only adults besides the parents or caretakers to fully examine the child's body. Therefore, pediatric practitioners play an instrumental role in both identifying and preventing abuse. Prevention practices such as screening for caretaker stress, discipline practices, substance abuse, and response to infant fussiness or crying can aid in the identification of individuals and families at increased risk for abuse. Practitioners can then initiate appropriate referrals to agencies and resources.

Child death investigation and review is also a key to developing prevention strategies. Not all jurisdictions, however, possess the appropriately trained pathologists and interagency communication pathways that would facilitate the dissemination of information about the family and a surveillance system to evaluate the data pertaining to infant and child fatalities (AAP, 1999). The investigation of unexpected child fatalities necessitates the participation of numerous individuals including medical examiners and coroners, public health officials, physicians and nurses, child welfare personnel, law enforcement, the judicial system, and mental health workers. Interagency collaboration in and among these fields can lead to an accurate determination as to the cause and circumstances surrounding the death. Information about the death of one child may generate knowledge leading to preventative strategies that will serve to protect the lives of other children (AAP, 1999).

Child and death review teams can ensure both the quality of the death investigation as well as the development of preventative strategies. An appropriately formed child fatality review team should evaluate the death investigation process, examine difficult or controversial cases, and monitor death certificates and statistics (AAP, 1999). Child death review teams should be established at the local and regional level within each of the states.

The Pennsylvania Child Death Review Team (CDRT) seeks to answer the questions of why children die in Pennsylvania and which deaths may have been preventable. The Pennsylvania Child Death Review Program has 44 local teams representing 48 counties reviewing over 90% of child deaths in Pennsylvania (Pennsylvania CDRT, 2002). The Pennsylvania CDRT is comprised of pediatricians, forensic pathologists, coroners/medical examiners, representatives from Pennsylvania departments of Health, Public Welfare, Community Affairs, the Attorney General's office, social services, and law enforcement. By identifying preventable deaths, Pennsylvania agencies can use the information to plan, target, and evaluate public health and protective service programs to prevent future fatalities.

Conclusion

he identification, investigation, clinical management, and prevention of SBS requires a cooperative multidisciplinary approach that relies on the knowledge and skill of all those involved. There is clearly a need for a united effort among health care, child welfare, law enforcement, social services, the court system, and education professionals as well as the community at large.

Knowledge of SBS needs to be provided to all individuals and groups involved with its detection, management, and prevention. Similarly, through research and creative preventative interventions, education regarding the hazards of shaking and the development of appropriate coping skills can be disseminated to the community. The future well-being of children who have been victim to or have the potential to become a victim of SBS rests with the multidisciplinary team's ability to collectively work toward the goal of preventing SBS.

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Nickolaus J. Miehl, MSN, RN, is an Instructor, Edinboro University of Pennsylvania, School of Nursing, Edinboro, PA.