Shaken baby syndrome: the first case reported in East Africa: case report

¹Department of Pediatrics and Child Health, Kilimanjaro Christian Medical Centre Moshi, Tanzania, ²Department of Radiology and Diagnostic Imaging, Kilimanjaro Christian Medical Centre Moshi, Tanzania, ³Department of Pediatrics and Child Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania, ⁴Institute of Public Health, Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College (KCMUCo), Moshi, Tanzania, ⁵Department of Community Medicine, Kilimanjaro Christian Medical Centre (KCMC), Moshi, Tanzania

^&Corresponding author
Kenan Bosco Nyalile, Department of Pediatrics and Child Health, Kilimanjaro Christian Medical Centre Moshi, Tanzania

Introduction    

Child abuse related deaths are mostly attributed to head trauma, which can be from direct blow to the head or from acceleration-deceleration injury. In 1972, Caffey described the “shaken baby syndrome” as an acceleration-deceleration head trauma in children due to vigorously shaking while holding the child [1]. This form of injury is difficult to detected until permanent damage or death occurs [2]. The risk is higher in babies of less than 1 year because they cry longer, more frequently and are more likely to be held and shaken compared to older children [3]. The presentation of Shaken baby syndrome is often nonspecific, and the diagnosis is challenging, in most cases there is no history of trauma [4]. The child may present with irritability, change in sleep pattern, inability to feed, vomiting, convulsions and in severe form of injuries with loss of consciousness, irregular breathing, and weak pulses [3,5]. Retinal hemorrhage, subdural hematoma and neurological abnormalities are some key clinical signs [6]. The primary trigger for shaken baby syndrome is inconsolable or excessive infant crying, other factors which can increase the risk are, young parents, unmarried status, first child, male infant, substance abuse by the parents, low socioeconomic status, and education level [5-7]. Shaken baby syndrome is potentially life-threatening and can lead to blindness, developmental delays, learning disabilities, paralysis, neurological damage or even death [8]. Head trauma is the most common cause of these infant traumatic deaths in high-income countries such as the United States and the United Kingdom [6]. The annual incidence of shaken Baby Syndrome in high-income countries is estimated to be 25 to 34 cases in 100,000 children younger than 1 year of age [7]. There is limited information on shaken baby syndrome in low-income countries such as Tanzania. We present a case of a 2-month baby girl admitted in our pediatrics unit with loss of consciousness, no clear history of trauma and upon investigation had a large acute on chronic subdural hematoma and a retinal hemorrhage.

Patient and observation     

Patient information: a previously healthy 2 months old female baby was brought to the hospital with loss of consciousness for 6 hours. Prior to this, the mother reports she was thrown up by her father as was trying to charm her up. She also presents with history of watery diarrhea and vomiting for one day.

Clinical findings: upon admission the child was lethargic with Glasgow Coma Scale (GCS) of 6/15, mildly pale, no sunken eyes, skin pinch returned in less than 2 seconds with cold extremities (grade 1) and cap refill of 4 seconds. There were, no sign of external injuries, bulging anterior fontanel, pupils were unequal reactive to light, and on muscoskeletal assessment including humeri, forearms, hands, femurs, lower legs, feet, chest (ribs, thoracic and upper lumbar-spine), pelvis, lumbosacral-cervical vertebrae and skull was normal.

Diagnostic approach

On admission a provisional diagnosis of hypovolemic shock was made since there was a history of vomiting and diarrhea and the clinical signs observed. MRDT done was negative. Blood workup: Hemoglobin was 6g/dl normocytic normochromic. Serum Sodium, Serum Potassium, Serum Chloride, Serum Bicarbonate, Serum Lactate, Total protein, and Albumin were within normal range, Liver Enzymes: aspartate aminotransferase (AST) was slightly raised 50 U/L, but alanine transaminase (ALT) was normal.

Brain computed tomography (CT) scan was done since there was a persistence of clouding of consciousness and revealed acute on chronic subdural hematoma on left convexity with midline shift toward the right and subfalcine and uncal herniation (Figure 1). Bleeding indices were ordered, and they were withing normal limits, thus bleeding disorder were ruled out. Fundoscopy done showed the baby had retinal hemorrhage. The presence of subdural hemorrhage, retinal hemorrhage and lack of external injury confirmed a classical triad of the shaken baby syndrome which was our final diagnosis with severe traumatic brain injury as differential. The case was reported to social welfare investigation was done in which the accidental nature of the child injury was concluded.

Therapeutic intervention: she was resuscitated with fluids and vasopressors, and she was out of shock. Then emergency craniotomy to relieve subdural hematoma was done. Post operation the baby had a temperature of 35.4°C, heart rate of 158 beats per minutes, respiratory rate of 39 cycles per minutes, oxygen saturation was 92% on oxygen, random blood sugar level was 16.4 mmol/L, cold extremities (grade 1) and capillary refill was 3 second. Baby was kept on dopamine infusion but unfortunately the next day baby clinically deteriorated and eventually passed away.

Patient consent: written informed consent was obtained from the patients' mother for publication for this case report and the accompanying images.

Discussion     

Vigorous shaking of the baby causes acceleration and deceleration of the intracranial compartments in relation to one another, resulting to diffuse brain damage [5]. The small body size, large head to body size ratio, weak neck muscles and soft skull with unfused sutures make infants more susceptible to injury from even the forces seen as harmless by the parents or caretaker [5,6] and similarly to our case where there was no clear suspicion of harm by the parent from shaking the baby. The diagnosis of shaken baby syndrome can be made when there is a triad of injuries consisting of subdural hemorrhage, retinal hemorrhage and encephalopathy, in the absence of external injuries [6]. In our case, the first impression was hypovolemic shock secondary to dehydration because there was history of vomiting and diarrhea. Upon investigations, the baby had both retinal hemorrhage and subdural hemorrhage, with no evidence of external injuries, leading to the diagnosis of Shaken Baby Syndrome. This is in line with cases of shaken baby syndrome reported in Turkey and Germany in which both retinal hemorrhage and subdural hemorrhage were present and no evidence of external injuries [9-11].

About 30% of shaken babies die and 85% suffer serious morbidities and lifelong disabilities such as blindness, developmental delays, learning disabilities and mental retardation [6]. In our case the baby died post craniotomy. This might be due to an old hemorrhage with permanent neurological damage and moreover, the body was unable to withstand the stresses that comes with the surgery. Mortality in shaken baby syndrome is high, as shown by studies in Germany and Turkey where more than half of the cases resulted to death [9-11]. Male caretakers or parents have been reported as the shakers in most cases of shaken baby syndrome compared to females [12]. In our case the father was reported to have bounced the baby in playful manner. Males are stronger and even when they play are a bit aggressive in nature and this may the cause of their dominance in these cases. In a study done in South Africa, shaking was identified as the cause of injury on 1 case among 7004 head injuries of children [13]. In our case the parents denied of shaking their baby at the beginning and after several efforts only the father admitted of throwing up the baby while trying to charm her up. Detection of chronic subdural hemorrhage indicates the baby was injured several times and on a longer duration. Thorough history taking from the family, is important to identify the source and type of trauma for effective prevention.

Conclusion     

In conclusion, given that this is the first case reported from our setting, there is a need to raise awareness among practitioners dealing with infants and toddlers on possibility of shaken baby syndrome when they encounter cases of head trauma and/or coma. We recommend clinical practitioners especially in low-income settings to properly take history to rule out shaken baby syndrome in infants termed as head injury cases, for better intervention since shaken baby syndrome cases are preventable.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

KBN and EJS were involved in diagnosis, management and writing of manuscript. AS was involved in interpreting radiological image. AMS and DNM were involved in investigation, writing part of manuscript. All authors reviewed and approved final manuscript.

Acknowledgements     

The authors would like to acknowledge the mother for permission to share her child’s medical history for educational purposes and publication.

Figure     

Figure 1: non-contrast axial and coronal CT of the brain shows an acute on chronic subdural hematoma along the left cerebral convexity measuring 1.8cm in maximum thickness; gross pressure effect seen on the left cerebral hemisphere with 2.1cm midline shift towards the right side and subfalcine/uncal herniation; massive ischaemic infarction of the left cerebral hemisphere with loss of grey white matter differentiation involving the left anterior, middle and posterior cerebral artery territories (ACA, MCA and PCA)

References