Study Examines Long-Term Effects of Shaken-Baby Syndrome

Each year hundreds of child mortalities are attributed to traumatic brain injury, or TBI. Thousands more will survive, often with lifelong consequences.

Both TBI and physical child abuse are major public health concerns for infants and young children. TBI is the most common cause of death and acquired brain injury in American children. Nearly 25 percent of infant and toddler TBI cases admitted to the pediatric intensive care unit are caused by physical child abuse. Although child abuse causes approximately 5 percent of brain injuries in children 1 to 4 years old, it produces 90 percent of serious brain injuries.

Linda Ewing-Cobbs, Ph.D., associate professor of pediatrics at The University of Texas Medical School at Houston, said, “He fell off the couch,” is the most frequent excuse given when an infant is brought into the hospital with a suspected abuse-related injury.

Ewing-Cobbs is principle investigator of a $3.2 million National Institute of Neurological Disorders and Stroke study titled “Accidental and Nonaccidental Pediatric Brain Injury.” The study aims to assess how developmental outcomes are influenced by neurological and demographic variables, such as age, age at injury, abusive versus accidental TBI, structural damage to brain regions, and how difficulties in basic cognitive functions relate to social competence, self-regulation, and early academic skill development.

“Our initial findings indicate significantly worse outcomes in children with abusive than accidental TBI,” Ewing-Cobbs said. “Of children who survived these abusive injuries, 45 percent scored in the deficient range on general mental and motor development tests, compared to only 4 percent of children with accidental TBI.”

Ewing-Cobbs’ collaborators include Mary Prasad, Ph.D., and Larry Kramer, M.D., at The University of Texas Health Science Center at Houston, and Joan Shook, M.D., and Donna Mendez, M.D., in Texas Children’s Hospital’s emergency medicine department.

For doctors who suspect child abuse, there are infant TBI clues which include retinal hemorrhages, old or unexplained fractures, old blood clots on the brain’s surface, internal cranial bleeding, acute brain swelling with surface blood clots, brain swelling and excessive water retention leading to elevated intracranial pressure, normal gray-white brain density loss, and seizures with no former history.

If child protection team findings suggest TBI with no physical injury history, they initiate comprehensive clinical, radiological, and social assessments, including a computerized tomography brain scan, detailed magnetic resonance imaging, a skeletal survey, an ophthalmologic evaluation, and a psychosocial interview.

“The earlier that brain injury occurs in the child’s life, the more severe the long-term neurological and developmental abnormalities,” Ewing-Cobbs said.

Some 6-week to 4-month old infants cry an average two to three hours a day, and some cry 20 to 30 percent more. If the crying upsets a parent who can’t calm the infant, and they shake the baby out of frustration and stress, it may make the baby quiet and drowsy. However, the results may be costly, Cobbs said.

The consequences of moderate to severe traumatic brain injury in infants are numerous, range from temporary to permanent developmental changes, and include physical, speech/language, cognitive, personality/behavioral, and nutritional/swallowing disorders.

“In the past five years, federal funding agencies have become interested in abusive brain injury in children. Several years ago, there were only two major biomedical studies of physical child abuse funded by the National Institutes of Health. One of the studies was ours,” Ewing-Cobbs said.

“Unfortunately, our longitudinal testing is not showing significant improvement in cognitive skills one to two years after the brain injury,” she said. “Given these persisting problems, it is clear that a substantial commitment needs to be made for long-term rehabilitation and educational interventions.”

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©2006 Texas Medical Center

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