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Age Group: The First Two Years

The Developing Person Through Childhood and Adolescence by Kathleen Stassen Berger

Chapter 5: Biosocial Development (Page 146)

CHIL 101: Human Growth & Development

By: Cameron Chong

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Causes
When a baby is shaken forcefully or violently, the baby's brain is repeatedly tossed against the inside of the skull. This motion ruptures blood vessels and breaks neural connections in the brain, leading to severe brain damage that can be life-threatening.

Symptoms
Difficulty staying awake, body tremors, trouble breathing, poor eating, vomiting, discolored skin, seizures, coma, and paralysis.

Consequences
Irreversible brain damage, permanent vision loss (partial or total), hearing loss, seizure disorders, development delays, intellectual disabilities, and cerebral palsy.

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Call 911 immediately if you suspect your child has shaken baby syndrome. Some babies will stop breathing after being shaken. If this occurs, CPR can keep your baby breathing while you wait for medical personnel to arrive.

The American Red Cross recommends the following steps to perform CPR:

Carefully put the baby on their back. If you suspect a spinal injury, it's best if two people gently move the baby so the head and neck don't twist.

Set up your position. If your infant is under age 1, put two fingers on the middle of the breastbone. If your child is over age 1, place one hand on the middle of the breastbone. Put your other hand on the baby's forehead to keep the head tilted back. For a suspected spinal injury, pull the jaw forward instead of tilting the head, and don't let the mouth close.

Perform chest compressions. Press down on the breastbone and push about halfway into the chest. Give 30 chest compressions without pausing while counting out loud. The compressions should be firm and fast.

Give rescue breaths. Check for breathing after the compressions. If there's no sign of breathing, tightly cover the baby's mouth and nose with your mouth. Make sure the airway is open and give two breaths. Each breath should last about one second to make the chest rise.

Continue CPR. Continue the cycle of 30 compressions and two rescue breaths until help arrives. Be sure to keep checking for breathing.

In some cases, the baby may vomit after being shaken. To prevent choking, gently roll the baby onto their side. Make sure to roll their entire body at the same time. If there's a spinal cord injury, this method of rolling reduces the risk of further damage to the spine. It's important that you don't pick up the baby or give the baby food or water.

There's no medication to treat shaken baby syndrome. In severe cases, surgery may be required to treat bleeding in the brain. This may involve placement of a shunt, or thin tube, to relieve pressure or to drain excess blood and fluid. Eye surgery may also be needed to remove any blood before it permanently affects vision.

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Shaken Baby Syndrome: Symptoms, Causes, and Treatments

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Call 911 immediately if you suspect your child has shaken baby syndrome. Some babies will stop breathing after being shaken. If this occurs, CPR can keep your baby breathing while you wait for medical personnel to arrive. The American Red Cross recommends the following steps to perform CPR: Carefully put the baby on their back.

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An inside look on the long-term impact on the victims of shaken baby syndrome. National experts also provide insight on prevention strategies.

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Diagnosis
Examination of child's medical history, physical exam to look for signs of injury and increased blood pressure, imaging tests (CT scan or MRI) to look for bleeding or injury in the brain, and X-rays to check for broken bones.
A doctor who suspects shaken baby syndrome MUST report it to the child welfare office and the police.

Treatment
Needs to be in the hospital (sometimes in the ICU), oxygen therapy to help child breathe, medications to reduce brain swelling, seizure medication, physical therapy, and surgery for brain bleeding.

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Topic Overview

What is shaken baby syndrome?

If you want to save this information but don't think it is safe to take it home, see if a trusted friend can keep it for you. Plan ahead. Know who you can call for help, and memorize the phone number.

Be careful online too. Your online activity may be seen by others. Do not use your personal computer or device to read about this topic. Use a safe computer such as one at work, a friend's house, or a library.

Shaken baby syndrome is brain injury that occurs when someone shakes a baby or throws a baby against an object. It is a form of child abuse. It may happen to children up to 5 years of age, but it is most common in babies younger than 1 year old.

It is never okay to shake or throw a young child. It may not leave any obvious sign of injury, but it can cause serious long-term problems or even death.

Shaken baby syndrome often occurs when a baby won't stop crying and a caregiver loses control of his or her emotions. Parents can help prevent this problem by learning healthy ways to relieve stress and anger. It's also important to choose child care providers carefully.

Shaken baby syndrome may also be called "shaken-impact syndrome." Many doctors use the term "abusive head trauma" to describe the injury. They may use "intentional head injury" to describe how it happened.

What causes the brain injury?

When a baby is shaken or thrown, the head twists or whips back and forth. This can cause tears in brain tissue, blood vessels, and nerves. The child's brain slams against the skull. This can cause bleeding and swelling in the brain.

Young children are at high risk for brain injury when they are shaken or thrown. That's because they have:

Heavy, large heads for their body size.

Weak neck muscles that don't hold up the head well.

Delicate blood vessels in their brains.

Normal play, such as bouncing a child on a knee or gently tossing a child in the air, does not cause shaken baby syndrome.

What are the symptoms?

Symptoms vary among children based on how old they are, how often they've been abused, how long they were abused each time, and how much force was used.

Mild injuries may cause subtle symptoms. For example, a child may:

Be fussy, grouchy, or sluggish.

Vomit.

Not be hungry.

A child with more severe injuries may have symptoms such as:

A child who has been shaken or thrown may also have other signs of abuse, such as broken bones, bruises, or burns.

Symptoms can start quickly, especially in a badly injured child. Other times, it may take a few days for brain swelling to cause symptoms.

Sometimes caregivers who harm a child will put the child to bed. They may hope that symptoms will get better with rest. By the time the child gets to a doctor, the child may need urgent care. In some cases, the child may be in a coma before a caregiver seeks help.

How is shaken baby syndrome diagnosed?

Shaken baby syndrome can be hard to detect because often there aren't clear signs of abuse. Instead, a baby may have vague symptoms, such as vomiting or a poor appetite. At first these symptoms may seem related to an infection, such as the flu or a kidney infection. Sadly, shaken baby syndrome may not be discovered until repeated abuse or more severe harm occurs.

To confirm a diagnosis of shaken baby syndrome, a doctor will:

Ask about the child's medical history, including when changes in behavior began.

Do a physical exam to look for signs of injury and increased blood pressure.

Do imaging tests such as a or an to look for bleeding or other injury in the brain.

Take to check for broken bones.

A doctor may also do tests to rule out other possible causes of the child's symptoms. For example, a lumbar puncture checks the spinal fluid for signs of meningitis . Blood tests may be done to check for internal injuries or to rule out other conditions, such as rare blood disorders.

A doctor who suspects shaken baby syndrome must report it to the local child welfare office and police.

How is it treated?

A child with shaken baby syndrome needs to be in the hospital, sometimes in an intensive care unit (ICU). Oxygen therapy may be used to help the child breathe. Doctors may give the child medicine to help ease brain swelling. Sometimes a cooling mattress will help lower the child's body temperature and reduce brain swelling.

Depending on the symptoms, doctors may try seizure medicine, physical therapy, or other treatments. A child who has severe bleeding in the brain may need surgery.

What are the long-term problems from shaken baby syndrome?

A child may have brain damage that causes one or more serious problems, such as:

Seizures. A baby may have uncontrolled muscle movement and be unable to speak, see, or interact normally.

Blindness or trouble seeing or hearing.

Cerebral palsy, with muscle stiffness (spasticity ) that results in awkward movements.

Intellectual disabilities that can affect every area of a child's life. For example, a child may have trouble learning to talk or may not be able to care for himself or herself in the future.

Learning disabilities that may not appear until the child starts school.

Emotional or behavior problems.

Some children die from their injuries.

What should you do if you suspect shaken baby syndrome?

It is important to get help if something doesn't seem right with your baby. Shaken baby syndrome may cause only mild symptoms at first, but any head injury in a young child can be dangerous.

Call 911 or other emergency services immediately if a child:

Young children can't defend themselves, so it is up to adults who care to protect them. If you suspect abuse and the child is not in immediate danger:

Call local child protective services or the police.

Do not confront the person who may have abused the child. This may cause more harm to the child.

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abusive head trauma (shaken baby syndrome)

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shaken baby syndrome - non-accidental injury

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shaken baby syndrome (intentional head injury)

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What is shaken baby syndrome? If you want to save this information but don't think it is safe to take it home, see if a trusted friend can keep it for you. Plan ahead. Know who you can call for help, and memorize the phone number. Be careful online too.

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Rise in the incidence of abusive head trauma during the COVID-19 pandemic

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Rise in the incidence of abusive head trauma during the COVID-19 pandemic

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This article highlights a possible increase of child abuse since the onset of the pandemic. The researchers find that the increase of incidence in abusive head trauma (shaken baby syndrome) at their institution may reflect a rise in domestic abuse in countries with social distancing measures.

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Introduction

Recent literature highlights a possible increase in child abuse during the coronavirus (SARS-CoV-2) pandemic. 1 We report a marked increase in the incidence of abusive head trauma (AHT) at our institution.

Methods

We reviewed the incidence of suspected AHT between 23 March and 23 April 2020-the month that the United Kingdom entered a period of national self-isolation-and compared this with the incidence in the previous 3 years.

All children received an ophthalmological assessment, skeletal survey, and computed tomography scan and magnetic resonance imaging of the head and whole spine as part of their investigation. Demographic data and clinical findings were recorded, including parental vulnerabilities and socioeconomic indexing by the Index of Multiple Deprivation.

Results

Ten children (six boys, four girls; mean age 192 days, range 17 to 401 days) with suspected AHT were seen during this time in comparison with a mean of 0.67 cases per month in the same period over the previous 3 years. This equates to a 1493% increase in cases of AHT ( figure 1). Age did not vary significantly between years (range 0.5 to 13 months).

Prior to presentation, 50% of patients were colic, 40% were apnoeic with decreasing consciousness, and 20% had seizures. Clinical examination revealed retinal haemorrhages (50%), extensive bruising (50%), scalp swelling (50%), and excoriation marks (10%). Radiological findings included subdural haemorrhage (60%), cerebral oedema (40%), parenchymal contusion (40%), skull fractures (40%), subarachnoid haemorrhage (30%), and extracranial fractures (30%).

All families live in areas with a higher than average Index of Multiple Deprivation (national mean 15 200; cohort mean 19 867), and 70% of parents had significant underlying vulnerabilities: two had previous criminal histories, three had mental health disorders, and four had financial concerns.

Discussion

The increase in incidence seen at our institution reflects a rise in domestic abuse in countries enforcing similar social distancing measures. 2 This sobering figure is likely under-represented due to public avoidance of hospitals at this time. 3 Notably, two parents in our cohort cited fears of contracting SARS-CoV-2 as a reason for delayed presentation.

International efforts to combat the pandemic focus on social distancing as a means of reducing transmission. The spectrum of socioeconomic and psychosocial challenges associated with such measures can increase parental stress, reflected as increased substance misuse among caregivers-a potential risk in itself. 2 Our cohort is aligned to the literature in its portrayal of socioeconomic deprivation and parental vulnerability as significant risk factors for abuse, both of which may be exacerbated as a result of the stresses imposed by quarantine measures. The child's increased exposure to their parents and decreased interaction with reporting bodies further heightens this risk. 2 4 The complex links between abuse, mental health, substance misuse, and socioeconomic circumstances are often interdependent and cannot be effectively addressed in isolation. 5

Hence, in the background of the intensely public SARS-CoV-2 pandemic, a more silent pandemic is occurring, of which the medical community must remain astutely aware.

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Rise in the incidence of abusive head trauma during the COVID-19 pandemic

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Recent literature highlights a possible increase in child abuse during the coronavirus (SARS-CoV-2) pandemic.1 We report a marked increase in the incidence of abusive head trauma (AHT) at our institution. We reviewed the incidence of suspected AHT between 23 March and 23 April 2020-the month that the United Kingdom entered a period of national self-isolation-and compared this with the incidence in the previous 3 years.

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Triggers/Risk Factors for Shaken Baby Syndrome

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Triggers/Risk Factors for Shaken Baby Syndrome

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This article reviews the possible triggers that lead to shaken baby syndrome and the risk factors for potential victims and perpetrators. This article also goes into the six protective factors against child maltreatment.

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A trigger is a prompt or external stimulus that leads to a behavior or causes a response-something that "sets you off." Triggers tell us "Do something now!" A trigger can be internal (fatigue, frustration, anger, desire) or external (a crying baby, a remark). It is known that certain triggers and risk factors increase the likelihood of a parent or caregiver's abusing an infant.

A risk factor is any characteristic of a person, a situation, or a person's environment that increase the likelihood that a person will engage in a particular behavior.

Triggers and risk factors are often related. For example, a crying baby often affects a mother's sleep, triggering frustration on the part of the mother. The mother's frustration may in turn trigger an emotional response in her male partner, telling him to "do something now." The trigger is associated with the mother's frustration and tiredness but the acting out often happens with the male. Helping parents and caregivers understand what triggers abusive behavior is the first step in preventing child abuse.

Triggers Associated with Shaking a Baby

Episodes of Crying

Inconsolable or excessive crying is the most common trigger for shaking a baby. Episodes of crying typically increase in the first month after birth, peak in the second month, and decrease thereafter (Parks et al., 2012). This is expressed in the chart below, which shows the normal and expected hours of fussing and crying from birth to 3 months of age.

Source: CDC.

Source: CDC.

Infant crying can be a frustrating issue for parent and caregivers who may not understand that crying is a normal development stage and will decline as the baby ages. A parent's perception of crying as a problem is the most common risk factor for SBS. Problem crying is also associated with early weaning from breast milk, frequent changes of formula, and parent depression symptoms (Cook et al., 2012).

Colic and the Rule of Threes (Wessell Criteria)

According to many experts, colic is inconsolable crying in an infant that lasts many hours a day, starting in the second week of life and lasting until about 3 months of age. About forty years ago, a pediatrician named Morris Wessel conducted a breakthrough study on excessively fussy children. The definition he chose to describe colicky babies was not considered scientific, but it stuck with physicians.

Wessel's definition of a colicky infant was a child who cried for more than 3 hours a day, for more than 3 days a week, for over 3 weeks. This is often referred to as the Rule of Threes and these rules came to be known as the Wessell Criteria, which are now used in most current studies of babies with colic (Amer Preg Assoc, 2013).

The natural course of infant colic symptoms appear by around 3 weeks, peak at 8 weeks, and remit beyond 12 weeks of a term infant's chronological age. Infant colic affects up to 20% of infants under 3 months. Infant colic has significant adverse effects on maternal mental health and family quality of life and is a trigger for child abuse and a risk factor for shaken baby syndrome. Infants in whom crying persists beyond 3 months are at risk of adverse outcomes in the school years, including anxiety, aggression, hyperactivity, allergy, and sleep disorders, and at more than double the risk of poor mental health in later years (Sung et al., 2012).

Infant Sleep Problems

Fifteen to thirty-five percent of parents report problems with their infant's sleep during the first 6 months of life. Common sleep problems include difficulty getting the infant to sleep at the start of the night and difficulty re-settling the infant overnight (Cook et al., 2012).

Preventing infant sleep problems may reduce rates of parental depression, which is particularly important with breast feeding mothers who may be reluctant to accept pharmacologic treatment for depression (Cook et al., 2012).

Maternal Fatigue and Depression

Postpartum maternal tiredness/fatigue is defined as an imbalance between activity and rest. Fatigue is a state which persists through the circadian rhythm and cannot be relieved through a single period of sleep (Kurth, et al, 2010).

Most new mothers report problems with tiredness or fatigue, and disquieting infant crying is the most commonly reported reason parents consult a health professional. Not surprisingly, the occurrence of postnatal tiredness is associated with the amount of infant crying. In the worst case, infant crying and increasing exhaustion can accumulate into a vicious circle and negatively affect family health (Kurth et al., 2010).

Comforting a crying baby while coping with personal tiredness can be a challenge. Maternal exhaustion has been identified as a predictor of postpartum depression, and persistently crying infants are at a higher risk for shaken baby syndrome or other forms of child abuse (Kurth et al., 2010).

Risk Factors for Child Maltreatment

There is really no particular personality type that's at risk. We all are at risk, and I think that it would be unfair of us to think that none of us can get frustrated by a crying baby. And we've all been frustrated by babies who are just crying, but most of us have the social support, we have some knowledge, we have self-control that we don't take these frustrations out on our really helpless young infants. But there are individuals, who because of what's going on and the stress that they have in their lives and the lack of social supports and their self-esteem and sometimes their lack of knowledge, they do take these frustrations out on babies.

We know that the majority of perpetrators of abusive head trauma are men, but we use that really in terms of thinking about prevention because women can harm children just as well as men. We also know that one of the strong risk factors is having an unrelated adult living in a household; we have many cases where a young mother, or a mother of a young baby, has a boyfriend living in the house. The boyfriend may not be biologically related to the child, and often when that young man is left in a caregiving role for that child, sometimes bad things happen. Those kinds of risk factors help us target prevention efforts and help us think about prevention, but in my mind, really, any adult who is tired and stressed, who is dealing with an irritable crying baby, is at risk.

Cindy Christian, MD
NICHD, 2013

Risk factors are characteristics associated with child maltreatment-they may or may not be direct causes. Certain characteristics have been found to increase a child's risk of being maltreated or a parent or caregiver's risk of abusing a child.

Although all caregivers are at risk for shaking a child, the presence of substance abuse, domestic violence, and mental health issues greatly increases the risk for an adult's committing child abuse or neglect. There is a higher incidence of fatalities and near-fatalities when these three factors are present (DCBS, 2012).

Many abusive parents believe that children exist to satisfy parental needs and that the child's needs are unimportant. Abusive parents may show disregard for the child's own needs, feelings, and limited abilities. Children who don't satisfy the parent's needs may become victims of child abuse.

Risk Factors for Victimization

According to Child Protective Services (CPS), more than 3.7 million children in the United States were the subjects of at least one CPS report in 2011. About 20% of these children were found to be victims of some sort of abuse (Children's Bureau, 2011).

Nationally, victims in the age group of birth to 1 year have the highest rate of victimization. This is split between the sexes, with boys accounting for 48.6% and girls accounting for 51.1%. Eighty-seven percent of victims were comprised of three races or ethnicities: White (43.9%), African American (21.5%), and Hispanic (22.1%) (Children's Bureau, 2011).

Special needs that may increase caregiver burden such as disabilities, mental retardation, mental health issues, and chronic physical illnesses also put a child at increased risk for maltreatment.

In the 2012 review of child abuse cases in Kentucky, the Department of Community Based Services (DCBS) uncovered the following risk factors that appeared to increase an infant's risk of being shaken, particularly when combined with a parent or caregiver who is not prepared to cope with caring for a baby:

Babies less than 1 year of age

Infant prematurity or disability

Being one of a multiple birth

Prior physical abuse or prior shaking

Risk Factors for Perpetration

A perpetrator is the person who is responsible for the abuse or neglect of a child. Perpetrators come from all walks of life, races, ethnicities, religions, and nationalities. They come from all professions and represent all levels of intelligence and standards of living. There is no single social group free from incidents of child abuse.

In 2011 the Children's Bureau, using data from CPS reports, found that for all forms of child abuse and neglect:

Four-fifths (84.6%) of perpetrators were between the ages of 20 and 49 years.

Four-fifths (80.8%) of perpetrators were parents.

Of the perpetrators who were parents, 87.6% were the biological parents. (Children's Bureau, 2011)

Analysis of perpetrator's confessions indicate that the majority of perpetrators are male and are most likely to be fathers, followed by boyfriends, female babysitters, and mothers, in descending order (Chiesa and Duhaime, 2009).

Parents who lack an understanding of a child's needs or who lack child development and parenting skills are at increased risk for maltreating a child under their care. Parents with a history of child maltreatment in their own family and parental thoughts and emotions that tend to support or justify maltreatment behaviors are also at increased risk of maltreating a child.

Substance abuse and mental health issues (eg, depression) put a parent or caregiver at increased risk for committing child abuse. Parental characteristics such as young age, low education, single parenthood, large number of dependent children, and low income are also risk factors for committing child maltreatment. A nonbiological transient caregiver in the home-such as the mother's male partner-is a risk factor for child abuse.

Family Risk Factors

Social isolation, family disorganization, dissolution, and violence-including domestic violence-are risk factors for a parent of caregiver committing child abuse. If a parent is stressed, has a poor relationship with the child, or engages in negative interactions with the child, they are at increased risk for committing child abuse.

Children may be in a caretaker role-for example, as a babysitter-and may be responsible for abusing a child in their care. Any adult caretaker may be considered responsible if they delegate care responsibilities to an inappropriate minor caregiver. A mandatory reporter who suspects that abuse has occurred when one child is caring for another is required by law to make a child abuse report.

Community Risk Factors

Certain factors within the community can increase the risk of a parent or caregiver's committing child abuse. Community violence, high community poverty rates, residential instability, high unemployment rates, high density of alcohol outlets, and poor social connections can increase the likelihood of a parent or caregiver abusing a child under their care.

Six Factors Protective Against Child Maltreatment

Protective factors are those factors that reduce or eliminate the risk of an infant's being shaken or abused. Protective factors serve as buffers, helping parents who might otherwise be at risk of abusing their children to find resources, supports, or coping strategies that allow them to parent effectively, even under stress.

Certain protective factors decrease a child's risk of being abused while other protective factors decrease a parent or caregiver's risk of abusing a child. Six specific protective factors have been shown to be particularly effective in the prevention of child abuse. Research has shown that these protective factors are linked to a lower incidence of child abuse and neglect (CWIG, 2013).

1. Nurturing and Attachment

A child's early experience of being nurtured and developing a bond with a caring adult affects all aspects of behavior and development. When parents and children have strong, warm feelings for one another, children develop trust that their parents will provide what they need to thrive, including love, acceptance, positive guidance, and protection (CWIG, 2013).

2. Knowledge of Parenting and Child Development

Discipline is both more effective and more nurturing when parents know how to set and enforce limits and encourage appropriate behaviors based on the child's age and level of development. Parents who understand how children grow and develop can provide an environment where children can live up to their potential. Child abuse and neglect are often associated with a lack of understanding of basic child development or an inability to put that knowledge into action. Timely mentoring, coaching, advice, and practice may be more useful to parents than information alone (CWIG, 2013).

3. Parental Resilience

Resilience is the ability to handle everyday stressors and recover from occasional crises. Parents who are emotionally resilient have a positive attitude, creatively solve problems, effectively address challenges, and are less likely to direct anger and frustration at their children. In addition, these parents are aware of their own challenges-for example, those arising from inappropriate parenting they received as children-and accept help and/or counseling when needed (CWIG, 2013).

4. Social Connections

Evidence links social isolation and perceived lack of support to child maltreatment. Trusted and caring family and friends provide emotional support to parents by offering encouragement and assistance in facing the daily challenges of raising a family. Supportive adults in the family and the community can model alternative parenting styles and can serve as resources for parents when they need help (CWIG, 2013).

5. Concrete Supports for Parents

Many factors beyond the parent-child relationship affect a family's ability to care for their children. Parents need basic resources such as food, clothing, housing, transportation, and access to essential services that address family-specific needs (eg, childcare, healthcare) to ensure the health and well-being of their children. Some families may also need support connecting to social services such as alcohol and drug treatment, domestic violence counseling, or public benefits. Providing or connecting families to the concrete supports that families need is critical. These combined efforts help families cope with stress and prevent situations where maltreatment could occur (CWIG, 2013).

6. Social and Emotional Competence of Children

Just like learning to walk, talk, or read, children must also learn to identify and express emotions effectively. When children have the right tools for healthy emotional expression, parents are better able to respond to their needs, which strengthens the parent-child relationship. When children's age, disability, or other factors affect their needs and the child is incapable of expressing those needs, it can cause parental stress and frustration. Developing emotional self-regulation is important for children's relationships with family, peers, and others (CWIG, 2013).

Professional Training

Providing training about protective factors for all people who work with children and families helps build a workforce with common knowledge, goals, and language. Professionals, from frontline workers to supervisors and administrators, can benefit from training that is tailored to their role and imparts a cohesive message focused on strengthening families.

Strategies for enhancing professional development:

Provide trainings on protective factors to current trainers so they can teach others.

Integrate family-strengthening themes and the protective factors into college, continuing education, and certificate programs for those working with children and families.

Incorporate family-strengthening concepts into new-worker trainings.

Develop online training and distance learning opportunities.

Provide training at conferences and meetings.

Reinforce family-strengthening training with structured mechanisms for continued support, such as reflective supervision and ongoing mentoring (CWIG, 2013)

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A trigger is a prompt or external stimulus that leads to a behavior or causes a response-something that "sets you off." Triggers tell us "Do something now!" A trigger can be internal (fatigue, frustration, anger, desire) or external (a crying baby, a remark).

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Shaken baby syndrome is a serious form of child abuse. Here are some calming tips if you are feeling overwhelmed so you can prevent it from happening:
1) Place the baby in a safe zone (ex: crib) and leave the room.
2) Take deep breaths and slowly count to 10.
3) Call someone to take over for a while.
4) Contact the 24-hour crying baby helpline at 866-243-BABY.

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The Developing Person Through Childhood and Adolescence by Kathleen Stassen Berger (Ch. 5, pg 146)

https://www.healthline.com/health/shaken-baby-syndrome#diagnosis

https://www.youtube.com/watch?v=_t9vH6tqwxg

https://www.mottchildren.org/health-library/hw169815#:~:text=To%20confirm%20a%20diagnosis%20of,other%20injury%20in%20the%20brain.

https://adc.bmj.com/content/106/3/e14

https://www.atrainceu.com/content/6-triggersrisk-factors-shaken-baby-syndrome

http://safebaby.org/shaken-baby-syndrome/#:~:text=Contact%20the%2024%2Dhour%20crying,helpline%20at%20866%2D243%2DBABY