Isabella didn't know not to cry.

The 3 1/2-month-old baby spent her days with her father while her mother went to work. He liked to play video games and watch TV, and became disturbed when the baby started crying. So he shook her until she stopped.

	Nearly 2,000 children annually are victims of shaken baby syndrome, a Children's Hospital professor of pediactrics says. Click photo for larger image.

Isabella's mother didn't know there was anything wrong. After a few days, relatives thought the baby was sleeping more than babies usually did, but everything seemed normal, until one morning, Isabella didn't wake up from a nap.

She was rushed to the hospital, where doctors found bruises on her shoulders and rib cage. Her head was swollen from the shaking, and doctors inserted a shunt to drain the brain of fluid.

After Isabella spent 12 days in the hospital, doctors said she would never be able to sit up by herself or even hold up her head. Her father, who admitted to the abuse, was sentenced to 22 months in prison. Her mother had a nervous breakdown.

"When we brought her home, the sadness that pervaded the house was almost unbearable," said Isabella's great-grandmother, Sara Minnich, of Tower City, Schuylkill County. She has been trying to educate people about this type of abuse, often called shaken baby syndrome, ever since the incident in 2000.

Diagnosis

Shaken baby syndrome is difficult for doctors to identify because babies can neither vocalize their symptoms nor report abuse. Head and brain injuries are also more difficult to see than external bruises and scrapes.

There are anywhere from 1,100 to 1,800 confirmed cases a year in the United States, according to Dr. Rachel Berger, an assistant professor of pediatrics at Children's Hospital of Pittsburgh, who has extensively researched this topic. About one-quarter to one-third of these children die, 5 percent to 10 percent have a good outcome and the rest have a significant disability.

The symptoms of shaken baby syndrome can range from sluggishness and lethargy to vomiting, but babies "can have incredibly bad injuries and not look that bad," said Berger.

For financial and logistical reasons, doctors cannot do a CT scan -- currently the best way to diagnose a shaken baby -- on every infant brought in to the hospital. This means that babies are often misdiagnosed or sent back home where they are abused again -- Berger estimates that one-third of babies she treats for abusive head injury had come in with the same symptoms before.

A blood test used in Europe screens for shaken baby syndrome by detecting chemicals that should be only in a child's brain; if they are in the blood stream, it means the child has suffered head trauma. The test has not yet been certified for use in the United States.

Without tests, the trauma to the brain is difficult to understand, but doctors do know that it's extremely serious.

"If you're going to die from child abuse, it's probably because of brain injury," Berger said.

Shaking a baby can cause the brain to swell but there is not very much room in the skull for it to expand. The pressure builds up in the brain, sometimes compressing it, said Dr. Patrick Kochanek, director of the Safar Center for Resuscitation Research at the University of Pittsburgh.

Infants' heads are proportionately larger than the rest of their body, and their weak necks mean that shaking makes their heads flop around more vigorously than an older child's would, said Dr. Mary Carrasco, a Mercy pediatrician who directs its child advocacy center. This is harmful because infants have more space between their skull and brain.

Many of the babies that Kochanek sees are brought in days after the abuse occurred, which he compares with having a bad automobile accident and waiting a few hours before calling the paramedics.

Some parents wait to bring a child in to the hospital because they do not know about the abuse; it's sometimes committed by a baby sitter or a boyfriend. But parents are also hesitant to bring children in to the hospitals if they realize they've done something wrong.

Risk factors

Parents and caregivers rarely plan to shake a child violently; they simply snap under the pressures of taking care of an infant who is crying for no discernible reason.

But most parents know that what they're doing is harmful; doctors say that the shaking necessary to cause harm to a baby is significant. "There is no way that any person would look at this and not know it was injurious," said Berger, who has seen videos taken from parent-cams of babies being abused and shaken.

"It's a combination of ignorance and total frustration at that particular moment," said Mercy's Carrasco.

Marcia Bronder Warren hears about frustrated parents every day as the director of prevention services at Family Resources, a nonprofit that works to stop child abuse and has offices in East Liberty, McKeesport, and Downtown. The organization is teaming with area hospitals this month to educate people about shaken baby syndrome.

Parents can call 1-800-641-4546, to talk about frustrations or fears, and Warren has spoken to some parents of newborns who feel that they have nowhere to turn.

Part of the message to parents is that it is OK to put the baby down and take a break, and that babies sometimes cry for no reason. "I hear parents talk about feelings of frustrations and distress and inadequacy, wondering why they can't calm their baby down," Warren said. "Being alone all day, and the physical exhaustion, puts parents in a vulnerable state."

A demographic study in Pennsylvania suggested that cases of abusive head injury were most common in children of younger parents, single parents and minorities. But despite those findings, doctors say that shaken baby syndrome can happen in every segment of society.

Prevention

Parents are the perpetrators of this abuse 75 percent of the time, said Dr. Mark Dias, a pediatric neurosurgeon at Penn State, and so educating them about shaken baby can reduce the incidence.

Dias has focused on educating parents before they even leave the hospital. He found that a low-cost parent education program at hospitals can reduce the incidence of shaken baby syndrome by up to 50 percent. He helped implement the program, which shows parents an informational video, in hospitals in the Buffalo, N.Y., area, and then tracked the incidence of abusive head injuries in the region for six years starting in 1998.

The program, which costs less than $10 per infant, reduced the incidence of abusive head injuries from 41.5 cases per 100,000 live births to 22.2 cases.

This is a cost-effective approach as well; some studies estimate that ongoing medical care for shaken baby syndrome can average around $300,000 per child. For babies severely injured, the costs can run at $1 million for three years.

Dias moved recently from Buffalo to State College, where he met Sara Minnich, Isabella's great-grandmother. They worked together to implement the program in Pennsylvania, which was one of the first states to mandate that it be put into action.

The bill has assuaged some of Minnich's feelings of anger toward the baby's father, who is now on parole but has no contact with the child.

Isabella Clark is now 4 1/2 years old, and she's able to walk and do many of the things that children are able to do, but it's much harder for her. She has vision problems and goes to a school for children with special needs. Minnich estimates that the medical costs in the first few years of Isabella's life exceeded $500,000.

"We try to make her as independent as she can be, but that's very limited at this point," Minnich said. "We really have to watch her to make sure she doesn't walk into things."

For now, Minnich and her daughter and grand-daughter are focused on helping Isabella thrive. They feel lucky that Isabella survived the ordeal, and say that the girl has a wonderful attitude toward life. But Minnich wonders if anyone involved will ever be able to forget those few minutes of abuse.

"It leaves the family forever shaken."