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Research Article

Knowledge and attitudes towards shaken baby syndrome among parents in Al-Aasa region, Saudi Arabia

[version 1; peer review: awaiting peer review]
PUBLISHED 09 May 2025
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This article is included in the Sociology of Health gateway.

This article is included in the Public Health and Environmental Health collection.

Abstract

Background

Shaken Baby Syndrome describes serious cranial trauma inflicted upon infants and young children, potentially leading to significant injury or death. This study aims to evaluate parents' knowledge and attitudes regarding Shaken Baby Syndrome in Al-Ahsa, Saudi Arabia.

Methods

A cross-sectional study was conducted in Al-Ahsa, focusing on all reachable parents of young children by using convenience sampling from June 2024 to August 2024, and data was collected using a pre-structured questionnaire.

Results

A total of 572 eligible parents participated, with ages ranging from 20 to over 40 years. The predominant gender of responders was female, comprising 433 (75.7%). A significant proportion of participants 432 (75.5%) displayed poor overall knowledge of Shaken Baby Syndrome, whereas 140 (24.5%) indicated competent knowledge and awareness. Female gender and parents with multiple children had a significant correlation with parents' understanding of Shaken Baby Syndrome (P< 0.05).

Conclusion

The study indicated that only around one-quarter of parents demonstrated a competent comprehension of Shaken Baby Syndrome, with mothers exhibiting more awareness. Consequently, health authorities must increase efforts to enhance public awareness of Shaken Baby Syndrome.

Keywords

Awareness, Head trauma, Knowledge, Shaken baby syndrome

Introduction

Shaken Baby Syndrome (SBS) is a type of traumatic brain injury that develops mostly when a baby is vigorously shaken.1 This can cause the brain to rebound within the skull, leading to bruising and bleeding. Such injuries can result in serious brain damage or even death.13 Shaken baby injuries typically occur in children under two years of age, but can also affect children up to five years old due to their larger head size and weaker neck muscles.

SBS was first described in 1984 when Ludwig and Warman conducted a study of 20 infants and young toddlers who had been shaken. None of them showed signs of a head impact injury.4 The American Academy of Pediatrics (AAP) now uses the term “abusive head trauma (AHT)” to refer to non-accidental brain damage caused by impact trauma, shaking, or a combination of the two.5 Globally, the estimated prevalence of Shaken Baby Syndrome (SBS) in infants under one year of age is 14 to 33.8 per 100,000.6 However, it’s believed that these numbers are underestimated due to reporting issues.7,8

Injuries caused by shaking babies have likely to cause serious neurological consequences including cerebral palsy, blindness, encephalopathy, mental retardation, learning disabilities, or even newborn mortality. Subdural hemorrhages are more frequent in younger children under the age of one.8 Several risk factors, including those related to the baby, the environment, and the parents, have been connected to abusive head trauma/shaken baby syndrome (SBS/AHT). Extremely poor educational levels, drug or alcohol abuse, young moms, unemployment, inadequate preparation for parenthood, solitary parenting, and parental depression are examples of high-risk factors for parents.6,7 Postpartum depression was another risk factor, and regardless of the perceived level of weeping, it was revealed to be an independent risk factor for shaking and smothering.8,9 Mothers who are depressed could be less tolerant of their babies crying.10,11 Domestic or social instability, partner violence, and poverty are environmental risk factors for child abuse.12 Studies examining parents’ attitudes and understanding about SBS are scarce in Saudi Arabia’s Eastern Province. To prevent the debilitating effects of SBS in newborns and babies, it would be helpful to understand the attitudes and knowledge of parents in this province on the disease. The current study aimed to assess knowledge and attitudes of parents regarding SBS in Al-Hasa Region, Saudi Arabia.

Methods

This is a descriptive cross-sectional study was conducted targeting all available and accessible parents for children in Al-Ahsa during the period from June 2024 to August 2024. Exclusion criteria includes young-aged mothers (less than 18 years), those with no children less than 4 years old, parents who refused to participate, parents of a neurological motor disorders child or parents with incomplete study questionnaires. Participants were recruited using the convenience sampling method. A pre-structured questionnaire was used as the data collection tool through an electronic survey disseminated via social media platforms. The study questionnaire was constructed by the study authors via a comprehensive literature review and expert consultation in the study field. The study questionnaire clarity and validity were assessed via 3- expert judge in the study field where all modifications were applied. The approved study questionnaire included bio-demographic data such as age gender, education, employment, children, and their caregiver data. The second section covered parents’ knowledge and awareness about shaken baby syndrome with one or more correct answers per question. The study questionnaire’s validity and reliability were assessed via a pilot study of 20 participants. The tool reliability was 0.73 based on α-Cronbach’s.

For the determination of the minimal participant number, the sample size formula for a single proportion was applied. Sample size formula for a single proportion was used to calculate the minimum number of required participants. A 50% of sample proportion, 95% confidence interval, and a sample error of 5%, were assumed to calculate the sample size. The final sample size was estimated to be a minimum 385 subjects. The final study questionnaire was distributed online via social media platforms to all eligible participants by the study researchers and their families till no more new participants were obtained.

Data were collected, reviewed, and analyzed using the Statistical Package for Social Sciences (SPSS) version 26 (Released 2019, Armonk, NY: IBM Corp).13 All statistical tests were two-tailed, with an alpha level of 0.05. A P-value of ≤0.05 was considered statistically significant. An overall knowledge score was calculated by summing the correct responses, where each correct answer was assigned a score of 1, and incorrect answers were given a score of 0. Participants with knowledge scores below 60% of correct responses were classified as having poor knowledge, while those with scores between 60% and 100% were considered to have good knowledge.

Descriptive analysis of categorical data was conducted using frequencies and percentages, while numerical data were presented as means with standard deviations. Additionally, participants’ knowledge and awareness of SBS were presented in tabular form, and the overall knowledge level was illustrated graphically. Multiple logistic regression model were employed to identify factors associated with participants’ knowledge of SBS.

Results

A total of 572 eligible parents completed the study questionnaire, with ages ranging from 20 to over 40 years and a mean age of 28.9 ± 11.4 years. Most respondents were female, corresponding to 433 (75.7%). Regarding education, 370 (64.7%) participants had attained a university-level education or higher, while 176 (30.8%) had completed secondary education. In terms of the number of children, 337 (58.9%) parents had 1 to 2 children, and 176 (30.8%) had 3 to 5 children. A total of 355 (62.1%) participants reported that the mother primarily provided childcare for children under the age of three years with assistance from the father, while 128 (22.4%) stated that the mother provided care alone ( Table 1).

Table 1. Socio-demographic characteristics of study participants, Al-Ahsa, Saudi Arabia (n=572).

Socio-demographics N %
Gender
Male13924.3%
Female43375.7%
Age in years
20-3030753.7%
31-4017530.6%
> 409015.7%
Educational level
Below secondary264.5%
Secondary17630.8%
University/above37064.7%
How many children?
1-2 children33758.9%
3-5 children17630.8%
> 5 children5910.3%
Who provides care for your child under the age of three
Mother with father’s help35562.1%
Mother only12822.4%
Father only61.0%
Baby setter295.1%
Others284.9%
Grandma264.5%
Work
Not working24342.5%
Part-time 11920.8%
Full time21036.7%
Daily work hours
< 6 hours4313.1%
6-8 hours19358.7%
9-12 hours7021.3%
> 12 hours237.0%

In terms of parents’ knowledge and awareness of SBS ( Table 2), only 128 (22.4%) participants had prior knowledge of SBS. Of these, 310 (54.2%) described it as a preventable tragedy, 31 (5.4%) as an assault on a child, and 26 (4.5%) as a homicide, while 131 (22.9%) recognized all these aspects. Regarding the age group most at risk for SBS, only 170 (29.7%) identified all age groups as vulnerable. A total of 181 (31.6%) were aware that it only takes a few seconds to cause harm by shaking a baby. When asked about the signs indicating that a baby or young child has been shaken, 81 (14.2%) identified rolling eyes, 104 (18.2%) mentioned vomiting, 55 (9.6%) referred to difficulty breathing and convulsions, 37 (6.5%) noted unconsciousness, and 295 (51.6%) were aware of all these symptoms. Concerning the reasons why fathers or male partners are more likely to shake a child, 219 (38.3%) identified all correct reasons, while 271 (47.4%) knew that infants are particularly vulnerable due to their large head-to-body ratio (25% of body weight) and developing brain. Additionally, 191 (33.4%) understood that any caregiver could be at risk of shaking a baby, and 195 (34.1%) knew that both parents and babysitters are equally at risk of this behavior.

Table 2. Parents knowledge and awareness about Shaken Baby Syndrome, Al-Ahsa, Saudi Arabia.

Knowledge items N %
Did you know about Shaken baby syndrome before Yes12822.4%
No44477.6%
Shaken baby syndrome is A Preventable tragedy31054.2%
An assault on a child315.4%
Often ruled homicide264.5%
All of the above 13122.9%
None of the above7412.9%
At what age are children at risk of being shaken? 6 months old or younger24743.2%
1 year old9616.8%
2 years old376.5%
4 years old223.8%
All of the above 17029.7%
How long does it take to shake a baby? Few seconds 18131.6%
1 minute14425.2%
2 minutes7513.1%
4 minutes498.6%
5 minutes12321.5%
What might you see to be a sign that a baby or young child has been shaken Rolling eyes8114.2%
Vomiting10418.2%
Difficulty breathing and convulsions559.6%
Unconsciousness376.5%
All of the above 29551.6%
Even though mothers are typically the main caregivers, why are fathers or male partners more likely to shake a baby or young child Men may not be used to a baby’s or young child’s crying14625.5%
Men may be less familiar with a baby’s or young child’s needs13523.6%
Men may have additional stresses407.0%
Men may use force when frustrated325.6%
All of the above 21938.3%
Why is a baby so easily hurt? Because they have strong neck muscle173.0%
Because they can tell us what they need223.8%
They have a heavy head – 25% of their body weight6811.9%
The brain is still developing19433.9%
Both C and D 27147.4%
Can a baby or young child become a victim of shaking baby syndrome while in the day care or by baby sitter Any caregiver is at risk of shaking a baby or young child 19133.4%
A baby or young child is only at risk of shaking while with someone they do not know7713.5%
A baby or young child is at risk of shaking while with someone they do know386.6%
None of the above6010.5%
All of the above20636.0%
Who do you think is more patient with a baby or young child—the parents or someone babysitting the child Both types of caregivers are equally at risk for shaking a baby or young child 19534.1%
Parents know their children well and may forgive them easily, they are less at risk for shaking their child12421.7%
Parents can become stressed from the day in and day out care and are at more risk for shaking their child8314.5%
Babysitters may take pride in being professional and are less at risk for shaking a child478.2%
Babysitters may not always be able to have the patience that a parent may have and are more at risk for shaking a child12321.5%

Table 3 presents parents’ knowledge of SBS, showing that 230 (40.2%) understood that there is no situation in which shaking a baby is acceptable, and 409 (71.5%) knew that SBS is preventable through education. Crying was correctly identified by 348 (60.8%) of parents as the primary trigger for shaking a child, but only 93 (16.3%) were aware that bouncing a baby on an adult’s knee does not cause SBS. In terms of the causes of SBS, 151 (26.4%) attributed it to crying, 68 (11.9%) to trauma, 51 (8.9%) to stress, and 302 (52.8%) recognized all these factors. The importance of taking a 10-minute break as a coping strategy was known by 234 (40.9%) of participants. Regarding the contributing factors to SBS, 101 (17.7%) identified underprivileged parents, 73 (12.8%) cited stressful jobs, 55 (9.6%) mentioned single parenting, and 343 (60%) acknowledged all these factors. A total of 303 (53%) of parents understood that shaking a baby can cause brain swelling.

Table 3. Parents knowledge and awareness about Shaken baby Syndrome, Al-Ahsa, Saudi Arabia, continued.

Knowledge, continued N %
Is there a situation that makes shaking a baby or young child OK? Yes9115.9%
No23040.2%
Sometimes25143.9%
Is shaken baby syndrome preventable? Yes, through education40971.5%
Only with your own children315.4%
Sometimes9416.4%
Never254.4%
Only if you love the child132.3%
The first reason triggers why someone shakes a child is Crying34860.8%
Loss of appetite376.5%
Laughing396.8%
None of the above14825.9%
Activities that DO NOT cause shaken baby syndrome The baby being bounced on an adult’s knee9316.3%
The baby falling off furniture or a counter7112.4%
The baby being tossed up and caught498.6%
The baby jerking in a car seat when a driver stops the car suddenly8314.5%
All of the above27648.3%
Shaken baby syndrome is the result of Trauma6811.9%
Stress518.9%
Crying15126.4%
All of the above30252.8%
A coping mechanism would be for the parent or caregiver Take a 10-minute break23440.9%
Place the child in a room by themselves457.9%
Leave the child with a neighbor5910.3%
None of the above23440.9%
A contributing factor in shaken baby syndrome is Underprivileged parents10117.7%
Stressful jobs7312.8%
Single parenting559.6%
All the above34360.0%
Shaking a baby Can cause the brain to swell30353.0%
Does not cause the brain to swell437.5%
Stops them from crying11720.5%
None of the above10919.1%

As shown in Figure 1, the majority of parents that correspond to 432 (75.5%) had an overall poor level of knowledge, while only 140 (24.5%) participants demonstrated good knowledge and understanding of SBS.

fbca31ac-2518-402f-8e6c-bc5c66f30857_figure1.gif

Figure 1. Overall parents' knowledge and perception about shaken baby syndrome, Al-Ahsa, Saudi Arabia.

Among all included factors in Table 4, female gender, educational level, and employment status shows a significant relation with SBS knowledge level. Females showed nearly tripled likelihood for good knowledge about SBS compared to males (OR=3.7; 95% CI: 1.85-7.22). Also, employed respondents showed 1.6 times more likelihood for good knowledge level than others (OR=1.60; 95% CI: 1.0-2.83). High educational level was associated with 25% less likelihood for good knowledge level about SBS (OR=0.75; 95% CI: 0.58-0.98). As for number of children, the higher number was significantly associated with 7% more likelihood to have good knowledge about SBS (OR=1.07; 95% CI: 1.01-2.35).

Table 4. Multiple logistic regression model for predictors of SBS knowledge level.

Factorsp-value ORA95% CI
Lower Upper
Age in years0.9480.990.771.27
Female gender0.001*3.661.857.22
Non-Saudi 0.8721.120.294.37
Married vs. unmarried0.4471.250.712.20
High educational level0.037*0.750.580.98
Employed0.049*1.601.002.83
Monthly income0.9420.990.691.40
Number of children0.047*1.071.012.35
Have a child with chronic disease0.5281.360.523.52

* P < 0.05 (significant).

Discussion

SBS is defined as “a devastating form of inflicted traumatic brain injury that occurs when a young child is violently shaken and subjected to rapid acceleration, deceleration, and rotational forces, with or without impact”.14

The study revealed that the majority of respondents were young mothers with high educational levels. Additionally, more than half of the parents surveyed were employed, predominantly in full-time jobs. Similar findings, where mothers are the main respondents, have been reported by other researchers.15,16 Regarding knowledge of SBS, approximately one-fourth of the mothers demonstrated awareness of SBS, while the majority did not. Only about 20% of the participants had heard of SBS before, and fewer than half were aware that children are most at risk during their first six months of life. Awareness of SBS-related symptoms, triggers, and associated brain trauma was also limited. Similar findings were reported by AlOmran HI et al. in Riyadh, where 32.1% of mothers had inadequate knowledge of SBS, although they displayed a positive attitude towards the risks associated with it.15 In the Eastern Province, Alghanim FF et al. found that only 33% of respondents believed shaking infants could cause harm.16 The most frequently reported side effects of shaking babies were learning deficiencies 23.5%, behavioral problems 23.8%, and cerebral hemorrhage 48.1%. Over two-thirds (72.5%) of participants expressed a desire to learn more about SBS.

In a study conducted in Tabuk City, Saudi Arabia, 57.6% of participants admitted to shaking their babies to quiet them within the first year of life. Furthermore, 67% were unaware of the risks associated with shaking infants, and approximately 70% had never heard of SBS, consistent with the findings of this study.17 In Makkah, Felemban TA et al.18 found that most participants had no prior knowledge of SBS, and among those who were aware, their sources of information were unreliable. A pilot awareness program conducted in Saudi Arabia also showed that 77% of participants had poor knowledge and awareness of SBS, including its risk factors and complications.19

Internationally, higher levels of awareness have been reported. Marcinkowska U et al. found that 43% of respondents had never heard of SBS, with 88% recognizing it as a form of violence, although only 57% understood that a single instance of shaking could lead to death, and only 19% identified men as the primary aggressors.20 Sixteen percent of medical staff were unaware of how long it takes for the consequences of shaking to manifest. In a population-based survey in Germany, 59.4% of respondents had prior knowledge of SBS.21 A study in Japan revealed that women exposed to public health practices had significantly higher awareness of the dangers of shaking infants.22 A multi-center case-control study in New Zealand found that the risk of abusive head trauma decreases with increasing maternal age and gestational age at birth.23 In Berthold et al.’s study, 98% of respondents were aware that SBS can be fatal.21 These discrepancies between Eastern and Western countries highlight the significant knowledge gaps regarding SBS, underscoring the need for educational initiatives to raise awareness in the studied region.

In terms of factors associated with parents’ knowledge and awareness of SBS, this study revealed that mothers had significantly higher levels of awareness and knowledge. Surprisingly, low education was also linked to higher knowledge, contrary to trends in the literature. The relationship between gender and knowledge has been examined in previous studies by Berthold et al.,21 Dias et al.,22 Bechtel et al.,24 and Simonnet et al.,25 all of which found that females had significantly higher knowledge of SBS compared to males. Additionally, Bechtel et al.24 found a significant relationship between education level and knowledge of SBS.

The study’s limitations include the fact that participants were recruited from a single geographical area in Saudi Arabia, which may restrict the generalizability of the findings to the entire country. A larger sample size, drawn from various regions across the nation, would be necessary to achieve a more comprehensive understanding. Nevertheless, the study involved a substantial number of participants, and its findings are consistent with existing literature.

Conclusions

The study revealed that nearly one in four parents had good knowledge of SBS and its associated risks. Mothers exhibited higher levels of knowledge, but lower education was also linked to higher awareness, which is an unexpected finding. Raising public awareness of SBS from a public health perspective is crucial. This includes educating parents and caregivers about the dangers of violently shaking a baby, the risk factors associated with SBS, its triggers, and prevention strategies. Increased awareness could help reduce the incidence of SBS. Health authorities should intensify efforts to raise public knowledge and awareness of SBS to prevent its harmful consequences.

Ethical approval and Informed consent

This research was approved by The Research Ethics Committee at King Faisal University with approval number KFU-REC-2023-DEC-ETHICS1732, issued on 13/12/2023. Electronic written consent was obtained from all participants at the beginning of the questionnaire, and only those who agreed to participate were included in the analysis.

Authors’ contributions

All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the work. Acquisition, analysis, or interpretation of data: KN, AN, GG, IG, MM, TD, LN, JQ, NA, SD, AA. Drafting of the manuscript: KN, AN, GG, IG, MM, TD, LN, JQ, NA, SD, JO. Critical review of the manuscript for important intellectual content: KN, AAN, AN, GA, IG, JO, AA. Supervision: KN.

Ethical approval

This research was approved by The Research Ethics Committee at King Faisal University with approval number KFU-REC-2023-DEC-ETHICS1732, issued on 13/12/2023. Electronic written consent was obtained from all participants at the beginning of the questionnaire, and only those who agreed to participate were included in the analysis.

Comments on this article Comments (1)

Version 1
VERSION 1 PUBLISHED 09 May 2025
  • Reader Comment 08 Aug 2025
    Sandeep Singh, Management (DPU-COL), Dr D Y Patil Vidyapeeth University, Pune, India
    08 Aug 2025
    Reader Comment
    Important Highlights in the Paper :
    1. The topic addresses a serious and preventable issue—Shaken Baby Syndrome (SBS)—that has significant consequences for infant health and safety. Focusing on parental
    ... Continue reading
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Al Noaim K, Alghafli G, Alghafli I et al. Knowledge and attitudes towards shaken baby syndrome among parents in Al-Aasa region, Saudi Arabia [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:485 (https://doi.org/10.12688/f1000research.163461.1)
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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
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Comments on this article Comments (1)

Version 1
VERSION 1 PUBLISHED 09 May 2025
  • Reader Comment 08 Aug 2025
    Sandeep Singh, Management (DPU-COL), Dr D Y Patil Vidyapeeth University, Pune, India
    08 Aug 2025
    Reader Comment
    Important Highlights in the Paper :
    1. The topic addresses a serious and preventable issue—Shaken Baby Syndrome (SBS)—that has significant consequences for infant health and safety. Focusing on parental
    ... Continue reading
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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