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. ^{1– 3} 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.

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.

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).

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 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.

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.

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).

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.

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.

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.

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.