The image of Ryan Sanders' tiny frame, cradled in tubes and gauze, looms at commuters. The baby's eyes are closed, and his face is half hidden under tape. He appears, as the words around him imply, shattered.

The troubling image first appeared on billboards with the message "Shaking a baby shatters lives." Now, that message has gone mobile. His image has been plastered on the back of public buses in Washington, D.C., and its suburbs. Other states have expressed interest in using the display.

The company that sold the advertisement space estimates the image will be seen 1.5 million times over the course of a month — making a loud statement by a boy who cannot speak.

The photo was taken when Ryan was 8 weeks old, on the day in 1992 when a caregiver shook him so violently that she left him permanently disabled. Now 14, he cannot talk, dress himself or brush his teeth alone. He continues to grow physically but has the cognitive ability of a toddler, his mother, Cathy Sanders, said. The bus campaign is her latest effort in a national campaign to spread the word about shaken baby syndrome.

"People need to understand that they can't take things out on children," said Sanders, of suburban Manassas, Va. "People, this is what a baby looks like when it's been shaken," she said. "I like people to understand it's violent, it's horrific."

Experts describe shaken baby syndrome as a head injury in which vigorous shaking causes the brain to slam back and forth against the skull. Infants are particularly susceptible because their necks are not well developed.

No clear statistics exist on how many shaken baby cases occur each year, but there are thousands, said Craig Futterman, president of the Fort Worth, Texas-based Shaken Baby Alliance and associate director of the Pediatric Intensive Care Unit at Inova Fairfax (Va.) Hospital for Children.

At Inova, Futterman said, he has seen hundreds of shaken children come in, with up to 50 dying.

"And that's (only) what we see," Futterman said, adding that thousands of cases are misdiagnosed or unreported each year. "This is a somewhat under-recognized disease."

'VERY LUCKY TO SURVIVE'

Years after Futterman treated Ryan, he saw a 5-month-old Centerville, Va., girl in a similar state visit the intensive care unit.

Photos of Olivia Adelmann look like Ryan's, her mother, Andrea Adelmann, said.

"It could be my daughter on the back of the buses," she said. "I think certainly drivers are going to notice when they are behind a bus like that."

Olivia was permanently injured in April 1998, on her fourth day with an in-home daycare provider. Adelmann said Olivia was asleep when she picked her up — the only clue something was wrong was the sporadic jerking of her arm and leg. Later that night, Adelmann took Olivia to the hospital after the jerking worsened and she could not wake her up.

"At the time, they didn't tell me, but she was very lucky to survive. They did not expect her to live," Adelmann said. "The entire left side of her brain is gone, it's been damaged so severely."

Olivia, 9, a second-grader, has mild paralysis on one side of her body, is blind in her left eye, and struggles with severe attention deficit disorder and learning disabilities, Adelmann said.

"The situation doesn't get any better; it just changes," Adelmann said.

The daycare provider, Margo Collado, was convicted of child abuse and sentenced to three years in prison in 1999.

Assistant Commonwealth's Attorney Sandra Sylvester in Prince William County, Va., has handled about 30 of these cases and describes them all as emotionally draining and difficult to prosecute.

"No one wants to believe that someone would pick up a baby ... and shake them to the point that their brain literally becomes scrambled," Sylvester said.

The oldest victim she has seen was 3; Ryan was among the youngest. The year he was injured, three other babies were also shaken in the county, with Ryan the only survivor, Sylvester said. She prosecuted the case against his caretaker, Eleanor Kay Hinegardner, who was convicted of felony child abuse and sentenced to four years in prison.

"There are some cases that you never stop thinking about, and he's one of them," Sylvester said. "Ryan was sentenced to life, as was his mom and dad. They got a life sentence."

EFFORT MAY EXPAND

Recently, Ryan visited a class Sylvester teaches at a suburban community college. He sat in his wheelchair, rocking himself and playing with his caregiver, unaware of the effect he was having on the students.

"The students were crying. They left in complete silence that day," Sylvester said. "This was a boy that the parents had all this promise and hope for. He should be playing ball and soccer and looking at girls. He's almost 15 years old."

Instead, the teenager is still being toilet trained and only recently started looking at himself in the mirror — a feat his parents celebrated, his mother said. He has cerebral palsy, optic nerve damage in both eyes and can walk for short distances, but not run or climb.

"The thing with a brain injury is you can regain what you lost," Sanders said. But with Ryan, "there was nothing to regain."

Pictures on Sanders' Web site, www.sbsprevention.com, show Ryan a day before the incident, a healthy baby sitting in a tub, and a day later, attached to a ventilator.

Ryan has no idea that he is the baby in the picture that has adorned billboards in several states over the past seven years and now buses, paid for through donations to her organization, Shaken Baby Prevention.

If the bus campaign is successful, Sanders said, Wisconsin, Minnesota and Florida have expressed an interest in using it.

But how does one measure success when talking about a picture, on a bus, for a month?

Sylvester said that she can speak only from what she has seen but that each time the billboards went up with Ryan's picture, a lull in shaken baby cases seemed to follow. It never lasted long, she said, maybe six months, maybe a bit longer.

"But at least for a short while, it does seem to stop," she said.