The scientific controversy over the so-called Shaken Baby Syndrome (SBS) (also known, with a few key differences indicated later, as Abusive Head Trauma, AHT) is a rich and highly complex multifaceted topic.

It involves a wide range of academic disciplines: pediatrics, neonatology, obstetrics, neurology, neuropathology, radiology, hematology, evidence-based medicine, biomechanics, statistics, epidemiology, psychology, among others. There are also ramifications in epistemology, medical ethics, criminal law, sociology...

As such, the mass of data and information collected in the past half-century is phenomenal. There has been hundreds of popular press articles and documentaries in the past decades, while the academic publications number in the thousands.

Investigating this hotly-debated subject is a challenging and even daunting endeavor.

Yet, contrary to many other contemporary academic topics, it remains practically feasible for a single, or a small group of, highly-motivated individual(s) to read a large part of the literature available and gain a deep comprehension of the relevant issues.

This task is not even reserved to doctors and researchers. With enough time and energy, anyone with acceptable academic reading skills and a minimal high-school level scientific background can form a robust, evidence-based, objective opinion by carefully learning about both sides of the controversy. That includes lawers, judges, law enforcement officers, social workers, and other professionals involved in these cases.

This post provides a few pointers to anyone interested in understanding the most pressing issues around SBS. It is by no means exhaustive. It suggests a bare minimum of essential resources one should look at before delving into more specific aspects of the controversy.

Summary

Table of contents

• Summary
• Overview
  • Caution to reader
  • "Adherents" vs "agnostics"
  • A tentative definition
    • Some medical terminology
  • Legal implications
  • A contested definition
  • The "triad"
    • Citations from the medical literature, old and new
  • Contested topics, open questions
• Selected bibliography
  • Books
  • Press investigations
  • Opinion pieces
  • Films, documentaries, talks
  • Governmental reports
  • Blog posts
  • PubPeer comments
  • Academic publications
    • History
    • Opiniated reviews
    • Systematic reviews
    • Neuropathology
    • Radiology
    • Retinal hemorrhage
    • Benign external hydrocephalus
    • Differential diagnoses
    • Animal models
    • Biomechanics and numerical modeling
    • Short falls
    • Confessions
    • Epidemiology and prevention
    • Medical ethics, medicolegal issues, cognitive biases

Overview

Before presenting some of the most important references on the subject, we will indicate the caution required when investigating the subject, and we will try to clarify the definitions and the most contentious points.

Caution to reader

It is crucially important to understand that SBS/AHT is not an academic subject like others, for reasons listed here:

1. SBS/AHT is not just an abstract controversy. It has major, direct judicial implications in courts all over the world on a daily basis (removal of children from their homes, criminal convictions of parents and caregivers). The judicial decisions pronounced on the basis of medical expert opinion on SBS/AHT have immediate consequences for the affected children and their families.

2. SBS/AHT is related to the delicate topics of child abuse and child protection. It specifically involves babies, including severely disabled or deceased infants. These concepts naturally elicit strong emotions in most individuals. This may sometimes hamper objective thinking in otherwise rationally-minded professionals such as doctors, scientists, judges, and lawyers.

3. This academic subject has major societal and political ramifications. Child protection is an important aspect of most Western public policies. Disclosing or recognizing possible systemic failures of governmental agencies and processes bears some political risk.

4. There is a significant amount of confusion and even obfuscation in the literature regarding terminology and definitions. The meaning of commonly-used terms has slowly, and often implicitly, evolved over the course of decades. Discrepancies only appear when confronting literature decades apart.

5. Terminology is often vague, unclear, and imprecise. Descriptions are often qualitative rather than quantitative. For example, the degree of force associated to an act of shaking is not described in terms of velocity or acceleration, but as an act "so violent that individuals observing it would recognize it as dangerous and likely to kill the child" (AAP 2001). These descriptions render scientific investigations difficult while making it clear they are designed for legal purposes.

6. The degree of polarization in this area is extreme. As a first approximation, one may consider a currently dominant view, supported by what we may call "SBS/AHT adherents", and a different view supported by "agnostics". Even the very existence of a legitimate controversy is denied by most adherents. We will discuss these terms later in this post.

7. The adherent side is presented as having near-universal institutional support. It is fundamentally important that, for the sake of making a robust, evidence-based scientific opinion, one must make a sustained effort to move beyond any argument from authority. The reader should not substitute collective certainty with scientific evidence. Although in general, institutional support may be expected to follow scientific evidence, this is not strictly guaranteed, particularly when there are major non-scientific (political, financial, societal...) ramifications. Thus, one should not rely on one's natural confidence in scientific authority; rather, the reader should keep an open mind and exercise critical thinking at all times, and never hesitate to question or double-check any explicit or implicit assumption.

8. As a corollary to this extremely polarized dispute, the field is replete with violent personal attacks, insults, ad-hominem arguments, straw-man arguments, misstatements, and misrepresentations. The reader needs to keep a calm, objective, rational mind and concentrate on nothing other than robust methodology and sound scientific evidence, leaving all emotion aside.

9. A superficial read of the SBS/AHT academic literature, especially reviews, is far from sufficient to gain a deep understanding of the issues at play. One has to comprehend their historical context and evolution over periods spanning many decades. It is often necessary to look up and read cited references repeatedly.

10. One must develop the unnatural habit of checking every cited and seemingly literature-supported item of information. It has been shown on multiple occasions that certain assertions cannot be accepted at face value, even when references are proposed. Examples may be given later.

11. Contrary to the philosophy of the open science movement, anonymized data on which medical studies are based is almost never available. This is partly explained by obvious issues related to the medical and judicial confidentiality of child abuse cases. For example, when a clinical study includes cases that received a medical determination of child abuse, the exact medical information used by researchers to make these determinations is not accessible, or in an extremely limited form (as a table or a graph in the publication). It has been shown that false positives are regularly and occultly integrated in SBS population studies, even when alternative diagnoses have been made and parents or caretakers have been cleared by the judicial system. When cases are selected based on the existence of confessions obtained during police interrogation, the context and specifics of the interrogation are not available. Since independent verification is impossible, the scientific value of most studies is limited by the opacity of the data they rely on. In this context, testimonies of individuals relating personal or professional experience of these cases may sometimes bring valuable insight.

12. When writing about this topic, it is often necessary to make obvious statements explicit, such as recalling that shaking a baby must be strictly avoided, that severe injuries are to be expected after inflicted head trauma in children, and that child abusers must be criminally prosecuted. The reason for stating the obvious is that SBS/AHT agnostics are often accused, without any supporting evidence, of "denying" the existence of child abuse, or pretending that "shaking is safe". In reality, the controversy pertains uniquely to the reliability with which child abuse can be inferred with a high degree of certainty based on a few medical findings alone.

"Adherents" vs "agnostics"

We will refer to both sides of the controversy as "SBS/AHT adherents" and "agnostics". This is not a perfect denomination, and in any case any choice of denomination can be considered biased by one side or another. We intend these terms to be understood precisely according to their definitions of the Collins dictionary:

• Adherent: "someone who holds a particular belief or supports a particular person or group"

• Agnostic: "a person who claims, with respect to any particular question, that the answer cannot be known with certainty"

Adherents generally believe that SBS/AHT is a valid, non-controversial medical diagnosis that has an extremely low rate of false positives (Narang 2016).

On the other side, whereas a very small number of authors may deny the "existence" of SBS/AHT, most merely point to a lack of scientific reliability and certainty about these medical determinations of abuse and, therefore, a possibly high number of wrongful convictions and miscarriages of justice. Here is a citation from some of these authors:

"Today, we are still seeking answers to the questions that we have been asking for 40 years or longer—questions such as, why do some infants or toddlers suddenly collapse or die? Why do some of these children have subdural hemorrhages while others do not? What does the presence of the triad (or some elements of the triad) tell us about the cause of the collapse or death? And are there any findings that can accurately distinguish between accidents, abuse and natural causes? For decades, we thought we had answers to some of these questions: we thought that the presence of the triad, or some of its elements, proved that the child had been shaken. Today, the correct answer to these questions is, 'we don't know.' And, until we do know, we are, in Dr. Duhaime's words, simply 'shooting in the dark.'" (Findley 2011, pp. 261-262, emphasis ours)

A tentative definition

A required first step when investigating such a subject is to be clear on definitions. The SBS/AHT controversy is so intense that even the most basic definitions are vigorously debated. The term "Shaken Baby Syndrome" has actually several totally different meanings, which is a major reason for the high degree of confusion and obfuscation surrounding this issue.

On the one hand, Shaken Baby Syndrome describes a child abuse act where an adult exasperated by the uncontrollable crying of a young baby holds the child under the arms and vigorously shakes him or her back and forth. The brutal and repeated angular movement sustained by the baby's head during this act, amplified by the weakness of neck muscles and relatively large size of the infant head, may cause neurological injuries. Severe disability or death may ensue. These dramatic consequences on the child justify prevention measures targeting parents and caregivers, but also healthcare professionals who should be trained to recognize characteric signs in young victims.

On the other hand, Shaken Baby Syndrome also describes a set of related scientific hypotheses that we will formulate as follows (medical terms will be explained briefly below):

1. Violent shaking causes rupture of bridging veins, intracranial hemorrhage, retinal hemorrhage, and brain injuries in infants. Other traumatic injuries to the head, neck, ribs, limbs, organs, and other parts of the body are possible, but absent in many cases.

2. When a child is violently shaken, severe neurological symptoms appear almost immediately (the child instantly loses consciousness or will undergo a dramatic and sudden change of mental state).

3. The only other possible causes of these medical findings are: a multistory fall, a high-speed motor vehicle accident, and extremely rare medical conditions such as glutaric aciduria, Menkes disease, some severe blood clotting disorders, and a few others. In other words, the medical findings mentioned above are thought to have a traumatic origin in nearly all cases. If no trauma is evoked by parents or caregivers, the only logical explanation is that they are lying.

Consequently, we propose the following tentative definition:

SBS Definition : Shaken Baby Syndrome refers to the idea that if an infant is found with a constellation of medical findings including one or several of: subdural hemorrhage (SDH), retinal hemorrhage (RH), and/or bridging vein thrombosis; if no history of a major trauma such as a multistory fall or a high-speed motor vehicle accident is given by the parents or caregivers; and if none of the few rare medical conditions mentioned above is found, then it can be concluded, by default but with near-absolute certainty, that the child has been violently shaken by the last person present with him or her when symptoms first appeared.

The first definition given above, related directly to an act of child abuse, is obviously non-controversial; all debate concerns only the second.

Surprisingly, a clear definition of SBS/AHT such as ours is rarely found in this explicit form in the medical literature, although it does appear in a few instances. It mostly emerges from the literature corpus as a de facto medical belief taught and shared by healthcare providers around the globe since the late 1970's and up to the 2010's. An abundant case law over the last five decades across many countries also shows that medical experts have long relied on this hypothesis in family and criminal courts.

Before we pursue, we must give some basic medical terminology.

Some medical terminology

• The brain is surrounded by three meningeal membranes: the pia, the arachnoid, and the dura mater.
• The space between the pia and the arachnoid is the subarachnoid space. It is filled with cerebrospinal fluid. The arachnoid and the dura mater are in continuity with one another, forming the subdural compartment which may contain fluid or blood.
• Subdural hemorrhage, blood in the subdural compartment, is found in up to 46% of newborns (Rooks 2008). An intracranial hemorrhage occurs when blood is found in any of the tissues or membranes within the head.
• Bridging veins drain the blood from the brain, crossing the subarachnoid space to enter sinuses within the dura.
• Retinal hemorrhage occurs when blood is found in the retina, at the back of the eyes. It is found in about 20% of newborns (Callaway 2016).

Legal implications

Our tentative definition of SBS has clear legal implications. Infantile subdural and retinal hemorrhage are considered to be so specific for violent child abuse that their sole presence in an infant, even with no sign of trauma on the body and no suspicion of abuse in the child's environment, constitutes an almost irrefutable proof that a criminal offence has occurred and, as such, justifies drastic child protection procedures, criminal prosecutions, and convictions.

In practice, medical determinations are almost always made similarly. Parents or caregivers bring a young child (most often aged less than 6 months, almost always less than 12) to the emergency room for subacute or acute symptoms such as seizures, fussiness, irritability, apnea, poor eating, vomiting, increasing head circumference... The child undergoes cranial CT or MRI and doctors find subdural collections and/or hemorrhage. Fundoscopy reveals retinal hemorrhage. The hospital team makes a medical determination of SBS/AHT and reports the family to authorities. Social and police investigations may lead to the removal of the child (and siblings, if any) from their familial environment, while parents or caregivers are prosecuted. At the trial, medical experts testify that their determination of child abuse is nearly certain.

We see here that the issue of SBS is really situated at the intersection of medicine, science, and law.

The degree of certainty with which medical experts determine the occurrence of abuse in these cases is important to the courts since, in common law jurisdictions, the legal standard of proof is "beyond a reasonable doubt". It is this certainty that can lead to criminal convictions, even when there is no other supporting evidence of child abuse beyond the medical determination of SBS.

🇫🇷  In legal systems based on civil law, such as France, the judges' and jurors' "intimate conviction" is the standard of proof (Esnard 2013). Here, too, the certainty with which highly-recognized and experienced judicial experts make a medical determination of child abuse has a direct impact on the "intimate conviction" of triers of facts. Presentations of slow-motion videos, or direct demonstrations, of an adult violently shaking a doll may also have a psychological impact on judges and jurors.

At the time of writing, the National Registry of Exonerations has identified 27 of exonerations of past convictions in SBS/AHT cases in the United States.

A contested definition

Norman Guthkelch, the British neurosurgeon who first evoked a possible causal link between shaking and infant subdural hemorrhage, has criticized the very term Shaken Baby Syndrome:

"In contrast, the appellation shaken baby syndrome (SBS) asserts a unique etiology (shaking). It also implies intent since it is difficult to 'accidentally' shake a baby. (...) Since subdural and retinal hemorrhages (with or without cerebral edema) may also be observed in accidental or natural settings, I suggest that the elements of the classic triad of retinal hemorrhage, subdural hemorrhage and cerebral edema would be better defined in terms of their medical features. Since subdural hemorrhages in infancy originate in the dura, perhaps "retino-dural hemorrhage of infancy" would be an acceptable name for the primary findings. (...) This would allow us to investigate causation without appearing to assume that we already know the answer." (Guthkelch 2012, p. 202, emphases ours)

This definition, criticized by agnostics, has also been largely abandoned by adherents.

In 2009, the American Academy of Pediatrics published a position paper recommending abandoning the use of Shaken Baby Syndrome, and replacing it with a newer and broader term, Abusive Head Trauma (AHT):

"Shaken baby syndrome is a subset of AHT. (...)

The term "shaken baby syndrome" has become recognized by the public (...) The American Academy of Pediatrics supports prevention efforts that reduce the frequency of AHT and recognizes the utility of maintaining the use of the term "shaken baby syndrome" for prevention efforts. Just as the public commonly uses the term "heart attack" and not "myocardial infarction," the term "shaken baby syndrome" has its place in the popular vernacular. However, for medical purposes, the American Academy of Pediatrics recommends adoption of the term "abusive head trauma" as the diagnosis used in the medical chart to describe the constellation of cerebral, spinal, and cranial injuries that result from inflicted head injury to infants and young children." (Christian 2009, p. 1410, emphases ours)

This definition shies away from considering isolated shaking as a specific abusive gesture. The newer term has a broader scope which encompasses all kinds of traumatic injuries inflicted to an infant's head, often involving direct impact to the head.

This change of definition only adds to the confusion, since it abandons the kernel of the issue: the link between shaking alone, without impact and purely intracranial findings. The association of non-accidental trauma involving impact to the head with severe injuries is not contested by anyone.

Agnostics also criticize the term Abusive Head Trauma on the basis that this term continues to conflate an intention (abuse) with a medical diagnosis. They contend that abuse is a legal determination, not a medical one (Findley 2019).

The "triad"

Alongside this shift of terminology, the SBS Definition indicated above was abandoned.

Historically, the term "triad" has been strongly associated with this definition.

The "triad" refers to three medical findings: subdural hemorrhage, retinal hemorrhage, and brain swelling. In the past, authors from both sides used this term to refer to the idea that the discovery of one or several of these medical findings alone, when unexplained by the story or by the discovery of the few rare medical causes, even without any traumatic injury to the skin, the bones, or the neck, suffices to "diagnose" child abuse with near-certainty.

We will abstain from using the term "triad", even if this term occurs frequently in the literature from both sides. It may lead to confusion as it is sometimes used when only one or two of its components are identified. Furthermore, these findings are likely to be pathophysiologically related, so their occurrence should not be considered as statistically-independent events.

Importantly, the very existence of the "triad", indicating a near-automatic determination of child abuse based on a few medical findings, is now denied by many adherents. Thus it is not just the scientific reliability of our tentative definition of SBS that is contested, but even whether this definition is used at all.

Indeed, adherents now claim that "diagnosing" SBS/AHT is a highly complex process that involves an entire multidisciplinary team, and that never relies on the sole observance of subdural and retinal hemorrhage:

"An abuse diagnosis relies upon careful review of all available data, often including data identified and assessed by a dedicated multidisciplinary team, a constellation of imaging findings in the brain, bones, neck, spine and abdomen, fundoscopic findings, interviews with caregivers, forensic data (including postmortem studies), the presence of additional or previous injuries to the child or siblings, the presence of other malicious injury (e.g., burns, bite marks) and exclusion of underlying diseases and accidental injury." (Saunders 2017, pp. 1386-1387)

Yet, even though the SBS Definition above has been officially renounced by several medical institutions, it continues to be used in the field by many medical professionals and judicial experts around the world. One of the reasons for this is the inertia of clinical practice and criminal justice.

🇫🇷  Curiously, France has adopted a peculiar stance in this international context by adopting national health guidelines in 2011 and 2017 that match almost perfectly with our tentative definition, but contradict the current international consensus (HAS 2017).

It should also be noted that, in the past ten years, the strong association of retinal hemorrhage with abuse has been slowly replaced by an association with severe retinal hemorrhage.

Citations from the medical literature, old and new

We give here a few relevant citations from the adherents' medical literature, illustrating a paradigm shift about the existence and validity of "triad"-based medical determinations of abuse between the late 1990's and the late 2010's. These citations are by no means exhaustive.

Contested topics, open questions

We propose some open debated questions, with links to scientific references below.

• What are the pathophysiological mechanisms of subdural and retinal hemorrhage in infants? See Neuropathology, Radiology, Retinal hemorrhage.
• What are the medical causes and risk factors of subdural and retinal hemorrhage in infants? See Benign external hydrocephalus, Differential diagnoses, Birth, Short falls.
• With no satisfactory experimental model of shaking, what evidence do we have that traumatic shaking alone (without impact) can rupture bridging veins and cause subdural and retinal hemorrhage? What is the temporal evolution of symptoms after trauma? See History, Animal models, Biomechanics and modeling, Radiology.
• How reliable are admissions of shaking obtained after medical determinations of SBS/AHT? What scientific evidence can we infer from the rare described cases of witnessed and videotaped shaking? See Confessions, Medical ethics, medicolegal issues, cognitive biases.
• What is the scientific impact of the circular reasoning issue that arises in the clinical literature (where medical determinations of SBS/AHT are made based on the very same findings that are being studied)? See Systematic reviews, Opiniated reviews, Epidemiology and prevention.
• What are the psychological, societal, ethical implications of medical determinations of child abuse? See Medical ethics, medicolegal issues, cognitive biases.

Selected bibliography

In the remainder of this post, we will give references to learn more about the controversy.

Notes

• We classified references between "SBS/AHT adherents" and "agnostics" when relevant. This distinction is not always clear and it is open to discussion.
• Some references may appear multiple times in different categories.
• References only available in French are indicated with a flag  🇫🇷.
• Important references are highlighted in yellow. This selection is subjective and also open to discussion.
• This bibliography will be completed over time. Contact me by email (see sidebar/footer on this page) to propose any corrections or additions.
• Many articles are behind a paywall. Older articles may also be hard to find. Contact me if you need the PDF of some articles.

Books

SBS/AHT adherents

• Reece 2015. To Tell the Truth: Based on the Author's Forty Years of Clinical and Trial Experiences in Abusive Head Trauma - Shaken Baby Syndrome Cases

• Palusci, Lazoritz 2001. The Shaken Baby Syndrome: A Multidisciplinary Approach

• 🇫🇷  Renier 2000. Le bébé secoué : Traumatisme crânien du nourrisson

Agnostics

• 🇫🇷  Echenne 2020. Le syndrome du bébé secoué. Hématomes sous-duraux et collections péri-cérébrales du petit nourrisson

• Papetti 2018. The Forensic Unreliability of the Shaken Baby Syndrome

• Tuerkheimer 2014. Flawed Convictions: "Shaken Baby Syndrome" and the Inertia of Injustice

Press investigations

In this section, we give references to press investigations specifically covering the scientific and legal controversy.

SBS/AHT adherents

• CNN 2021. Justice for Rehma

Agnostics

• The Appeal 2022. A Judge Finally Called Bs On ‘Shaken Baby Syndrome'

• 🇫🇷  Revue XXI 2022. Contre-enquête sur les bébés secoués

• 🇫🇷  Le Figaro 2022. Bébés secoués : quand des parents crient à l'erreur de diagnostic

• 🇫🇷  Causette 2022. Placements abusifs d'enfants : le calvaire des familles

• 🇫🇷  Le Monde 2021. Faux aveux : le cas des bébés secoués

• The Appeal 2020. How Dubious Science Helped Put A New Jersey Woman In Prison For Killing A Baby In Her Care

• 🇫🇷  Le Monde 2019. Le diagnostic du syndrome du bébé secoué donne lieu à une guerre d'experts

• The Guardian 2017. ‘We believe you harmed your child': the war over shaken baby convictions

• Slate 2017. Wrongly Imprisoned for Killing His Infant Daughter, a Father Could Go Free This Week

• New Scientist 2016. Evidence of 'shaken baby' questioned by controversial study

• New York Times 2015. Shaken Baby Syndrome: A Diagnosis That Divides the Medical World

• Washington Post 2015. A disputed diagnosis imprisons parents

• NPR 2011. Rethinking Shaken Baby Syndrome

The Waney Squier case

Waney Squier, a pediatric neuropathologist from Oxford University, UK, changed her mind about the scientific reliability of SBS/AHT in the early 2000's. She was struck off the General Medical Council (GMC) in March 2016, reinstated in appeal in November 2016, but she was not allowed to give expert evidence in court for three years.

• Macdonald 2019. Prometheus shaken baby debate

• The Justice Gap 2018. Waney Squier: 'Science is not a democracy'

• The Times 2016. Why I denied shaken baby syndrome

• The Guardian 2016. Doctor wins appeal over shaken baby syndrome trials evidence

• The Guardian 2016, Clive Stafford Smith. The science of shaken baby syndrome

• The Guardian 2016. Why the shaken baby syndrome tribunal led to Dr Waney Squier being struck off

• BBC 2016. Should Waney Squier have been struck off over shaken baby syndrome?

• The Guardian 2008. Beyond reasonable doubt

Opinion pieces

SBS/AHT adherents

• Boston Globe, Sabir 2019. Shaken Baby Syndrome no 'controversy' at all

• Washington Post, McCarthy 2017. Shaken baby syndrome is real — and its victims need justice

• The Guardian, Campbell 2016. Battlelines drawn as shaken baby syndrome controversy set to run

• KevinMD, Johnson 2015. The controversy about shaken baby syndrome actually isn't one at all

Agnostics

• The Wall Street Journal, Bobrow 2022. The Debate Over Shaken Baby Syndrome

• Innocence Network 2019. Statement Of The Innocence Network On Shaken Baby Syndrome/Abusive Head Trauma

• Washington Post, Balko 2014. ‘Shaken baby syndrome' and the flawed science in our criminal courts

Films, documentaries, talks

Documentaries

• 🇫🇷  Jusqu'à l'appel 2022

• Retro report 2015. The Nanny Murder Case: Shaken Baby Syndrome on Trial

• The Syndrome 2015.

Video interviews

• A 22-minute videotaped interview with Norman Guthkelch, 2013

• A 2-minute video excerpt of an interview with Norman Guthkelch, 2015

• A 26-second video excerpt of an interview with Norman Guthkelch, 2015

Conferences

• TEDxWandsworth, Waney Squier 2016. I believed in Shaken Baby Syndrome until science showed I was wrong

• TEDxButler, Jessica Henry, 2021 No-Crime Wrongful Convictions

Blog posts

• 🇫🇷  List of witnessed or videotaped shaking incidents

• 🇫🇷  False allegations of conflicts of interest between the Swedish (SBU) report and a Swedish radiologist, Peter Aspelin

PubPeer comments

• PubPeer comment about an article on SBS in daycare centers, 2020

Governmental reports

We give references to official position papers, or "consensus" papers, organized by countries rather than by side.

United States

• Narang 2020. Abusive Head Trauma in Infants and Children

• Choudhary 2018. Consensus statement on abusive head trauma in infants and young children

• Christian 2009. Abusive Head Trauma in Infants and Children

• Case 2001. Position Paper on Fatal Abusive Head Injuries in Infants and Young Children

• COCAN 1993. Shaken Baby Syndrome: Inflicted Cerebral Trauma

Canada

• Ontario Ministry of the Attorney General 2011. Committee Report To The Attorney General: Shaken Baby Death Review

Sweden

• SBU 2016. Traumatic shaking – The role of the triad in medical investigations of suspected traumatic shaking

• Debate after the publication of the SBU report (2016-2019)

France

• 🇫🇷  HAS 2017. Syndrome du bébé secoué ou traumatisme crânien non accidentel par secouement

• 🇫🇷  HAS 2011. Syndrome du bébé secoué : Rapport d’orientation de la commission d’audition

Academic publications

In this section, we give some of the main references to medical, scientific, and legal academic publications, sorted by category and date of publication. There are about ten times more publications in the literature. We try to give references from both sides of the controversy, when this distinction makes sense.

History

The publications below are considered as the seminal works leading to the recognition of shaken baby syndrome. The two main figures are John Caffey (1895-1978), American pediatric radiologist, and Norman Guthkelch (1915-2016), British pediatric neurosurgeon.

Agnostics claim that initial works on SBS were based on anecdotal evidence and misunderstandings, notably misinterpretation of the study by Pakistani American neurosurgeon Ayub Ommaya in 1968 on whiplash injuries in monkeys. For them, SBS was applied in court before it was ever validated by robust scientific studies. In the last few years of his life, Norman Guthkelch has also criticized the way medical determinations of SBS were made.

• Lazoritz 1997. The whiplash shaken infant syndrome: Has Caffey's syndrome changed or have we changed his syndrome?

• Ludwig 1984. Shaken baby syndrome: A review of 20 cases

• Heins 1984. The 'Battered Child' Revisited

• Caffey 1974. The Whiplash Shaken Infant Syndrome

• Caffey 1972. On the Theory and Practice of Shaking Infants Its Potential Residual Effects of Permanent Brain Damage and Mental Retardation

• Silverman 1972. Unrecognized Trauma in Infants, the Battered Child Syndrome, and the Syndrome of Ambroise Tardieu

• Guthkelch 1971. Infantile Subdural Haematoma and its Relationship to Whiplash Injuries

• Ommaya 1968. Whiplash Injury and Brain Damage: An Experimental Study

• Till 1968. Subdural Haematoma and Effusion in Infancy

• Caffey 1965. Significance of the history in the diagnosis of traumatic injury to children

• Kempe 1962. The Battered-Child Syndrome

• Guthkelch 1953. Subdural Effusions in Infancy: 24 Cases

• Ingraham 1939. Subdural Hematoma In Infancy And Childhood

• Sherwood 1930. Chronic Subdural Hematoma In Infants

Opiniated reviews

We give here references to reviews that may be found to present a bias toward one side of the controversy.

SBS/AHT adherents

• Vinchon 2022. The legal challenges to the diagnosis of shaken baby syndrome or how to counter 12 common fake news

• Lindberg 2019. The "New Science" of Abusive Head Trauma

• Duhaime 2019. Abusive head trauma: evidence, obfuscation, and informed management

• Vinchon 2017. Shaken baby syndrome: what certainty do we have?

• Greeley 2015. Abusive Head Trauma: A Review of the Evidence Base

• Narang 2014. Abusive Head Trauma: Past, Present, and Future

• Moreno 2013. The Supreme Court Screws up the Science: There Is No Abusive Head Trauma/Shaken Baby Syndrome Scientific Controversy

• Narang 2011. A Daubert Analysis of Abusive Head Trauma/Shaken Baby Syndrome I

• Narang 2011. A Daubert Analysis of Abusive Head Trauma/Shaken Baby Syndrome II

• Minns 2005. Shaken baby syndrome: theoretical and evidential controversies

• Blumenthal 2002. Shaken baby syndrome

• Duhaime 1998. Nonaccidental Head Injury in Infants — The "Shaken-Baby Syndrome"

Agnostics

• Papetti 2019. Outside the Echo Chamber: A Response to the Consensus Statement on Abusive Head Trauma in Infants and Young Children

• Findley 2019. Feigned consensus: usurping the law in shaken baby syndrome/abusive head trauma prosecutions

• Macdonald 2019. Prometheus shaken baby debate

• Aspelin 2017. Keynote Address: Can a Sign or Occult Finding Predict a Causal Relationship?: How to Reason About Possible Child Abuse

• Gabaeff 2016. Exploring the controversy in child abuse pediatrics and false accusations of abuse

• Squier 2016. Shaken Baby Syndrome (Chapter 4), in Forensic Science Reform: Protecting the Innocent

• Findley 2012. Shaken Baby Syndrome, Abusive Head Trauma, and Actual Innocence: Getting It Right

• Guthkelch 2012. Problems of Infant Retino-Dural Hemorrhage with Minimal External Injury

• Tuerkheimer 2010. Science-Dependent Prosecution and the Problem of Epistemic Contingency: A Study of Shaken Baby Syndrome

• Tuerkheimer 2009. The Next Innocence Project: Shaken Baby Syndrome and the Criminal Courts

Systematic reviews

• Lynøe 2017. Insufficient evidence for 'shaken baby syndrome'—a systematic review

• Donohoe 2003. Evidence-Based Medicine and Shaken Baby Syndrome Part I: Literature Review, 1966–1998

Neuropathology

We now move to more technical references.

Reading studies in neuropathology and forensic pathology ideally requires some minimal knowledge of the child's brain anatomy, physiological and pathological processes in tissues, cell biology, molecular biology, and immunostaining techniques.

By understanding the natural reactions of cells and tissues to pathological conditions such as mechanical trauma or hypoxia-anoxia (lack of oxygen), and by observing the tissues of deceased infants, pathologists can elaborate and verify hypotheses related to the causes of observed medical findings.

On the other hand, whereas radiology allows one to make observations of medical findings in the tissues of living patients, it is typically required to make a careful comparison with pathological findings in order to verify the observations and infer causative mechanisms, in particuler when evaluating the traumatic or non-traumatic nature of specific findings.

A significant aspect of the SBS/AHT controversy pertains to neuropathological discussions about the traumatic or non-traumatic nature of specific brain lesions observed in deceased infants, as this strongly determines whether child abuse will be ultimately retained as the cause of death or not.

Whereas traumatic brain injury seemed to be common in children who died with a medical determination of SBS/AHT, it has been shown in the last two decades that hypoxia is significantly more commonly observed than axonal damage, for reasons that remain unclear and debated.

Similar discussions also exist regarding bridging veins, subdural, and retinal hemorrhage.

SBS/AHT adherents

• Rambaud 2015. Bridging veins and autopsy findings in abusive head trauma

• Matschke 2015. Encephalopathy and death in infants with abusive head trauma is due to hypoxic-ischemic injury following local brain trauma to vital brainstem centers

• Hurley 2014. Is there a causal relationship between the hypoxia–ischaemia associated with cardiorespiratory arrest and subdural haematomas? An observational study

• Matshes 2001. Shaken Infants Die of Neck Trauma, Not of Brain Trauma

• Matschke 2009. Ocular pathology in shaken baby syndrome and other forms of infantile non-accidental head injury

• Case 2008. Inflicted Traumatic Brain Injury in Infants and Young Children

• Duhaime 2007. Traumatic brain injury in infants: the phenomenon of subdural hemorrhage with hemispheric hypodensity ("Big Black Brain")

• Byard 2007. Lack of Evidence for a Causal Relationship between Hypoxic-Ischemic Encephalopathy and Subdural Hemorrhage in Fetal Life, Infancy, and Early Childhood

• Punt 2004. The ‘unified hypothesis' of Geddes et al. is not supported by the data

• Shannon 1998. Axonal injury and the neuropathology of shaken baby syndrome

Agnostics

• Squier 2016. Infants dying suddenly and unexpectedly share demographic features with infants who die with retinal and dural bleeding: a review of neural mechanisms

• Scheimberg 2013. Nontraumatic Intradural and Subdural Hemorrhage and Hypoxic Ischemic Encephalopathy in Fetuses, Infants, and Children up to Three Years of Age: Analysis of Two Audits of 636 Cases from Two Referral Centers in the United Kingdom

• Squier 2012. The pathophysiology of brain swelling associated with subdural hemorrhage: the role of the trigeminovascular system

• Squier 2011. The "Shaken Baby" syndrome: pathology and mechanisms

• Cohen 2010. Subdural hemorrhage, intradural hemorrhage and hypoxia in the pediatric and perinatal post mortem: Are they related? An observational study combining the use of post mortem pathology and magnetic resonance imaging

• Mack 2009. Anatomy and development of the meninges: implications for subdural collections and CSF circulation

• Squier 2009. The neuropathology of infant subdural haemorrhage

• Cohen 2009. Evidence of Occurrence of Intradural and Subdural Hemorrhage in the Perinatal and Neonatal Period in the Context of Hypoxic Ischemic Encephalopathy: An Observational Study from Two Referral Institutions in the United Kingdom

• Geddes 2004. Inflicted head injury in infants

• Geddes 2003. Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in ‘shaken baby syndrome'?

• Geddes 2001. Neuropathology of inflicted head injury in children: II. Microscopic brain injury in infants

• Geddes 2001. Neuropathology of inflicted head injury in children: I. Patterns of brain damage

Radiology

We refer to the introduction of the Neuropathology section above.

Some authors remind that radiology alone may not yield a reliable medical determination of abuse:

"The medical and imaging evidence, particularly when there is only central nervous system injury, cannot reliably diagnose intentional injury. Only the child protection investigation may provide the basis for inflicted injury in the context of supportive medical, imaging, biomechanical, or pathological findings." (Barnes 2007, p. 53)

SBS/AHT adherents

• Sidpra 2021. Abusive head trauma: neuroimaging mimics and diagnostic complexities

• Orman 2019. MRI Findings in Pediatric Abusive Head Trauma: A Review

• Mankad 2019. The neuroimaging mimics of abusive head trauma

• Wright 2017. CNS Injuries in Abusive Head Trauma

• Nixon 2016. Imaging of Abusive Head Trauma: A Review and Update

• Choudhary 2015. Venous injury in abusive head trauma

• Hsieh 2015. Revisiting Neuroimaging of Abusive Head Trauma in Infants and Young Children

• Girard 2015. Neuroimaging differential diagnoses to abusive head trauma

• Hahnemann 2014. Imaging of bridging vein thrombosis in infants with abusive head trauma: the "Tadpole Sign".

• Stoodley 2014. Controversies in non-accidental head injury in infants

• Choudhary 2014. Imaging of spinal injury in abusive head trauma: a retrospective study

• Hedlund 2012. Subdural Hemorrhage in Abusive Head Trauma: Imaging Challenges and Controversies

• Adamsbaum 2012. Abusive head trauma: don't overlook bridging vein thrombosis

• Kemp 2011. Neuroimaging: what neuroradiological features distinguish abusive from non-abusive head trauma? A systematic review

• Fernando 2008. Neuroimaging of nonaccidental head trauma: pitfalls and controversies

Agnostics

• Zahl 2021. Thrombosis is not a marker of bridging vein rupture in infants with alleged abusive head trauma

• Wester 2021. Re-evaluation of medical findings in alleged shaken baby syndrome and abusive head trauma in Norwegian courts fails to support abuse diagnoses

• Barnes 2011. Imaging of Nonaccidental Injury and the Mimics: Issues and Controversies in the Era of Evidence-Based Medicine

• Barnes 2010. Infant Acute Life-Threatening Event—Dysphagic Choking Versus Nonaccidental Injury

• Banes 2008. Traumatic Spinal Cord Injury: Accidental Versus Nonaccidental Injury

• Barnes 2007. Imaging of the Central Nervous System in Suspected or Alleged Nonaccidental Injury, Including the Mimics

• Barnes 2002. Ethical Issues in Imaging Nonaccidental Injury: Child Abuse

Retinal hemorrhage

The pathophysiological mechanisms of retinal hemorrhage is incompletely understood. As a first approximation, SBS/AHT adherents believe they occur due to the vitreo-retinal traction during traumatic shaking, whereas agnostics believe they occur as a consequence of raised intracranial pressure and/or intracranial hemorrhage.

SBS/AHT adherents

• Shi 2019. Retinal Findings in Young Children With Increased Intracranial Pressure From Nontraumatic Causes

• Wang 2018. Retinal Hemorrhages in Shaken Baby Syndrome

• Hansen 2018. Retinal Hemorrhages: Abusive Head Trauma or Not?

• Binenbaum 2014. The eye in child abuse: Key points on retinal hemorrhages and abusive head trauma

• Levin 2014. Retinal Hemorrhage in Abusive Head Trauma: Finding a Common Language

• Maguire 2013. Retinal haemorrhages and related findings in abusive and non-abusive head trauma: a systematic review

• Binenbaum 2013. Patterns of Retinal Hemorrhage Associated With Increased Intracranial Pressure in Children

• Hang 2013. Retinal Hemorrhage After Cardiopulmonary Resuscitation With Chest Compressions

• Burkhart 2012. Risk factors associated with retinal hemorrhage in suspected abusive head trauma

• Bhardwaj 2010. A Systematic Review of the Diagnostic Accuracy of Ocular Signs in Pediatric Abusive Head Trauma

• Levin 2010. Retinal Hemorrhage in Abusive Head Trauma

• Morad 2010. Retinal haemorrhage in abusive head trauma

• Binenbaum 2009. Odds of abuse associated with retinal hemorrhages in children suspected of child abuse

• Rangarajan 2009. Finite element model of ocular injury in abusive head trauma

• Tang 2008. Shaken Baby Syndrome A Review and Update on Ophthalmologic Manifestations

• Hans 2008. A finite element infant eye model to investigate retinal forces in shaken baby syndrome

• Goldman 2005. Severe cough and retinal hemorrhage in infants and young children

• Schloff 2002. Retinal findings in children with intracranial hemorrhage

• Morad 2002. Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome

• Clark 2001. Retinal Hemorrhages: Evidence of Abuse or Abuse of Evidence?

• Gayle 1995. Retinal hemorrhage in the young child: A review of etiology, predisposed conditions, and clinical implications

• Wilkinson 1989. Retinal Hemorrhage Predicts Neurologic Injury in the Shaken Baby Syndrome

• Lambert 1986. Optic Nerve Sheath and Retinal Hemorrhages Associated With the Shaken Baby Syndrome

Agnostics

• Thiblin 2021. Retinal haemorrhage in infants investigated for suspected maltreatment is strongly correlated with intracranial pathology

• Shuman 2017. Severe Retinal Hemorrhages with Retinoschisis in Infants are Not Pathognomonic for Abusive Head Trauma

• Gabaeff 2011. Challenging the Pathophysiologic Connection between Subdural Hematoma, Retinal Hemorrhage and Shaken Baby Syndrome

• Mena 2011. Ocular Findings in Raised Intracranial Pressure A Case of Terson Syndrome in a 7-Month-Old Infant

• Clarke 2009. Vitreoretinal traction is a major factor in causing the haemorrhagic retinopathy of abusive head injury? – No

Birth

Between a quarter and a half of all asymptomatic neonates present subdural and/or retinal hemorrhage in their first days of life. Although they typically cause no symptoms and resolve in a few days, they may persist and cause complications in a small proportion of cases.

An often-cited study is Rooks 2008 who found subdural hemorrhage within 72 hours of delivery in 46% of 101 asymptomatic neonates. The hemorrhage resolved spontaneously within three months in all cases, but one child had a new extraaxial collection on follow-up at 26 days which raised concern for abuse, which was ruled out after a full investigation. This case shows that birth intracranial hemorrhage may sometimes persist after several weeks and be misinterpreted as child abuse:

"Initially, this patient had bilateral posterior occipital SDHs, which were being followed for resolution. At 26 days of life, the patient returned for the follow-up MR imaging and was noted to have a 1-cm extraaxial left frontal collection that did not conform to CSF attenuation, consistent with a spontaneous SDH. The patient was admitted for full evaluation for nonaccidental injury to include skeletal survey, ophthalmologic examination, coagulation panel, metabolic studies, as well as social work enquiries. These investigations did not reveal any additional injuries or findings to support NAI [Nonaccidental Injury] as an etiology of the spontaneous frontal SDH (Fig 4). At a 5-month follow-up MR imaging, the left frontal SDH resolved; however, the subarachnoid space remained prominent in this patient. This finding suggests that though not typical in a neonate, prominent extra-axial space is a predisposing factor for SDHs as has been reported by other authors." (Rooks 2008, pp. 1087-1088 , emphases ours)

More rarely, traumatic births may also cause symptomatic intracranial hemorrhage.

Intracranial hemorrhage

• Nikam 2021. Birth-related subdural hemorrhage: prevalence and imaging morphology

• Zamora 2020. Subdural Hemorrhage in Asymptomatic Neonates: Neurodevelopmental Outcomes and MRI Findings at 2 Years

• Tan 2018. Intracranial hemorrhage in neonates: A review of etiologies, patterns and predicted clinical outcomes

• Hong 2018. Intracranial hemorrhage in term neonates

• Shah 2016. Intracranial Hemorrhage in the Neonate

• Gupta 2009. Intracranial Hemorrhage in Term Newborns: Management and Outcomes

• Rooks 2008. Prevalence and Evolution of Intracranial Hemorrhage in Asymptomatic Term Infants

• Looney 2007. Intracranial Hemorrhage in Asymptomatic Neonates: Prevalence on MR Images and Relationship to Obstetric and Neonatal Risk Factors

Retinal hemorrhage

• Callaway 2016. Retinal and Optic Nerve Hemorrhages in the Newborn Infant: One-Year Results of the Newborn Eye Screen Test Study

• Laghmari 2014. Birth-related retinal hemorrhages in the newborn: incidence and relationship with maternal, obstetric and neonatal factors

• Watts 2013. Newborn retinal hemorrhages: A systematic review

• Choi 2011. Retinal Hemorrhage Associated with Perinatal Distress in Newborns

• Hughes 2006. Incidence, Distribution, and Duration of Birth-Related Retinal Hemorrhages: A Prospective Study

• Emerson 2001. Incidence and rate of disappearance of retinal hemorrhage in newborns

• Bergen 1976. Retinal hemorrhages in the newborn

Benign external hydrocephalus

Benign external hydrocephalus (BEH), also known as enlarged extraaxial spaces, enlargement of subarachnoid spaces, or many other terms, is a medical condition "associating a rapid increase in head circumference, combined with enlarged subarachnoid spaces as seen on neuroimaging—especially overlying the frontal lobes—and normal or only moderately enlarged ventricles" (Zahl 2011). It is often considered as a risk factor for the development of quasi-spontaneous subdural hemorrhage and retinal hemorrhage, although not by part of the SBS/AHT adherents. Some authors believe that a number of children with BEH are misdiagnosed with SBS/AHT, especially due to imaging similarities.

SBS/AHT adherents

• Caré 2021. Macrocephaly and subdural collections

• Hansen 2017. Evaluations for abuse in young children with subdural hemorrhages: findings based on symptom severity and benign enlargement of the subarachnoid spaces

• Fingarson 2016. Enlarged subarachnoid spaces and intracranial hemorrhage in children with accidental head trauma

• Wittschieber 2015. Subdural Hygromas in Abusive Head Trauma: Pathogenesis, Diagnosis, and Forensic Implications

• Greiner 2013. Prevalence of Subdural Collections in Children with Macrocrania

• McKeag 2012. Subdural hemorrhage in pediatric patients with enlargement of the subarachnoid spaces

• Vinchon 2010. Subdural hematoma in infants: can it occur spontaneously? Data from a prospective series and critical review of the literature

• Raul 2008. Influence of the benign enlargement of the subarachnoid space on the bridging veins strain during a shaking event: a finite element study

Neutral/agnostics

• Alshareef 2022. Prevalence of Visible Subdural Spaces in Benign Enlargement of Subarachnoid Spaces in Infancy: A Retrospective Analysis Utilizing Magnetic Resonance Imaging

• Andersson 2022. External Hydrocephalus as a Cause of Infant Subdural Hematoma: Epidemiological and Radiological Investigations of Infants Suspected of Being Abused

• Scheller 2021. Is external hydrocephalus a possible differential diagnosis when child abuse is suspected?

• Zahl 2019. Clinical, Radiological, and Demographic Details of Benign External Hydrocephalus: A Population-Based Study

• Zahl 2019. Examining perinatal subdural haematoma as an aetiology of extra-axial hygroma and chronic subdural haematoma

• Miller 2015. The Significance of Macrocephaly or Enlarging Head Circumference in Infants With the Triad

• Tucker 2015. Macrocephaly in infancy: benign enlargement of the subarachnoid spaces and subdural collections

• Zahl 2011. Benign external hydrocephalus: a review, with emphasis on management

• Ghosh 2011. Subdural Hematoma in Infants Without Accidental or Nonaccidental Injury: Benign External Hydrocephalus, a Risk Factor

• Pittman 2003. Significance of a Subdural Hematoma in a Child with External Hydrocephalus

• Ravid 2002. External hydrocephalus: a probable cause for subdural hematoma in infancy

• Papasian 2000. A Theoretical Model of Benign External Hydrocephalus That Predicts a Predisposition towards Extra-Axial Hemorrhage after Minor Head Trauma

• Piatt 1999. A pitfall in the diagnosis of child abuse: external hydrocephalus, subdural hematoma, and retinal hemorrhages

Differential diagnoses

• Anderst 2021. Subdural hemorrhage in a cohort with cerebral sinovenous thrombosis: Application to abusive head trauma

• Mankad 2019. The neuroimaging mimics of abusive head trauma

• Akinseye 2019. Imaging findings of Menkes disease, a radiographic mimic of abusive trauma

• Pomeranz 2018. Child Abuse and Conditions That Mimic It

• Anderst 2018. Relevance of Abusive Head Trauma to Intracranial Hemorrhages and Bleeding Disorders

• Christian 2017. Medical Mimics of Child Abuse

• Isaac 2017. A Unique Type of Birth Trauma Mistaken for Abus

• Shur 2015. Genetic differentials of child abuse: Is your case rare or real?

• Patel 2015. Common skin and bleeding disorders that can potentially masquerade as child abuse

• Jenny 2014. Alternate theories of causation in abusive head trauma: What the science tells us

• Jackson 2012. Challenges in the evaluation for possible abuse: Presentations of congenital bleeding disorders in childhood

• McLean 2012. Does Intracranial Venous Thrombosis Cause Subdural Hemorrhage in the Pediatric Population?

• Stray-Pedersen 2010. An infant with subdural hematoma and retinal hemorrhages: does von Willebrand disease explain the findings?

• Nassogne 2002. Massive subdural haematomas in Menkes disease mimicking shaken baby syndrome

• Hymel 1997. Coagulopathy in Pediatric Abusive Head Trauma

Animal models

Obviously, shaking cannot be reproduced in infants in an experimental setting. Researchers have instead investigated shaking in animal models. To date, results have been inconclusive: the characteristic features of the triad, including bridging vein rupture, subdural hematoma, and retinal hemorrhage, have not yet been observed in animal models of shaking. On the other hand, traumatic cervical and brain injuries have been described.

"The experimental animal models, in both laboratory rodents and domestic animal species, developed to date were unable to reliably replicate the full spectrum of neuropathologic changes found in human infant AHT." (Finnie 2022)

• Finnie 2022. Animal models of pediatric abusive head trauma

• Daniel 2022. Comparative study of brain damage and oxidative stress using two animal models of the shaken baby syndrome

• Pasquesi 2020. Predictions of neonatal porcine bridging vein rupture and extra-axial hemorrhage during rapid head rotations

• Vester 2019. Modeling of inflicted head injury by shaking trauma in children: what can we learn? Part I: A systematic review of animal models

• Pasquesi 2018. Measurement and Finite Element Model Validation of Immature Porcine Brain–Skull Displacement during Rapid Sagittal Head Rotations

• Pasquesi 2016. Repeated Loading Behavior of Pediatric Porcine Common Carotid Arteries

• Lintern 2015. Head kinematics during shaking associated with abusive head trauma

• Anderson 2014. Biomechanical studies in an ovine model of non-accidental head injury

• Xiong 2013. Animal models of traumatic brain injury

• Finnie 2011. Neuropathological changes in a lamb model of non-accidental head injury (the shaken baby syndrome)

• Finnie 2011. Diffuse neuronal perikaryal amyloid precursor protein immunoreactivity in an ovine model of non-accidental head injury (the shaken baby syndrome)

• Coats 2010. Ocular Hemorrhages in Neonatal Porcine Eyes from Single, Rapid Rotational Events

• Bonnier 2009. Animal models of shaken baby syndrome: revisiting the pathophysiology of this devastating injury

• Smith 2009. Infant Rat Model of the Shaken Baby Syndrome: Preliminary Characterization and Evidence for the Role of Free Radicals in Cortical Hemorrhaging and Progressive Neuronal Degeneration

• Serbanescu 2008. Natural animal shaking: a model for non-accidental head injury in children?

• Bonnier 2006. Delayed White Matter Injury in a Murine Model of Shaken Baby Syndrome

• Levchakov 2006. Computational Studies of Strain Exposures in Neonate and Mature Rat Brains during Closed Head Impact

• Mao 2006. Application of a finite element model of the brain to study traumatic brain injury mechanisms in the rat

Biomechanics and numerical modeling

Biomechanics is another research avenue, where physical or virtual models of a baby's head are developed and subject to various traumatic conditions. Kinematics and materials deformations can be measured and compared to known or estimated tissue injury thresholds.

Understanding of biomechanical properties of pediatric tissues remains elusive, whereas scaling of injury thresholds from animal models or adults to human infants is challenging.

Results have been inconclusive so far, and it remains unclear whether shaking alone can generate sufficient forces to cause traumatic rupture of bridging veins, subdural hemorrhage, and retinal hemorrhage. Forensic implications of such negative findings are also unclear due to intrinsic limitations of biomechanical and finite element models.

On the other hand, forces generated during impacts have been found to be consistently larger than with shaking alone.

"Although only Cory and Jones reported rotational head accelerations in excess of predicted injury thresholds for concussion, no study has to date demonstrated that shaking alone, without an associated impact, exceeds the injury thresholds associated with SDH." (Jones 2015, p. 292)

SBS/AHT adherents

• Stray-Pedersen 2021. Violent Infant Surrogate Shaking: Continuous High-Magnitude Centripetal Force and Abrupt Shift in Tangential Acceleration May Explain High Risk of Subdural Hemorrhage

• Suh 2020. Determining the Tractional Forces on Vitreoretinal Interface Using a Computer Simulation Model in Abusive Head Trauma

• van Zandwijk 2019. Modeling of inflicted head injury by shaking trauma in children: what can we learn? Part II: A systematic review of mathematical and physical models

• Jenny 2017. Biomechanical Response of the Infant Head to Shaking: An Experimental Investigation

• Yoshida 2014. A finite element analysis of the retinal hemorrhages accompanied by shaken baby syndrome/abusive head trauma

• Nadarasa 2014. Update on injury mechanisms in abusive head trauma - shaken baby syndrome

• Yamasaki 2014. Experimental analyses of the retinal and subretinal haemorrhages accompanied by shaken baby syndrome/abusive head trauma using a dummy doll

• Roth 2010. Finite element modelling of paediatric head impact: Global validation against experimental data

• Roth 2008. Finite element analysis of child head injuries in the field of child abuse

• Raul 2008. Influence of the benign enlargement of the subarachnoid space on the bridging veins strain during a shaking event: a finite element study

• Pierce 2008. Injury Biomechanics and Child Abuse

• Bertocci 2006. Applications of Biomechanics Aiding in the Diagnosis of Child Abuse

• Cirovic 2005. Mechanistic hypothesis for eye injury in infant shaking

• Oehmichen 2005. Fall or Shaken: Traumatic Brain Injury in Children Caused by Falls or Abuse at Home - A Review on Biomechanics and Diagnosis

• Prange 2003. Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants

• Cory 2003. Can Shaking Alone Cause Fatal Brain Injury?: A biomechanical assessment of the Duhaime shaken baby syndrome model

Neutral/agnostics

• Davison 2022. A Biomechanical Assessment of Shaken Baby Syndrome: What About the Spine?

• Wilhelm 2020. Injury Biomechanics of a Child's Head: Problems, Challenges and Possibilities with a New aHEAD Finite Element Model

• Schiks 2020. Thresholds for the assessment of inflicted head injury by shaking trauma in infants: a systematic review

• Miller 2020. An envelope of linear and rotational head motion during everyday activities

• Burgos-Flórez 2020. Stress and strain propagation on infant skull from impact loads during falls: a finite element analysis

• Li 2019. Infant skull fractures: Accident or abuse?: Evidences from biomechanical analysis using finite element head models

• Brooks 2018. Finite element models and material data for analysis of infant head impacts

• Johnson 2018. Response to Jenny et al.: Biomechanical Response of the Infant Head to Shaking: An Experimental Investigation

• Reinmann 2018. Fundamental Limits of Shaking a Baby

• Jones 2017. Development and validation of a physical model to investigate the biomechanics of infant head impact

• Pasquesi 2017. Failure and Fatigue Properties of Immature Human and Porcine Parasagittal Bridging Veins

• Lee 2016. Biomechanical, Epidemiologic, and Forensic Considerations of Pediatric Head Injuries

• Jones 2015. Development of a computational biomechanical infant model for the investigation of infant head injury by shaking

• Sullivan 2015. Biofidelic neck influences head kinematics of parietal and occipital impacts following short falls in infants

• Goriely 2015. Mechanics of the brain: perspectives, challenges, and opportunities

• Couper 2015. Infant brain subjected to oscillatory loading

• Jones 2014. Development of a computational biomechanical infant model for the investigation of infant head injury by shaking

• Thompson 2011. Pediatric short-distance household falls: Biomechanics and associated injury severity

• Lloyd 2011. Biomechanical Evaluation of Head Kinematics During Infant Shaking Versus Pediatric Activities of Daily Living

• Jones 2011. The potential effects of floor impact surfaces on infant head injury outcome during a short fall

• Funk 2010. Head and Neck Loading in Everyday and Vigorous Activities

• Ibrahim 2010. Biomechanics of the toddler head during low-height falls: an anthropomorphic dummy analysis

• Cheng 2010. Study of an infant brain subjected to periodic motion via a custom experimental apparatus design and finite element modelling

• Couper 2009. Mechanical response of infant brain to manually inflicted shaking

• Coats 2008. Potential for head injuries in infants from low-height falls

• Wolfson 2005. Rigid-body modelling of shaken baby syndrome

• Goldsmith 2004. A Biomechanical Analysis of the Causes of Traumatic Brain Injury in Infants and Children

• Ommaya 2002. Biomechanics and neuropathology of adult and paediatric head injury

• Prange 2002. Regional, Directional, and Age-Dependent Properties of the Brain Undergoing Large Deformation

• Hymel 1998. Abusive Head Trauma? A Biomechanics-Based Approach

• Duhaime 1987. The shaken baby syndrome: A clinical, pathological, and biomechanical study

Short falls

Severe injuries following short falls are rare, but how rare they are is controversial. To some authors, they are so exceptional that histories of short falls can be considered to be falsified in almost all severe or fatal cases. To other authors, these statistical arguments are not correct, and short falls should be considered as an important differential diagnosis of subdural and retinal hemorrhage in infants.

SBS/AHT adherents

• Atkinson 2018. Childhood Falls With Occipital Impacts

• Chadwick 2008. Annual Risk of Death Resulting From Short Falls Among Young Children: Less Than 1 in 1 Million

• Case 2008. Accidental Traumatic Head Injury in Infants and Young Children

• Buys 1992. Retinal Findings after Head Trauma in Infants and Young Children

• Chadwick 1991. Deaths from falls in children: how far is fatal?

Agnostics/neutral

• Rossant 2024. Statistical models of hospital patient fatality rates after accidental falls in children

• Akutsu 2022. Infantile subdural hematoma in Japan: A multicenter, retrospective study by the J-HITs (Japanese head injury of infants and toddlers study) group

• Schneps 2020. Short falls and shaken baby syndrome: numerical and reasoning errors

• Aoki 2020. Infantile Acute Subdural Hematoma with Retinal Hemorrhage Caused by Minor Occipital Impact Witnessed by an ICU Nurse: A Case Report

• Mulligan 2017. Injury from falls in infants under one year

• Schuman 2016. Severe Retinal Hemorrhages with Retinoschisis in Infants are Not Pathognomonic for Abusive Head Trauma

• Sadia 2016. Bilateral multilayered retinal haemorrhages after a short distance accidental fall in an infant

• Thomas 2013. Patterns of accidental craniocerebral injury occurring in early childhood

• Lantz 2011. Fatal Acute Intracranial Injury, Subdural Hematoma, and Retinal Hemorrhages Caused by Stairway Fall

• Scott 2003. Delayed Sudden Death in an Infant Following an Accidental Fall A Case Report With Review of the Literature

• Fung 2002. Unexplained subdural hematoma in young children: Is it always child abuse?

• Plunkett 2001. Fatal Pediatric Head Injuries Caused by Short-Distance Falls

• Warrington 2001. Accidents and resulting injuries in premobile infants: data from the ALSPAC study

• Aoki 1984. Infantile acute subdural hematoma: Clinical analysis of 26 cases

• Kravitz 1969. Accidental Falls From Elevated Surfaces In Infants From Birth To One Year Of Age

Confessions

Many authors from both sides agree that, since experiments cannot be conducted on babies, and since videotaped and witnessed shaking events are vanishingly rare, confessions are the main evidentiary basis of SBS/AHT. Adherents believe in the validity of most confessions of shaking, while agnostics claim they are unreliable due to the existence of guilty pleas and false confessions during police interrogation.

For a SBS/AHT adherent:

"To those who argue that the contribution of shaking to the pathophysiology of AHT is a hypothesis lacking a sufficient evidentiary base, the consistent and repeated observation that confessed shaking results in stereotypical injuries that are so frequently encountered in AHT—and which are so extraordinarily rare following accidental/impact injuries—is the evidentiary basis for shaking." (Dias 2011, p. 310)

For agnostics:

"Moreover, (...) it is unsettling that physicians would rely so heavily on purported perpetrator confessions as somehow validating questionable SBS/AHT beliefs. Approximately twenty-five percent of the DNA exonerations in this country were in cases where the innocent defendant had allegedly confessed (...). Many purported SBS "confessions" are obtained pursuant to plea agreements; or as a requirement to retain or regain parental rights in dependency proceedings; or the confession was merely to shaking the child in an effort to resuscitate after the child had already collapsed; or the confession was induced by law enforcement through suggestion that confessing to shaking would allow the child to receive important medical treatment or was the "only" possible explanation for the child's condition." (Papetti 2019, pp. 342-343)

SBS/AHT adherents

• Vinchon 2022. Confessed versus denied inflicted head injuries in infants: similarities and differences

• Edwards 2020. What Do Confessions Reveal about Abusive Head Trauma? A Systematic Review

• Feld 2018. Shaken baby syndrome—what convicted perpetrators report

• Vinchon 2017. Response to Lyn∅e: questions about isolated trauma shaking and confessions

• De Leeuw 2013. Confessed Abusive Blunt Head Trauma

• Bell 2011. Abusive head trauma: A perpetrator confesses

• Esernio-Jenssen 2011. Abusive Head Trauma in Children: A Comparison of Male and Female Perpetrators

• Adamsbaum 2010. Abusive Head Trauma: Judicial Admissions Highlight Violent and Repetitive Shaking

• Vinchon 2010. Confessed abuse versus witnessed accidents in infants: comparison of clinical, radiological, and ophthalmological data in corroborated cases

• Biron 2005. Perpetrator accounts in infant abusive head trauma brought about by a shaking event

• Starling 1995. Abusive Head Trauma: The Relationship of Perpetrators to Their Victims

Agnostics

• Rossant 2023. Why admitted cases of AHT make a low quality reference standard: A survey of people accused of AHT in France

• Lynøe 2022. Circular reasoning, confessions and abusive head trauma: A critical analysis of Edwards et al.

• Thiblin 2020. Medical findings and symptoms in infants exposed to witnessed or admitted abusive shaking: A nationwide registry study

• Johnson 2020. Shaken Baby Syndrome/Abusive Head Trauma: Wrongful Conviction Risks, Mis-information Effects, and Psychological Consultation

• Brook 2019. Is there an evidentiary basis for shaken baby syndrome? The conviction of Joby Rowe

• Leo 2017. Police Interrogation, False Confessions, and Alleged Child Abuse Cases

• Frenda 2016. Sleep deprivation and false confessions

• Kassin 2015. The Social Psychology of False Confessions

• Shaw 2015. Constructing Rich False Memories of Committing Crime

• Tuerkheimer 2014. Flawed Convictions: "Shaken Baby Syndrome" and the Inertia of Injustice

• Cutler 2014. Interrogations and False Confessions: A Psychological Perspective

• Kassin 2012. Why confessions trump innocence

• Findley 2012. Shaken Baby Syndrome, Abusive Head Trauma, and Actual Innocence: Getting It Right

• Gudjonsson 2011. Suspect Interviews and False Confessions

• Leo 2010. From False Confession to Wrongful Conviction: Seven Psychological Processes

• Leo 2010. Psychological and Cultural Aspects of Interrogations and False Confessions: Using Research to Inform Legal Decision-Making

• Kassin 2010. Police-Induced Confessions: Risk Factors and Recommendations

• Kopelman 2010. Varieties of false memories

• Leo 2009. False Confessions: Causes, Consequences and Implications

• Leo 2009. What do potential jurors know about police interrogation techniques and false confessions?

• Kassin 2008. The Psychology of Confessions

• Kassin 2008. False Confessions: Causes, Consequences, and Implications for Reform

• Kassin 2007. Internalized False Confessions

• Leestma 2006. Shaken baby syndrome: do confessions by alleged perpetrators validate the concept?

• Kassin 2005. On the Psychology of Confessions: Does Innocence Put Innocents at Risk?

• Kassin 2005. "I'd Know a False Confession if I Saw One": A Comparative Study of College Students and Police Investigators

• Henkel 2004. Memory distortions in coerced false confessions: a source monitoring framework analysis

• Kassin 2004. The Psychology of Confessions: A Review of the Literature and Issues

• Kassin 1997. The psychology of confession evidence

• Ofshe 1997. The Social Psychology of Police Interrogation: The Theory and Classification of True and False Confessions

• Kassin 1996. The Social Psychology of False Confessions: Compliance, Internalization, and Confabulation

• Gudjonsson 1990. A Proven Case of False Confession: Psychological Aspects of the Coerced-Compliant Type

Epidemiology and prevention

Epidemiological studies investigate the demographics of children diagnosed with SBS/AHT, the incidence of these medical determinations, and the impact of prevention programs on the global incidence of determinations of abuse.

SBS/AHT adherents

• Lãzãrescu 2022. Abusive Head Trauma in Infants During the COVID-19 Pandemic in the Paris Metropolitan Area

• Caron 2022. Incidence of child abuse with subdural hemorrhage during the first year of the COVID-19 pandemic: a nationwide study in France

• Dias 2021. Preventing abusive head trauma: can educating parents reduce the incidence?

• Sidpra 2020. Rise in the incidence of abusive head trauma during the COVID-19 pandemic

• Rey-Salmon 2020. Abusive Head Trauma in Day Care Centers

• Rebbe 2020. Incidence and Risk Factors for Abusive Head Trauma: A Population-Based Study

• Barr 2018. Eight-year outcome of implementation of abusive head trauma prevention

• Duzinski 2018. Effectiveness of a Pediatric Abusive Head Trauma Prevention Program Among Spanish-Speaking Mothers

• Dias 2017. Association of a Postnatal Parent Education Program for Abusive Head Trauma With Subsequent Pediatric Abusive Head Trauma Hospitalization Rates

• Lopes 2016. Pediatric Abusive Head Trauma Prevention Initiatives: A Literature Review

• Ornstein 2016. The impact of an educational intervention on knowledge about infant crying and abusive head trauma

• Cowley 2015. Validation of a Prediction Tool for Abusive Head Trauma

• Fujiwara 2015. Effectiveness of public health practices against shaken baby syndrome/abusive head trauma in Japan

• Zolotor 2015. Effectiveness of a Statewide Abusive Head Trauma Prevention Program in North Carolina

• Shanahan 2013. National, Regional, and State Abusive Head Trauma: Application of the CDC Algorithm

• Liley 2012. Infant abusive head trauma: Incidence, outcomes and awareness

• Maguire 2011. Estimating the Probability of Abusive Head Trauma: A Pooled Analysis

• Runyan 2008. The Challenges of Assessing the Incidence of Inflicted Traumatic Brain Injury: A World Perspective

• Dias 2005. Preventing Abusive Head Trauma Among Infants and Young Children: A Hospital-Based, Parent Education Program

• Jenny 1999. Analysis of Missed Cases of Abusive Head Trauma

Agnostics

• Lynøe 2021. Why Programs for Managing Colicky Crying Fail to Prevent Abusive Head Trauma and Suggestions for Improvement

• Högberg 2018. Infant abuse diagnosis associated with abusive head trauma criteria: incidence increase due to overdiagnosis?

• Högberg 2018. Epidemiology of subdural haemorrhage during infancy: A population-based register study

• Andersson 2017. National study shows that abusive head trauma mortality in Sweden was at least 10 times lower than in other Western countries

Medical ethics, medicolegal issues, cognitive biases

SBS/AHT adherents

• Narang 2021. Overturned abusive head trauma and shaken baby syndrome convictions in the United States: Prevalence, legal basis, and medical evidence

• Bass 2020. Medicolegal issues in abusive head trauma for the pediatric neurosurgeon

• Cowley 2018. Factors influencing child protection professionals' decision-making and multidisciplinary collaboration in suspected abusive head trauma cases: A qualitative study

• Narang 2016. Acceptance of Shaken Baby Syndrome and Abusive Head Trauma as Medical Diagnoses

• Albert 2012. Ensuring Appropriate Expert Testimony for Cases Involving the "Shaken Baby"

• Holmgren 2013. Ethical Issues in Forensic Testimony Involving Abusive Head Trauma

• Garrett 2012. Overcoming Defense ExpertTestimony in Abusive Head Trauma Cases

Agnostics

• Kukucka 2022. Human Factors in Forensic Science: Psychological Causes of Bias and Error

• Brown 2021. Ethical challenges in child abuse: what is the harm of a misdiagnosis?

• Dror 2021. Cognitive bias in forensic pathology decisions

• Högberg 2020. Parents' experiences of seeking health care and encountering allegations of shaken baby syndrome: A qualitative study

• Johnson 2020. Shaken Baby Syndrome/Abusive Head Trauma: Wrongful Conviction Risks, Mis-information Effects, and Psychological Consultation

• Lynøe 2020. Denialism Preserves Scientific Controversies: a Case Study of Abusive Head Trauma Research

• Lynøe 2020. Can Burnout Among Child Abuse Clinicians be Caused by Doubt that They are Doing the Right Thing?

• Skellern 2020. Thinking fast and slow in the evaluation of injury plausibility in child protection

• Lynøe 2020. The Unspoken Shaken Baby Lie Detector Algorithm—An Analysis of Diagnostic Procedures in Cases of Allegedly Abusive Head Trauma without External Signs of Trauma

• Lynøe 2020. Do Child Abuse Pediatricians Search for a "Pediatric Vulcan Planet"? Comparison of Controversies about the Vulcan-Must-Exist-Theory and the Infant-Must-Have-Been-Shaken-Theory

• Lynøe 2019. Hidden clinical values and overestimation of shaken baby cases

• Lynøe 2018. From Child Protection to Paradigm Protection—The Genesis, Development, and Defense of a Scientific Paradigm

• Dror 2018. When expert decision making goes wrong: Consensus, bias, the role of experts, and accuracy

• Kukucka 2017. Cognitive Bias and Blindness: A Global Survey of Forensic Science Examiners

• Cuellar 2017. Causal reasoning and data analysis: problems with the abusive head trauma diagnosis

• Skellern 2015. Minimising bias in the forensic evaluation of suspicious paediatric injury

• Meriwether 1986. Child Abuse Reporting Laws: Time for a Change

• Besharov 1986. Unfounded allegations-a new child abuse problem