Shaken Baby Syndrome and the Legal Perspective

  • Sarathchandra Kodikara
  • Michael Pollanen
Reference work entry


Shaken baby syndrome (SBS) is defined by the presence of a triad of findings (subdural hemorrhage [SDH], retinal hemorrhages [RH], and hypoxic-ischemic encephalopathy [HIE]) in the absence of scalp and/or skull fracture that indicate head injury in an infant or young child caused by violent shaking. While some authorities accept the triad as diagnostic of SBS, there is some skepticism by other experts, creating some controversy.

The core evidence shows that shaking alone is not as frequently fatal as are blunt impacts of the head. It is apparent that, in some instances, shaking itself can cause fatal head injury. Although short falls rarely cause fatal head injury with the triad, an overlap between the clinicopathological findings of SBS and short falls can be seen, which sometimes seems inseparable. In the majority of accidental and nonaccidental fatal head injury cases studied, the infants became immediately unconscious at the time of incident. If not immediately unconscious, only a brief lucid interval with symptoms is present followed by progressive deterioration. Subject to few exceptions, the majority of infants who acutely collapse with the triad have a head injury. Therefore, it is important for the forensic pathologist to keep an open mind, acknowledging the existence of both traumatic and non-traumatic causes of the triad, in the differential diagnosis. Although many sources indicate that shaking causes characteristic RH, there is also contrary evidence showing that so-called characteristic RH can have causes other than shaking. Due to such persistent controversies, there is no uniform consensus on the reliability of diagnosing SBS simply from the presence of RH.


Head Injury Skull Fracture Retinal Hemorrhage Abusive Head Trauma Glutaric Aciduria Type 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors acknowledge the contribution of Drs. Toby Rose, Kristopher Cunningham, Jeff Tanguay, and Charis Kepron in the critical review of this chapter. The authors are also grateful to Mr. Patrick Kim for his valuable assistance in preparing the manuscript.


  1. 1.
    Guthkelch AN. Infantile subdural haematoma and its relationship to whiplash injuries. BMJ. 1971;2:430–1.PubMedCrossRefGoogle Scholar
  2. 2.
    Caffey J. On the theory and practice of shaking infants. Its potential residual effects of permanent brain damage and mental retardation. Am J Dis Child. 1972;124:161–9.PubMedGoogle Scholar
  3. 3.
    Caffey J. The whiplash shaken infant syndrome: manual shaking by the extremities with whip-lash induced intracranial and intraocular bleedings, linked with residual permanent brain damage and mental retardation. Pediatrics. 1974;54:396–403.PubMedGoogle Scholar
  4. 4.
    Duhaime AC, Gennarelli TA, Thibault LE, Bruce DA, Margulies SS, Wiser R. The shaken baby syndrome: a clinical, pathological, and biomechanical study. J Neurosurg. 1987;66:409–15.PubMedCrossRefGoogle Scholar
  5. 5.
    Prange MT, Coats B, Duhaime AC, Margulies SS. Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants. J Neurosurg. 2003;99:143–50.PubMedCrossRefGoogle Scholar
  6. 6.
    Cory CZ, Jones MD. Can shaking alone cause fatal brain injury? A biomechanical assessment of the Duhaime shaken baby syndrome model. Med Sci Law. 2003;43:317–33.PubMedCrossRefGoogle Scholar
  7. 7.
    Roth S, Raul JS, Ludes B, Willinger R. Finite element analysis of impact and shaking inflicted to a child. Int J Legal Med. 2007;121:223–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Gill JR, Goldfeder LB, Armbrustmacher V, Coleman A, Mena H, Hirsch CS. Fatal head injury in children younger than two years in New York city and an overview of the shaken baby syndrome. Arch Pathol Lab Med. 2009;133:619–27.PubMedGoogle Scholar
  9. 9.
    Geddes JF, Tasker RC, Hackshaw AK, Nickols CD, Adams GGW, Whitwell HL, Scheimberg I. Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in ‘shaken baby syndrome’? Neuropathol Appl Neurobiol. 2003;29:14–22.PubMedCrossRefGoogle Scholar
  10. 10.
    Dyer C. Diagnosis of “shaken baby syndrome” still valid, appeal court rules. BMJ. 2005;331:253.Google Scholar
  11. 11.
    Pollanen MS. Subdural hemorrhage in infancy: keep an open mind. Forensic Sci Med Pathol. 2011;7:298–300.PubMedCrossRefGoogle Scholar
  12. 12.
    Leestma JE. Case analysis of brain-injured admittedly shaken infants 54 cases, 1969–2001. Am J Forensic Med Pathol. 2005;26:199–212.PubMedCrossRefGoogle Scholar
  13. 13.
    Chadwick DL, Bertocci G, Castillo E, Frasier L, Guenther E, Hansen K, Herman B, Krous HF. Annual risk of death resulting from short falls among young children: less than 1 in million. Pediatrics. 2008;121:1213–24.PubMedCrossRefGoogle Scholar
  14. 14.
    Plunkett J. Fatal pediatric head injuries caused by short-distance falls. Am J Forensic Med Pathol. 2001;22:1–12.PubMedCrossRefGoogle Scholar
  15. 15.
    Thompson AK, Bertocci G, Rice W, Pierce MC. Pediatric short-distance household falls: biomechanics and associated injury severity. Accid Anal Prev. 2011;43:143–50.PubMedCrossRefGoogle Scholar
  16. 16.
    Trenchs V, Curcoy AI, Morales M, Serra A, Navarro R, Pou J. Retinal haemorrhages in head trauma resulting from falls: differential diagnosis with non-accidental trauma in patients younger than 2 years of age. Childs Nerv Syst. 2008;24:815–20.PubMedCrossRefGoogle Scholar
  17. 17.
    Reece RM, Sege R. Childhood head injuries: accidental or inflicted? Arch Pediatr Adolesc Med. 2000;154:11–5.PubMedGoogle Scholar
  18. 18.
    Lantz PE, Couture DE. Fatal acute intracranial injury, subdural hematoma, and retinal hemorrhages caused by stairway fall. J Forensic Sci. 2011;56:1648–53.PubMedCrossRefGoogle Scholar
  19. 19.
    Gilliland MGF. Interval duration between injury and severe symptoms in nonaccidental head trauma in infants and young children. J Forensic Sci. 1998;43:723–5.PubMedGoogle Scholar
  20. 20.
    Arbogast KB, Margulies SS, Christian CW. Initial neurologic presentation in young children sustaining inflicted and unintentional fatal head injuries. Pediatrics. 2005;116:180–4.PubMedCrossRefGoogle Scholar
  21. 21.
    Boos SC. The timing of clinical presentation after inflicted childhood neurotrauma- Response. In: Reece RM, Nicholson CE, editors. Proceedings of a multidisciplinary, modified, evidence-based conference. Maryland: American Academy of Pediatrics; 2003. p. 69–73.Google Scholar
  22. 22.
    Willman KY, Bank DE, Senac M, Chadwick DL. Restricting the time of injury in fatal inflicted head injuries. Child Abuse Negl. 1997;21:929–40.PubMedCrossRefGoogle Scholar
  23. 23.
    Gilles EE, Nelson MD. Cerebral complications of nonaccidental head injury in childhood. Pediatr Neurol. 1998;19:119–28.PubMedCrossRefGoogle Scholar
  24. 24.
    Huntington R. Symptoms following head injury. Am J Forensic Med Pathol. 2002;23:105.PubMedCrossRefGoogle Scholar
  25. 25.
    Denton S, Mileusnic D. Delayed sudden death in an infant following an accidental fall: a case report with review of the literature. Am J Forensic Med Pathol. 2003;24:371–6.PubMedCrossRefGoogle Scholar
  26. 26.
    Ommaya AK, Gennarelli TA. Cerebral concussion and traumatic unconsciousness: correlation of experimental and clinical observations on blunt head injuries. Brain. 1974;97:633–54.PubMedCrossRefGoogle Scholar
  27. 27.
    Stray-Pedersan A, Omland S, Nedregaard B, Klevberg S, Rognum TO. An infant with subdural hematoma and retinal hemorrhages: does von Willebrand disease explain the findings? Forensic Sci Med Pathol. 2011;7:37–41.CrossRefGoogle Scholar
  28. 28.
    Guddat SS, Ehrlich E, Martin H, Tsokos M. Fatal spontaneous subdural bleeding due to neonatal giant cell hepatitis: a rare differential diagnosis of shaken baby syndrome. Forensic Sci Med Pathol. 2011;7:294–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Hoffmann GF, Naughten ER. Abuse or metabolic disorder? Arch Dis Child. 1998;78:395.CrossRefGoogle Scholar
  30. 30.
    Reece RM. Differential diagnosis of inflicted childhood neurotrauma. In: Reece RM, Nicholson CE, editors. Proceedings of a multidisciplinary, modified, evidence-based conference. Maryland: American Academy of Pediatrics; 2003. p. 17–31.Google Scholar
  31. 31.
    Whitby EH, Griffiths PD, Rutter S, Smith MF, Sprigg A, Ohadike P, Davies NP, Rigby AS, Paley MN. Frequency and natural history of subdural haemorrhages in babies and relation to obstetric factors. Lancet. 2004;363:846–51.PubMedCrossRefGoogle Scholar
  32. 32.
    Geddes JF, Talbert DG. Paroxysmal coughing, subdural and retinal bleeding: a computer modelling approach. Neuropathol Appl Neurobiol. 2006;32:625–34.PubMedCrossRefGoogle Scholar
  33. 33.
    Levin AV, Forbes B, Alexander R, Jenny C, Binenbaum G. Abusive head trauma/Shaken baby syndrome. Clinical statement. Am Acad Ophthalmol. 2010. Accessed 24 March 2012.
  34. 34.
    Levin AV. Retinal hemorrhage in abusive head trauma. Pediatrics. 2010;126:961–70.PubMedCrossRefGoogle Scholar
  35. 35.
    Lantz PE, Sinal SH, Stanton CA, Weaver Jr RG. Perimacular retinal folds from childhood head trauma. BMJ. 2004;328:754–6.PubMedCrossRefGoogle Scholar
  36. 36.
    Kivlin JD, Currie ML, Greenbaum J, Simons KB, Jentzen J. Retinal hemorrhages in children following fatal motor vehicle crashes; a case series. Arch Ophthalmol. 2008;126:800–4.PubMedCrossRefGoogle Scholar
  37. 37.
    Levin AV. Ophthalmic manifestations of inflicted childhood neurotrauma. In: Reece RM, Nicholson CE, editors. Inflicted childhood neurotrauma. Proceedings of a multidisciplinary, modified, evidence-based conference. Maryland: American Academy of Pediatrics; 2003. p. 127–59.Google Scholar
  38. 38.
    Rangarajan N, Kamalakkannan SB, Hasija V, Shams T, Jenny C, Serbanescu I, Ho J, Rusinek M, Levin AV. Finite element model of ocular injury in abusive head trauma. J AAPOS. 2009;13:364–9.PubMedCrossRefGoogle Scholar
  39. 39.
    Gnanaraj L, Gilliland MGF, Yahya RR, Rutka JT, Drake J, Dirks P, Levin AV. Ocular manifestations of crush head injury in children. Eye. 2007;21:5–10.PubMedCrossRefGoogle Scholar
  40. 40.
    Schloff S, Mullaney PB, Armstrong DC, Simantirakis E, Humphreys RP, Myseros JS, Buncic R, Levin AV. Retinal findings in children with intracranial hemorrhage. Ophthalmology. 2002;109:1472–6.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  1. 1.Department of Laboratory Medicine and Pathobiology, Faculty of MedicineUniversity of TorontoTorontoCanada
  2. 2.Department of Forensic Medicine, Faculty of MedicineUniversity of PeradeniyaPeradeniyaSri Lanka
  3. 3.Ontario Forensic Pathology ServicesTorontoCanada
  4. 4.Centre for Forensic Science and Medicine, Department of Laboratory Medicine and PathobiologyUniversity of TorontoTorontoCanada

Personalised recommendations