Shaken Baby Syndrome

Abstract

The shaken baby syndrome is highly contentious. The term is characteristically applied to infants showing a triad of subdural haemorrhage, retinal haemorrhage and encephalopathy. These three features form part of a cascade of events due to a variety of natural diseases and impact, whether inflicted or accidental. Subdural bleeding and retinal bleeding are very common after birth and reflect immaturity of the brain and its coverings. The demographics of babies with the triad overlap with SIDS (sudden infant death syndrome), suggesting that they may be a subgroup of SIDS.

Over 40 years after the shaking hypothesis was proposed, a systematic review has concluded that it is unjustifiable to infer that shaking has taken place on the basis of this triad. Unless doctors and the courts are aware of this and of the alternative causes of the triad, we risk wrongful convictions and wrongful removal of babies from innocent parents and carers.

Key Concepts

  • Shaken baby syndrome is a hypothesis and has not to date been supported by science.
  • There is insufficient evidence to infer that shaking has occurred on the basis of patterns of intracranial bleeding.
  • Bleeding into the dural membrane around the brain is common in infants and a function of immaturity.
  • Bleeding into the eyes (retinal haemorrhage) results from raised pressure within the head from any cause.
  • Retinal haemorrhage is commonly associated with subdural bleeding of any cause and may serve as a marker for it.
  • Encephalopathy is a nonspecific response of the brain.
  • An understanding of the specific pathophysiology of the infant brain is essential to determining causes of retinodural bleeding.
  • Until it is widely recognised that shaking cannot be diagnosed on the basis of patterns of intracranial bleeding, we risk miscarriage of justice and wrongful allegations of abuse.

Keywords: shaken baby syndrome; subdural haemorrhage; retinal haemorrhage; nonaccidental injury; abusive head trauma

Figure 1. Chart displaying data derived from experiments using an instrumented CRABI‐12 dummy (equivalent to 12‐month‐old baby). A number of horizontal drops of the dummy were performed from heights of 1, 2, 3, 4 and 5 ft above a linoleum‐covered hard floor (a), with an impact to the occipital region of the head. The resultant forces are markedly different from shakes and are compared with other known and studied injury scenarios, such as concussive forces suffered by professional football players, car crash victims without head injuries as studied with the CRABI‐6 dummy (equivalent to a 6‐month‐old baby) and car crash victims with head injuries as studied with a CRABI‐6 dummy. Injury reference values (IRVs), in g, are derived from the work of Mertz and Klinich . Courtesy of Dr Chris van Ee.
Figure 2. (A) Diagram (a) illustrates the relationship between the dura and the skull (above) and the arachnoid layer below. In life, these membranes are in continuity with one another. Subdural bleeding originates in the border cell layer (b), splitting it from the outer layers of the dura. Reproduced with permission from Mack et al. 2009 © Springer. (B) Surface of a fresh infant brain at autopsy. The dura has been opened and lifted. The black arrow indicates the cut edge of the dura swollen by fresh bleeding into it. Beneath is a thin film of fresh blood, more is seen on the brain surface (white arrow). Bridging veins are not exposed in this image. This baby died with severe hypoxic injury shortly after birth. Courtesy of Dr Irene Scheimberg.
Figure 3. (a) Skull of an infant at autopsy. The anterior fontanelle (F) has been incised and a flap lifted to demonstrate the convexity of the brain and two bridging veins (arrows) extending from the brain surface into the dura above. (b) Autopsy resin injection of adult bridging vein entering the dura. The vein (containing blue resin) enters the dura close to the lateral lacunae (arrowheads) of the superior sagittal sinus. Arachnoid granulations are indicated with asterisks. Note the vein has a sheath of fibrous tissue around it (black arrow) after it leaves the arachnoid membrane. (b) Reproduced with permission from Han et al. 2008 © Oxford University Press.
Figure 4. (a) Section of the dura (D) stained with haematoxylin and eosin. The dura is pale pink, fresh blood is dark pink. There is extensive bleeding into the dura and falx (F). Blood is prominent around the superior sagittal sinus (S). Arrows indicate places where the blood extends through the dura onto the subdural surface. (b) Higher power image of dura stained with Van Gieson stain. The dural fibres stain pink and the red cells stain yellow. The blood can be seen separating the fibres of the dura and leaking onto the surface (arrow).
Figure 5. Healing subdural membrane (M) beneath the dura (D). The membrane is old; the baby suffered trauma to the head 4 months before death. An arrow indicates a row of small reactive blood vessels in the deep layer of the dura and to the left a mass of fresh haemorrhage (H), likely to have originated in these delicate new blood vessels.
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Further Reading

Barnes PD (2011) Imaging of nonaccidental injury and the mimics: issues and controversies in the era of evidence‐based medicine. Radiologic Clinics of North America 49 (1): 205–229.

Findley KA, Barnes PD, Moran D and Squier W (2012) Shaken baby syndrome, abusive head trauma and actual innocence: getting it right. Houston Journal of Health Law & Policy 12 (2): 209–312.

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SBU (2016) Traumatic shaking. The role of the triad in medical investigations of suspected traumatic shaking. A systematic review. SBU assessment Report No 255E 2016. ISBN 978-91-85413-98-0.

Tuerckheimer D (2014) “Flawed Convictions” “Shaken Baby syndrome” and the Inertia of Injustice. Oxford: Oxford University Press. ISBN 978-0-19-991363-3.

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Squier, Waney(Oct 2017) Shaken Baby Syndrome. In: eLS. John Wiley & Sons Ltd, Chichester. http://www.els.net [doi: 10.1002/9780470015902.a0027177]