Shaken Baby Syndrome


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. © 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. © 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.


Arbogast KB, Margulies SS and Christian CW (2005) Initial neurologic presentation in young children sustaining inflicted and unintentional fatal head injuries. Pediatrics 116 (1): 180–184.

Brennan LK, Rubin D, Christian CW, et al. (2009) Neck injuries in young pediatric homicide victims. Journal of Neurosurgery. Pediatrics 3 (3): 232–239.

Browder J, Kaplan HA and Krieger AJ (1975) Venous lakes in the suboccipital dura mater and falx cerebelli of infants: surgical significance. Surg Neurol 4: 53–55.

Caffey J (1965) Significance of the history in the diagnosis of traumatic injury to children. Howland Award Address. Journal of Pediatrics 67 (5): 1008–1014.

Caffey J (1972) On the theory and practice of shaking infants. Its potential residual effects of permanent brain damage and mental retardation. American Journal of Diseases of Children 124 (2): 161–169.

Caffey J (1974) The whiplash shaken infant syndrome: manual shaking by the extremities with whiplash‐induced intracranial and intraocular bleedings, linked with residual permanent brain damage and mental retardation. Pediatrics 54 (4): 396–403.

Chadwick DL, Kirschner RH, Reece RM, et al. (1998) Shaken baby syndrome – a forensic pediatric response. Pediatrics 101 (2): 321–323.

Christian CW and Block R (2009) Abusive head trauma in infants and children. Pediatrics 123 (5): 1409–1411.

Cowan F and Thoresen M (1985) Changes in superior sagittal sinus blood velocities due to postural alterations and pressure on the head of the newborn infant. Pediatrics 75 (6): 1038–1047.

Crane J (2015) 'The bones tell a story the child is too young or too frightened to tell': The Battered Child Syndrome in Post‐war Britain and America. Social History of Medicine 28 (4): 767–788.

Dlamini N, Billinghurst L and Kirkham FJ (2010) Cerebral venous sinus (sinovenous) thrombosis in children. Neurosurgery Clinics of North America 21 (3): 511–527.

Duhaime AC, Gennarelli TA, Sutton LN and Schut L (1988) "Shaken baby syndrome": a misnomer? Journal of Pediatric Neurosciences 4 (2): 77–86.

Emerson MV, Jakobs E and Green WR (2007) Ocular autopsy and histopathologic features of child abuse. Ophthalmology 114: 1384–1394.

Forbes BJ, Rubin SE, Margolin E and Levin AV (2010) Evaluation and management of retinal hemorrhages in infants with and without abusive head trauma. Journal of AAPOS: The Official Publication of the American Association for Pediatric Ophthalmology and Strabismus/American Association for Pediatric Ophthalmology and Strabismus 14 (3): 267–273.

Friede RL (1989) Subdural haematomas, hygromas and effusions. In: Friede RL (ed) Developmental Neuropathology, 2nd edn, pp. 198–208. Springer‐Verlag: Gottingen.

Fuchs S, Barthel MJ, Flannery AM and Christoffel KK (1989) Cervical spine fractures sustained by young children in forward‐facing car seats. Pediatrics 84 (2): 348–354.

Geddes JF, Hackshaw AK, Vowles GH, Nickols CD and Whitwell HL (2001a) Neuropathology of inflicted head injury in children. I. Patterns of brain damage. Brain 124 (Pt 7): 1290–1298.

Geddes JF, Vowles GH, Hackshaw AK, et al. (2001b) Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants. Brain 124 (Pt 7): 1299–1306.

Greeley CS (2014) "Shaken baby syndrome" and forensic pathology. Forensic Science, Medicine and Pathology 10 (2): 239–241.

Guthkelch AN (1971) Infantile subdural haematoma and its relationship to whiplash injuries. British Medical Journal 2 (759): 430–431.

Hall JR, Reyes HM, Horvat M, Meller JL and Stein R (1989) The mortality of childhood falls. Journal of Trauma 29 (9): 1273–1275.

Han H, Yao Z, Wang H, et al. (2008) Dural entrance of the bridging vein into the transverse sinus provides a reliable measure for preoperative planning: an anatomic comparison between cadavers and neuroimages. Neurosurgery 62 (5 Suppl 2): ONS289‐295; discussion ONS295‐286.

Jones MD, Martin PS, Williams JM, Kemp AM and Theobald P (2014) Development of a computational biomechanical infant model for the investigation of infant head injury by shaking. Med Sci Law 55 (4): 291–299.

Kempe CH, Silverman FN, Steele BF, Droegemueller W and Silver HK (1962) The battered‐child syndrome. JAMA 181: 17–24.

Klinich KD, Hulbert GM and Schneider LW (2002) Estimating Infant Head Injury Criteria and Impact Response Using Crash Reconstruction and Finite Element Modeling. Stapp Car Crash Journal 46: 1–30.

Lynoe N, Elinder G, Hallberg B, et al. (2017) Insufficient evidence for 'shaken baby syndrome' ‐ a systematic review. Acta Paediatrica 106 (7): 1021–1027.

Mack J, Squier W and Eastman JT (2009) Anatomy and development of the meninges: implications for subdural collections and CSF circulation. Pediatric Radiology 39 (3): 200–210.

Maguire SA, Kemp AM, Lumb RC and Farewell DM (2011) Estimating the probability of abusive head trauma: a pooled analysis. Pediatrics 128 (3): e550–e564.

Matshes E (2010) Retinal and Optic Nerve Sheath Haemorrhages are not Pathognomonic of Abusive Head Injury (abstract). Proceedings of the American Academy of Forensic Sciences.

Mertz HJ (1993) Anthropomorphic test devices. In: Nahum AM and Melvin JW (eds.) Accidental Injury. Biomechanics and Prevention, pp. 66–80. New York: Springer Verlag.

Minns RA, Jones PA, Tandon A, et al. (2017) Raised intracranial pressure and retinal haemorrhages in childhood encephalopathies. Developmental Medicine and Child Neurology 59 (6): 597–604.

Narang SK and Greeley CS (2017) Lynoe et al.‐#theRestoftheStory. Acta Paediatrica 106 (7): 1047–1049.

Oehmichen M, Schleiss D, Pedal I, et al. (2008) Shaken baby syndrome: re‐examination of diffuse axonal injury as cause of death. Acta Neuropathologica 116 (3): 317–329.

Piteau SJ, Ward MG, Barrowman NJ and Plint AC (2012) Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review. Pediatrics 130 (2): 315–323.

Plunkett J (2001) Fatal pediatric head injuries caused by short‐distance falls. American Journal of Forensic Medicine and Pathology 22 (1): 1–12.

R‐v‐Harris (2005) R‐v‐Harris and Others. [2005] EWCA Crim 1980.

Richards PG, Bertocci GE, Bonshek RE, et al. (2006) Shaken baby syndrome. Archives of Disease in Childhood 91 (3): 205–206.

Rooks VJ, Eaton JP, Ruess L, et al. (2008) Prevalence and evolution of intracranial hemorrhage in asymptomatic term infants. AJNR. American Journal of Neuroradiology 29 (6): 1082–1089.

Royal College of Pathologists (2009) Report of a Meeting on the Pathology of Traumatic Head Injury in Children.

Scheimberg I, Cohen MC, Zapata Vazquez RE, et al. (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. Pediatric and Developmental Pathology 16 (3): 149–159.

Sebire G, Tabarki B, Saunders DE, et al. (2005) Cerebral venous sinus thrombosis in children: risk factors, presentation, diagnosis and outcome. Brain 128 (Pt 3): 477–489.

Squier W, Mack J and Jansen AC (2016) Infants dying suddenly and unexpectedly share demographic features with infants who die with retinal and dural bleeding: a review of neural mechanisms. Developmental Medicine and Child Neurology 58 (12): 1223–1234.

Starling SP, Patel S, Burke BL, et al. (2004) Analysis of perpetrator admissions to inflicted traumatic brain injury in children. Archives of Pediatrics & Adolescent Medicine 158 (5): 454–458.

Steinbok P, Singhal A, Poskitt K and Cochrane DD (2007) Early hypodensity on computed tomographic scan of the brain in an accidental pediatric head injury. Neurosurgery 60 (4): 689–694; discussion 694–685.

Taylor GA (1992) Intracranial venous system in the newborn. Radiology 183 (2): 449–452.

Till K (1968) Subdural Haematoma and Effusion in Infancy. British Medical Journal 3: 400–402.

Vinchon M, Defoort‐Dhellemmes S, Desurmont M and Dhellemmes P (2005) Accidental and nonaccidental head injuries in infants: a prospective study. Journal of Neurosurgery 102 (4 Suppl): 380–384.

Vinchon M, Desurmont M, Soto‐Ares G and De Foort‐Dhellemmes S (2010) Natural history of traumatic meningeal bleeding in infants: semiquantitative analysis of serial CT scans in corroborated cases. Childs Nervous System 26 (6): 755–762.

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.

Squier W (2008) Shaken baby syndrome: the quest for evidence. Developmental Medicine and Child Neurology 50 (1): 10–14.

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. [doi: 10.1002/9780470015902.a0027177]