Do a Google search for “Shaken Baby Syndrome” and you’ll find pages and pages of links to web sites containing statements like those in bold italic below. This section takes a critical look at each statement about Shaken Baby Syndrome that appears on the web site of a major, well-respected hospital.
Claim: Shaken baby syndrome is a serious brain injury resulting from forcefully shaking an infant or toddler.
Shaken Baby Syndrome (SBS) is a diagnosis that purports to state the cause of serious and apparently traumatic brain injury in an infant or toddler having little or no external evidence and no history of major trauma. It rests on a plausible but as-yet-unproved hypothesis that doctors who encounter a certain combination or “constellation” of injuries in a baby can infer that a violent shaking event occurred shortly before the serious or alarming symptoms that led to medical attention. The constellation of injuries has yet to be observed in a child who has been violently shaken in public or on videotape, which casts doubt on the inference.
It’s also known as abusive head trauma, shaken impact syndrome, inflicted head injury or whiplash shaken infant syndrome.
The name for the syndrome has changed several times. Here’s why:
Whiplash Shaken Infant Syndrome: Dr. John Caffey, who popularized the hypothesis in the early 1970s, named it the Whiplash Shaken Impact Syndrome.(1) A few years earlier, Dr. Ayub Ommaya had published a groundbreaking article “Whiplash Injury and Brain Damage.”(2) Dr. Ommaya’s biomechanical experiments with rhesus monkeys proved that brain damage can occur from whiplash without the head being impacted. His work led to laws requiring headrests in motor vehicles. Could whiplash cause brain damage in infants? Could it explain the “extraordinary diagnostic contradiction” of babies with no history or external signs of trauma yet serious or even fatal internal findings consistent with trauma?
Shaken Baby Syndrome: In 1984, Dr. Stephen Ludwig published a paper using the term Shaken Baby Syndrome (SBS).(3) That soon became the popular term for the diagnosis and is used to this day.
Shaken Impact Syndrome: The SBS hypothesis was embraced by the medical community and taught as fact in medical schools before any testing was done. The first effort to scientifically validate it was reported in a paper by Ann-Christine Duhaime and colleagues in 1987.(4) Duhaime created a model of a 1-month-old infant and attached accelerometers. Volunteers shook the models as hard as they could, impacting some of them after shaking on padded surfaces and some on hard surfaces. Here are the reported results:
“All shakes fell below injury thresholds established for subhuman primates scaled for the same brain mass, while impacts spanned concussion, subdural hematoma, and diffuse axonal injury ranges. It was concluded that severe head injuries commonly diagnosed as shaking injuries require impact to occur and that shaking alone in an otherwise normal baby is unlikely to cause the shaken baby syndrome.”
It should be noted that no biomechanical study since 1987 has shown that shaking alone produces force equal to or greater than the force of a short fall onto a hard surface.
Ideally, Duhaime’s study would have sent scientists back to the drawing board to re-evaluate the hypothesis and conduct further testing. By 1987, however, more than 50 people had been convicted. Withdrawal of the hypothesis would call those convictions into question. Instead, the hypothesis was modified and renamed Shaken Impact Syndrome. An assumption was added that defendants slammed or threw the baby onto a soft surface after a violent shaking. Some doctors wondered, if impact was necessary, how could anyone know that the impact was intentional rather than accidental?
Abusive Head Trauma / Inflicted Head Injury. By 2009, prosecutions were being hampered somewhat by the question of whether the baby’s condition had been caused by shaking alone, shaking plus impact, or impact alone. The American Academy of Pediatrics recommended that the diagnostic term Shaken Baby Syndrome be replaced with Abusive Head Trauma. The new term was less specific with regard to mechanism, but more specific with regard to intent. It relieved prosecutors of the need to say exactly what happened, the cause was definitely abusive, definitely inflicted. It was not natural or accidental. Prosecutors were relieved of the need to prove a specific mechanism.
A hypothesis was embraced as fact. Any evidence to the contrary was rejected.
Claim: Shaken baby syndrome destroys a child’s brain cells and prevents his or her brain from getting enough oxygen.
Brain swelling destroys a child’s brain cells and prevents his or her brain from getting enough oxygen, regardless of what caused the swelling. Baby brains have a tendency to swell uncontrollably. It’s called Big Black Brain because the brain looks black on a CT scan. Swelling prevents blood and therefore oxygen from getting to and through the brain. Parts of the brain can die before the swelling abates, causing handicaps. If the entire brain dies, the child dies. Once a baby’s brain starts to swell uncontrollably, there is little doctors can do other than remove part of the skull or evacuate pooled blood if there is any in an attempt to reduce pressure.
Claim: This form of child abuse can cause permanent brain damage or death.
Brain swelling, regardless of the reason for the swelling, can cause permanent brain damage or death.
Claim: Shaken baby syndrome is preventable.
Based on the assumption that shaking causes brain damage and doctors are rightly making that inference, much money and time has been spent on educational resources warning caretakers not to shake babies. Although those programs have succeeded in relieving stress by teaching parents how to cope with crying, they have not reduced the incidence of Shaken Baby Syndrome. The fact that prevention programs have been ineffective can be seen as evidence that something unknown could be causing the damage. Perhaps there are congenital or environmental factors as yet undiscovered.
Help is available for parents who are at risk of harming a child.
Help is available to help parents become better and happier parents regardless of whether they’re at risk of harming a child. The more you know, the more pleasant and rewarding it will be to share a home with children of any temperament. It is a parent or caretaker’s responsibility to seek help before any situation becomes overly stressful.
Parents can also educate other caregivers about the dangers of shaken baby syndrome.
Parents can educate other caregivers about becoming better parents. Parent support groups exist online as well as in many communities. Consider forming a support group. Create a list of people to consult for ideas or in-person assistance. In the “old days”, extended families often lived under the same roof or in the same neighborhood, forming a natural support group. Grandparents, aunts and uncles were available to teach, support and assist young parents. You can create your own support group even as a single parent.
Claim: Shaken baby syndrome symptoms and signs include:
- Extreme fussiness or irritability
- Difficulty staying awake
- Breathing problems
- Poor eating
- Vomiting
- Pale or bluish skin
- Seizures
- Paralysis
- Coma
Brain swelling has the above-listed signs and symptoms, regardless of what caused the swelling. Because many of the signs listed can seem just slightly off normal (irritability, sleepiness, poor eating), it may be hard to recognize how serious a situation is until the baby has a seizure, stops breathing or turns blue. It is better to be safe than sorry. Know that vomiting, especially projectile vomiting, and other things on the list can signal brain swelling and impending brain damage.
Claim: While sometimes there’s bruising on the face, you may not see signs of physical injury to the child’s outer body.
As stated elsewhere, the Shaken Baby Syndrome hypothesis came about in the first place as a plausible explanation for the “extraordinary diagnostic contradiction” of babies with serious or fatal brain damage that appeared traumatic in origin but little or no evidence of trauma to the outer body.
Claim: Injuries that might not be immediately seen include bleeding in the brain and eyes, spinal cord damage, and fractures of the ribs, skull, legs and other bones.
The diagnosis of Shaken Baby Syndrome is made when doctors see a “constellation” of medical findings thought, but not proven, to be associated with shaking. The three findings most closely associated with SBS in current literature are retinal hemorrhages (bleeding in the eyes), subdural hematoma (a collection of blood between layers of tissue encasing the brain), and brain swelling. This has been called the “triad” and was at one time considered “pathognomonic” (exclusively diagnostic of) Shaken Baby Syndrome. If each sign or symptom is allegorically a “star” in the “constellation”, these three were the brightest, like Orion’s belt. Additional “stars” might be fractures, spinal cord damage, etc.
No publicly witnessed or videotaped violent shaking events to date (and there have been several) has led to the “triad” of retinal hemorrhages, subdural hematomas and brain swelling. Association has not yet been proved, let alone causation. The diagnosis itself should have been subject to increased scrutiny decades ago.
Claim: Many children with shaken baby syndrome show signs and symptoms of prior child abuse.
Many children who are abused in any way show signs and symptoms of prior abuse. When abuse by shaking is suspected, Child Abuse Pediatricians order tests to search for “occult” or hidden injuries. One such test is the skeletal survey, during which a baby’s entire body is x-rayed to look for hidden fractures. Many parents are completely stunned when told that their baby has “multiple healing fractures”. Fractures are painful, yet the baby never seemed to be in pain.
Skeletal surveys are not given unless child abuse is suspected. There are no controls. Some of the lesions (abnormalities) seen in a skeletal survey, especially those in growth plates such as chronic metaphyseal lesions (CMLs) might not be traumatic in origin. They might be a normal part of growing, osteoblasts temporarily outpacing osteoclasts, perhaps.
Something else that is deemed a sign of prior abuse is chronic subdural hematoma. A large number of babies are born with subdural hematomas. Birth is traumatic! Some subdural collections disappear sooner than others. There are causes of subdural collections other than abuse, but when abuse is suspected, everything is interpreted through that lens.
Claim: In mild cases of shaken baby syndrome, a child may appear normal after being shaken, but over time they may develop health or behavioral problems.
A corollary to this statement is in severe cases of diagnosed Shaken Baby Syndrome, a child will not appear normal after the event. Doctors are taught that in cases of irreversible brain damage or death, signs are immediate and unmistakable, therefore the last person alone with the child is criminally responsible.
A problem prosecutors faced in the 1990s was the defense assertion that someone had violently shaken the baby before he or she came into the care of the accused person. That raised reasonable doubt. Research was needed.
In 1995, Nashelsky and Dix(6) published an article stating that only three cases in the medical literature contained sufficient detail to determine the interval between assault and onset of symptoms. In one of those cases, a baby sitter admitted to shaking the child four days prior to his collapse. Willman et al.(7) in 1997 concluded, “Except in cases involving epidural hematomas, the time of injury in a fatal head injury case can be restricted to the last confirmed period of normal consciousness for the child.” M.G.F. Gilliland published a major article(8) in 1998 reporting the duration between injury and severe symptoms in 76 cases. “Our data indicate that the interval is brief (less than 24 hours) in almost ¾ of cases of head injury death, especially in shaking injuries.” That means ¼ did not display alarming symptoms for 24 or more hours. In one case, the interval was 72 hours. She noted that independent observers described the child as “not normal” during the interval, with nonspecific symptoms such as listlessness, fussiness or vomiting.
A letter to the editor in the American Journal of Forensic Medicine and Pathology in 2002(9) provides strong evidence that a “lucid interval” (period during which the child seems more or less normal) is possible. A baby was brought to the hospital on the morning of September 18, 1999 for vomiting that had lasted 24 hours. She was admitted because child abuse was suspected. It wasn’t until 2:00 the following morning that a nurse noticed decreased respirations (an alarming sign). The baby’s brain was swelling. She subsequently died. Her parents fled to Mexico.
“The child did have some symptoms, but clearly the severe intracranial injury symptoms, which were confirmed on repeat computed tomography and autopsy, were delayed for several hours, during which time she was under our view and review in the hospital.”(9)
To this day, parents are expected to know that their baby is in serious trouble, even though medical personnel did not know in this case. If parents cannot explain a baby’s condition to a doctor’s satisfaction, they are thought to have caused it.
When to See a Doctor
Seek immediate help if you suspect your child has been injured by violent shaking.
Seek immediate help if you suspect your child’s brain might swelling for any reason. Know the signs and symptoms listed above. You may be tempted to think the baby has a virus or something innocuous. Trust your gut if something seems unusual and seek medical care. It’s better to be safe than sorry when it comes to brain swelling.
Call 911 or emergency help, or take your child to the nearest emergency room.
This is a surprising statement. Parents who have rushed their child to the nearest emergency room rather than call 911 have been accused of delay in seeking treatment and had that used against them in court as evidence of guilt. Robert Roberson drove Nikki to the hospital and it was used against him. The safest course of action is to call 911 immediately.
Getting medical care right away may save your child’s life or prevent serious health problems.
Unfortunately, if a baby’s brain has begun swelling uncontrollably, there might be little doctors can do other than remove a portion of the skull or evacuate blood to relieve pressure. The baby has a better chance under medical care than not. Sometimes police during an interrogation will tell a parent or baby sitter that the baby’s outcome depends on them telling “the truth” (i.e. what they believe to be true, that you violently shook the baby). That is not the case. Medical treatment will be the same regardless of what caused the swelling.
Health care professionals are legally required to report all suspected cases of child abuse to state authorities.
This is true, and can contribute to wrongful accusations. A doctor may express a tentative suspicion to police (as required by law), that is misunderstood as a definitive conclusion, prompting police to conduct a guilt-presumptive interrogation. Unless the history matches what police believe happened, the parent is deemed a liar. Lying is evidence of guilt.
Innocent parents or baby sitters should not talk with police with an attorney present. Calmly and repeatedly, like a broken record, say, “I want an attorney here when I talk with you.” Police are required by law to honor that request. People have “confessed” to escape the immediate pressure of an interrogation. They could have ended the pressure by saying, “I want an attorney to be present.” Say it calmly over and over if necessary but do NOT say anything else.
Causes
Babies have weak neck muscles and can’t support the weight of their heads.
This is true. A baby’s head should ALWAYS be gently supported. NEVER violently shake a baby or be violent with a baby in any way. Err on the side of caution.
If the Shaken Baby Syndrome hypothesis were true, neck damage would be expected. Forces would necessarily travel through the neck to reach the brain and eyes. Yet few babies diagnosed with SBS have serious neck damage.
A study published in 2005 by Dr. Faris Bandak(9) reported:
We have determined that an infant head subjected to the levels of rotational velocity and acceleration called for in the SBS literature would experience forces on the infant neck far exceeding the limits of structural failure of the cervical spine. … These findings are not consistent with the current clinical SBS experience and are in stark contradiction with the reported rarity of cervical spine injury in children diagnosed with SBS. … A re-evaluation of the current diagnostic criteria for the SBS and its application is suggested.
As happened when other experimental evidence undercut the SBS hypothesis, no re-evaluation occurred. Proponents of the hypothesis doubled down.
If a biomechanical study indicates anything other than what the hypothesis dictates, the study is deemed wrong, not the hypothesis. “In theory, facts determine the theory, but in fact, theory determines the facts.” It is scientific to allow facts to challenge theories. It is ideological to allow theories to determine what facts will be accepted.
Claim: If a baby is forcibly shaken, their fragile brain moves back and forth inside the skull. This causes bruising, swelling and bleeding.
This states the hypothesis, that shaking causes movement of the brain within the skull and that leads to the damage associated with Shaken Baby Syndrome. Even if true, it may not be the sole cause of the “constellation” of findings. Some doctors have testified that the shaking is so violent that the back of the baby’s head impacts the spine with force. Is that possible without neck damage?
Claim: Shaken baby syndrome usually occurs when a parent or caregiver severely shakes a baby or toddler due to frustration or anger — often because the child won’t stop crying.
It is part of the hypothesis that a stressed caregiver “snaps” and violently assaults a baby. Any history given by the person who was with the baby at the time is discounted in favor of a substitute history that includes crying, stress, “snapping” and shaking / throwing. Anything a parent says that is consistent with the assumed history is accepted as true. Anything inconsistent is deemed false. The theory determines the “facts” that are accepted as “true”.
Claim: Shaken baby syndrome isn’t usually caused by bouncing a child on your knee or minor falls.
The word “usually” in this statement is curious. Does that mean it is sometimes caused by bouncing on the knee or a minor fall?
A problem with the Shaken Baby Syndrome hypothesis is that the word “shake” can mean many things, from violent, abusive attack to dandling, moving a baby or young child up and down playfully to comfort and calm. Police will ask a caregiver, “Did you shake the baby?” meaning a violent, abusive assault. The caregiver, thinking back, might say yes, meaning a jostle to rouse the baby. Police then interpret that as an admission or confession to a crime.
Dr. Caffey, who popularized the hypothesis, advised against baby bouncers, infant jumpers, powered cradles and rocking horses. He cautioned against transporting infants in jolting vehicles over rough roads, on snowmachines or in speedboats over rough water.
A hindrance to successful prosecution early on was the defense claiming that innocent actions caused the syndrome, so the hypothesis was modified. The 2001 American Academy of Pediatrics Technical Report(10) said, “The act of shaking leading to shaken baby syndrome is so violent that individuals observing it would recognize it as dangerous and likely to kill the child.”
For many years, doctors testified that short falls cannot cause death. Dr. John Plunkett published a landmark study in 2001(11) in which he reported 18 deaths after documented short falls. Some of the children had retinal and subdural hemorrhages. Because abuse was not suspected, many children’s eyes were not checked. One fall was captured on videotape, fortunately for the caretakers who were initially suspected of abuse.
The 2001 American Academy of Pediatrics Technical Report(10) stated, “The constellation of these injuries does not occur with short falls.” That statement was eliminated from the 2009 Policy Statement. No one claims that short falls often cause death, but it can happen rarely. It is difficult if not impossible in a particular case to say for certain that a short fall did not cause death.
Risk Factors
Claim: The following things may increase the risk that parents or caregivers are more likely to forcefully shake a baby and cause shaken baby syndrome:
- Unrealistic expectations of babies
- Young or single parenthood
- Stress
- Domestic violence
- Alcohol or substance abuse
- Unstable family situations
- Depression
- A history of mistreatment as a child
These are risk factors for any sort of abuse, not just Shaken Baby Syndrome. Even the presence of every risk factor does not prove abuse. Statistics do not apply in individual cases. Some people with no risk factors abuse children. Others with many risk factors do not.
Claim: Also men are more likely to cause shaken baby syndrome than are women.
In a data set of more than 6,500 cases, 73% of the defendants were male. That could mean that men are more likely to commit the crime or that men are more likely to be accused of committing the crime.
Complications
Claim: Even brief shaking of an infant can cause irreversible brain damage.
As mentioned before, no publicly witnessed or videotaped violent shaking events to date have led to the “constellation” of medical findings used to diagnose a violent shaking event.
On one hand, parents are told “one shake is all it takes”. On the other hand, violent repetitive cyclical nature of shaking with parts of the brain rotating at different speeds is said to be needed. Which is it?
Claim: Many children affected by shaken baby syndrome die. Survivors of shaken baby syndrome may require lifelong medical care for conditions such as:
- Partial or total blindness
- Developmental delays, learning problems or behavior issues
- Intellectual disability
- Seizure disorders
- Cerebral palsy, a disorder that affects movement and muscle coordination
Many brain-damaged children die. Survivors may require lifelong medical care. The families who love and care for brain damaged children need support. The millions of dollars that are currently spent to convict and incarcerate parents with no history of violence might better be directed toward help for families with children whose brains have been damaged.
Footnotes:
- Caffey J. The Whiplash Shaken-Infant Syndrome. Pediatrics. 1974;54:396-403.
- Ommaya AK et al. Whiplash Injury and Brain Damage. JAMA. 1968;204,285-289.
- Ludwig S. Shaken Baby Syndrome: A Review of 20 Cases. Ann Emerg Med. 1984;13(2):104-7.
- Duhaime AC et al. The shaken baby syndrome: A clinical, pathological, and biomechanical study. J Neurosurg. 1987:66:409-415.
- Nashelsky MB and Dix JD. Am J Forensic Med Pathol. 1995 Jun;16(2):154-7.
- Willman et al. Restricting the time of injury in fatal inflicted head injuries. Child Abuse Negl. 1997 Oct;21(10):929-40.
- Gilliland MGF. Interval Duration Between Injury and Severe Symptoms in Nonaccidental Head Trauma in Infants and Young Children. J Forensic Sci. 1998 May;43(3):723-5.
- Huntington RW III. Symptoms Following Head Injury. Am J Forensic Med Pathol. 2002 Mar;23(1):105.
- Bandak FA. Shaken baby syndrome: A biomechanics analysis of injury mechanisms. Forensic Sci Int.
2005 Jun 30;151(1):71-9. - Shaken Baby Syndrome: Rotational Cranial Injuries – Technical Report. Pediatrics. 2001;108:206-210.
- Plunkett J. Fatal Pediatric Head Injuries Caused by Short-Distance Falls. Am J Forensic Med Pathol. 2001;22:1-12.