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<!-- Definition and symptoms -->
'''Shaken baby syndrome''' ('''SBS'''), also known as '''abusive head trauma''' ('''AHT'''), is a medical condition in children younger than five years old,<ref name="CDC2017">{{cite web |date=4 April 2017 |title=Preventing Abusive Head Trauma in Children |url=https://www.cdc.gov/violenceprevention/childmaltreatment/Abusive-Head-Trauma.html |archive-url=https://web.archive.org/web/20170611212045/https://www.cdc.gov/violenceprevention/childmaltreatment/Abusive-Head-Trauma.html |archive-date=11 June 2017 |access-date=9 June 2017 |website=www.cdc.gov |language=en-us}}</ref> generally caused by blunt trauma, vigorous shaking, or a combination of both.<ref name="Sha2015" /> SBS is the leading cause of fatal head injuries in children under two,<ref name=":1">{{cite journal | vauthors = | title = Consensus Statement: Abusive Head Trauma in Infants and Young Children | journal = Pediatrics | volume = 142 | issue = 2 | date = August 2018 | pmid = 30061300 | doi = 10.1542/peds.2018-1504 | s2cid = 51878771 | doi-access = free }}</ref> with a risk of death of about 25%.<ref name="CDC2017" /> The most common symptoms include [[retinal hemorrhage|retinal bleeds]], multiple fractures of the [[long bones]], and [[subdural hematoma]]s (bleeding in the brain).<ref name="NINDS_info">{{Cite web |url=http://www.ninds.nih.gov/disorders/shakenbaby/shakenbaby.htm |title=NINDS Shaken Baby Syndrome information page |date=14 February 2014 |publisher=[[National Institute of Neurological Disorders and Stroke]] |archive-url=https://web.archive.org/web/20140529085726/http://www.ninds.nih.gov/disorders/shakenbaby/shakenbaby.htm |archive-date=29 May 2014 |access-date=23 June 2008 }}</ref>
<!-- Cause and diagnosis -->
The condition is often caused by violent shaking with or without blunt impact that can lead to long-term health consequences for infants or children.<ref name="CDC2017" /> Diagnosis can be difficult as symptoms may be nonspecific.<ref name="Sha2015" /> A [[CT scan]] of the head is typically recommended if a concern is present.<ref name="Sha2015" /> If there are concerning findings on the CT scan, a full work-up for [[child abuse]] should occur, including an eye exam and skeletal survey. Retinal hemorrhage is highly associated with AHT, occurring in 78% of cases of AHT versus 5% of cases of non-abusive head trauma.<ref name=":2">{{cite journal | vauthors = Maguire SA, Watts PO, Shaw AD, Holden S, Taylor RH, Watkins WJ, Mann MK, Tempest V, Kemp AM | title = Retinal haemorrhages and related findings in abusive and non-abusive head trauma: a systematic review | journal = Eye | volume = 27 | issue = 1 | pages = 28–36 | date = January 2013 | pmid = 23079748 | pmc = 3545381 | doi = 10.1038/eye.2012.213 }}</ref><ref name="Chri2009">{{cite journal |
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Retinal hemorrhage (bleeding) occurs in around 85% of SBS cases and the severity of retinal hemorrhage correlates with severity of head injury.<ref name=":2" /> The type of retinal bleeds are often believed to be particularly characteristic of this condition, making the finding useful in establishing the diagnosis.<ref name="Levin2010">{{cite journal | vauthors = Levin AV | title = Retinal hemorrhage in abusive head trauma | journal = Pediatrics | volume = 126 | issue = 5 | pages = 961–970 | date = November 2010 | pmid = 20921069 | doi = 10.1542/peds.2010-1220 | url = http://pediatrics.aappublications.org/content/126/5/961.long | url-status = live | s2cid = 11456829 | archive-url = https://web.archive.org/web/20141020182726/http://pediatrics.aappublications.org/content/126/5/961.long | archive-date = 20 October 2014 }}</ref>
Fractures of the [[vertebrae]], [[long bones]], and [[ribs]] may also be associated with SBS.<ref>{{cite journal | vauthors = Kempe CH, Silverman FN, Steele BF, Droegemueller W, Silver HK | title = The battered-child syndrome | journal = JAMA | volume = 181 | pages = 17–24 | date = July 1962 | pmid = 14455086 | doi = 10.1001/jama.1962.03050270019004 | citeseerx = 10.1.1.589.5168 }}</ref>
==History==▼
In 1971, [[Norman Guthkelch]] proposed<ref>{{cite journal |
==Epidemiology==
The incidence of shaking baby syndrome is unknown due to difficulty in diagnosis, which may be caused by lack of centralized reporting system, absent signs of maltreatment, unclear presentation, and acute head trauma being classified under chronic neglect.<ref name="Joyce_Gossman_Huecker_2023">{{cite book |title=StatPearls |vauthors
Small children are at particularly high risk for abuse associated with SBS given the large difference in size between the small child and the caretaker.<ref name="pmid11433079" /> SBS is primarily observed in children under the age of two but may occur in those up to age five.<ref name="pmid11433079" /> The majority of cases typically occur before the infant's first birthday with the average victim age between three
==Risk factors==
Common risk factors for
Episodes of [[baby colic|colic]] are greatest at 6 to 8 weeks of age, and studies have shown a peak in SBS incidence during this time as parents may perceive these episodes as excessive crying.<ref name="Joyce_Gossman_Huecker_2023" /> Caregivers that are at risk for becoming abusive often have unrealistic expectations of the child and may display "role reversal", expecting the child to fulfill the needs of the caregiver.<ref name="pmid11433079" /> [[Substance abuse]] and emotional stress, resulting for example from low [[socioeconomic status]] or family instability, are other risk factors for aggression and impulsiveness in caregivers.<ref name="pmid11433079" /><ref name=":6">{{cite journal | vauthors = Karibe H, Kameyama M, Hayashi T, Narisawa A, Tominaga T | title = Acute Subdural Hematoma in Infants with Abusive Head Trauma: A Literature Review | journal = Neurologia Medico-Chirurgica | volume = 56 | issue = 5 | pages = 264–273 | date = May 2016 | pmid = 26960448 | pmc = 4870181 | doi = 10.2176/nmc.ra.2015-0308 }}</ref> Caregivers of any gender can cause SBS, but cases of SBS have been reported to be more common amongst younger parents.<ref name="pmid11433079" /><ref name=":6" /> Studies have shown increased prevalence of SBS among parents 34 years old or younger, especially 24 years old or younger.<ref
At the community level, risk factors for shaken baby syndrome include social isolation, lack of recreational facilities, lack of external support from family or governmental agencies, unsafe neighborhoods and societal factors such as poverty.<ref name=":11" /><ref name=cs/>
▲Episodes of colic are greatest at 6 to 8 weeks of age, and studies have shown a peak in SBS incidence during this time as parents may perceive these episodes as excessive crying.<ref name="Joyce_Gossman_Huecker_2023" /> Caregivers that are at risk for becoming abusive often have unrealistic expectations of the child and may display "role reversal", expecting the child to fulfill the needs of the caregiver.<ref name="pmid11433079" /> [[Substance abuse]] and emotional stress, resulting for example from low [[socioeconomic status]] or family instability, are other risk factors for aggression and impulsiveness in caregivers.<ref name="pmid11433079" /><ref name=":6">{{cite journal | vauthors = Karibe H, Kameyama M, Hayashi T, Narisawa A, Tominaga T | title = Acute Subdural Hematoma in Infants with Abusive Head Trauma: A Literature Review | journal = Neurologia Medico-Chirurgica | volume = 56 | issue = 5 | pages = 264–273 | date = May 2016 | pmid = 26960448 | pmc = 4870181 | doi = 10.2176/nmc.ra.2015-0308 }}</ref> Caregivers of any gender can cause SBS, but cases of SBS have been reported to be more common amongst younger parents.<ref name="pmid11433079" /><ref name=":6" /> Studies have shown increased prevalence of SBS among parents 34 years old or younger, especially 24 years old or younger.<ref>{{Cite journal |date=2016-01-05 |title=Self-Reported Prevalence and Risk Factors for Shaking and Smothering Among Mothers of 4-Month-Old Infants in Japan |journal=Journal of Epidemiology |volume=26 |issue=1 |pages=4–13 |doi=10.2188/jea.JE20140216 |issn=0917-5040 |pmc=4690735 |pmid=26639749 | vauthors = Fujiwara T, Yamaoka Y, Morisaki N }}</ref> Although it had been previously speculated that SBS was an isolated event, evidence of prior child abuse is a common finding.<ref name="pmid11433079" /> In an estimated 33–40% of cases, evidence of prior head injuries, such as old intracranial bleeds, is present.<ref name="pmid11433079" />
==Mechanism==
Shaken Baby Syndrome, also called as Shaken Impact Syndrome, is a severe form of child abuse. It occurs when parents or caregivers shakes a baby.<ref>{{Cite web |title=Shaken Baby Syndrome |url=https://www.aans.org/patients/conditions-treatments/shaken-baby-syndrome/ |access-date=2024-07-29 |website=AANS |language=en-US}}</ref> There is a strong association between crying and SBS, where studies indicate 1-6% of parents
Effects of SBS are thought to be [[diffuse axonal injury]], [[hypoxia (medical)|oxygen deprivation]] and [[cerebral edema|swelling of the brain]],<ref name="Miehl">{{cite journal | vauthors = Miehl NJ | title = Shaken baby syndrome | journal = Journal of Forensic Nursing | volume = 1 | issue = 3 | pages = 111–117 | year = 2005 | pmid = 17073042 | doi = 10.1097/01263942-200509000-00006 | url = http://www.medscape.com/viewarticle/515880 | url-status = live | access-date = 27 April 2011 | archive-url = https://web.archive.org/web/20140305145648/http://www.medscape.com/viewarticle/515880 | archive-date = 5 March 2014 }}</ref> which can raise [[intracranial pressure|pressure inside the skull]] and damage delicate brain tissue, although witnessed shaking events have not led to such injuries. Direct injuries
Traumatic shaking occurs when a child is shaken in such a way that its head is flung backwards and forwards.<ref name=":0">{{Cite book |url=http://www.sbu.se/en/publications/sbu-assesses/traumatic-shaking--the-role-of-the-triad-in-medical-investigations-of-suspected-traumatic-shaking/ |title=Traumatic shaking – The role of the triad in medical investigations of suspected traumatic shaking |date=26 October 2016 |publisher=Swedish Agency for Health Technology Assessment and Assessment of Social Services |isbn=978-91-85413-98-0 |series=SBU Assessment |pages=9–15 |language=en |access-date=8 June 2017 |archive-url=https://web.archive.org/web/20170606083919/http://www.sbu.se/en/publications/sbu-assesses/traumatic-shaking--the-role-of-the-triad-in-medical-investigations-of-suspected-traumatic-shaking/ |archive-date=6 June 2017 |url-status=live}}</ref> This swift movement resulted in collision of brain to the skull, potentially tearing blood vessels and leading to bleeding around the brain, resulting in the formation of hematoma. As the hematoma enlarges, it can increase pressure within the skull, causing further injury to the brain.<ref name="Joyce_Gossman_Huecker_2023" /> The In 1971, Guthkelch, a neurosurgeon, hypothesized that such shaking can result in a subdural hematoma, in the absence of any detectable external signs of injury to the skull.<ref name=":0" /> The article describes two cases in which the parents admitted that for various reasons they had shaken the child before it became ill.<ref name=":0" /> Moreover, one of the babies had retinal hemorrhages.<ref name=":0" /> The association between traumatic shaking, subdural hematoma and retinal hemorrhages was described in 1972 and referred to as ''whiplash shaken infant syndrome''.<ref name=":0" /> The injuries were believed to occur because shaking the child subjected the head to acceleration–deceleration and rotational forces.<ref name=":0" />
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* [[Subarachnoid hemorrhage]], bleeding between the brain and arachnoid
* Direct [[Traumatic brain injury|brain trauma]], due to the brain striking the inner surfaces of the skull.
* Eye injury, retinal hemorrhage caused by to and
* Skeletal injury, posterior rib fracture caused by squeezing the chest as the child is tightly gripped.<ref>{{Cite journal |last=Blumenthal |first=I. |date=December 2002 |title=Shaken baby syndrome |journal=Postgraduate Medical Journal |volume=78 |issue=926 |pages=732–735 |doi=10.1136/pmj.78.926.732 |issn=0032-5473 |pmc=1757926 |pmid=12509690}}</ref><ref>{{Cite journal |last1=Cheshire |first1=Emma C. |last2=Harris |first2=Neil C. |last3=Malcomson |first3=Roger D. G. |last4=Amoroso |first4=Jasmin M. |last5=Moreton |first5=Janine E. |last6=Biggs |first6=Mike J. P. |date=2024-08-01 |title=Macroscopic and histological examination of human bridging veins
=== Signs and Symptoms of SBS ===
Possible signs and symptoms of Shaken Baby Syndrome include lethargy, decreased muscle tone, and extreme irritability. Affected infants may show a decreased in appetite, poor feeding, or vomiting without an apparent reason. Physical sign can include grab-type bruise on the arms or chest, and lack of smiling or vocalization. Other symptoms includes poor sucking or swallowing, rigidity or posturing, and difficulty breathing. There may be a decreased level of consciousness. The soft spot on the head may appear bulging, and the infant might struggle to lift their head. In addition, the infant's eyes might not focus or track movement properly, and the pupils may be of unequal size.
=== Consequences of SBS ===
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==Diagnosis==
Diagnosis can be difficult as symptoms may be nonspecific.<ref name=Sha2015/> Symptoms may include altered mental status, trouble breathing, and vomiting.<ref name=":4">{{cite journal | vauthors = Maiese A, Iannaccone F, Scatena A, Del Fante Z, Oliva A, Frati P, Fineschi V | title = Pediatric Abusive Head Trauma: A Systematic Review | journal = Diagnostics | volume = 11 | issue = 4 | page = 734 | date = April 2021 | pmid = 33924220 | pmc = 8074611 | doi = 10.3390/diagnostics11040734 | doi-access = free }}</ref> As a result, about 31% of true SBS cases may go unnoticed initially. However, imaging can provide valuable information about a potential SBS diagnosis.<ref name=":3">{{cite journal | vauthors = Wright JN | title = CNS Injuries in Abusive Head Trauma | journal = AJR. American Journal of Roentgenology | volume = 208 | issue = 5 | pages = 991–1001 | date = May 2017 | pmid = 28245144 | doi = 10.2214/AJR.16.17602 }}</ref> Imaging must be performed within at least 24 hours of the suspected injury to detect brain edema characteristic of SBS.<ref>{{Cite journal |last1=Latino |first1=Anna Libera |last2=Miglioranzi |first2=Paola |last3=Coppo |first3=Elena |last4=Giannotta |first4=Federica |date=2024-09-01 |title=Knowing, recognizing, and preventing shaken baby syndrome: The role of primary care pediatrician |url=https://www.sciencedirect.com/science/article/pii/S2667009724000745 |journal=Global Pediatrics |volume=9 |page=100206 |doi=10.1016/j.gpeds.2024.100206 |issn=2667-0097|doi-access=free }}</ref> A [[CT scan]] of the head is typically recommended if a concern is present.<ref name=Sha2015/> If there are concerning findings, a brain [[Magnetic resonance imaging|MRI]] is also recommended, which can further reveal [[
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<!--Williams Obstetrics is the title of the book. It would be really helpful if both of these citations came from the same version of the book, ideally the one on the Internet Archive.-->
Gestational problems affecting both mother and fetus, the birthing process, prematurity and nutritional deficits can accelerate skeletal and hemorrhagic pathologies that can also mimic SBS, even before birth.<ref name="Cushing">{{cite journal | vauthors = Cushing H, Goodrich JT | title = Reprint of "Concerning Surgical Intervention for the Intracranial Hemorrhages of the New-born" by Harvey Cushing, M.D. 1905 | journal = Child's Nervous System | volume = 16 | issue = 8 | pages = 484–492 | date = August 2000 | pmid = 11007498 | doi = 10.1007/s003810000255 | s2cid = 37717586 }}</ref><ref name="Williams 1997">{{Cite book | author=Williams Obstetrics | title=Diseases and Injuries of the Fetus and Newborn | volume=20 | chapter=Chapter 20 | year=1997 | pages=[https://archive.org/details/williamsobstetri00cunn_0/page/997 997–998] | publisher=Appleton & Lange |location=Stamford, CT | isbn=978-0-8385-9638-8 | chapter-url-access=registration | chapter-url=https://archive.org/details/williamsobstetri00cunn_0 | url=https://archive.org/details/williamsobstetri00cunn_0/page/997 }}</ref><ref name="Williams 2005">{{Cite book| author=Williams Obstetrics | title= Diseases and Injuries of the Fetus and Newborn| volume= 22 | chapter=Chapter 29 | year=2005 | pages=649–691 | publisher= McGraw-Hill Companies | isbn=978-0-07-141315-2}}</ref><ref name="Looney">{{cite journal | vauthors = Looney CB, Smith JK, Merck LH, Wolfe HM, Chescheir NC, Hamer RM, Gilmore JH | title = Intracranial hemorrhage in asymptomatic neonates: prevalence on MR images and relationship to obstetric and neonatal risk factors | journal = Radiology | volume = 242 | issue = 2 | pages = 535–541 | date = February 2007 | pmid = 17179400 | doi = 10.1148/radiol.2422060133 }}</ref>{{
==Prevention==
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==Treatment==
Treatment involves monitoring [[intracranial pressure]] (the pressure within the skull). Treatment occasionally requires surgery, such as to place a [[cerebral shunt]] to drain fluid from the [[cerebral ventricles]], and, if an [[intracranial hematoma]] is present, to drain the blood collection.<ref name="Miehl"/><ref name=Sha2015/>
==Prognosis==
Prognosis depends on severity and can range from total recovery to severe disability to death when the injury is severe.<ref name="Miehl"/>
One third of these patients die, one third survives with a major neurological condition, and only one third survives in good condition; therefore shaken baby syndrome puts children at risk of long-term disability.<ref>{{cite journal | vauthors = Perkins S | title = An Ecological Perspective on the Comorbidity of Childhood Violence Exposure and Disabilities: Focus on the Ecology of the School | journal = Psychology of Violence | volume = 2 | issue = 1 | pages = 75–89 | date = January 2012 | pmid = 34621555 | pmc = 8494429 | doi = 10.1037/a0026137 }}</ref><ref>{{cite journal | vauthors = Keenan HT, Runyan DK, Marshall SW, Nocera MA, Merten DF | title = A population-based comparison of clinical and outcome characteristics of young children with serious inflicted and noninflicted traumatic brain injury | journal = Pediatrics | volume = 114 | issue = 3 | pages = 633–639 | date = September 2004 | pmid = 15342832 | pmc = 2366031 | doi = 10.1542/peds.2003-1020-L }}</ref> The most frequent neurological impairments experienced by 70% of SBS survivors are learning disabilities, seizure disorders, speech disabilities, [[hydrocephalus]], [[cerebral palsy]], and visual disorders.<ref name="Oral"/><ref name=":5">{{cite journal | vauthors = Narang SK, Fingarson A, Lukefahr J | title = Abusive Head Trauma in Infants and Children | journal = Pediatrics | volume = 145 | issue = 4 | date = April 2020 | pmid = 32205464 | doi = 10.1542/peds.2020-0203 | first11 = Antoinette | first9 = Suzanne B. | first5 = Andrew P. | first6 = Emalee G. | first7 = Amy R. | first8 = Amanda Bird | first12 = Lori A. | first13 = Stephen A. | first10 = Sheila M. | first14 = Bethany | first15 = Rebecca L. }}</ref> Endocrine disorders may also develop years after the initial trauma. It is recommended that survivors of SBS be referred to medical homes for continuous follow-up by pediatricians and their healthcare team.<ref name=":5" />
==
The association of diagnosed SBS with deliberate assault is a matter of legal and medical contention, with conflicting opinions as to whether one necessarily implies the other. One of the main contentions is that many medical definitions create a biased picture of the defendants, marking them as the aggressor and implicitly providing a guilty verdict.<ref>{{cite journal | vauthors = Zakirova EB | title = Shaken Baby Syndrome: as a Controversy in Wrongful Conviction Cases | journal = Albany Law Review | volume = 81 | issue = 3 | pages = 1027–1046 | date = 2018 | pmid = 30081438 | url = https://www.albanylawreview.org/api/v1/articles/69951-shaken-baby-syndrome-as-a-controversy-in-wrongful-conviction-cases.pdf }}</ref> Simply, this diagnosis blurs the line between diagnosis and verdict.<ref>{{Cite web |last=Wrennall |date=2015 |title=Open Letter on Shaken Baby Syndrome and Courts: A False and Flawed Premise |url=https://www.marshamills.org/open_letter_on_sbs.pdf}}</ref>▼
▲The incidence of shaking baby syndrome is unknown due to difficulty in diagnosis, which may be caused by lack of centralized reporting system, absent signs of maltreatment, unclear presentation, and acute head trauma being classified under chronic neglect.<ref name="Joyce_Gossman_Huecker_2023">{{cite book | vauthors = Joyce T, Gossman W, Huecker MR | chapter = Pediatric Abusive Head Trauma |date=2023-05-22 | title = StatPearls | chapter-url=http://www.ncbi.nlm.nih.gov/books/NBK499836/ |access-date=2024-07-23 |place=Treasure Island, FL | publisher = StatPearls Publishing |pmid=29763011 }}</ref> Incidence is estimated to be 35 out of 100,000 infants, 65% of these infants have significant neurological disabilities, and 5 to 35% of infants die as a result of sustained injuries.<ref name="Joyce_Gossman_Huecker_2023" /> For children under the age of one, US-based studies have found rates of 27.5 out of 100,000 infants for the years 1997 and 2000 and a rate of 32.2 out of 100,000 in the year 2003.<ref>{{Cite journal |last1=Rebbe |first1=Rebecca |last2=Mienko |first2=Joseph A. |last3=Martinson |first3=Melissa L. |date=2020 |title=Incidence and Risk Factors for Abusive Head Trauma: A Population-Based Study |journal=Child Abuse Review (Chichester, England : 1992) |volume=29 |issue=3 |pages=195–207 |doi=10.1002/car.2630 |issn=1099-0852 |pmc=7567009 |pmid=33071539}}</ref> However, these statistics are presumably underestimates of the actual incidence of SBS as there are children whose injuries may not be perceived as serious enough to be hospitalized and those who have been hospitalized but diagnosis was missed.<ref>{{Cite journal |last=Laurent-Vannier |first=Anne |date=November 2022 |title=Shaken Baby Syndrome (SBS) or Pediatric Abusive Head Trauma from Shaking: Guidelines for Interventions During the Perinatal Period from the French National College Of Midwives |journal=Journal of Midwifery & Women's Health |language=en |volume=67 |issue=S1 |pages=S93–S98 |doi=10.1111/jmwh.13427 |doi-access=free |pmid=36480666 |issn=1526-9523}}</ref>
While it is widely accepted that physical abuse can lead to SBS, there is debate on if the reverse is true. In other words, can an SBS diagnosis prove that violent, intentional abuse occurred? This debate arises from the difficulty of diagnosing this condition as well as the possibility of non-abuse related causes, such as neglect, an unintentional accident, or even the trauma of birth.<ref name=":9">{{Cite journal |last=Findley |first=Keith |date=2020 |title=Feigned Consensus: Usurping the Law in Shaken Baby Syndrome/ Abusive Head Trauma Prosecutions |url=https://repository.law.umich.edu/cgi/viewcontent.cgi?article=3104&context=articles |journal=University of Michigan Law School Scholarship Repository |pages=1247 |quote=Likewise, child abuse pediatrician John Leventhal at Yale notes that, when evaluating a child for suspected abuse, the physician must consider what he calls two important questions: First, are the child’s findings due to trauma or a medical problem (or a combination of the two)? Second, if trauma, are the injuries due to abuse as opposed to neglect, an unintentional (or accidental) cause orbirth trauma?}}</ref> However, there is critique against this argument since not every condition requires confirmation of the original event to be diagnosed.
▲Small children are at particularly high risk for abuse associated with SBS given the large difference in size between the small child and the caretaker.<ref name="pmid11433079" /> SBS is primarily observed in children under the age of two but may occur in those up to age five.<ref name="pmid11433079" /> The majority of cases typically occur before the infant's first birthday with the average victim age between three to eight months old.<ref>{{Cite web |title=Shaken Baby Syndrome |url=https://www.aans.org/patients/conditions-treatments/shaken-baby-syndrome/ |access-date=2024-07-30 |website=AANS |language=en-US}}</ref> In the US, deaths due to SBS constitute about 10% of deaths due to child abuse.<ref name="Joyce_Gossman_Huecker_2023"/>
The concern when combining these two factors is that it allows physicians to provide a definite cause for a condition which can have life-changing legal implications for the person accused of causing it. This is problematic since in many states, such legal sentencing is typically rendered by multidisciplinary child-abuse-prevention teams (physicians, social workers, and law enforcement).<ref name=":9" /> This has led to a strong debate on whether or not SBS is a medical or legal conclusion.
▲==History==
▲In 1971, [[Norman Guthkelch]] proposed<ref>{{cite journal | vauthors = Guthkelch AN | title = Infantile subdural haematoma and its relationship to whiplash injuries | journal = British Medical Journal | volume = 2 | issue = 5759 | pages = 430–431 | date = May 1971 | pmid = 5576003 | pmc = 1796151 | doi = 10.1136/bmj.2.5759.430 }}</ref> that [[whiplash injury]] caused subdural bleeding in infants by tearing the veins in the subdural space.<ref>{{cite journal | vauthors = David TJ | title = Shaken baby (shaken impact) syndrome: non-accidental head injury in infancy | journal = Journal of the Royal Society of Medicine | volume = 92 | issue = 11 | pages = 556–561 | date = November 1999 | pmid = 10703491 | pmc = 1297429 | doi = 10.1177/014107689909201105 }}</ref><ref>{{cite web |url=http://www.argumentcritique.com/uploads/1/0/3/1/10317653/guthkelch_lw.pdf |title=Integrity in Science: The Case of Dr Norman Guthkelch, 'Shaken Baby Syndrome' and Miscarriages of Justice | vauthors = Wrennall L |archive-url=https://web.archive.org/web/20150309043634/http://www.argumentcritique.com/uploads/1/0/3/1/10317653/guthkelch_lw.pdf |archive-date=9 March 2015 |website=Argument & Critique}}</ref> The term "whiplash shaken infant syndrome" was introduced by Dr. [[John Caffey]], a pediatric radiologist, in 1973,<ref>{{cite journal | vauthors = Caffey J | title = 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 | journal = Pediatrics | volume = 54 | issue = 4 | pages = 396–403 | date = October 1974 | pmid = 4416579 | doi = 10.1542/peds.54.4.396 | url = http://pediatrics.aappublications.org/cgi/content/abstract/54/4/396 | access-date = 30 April 2011 | url-status = live | s2cid = 36294809 | archive-url = https://web.archive.org/web/20100313182616/http://pediatrics.aappublications.org/cgi/content/abstract/54/4/396 | archive-date = 13 March 2010 }}</ref> describing a set of symptoms found with little or no external evidence of head trauma, including retinal bleeds and intracranial bleeds with subdural or [[Subarachnoid hemorrhage|subarachnoid bleeding]] or both.<ref name="Caffey J 1972 161–9">{{cite journal | vauthors = Caffey J | title = On the theory and practice of shaking infants. Its potential residual effects of permanent brain damage and mental retardation | journal = American Journal of Diseases of Children | volume = 124 | issue = 2 | pages = 161–169 | date = August 1972 | pmid = 4559532 | doi = 10.1001/archpedi.1972.02110140011001 }}</ref> Development of [[computed tomography]] and [[magnetic resonance imaging]] techniques in the 1970s and 1980s advanced the ability to diagnose the syndrome.<ref name=pmid11433079/>
▲The association of diagnosed SBS with deliberate assault is a matter of legal and medical contention, with conflicting opinions as to whether one necessarily implies the other. One of the main contentions is that many medical definitions create a biased picture of the defendants, marking them as the aggressor and implicitly providing a guilty verdict.<ref>{{cite journal | vauthors = Zakirova EB | title = Shaken Baby Syndrome: as a Controversy in Wrongful Conviction Cases | journal = Albany Law Review | volume = 81 | issue = 3 | pages = 1027–1046 | date = 2018 | pmid = 30081438 | url = https://www.albanylawreview.org/api/v1/articles/69951-shaken-baby-syndrome-as-a-controversy-in-wrongful-conviction-cases.pdf }}</ref>
The [[United States President's Council of Advisors on Science and Technology|President's Council of Advisers on Science and Technology]] (PCAST) noted in its September 2016 report that there are concerns regarding the scientific validity of forensic evidence of abusive head trauma that "require urgent attention".<ref>{{Cite report |url=https://obamawhitehouse.archives.gov/sites/default/files/microsites/ostp/PCAST/pcast_forensic_science_report_final.pdf |title=Forensic Science in Criminal Courts: Ensuring Scientific Validity of Feature-Comparison Methods |date=September 2016 |page=23 |access-date=31 December 2016 |archive-url=https://web.archive.org/web/20170120233219/https://obamawhitehouse.archives.gov/sites/default/files/microsites/ostp/PCAST/pcast_forensic_science_report_final.pdf |archive-date=20 January 2017 |url-status=live}}</ref> Similarly, the Maguire model, suggested in 2011 as a potential statistical model for determining the probability that a child's trauma was caused by abuse, has been questioned.<ref>{{Cite journal | vauthors = Cuellar M |date=2017-12-01 |title=Causal reasoning and data analysis: problems with the abusive head trauma diagnosis |url=http://academic.oup.com/lpr/article/16/4/223/4557531 |journal=Law, Probability and Risk |language=en |volume=16 |issue=4 |pages=223–239 |doi=10.1093/lpr/mgx011 |issn=1470-8396}}</ref> A proposed clinical prediction rule with high sensitivity and low specificity, to rule out
In July 2005, the [[Court of Appeal (England and Wales)|Court of Appeal of England and Wales]] heard four appeals of SBS convictions: one case was dropped, the sentence was reduced for one, and two convictions were upheld.<ref name="Leeuw07">{{Cite journal |vauthors=De Leeuw M, Jacobs W |year=2007 |title=Shaken baby syndrome: The classical clinical triad is still valid in recent court rulings |journal=Critical Care |volume=11 |issue=Supplement 2 |page=416 |doi=10.1186/cc5576 |pmc=4095469 |pmid=<!--none found--> |doi-access=free}}</ref> The court found that the classic triad of retinal bleeding, subdural hematoma, and acute [[encephalopathy]] are not 100% diagnostic of SBS and that clinical history is also important. In the Court's ruling, they upheld the clinical concept of SBS but dismissed one case and reduced another from murder to manslaughter.<ref name="Leeuw07"/> In their words: "Whilst a strong pointer to NAHI [non-accidental head injury] on its own we do not think it possible to find that it must automatically and necessarily lead to a diagnosis of NAHI. All the circumstances, including the clinical picture, must be taken into account."<ref>{{Cite news |date=21 July 2005 |title=Shaken baby convictions overturned |url=https://www.theguardian.com/child/story/0,,1533200,00.html |access-date=15 October 2006 |work=[[The Guardian]]}}</ref>
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In 2022, [[Channel 4]] in the UK broadcast a documentary called ''The Killer Nanny: Did She Do It?'' concerning the [[Louise Woodward case]]. In it, civil rights lawyer Clive Stafford Smith stated, "shaken baby syndrome is bullshit".<ref>{{Cite web |date=9 January 2022 |title=The Killer Nanny: Did She Do It? |url=https://www.channel4.com/programmes/the-killer-nanny-did-she-do-it |access-date=20 January 2022 |website=Channel 4}}{{subscription required}}</ref>
In 2023, a New Jersey appellate court upheld a lower court's decision to bar the inclusion of SBS in two recent child abuse cases. In the decision, several reasons cited. First, there was a split in the pediatrics and biomechanics community over whether shaking alone is sufficient to cause the syndrome. This resulted in [[Expert witness|expert testimony]] being dismissed.<ref name=":8">{{Cite web |last=DiFilippo |first=Dana |date=2023-09-13 |title=Appeals court agrees shaken baby syndrome is 'junk science' in some cases • New Jersey Monitor |url=https://newjerseymonitor.com/2023/09/13/appeals-court-agrees-shaken-baby-syndrome-is-junk-science-in-some-cases/ |access-date=2024-07-28 |website=New Jersey Monitor |language=en-US}}</ref> Additionally, in each case, SBS was difficult to conclude and there was difficulty proving assault otherwise.<ref>State of New Jersey v. Darryl Nieves, State of New Jersey v. Michael Cifelli (Superior Court of New Jersey Appellate Division September 13, 2023). https://www.njcourts.gov/system/files/court-opinions/2023/a2069-21a2936-21.pdf</ref> However, these cases only set precedent for a narrow subsection of cases of SBS where there is no sign of impact to the babies head as well as no other means to demonstrate abuse.<ref name=":8" /> There has been pushback against the decision. One such critique expresses that while the court may not have found diagnosis by exclusion to be convincing enough for diagnosis and thus conviction, [[differential diagnosis]] is an acceptable diagnostic technique as ruled by other courts.<ref name=":10">{{Cite web |date=2023-12-13 |title=When the Law of Scientific Evidence Collides with Medical Practice - Bill of Health |url=https://blog.petrieflom.law.harvard.edu/2023/12/13/when-the-law-of-scientific-evidence-collides-with-medical-practice/ |access-date=2024-07-31 |website=blog.petrieflom.law.harvard.edu |language=en-US}}</ref> Additionally, other conditions can still be reliably diagnosed without confirmation of the original insult, such as asbestos and sports-related injuries.<ref name=":10" />
==See also==
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