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'{{Multiple issues| {{Unbalanced|date=June 2021}} {{POV lead|date=June 2021}} {{One source|article's introduction|date=June 2021}} {{Synthesis|article's introduction|date=June 2021}} {{cleanup rewrite|date=June 2021}} }} {{Infobox medical condition (new) | name = Shaken baby syndrome | synonyms = abusive head trauma, non accidental head injury | image = CTheatInfantAbusiveheadtrauma.png | caption = An [[intraparenchymal bleed]] with overlying [[skull fracture]] from shaken baby syndrome | symptoms = Variable<ref name=Sha2015/> | complications = [[Seizures]], [[visual impairment]], [[cerebral palsy]], [[cognitive deficit|cognitive impairment]]<ref name=Ad2014/><ref name=Sha2015/> | onset = Less than 5 years old<ref name=CDC2017/> | duration = | types = | causes = Blunt trauma, vigorous shaking<ref name=Sha2015/> | risks = | diagnosis = [[CT scan]]<ref name=Sha2015/> | differential = | prevention = Educating new parents<ref name=Sha2015/> | treatment = | medication = | prognosis = Long term health problems common<ref name=CDC2017/> | frequency = 3 per 10,000 babies per year (US)<ref name=Sha2015/> | deaths = ≈25% risk of death<ref name=CDC2017/> }} <!-- Definition and symptoms --> '''Shaken baby syndrome''' ('''SBS'''), also known as '''abusive head trauma''' ('''AHT'''), is the leading cause of fatal head injuries in children younger than 2 years.<ref name=":1">{{Cite journal |date=2018-08-01 |title=Consensus Statement: Abusive Head Trauma in Infants and Young Children |url=http://dx.doi.org/10.1542/peds.2018-1504 |journal=Pediatrics |volume=142 |issue=2 |doi=10.1542/peds.2018-1504 |issn=0031-4005}}</ref> There is controversy regarding the medical validity of AHT, there have been no cases of shaken baby syndrome that had witnesses of the supposed initial trauma. Geddes and colleagues hypothesize that it is caused by respiratory abnormalities leading to hypoxia and swelling of the brain<ref name " :2"<ref>{{cite journal |last1=Geddes |first1=J |last2=Tasker |first2=R |last3=Nickols |first3=C |last4=Adams |first4=G |last5=Whitwell |first5=H |last6=Scheimberg |first6=I |title=Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in 'shaken baby syndrome'? |journal=Neuropathy and applied Neurobiology |date=February 2003 |doi=10.1046/j.1365-2990.2003.00434.x |pmid=12581336 |url=https://pubmed.ncbi.nlm.nih.gov/12581336/ |access-date=3/14/2022}}</ref>. Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in 'shaken baby syndrome'? Neuropathol Appl Neurobiol. 2003 Feb;29(1):14-22. doi: 10.1046/j.1365-2990.2003.00434.x. Erratum in: Neuropathol Appl Neurobiol. 2003 Jun;29(3):322. PMID: 12581336.";></ref> However, the courtroom has become a forum for speculative theories that cannot be reconciled with generally accepted medical literature.<ref name=":1" /> Often there are no visible signs of trauma.<ref name="Sha2015">{{cite journal |last1=Shaahinfar |first1=A |last2=Whitelaw |first2=KD |last3=Mansour |first3=KM |date=June 2015 |title=Update on abusive head trauma. |journal=Current Opinion in Pediatrics |volume=27 |issue=3 |pages=308–14 |doi=10.1097/mop.0000000000000207 |pmid=25768258 |s2cid=38035821}}</ref> Complications include [[seizures]], [[visual impairment]], [[cerebral palsy]], [[cognitive deficit|cognitive impairment]] and death.<ref name=Ad2014>{{cite book|title=Advanced Pediatric Assessment, Second Edition|date=2014|publisher=Springer Publishing Company|isbn=9780826161765|page=484|edition=2|url=https://books.google.com/books?id=LbvxBQAAQBAJ&pg=PA484|language=en|url-status=live|archive-url=https://web.archive.org/web/20171105195726/https://books.google.com/books?id=LbvxBQAAQBAJ&pg=PA484|archive-date=2017-11-05}}</ref><ref name=Sha2015/> <!-- Cause and diagnosis --> The cause may be blunt trauma, vigorous shaking, or a combination of both.<ref name=Sha2015/> Often this occurs as a result of a caregiver becoming frustrated due to the child crying.<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 |last=Maguire |first=S A |last2=Watts |first2=P O |last3=Shaw |first3=A D |last4=Holden |first4=S |last5=Taylor |first5=R H |last6=Watkins |first6=W J |last7=Mann |first7=M K |last8=Tempest |first8=V |last9=Kemp |first9=A M |date=January 2013 |title=Retinal haemorrhages and related findings in abusive and non-abusive head trauma: a systematic review |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3545381/ |journal=Eye |volume=27 |issue=1 |pages=28–36 |doi=10.1038/eye.2012.213 |issn=0950-222X |pmc=3545381 |pmid=23079748}}</ref> See [[child abuse]].<ref name=Chri2009>{{cite journal|last1=Christian|first1=CW|last2=Block|first2=R|title=Abusive head trauma in infants and children.|journal=Pediatrics|date=May 2009|volume=123|issue=5|pages=1409–11|pmid=19403508|doi=10.1542/peds.2009-0408|doi-access=free}}</ref> <!-- Treatment and epidemiology --> Educating new parents appears to be beneficial in decreasing rates of the condition.<ref name=Sha2015/> Treatment occasionally requires surgery, such as to place a [[cerebral shunt]].<ref name=Sha2015/> SBS is estimated to occur in 3 to 4 per 10,000 babies a year.<ref name=Sha2015/> It occurs most frequently in those less than five years of age.<ref name=CDC2017>{{cite web|title=Preventing Abusive Head Trauma in Children|url=https://www.cdc.gov/violenceprevention/childmaltreatment/Abusive-Head-Trauma.html|website=www.cdc.gov|access-date=9 June 2017|language=en-us|date=4 April 2017|url-status=dead|archive-url=https://web.archive.org/web/20170611212045/https://www.cdc.gov/violenceprevention/childmaltreatment/Abusive-Head-Trauma.html|archive-date=11 June 2017}}</ref> The risk of death is about 25%.<ref name=CDC2017/> The diagnosis 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=2014-02-14 |publisher=[[National Institute of Neurological Disorders and Stroke]] |url-status=dead |archive-url=https://web.archive.org/web/20140529085726/http://www.ninds.nih.gov/disorders/shakenbaby/shakenbaby.htm |archive-date=2014-05-29 |access-date=2008-06-23 }}</ref> These signs have evolved through the years as the accepted and recognized signs of child abuse. Medical professionals strongly suspect shaking as the cause of injuries when a young child presents with retinal bleed, [[bone fracture|fractures]], [[soft tissue]] injuries or subdural hematoma, that cannot be explained by accidental trauma or other medical conditions.<ref>B.G.Brogdon, Tor Shwayder, Jamie Elifritz ''Child Abuse and its Mimics in Skin and Bone''</ref> 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|author=Levin AV|title=Retinal hemorrhage in abusive head trauma|journal=Pediatrics|volume=126|issue=5|pages=961–70|date=November 2010|pmid=20921069|url=http://pediatrics.aappublications.org/content/126/5/961.long|doi=10.1542/peds.2010-1220|s2cid=11456829|url-status=live|archive-url=https://web.archive.org/web/20141020182726/http://pediatrics.aappublications.org/content/126/5/961.long|archive-date=2014-10-20}}</ref> [[Fracture]]s 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> Dr. John Caffey reported in 1972 that metaphyseal avulsions (small fragments of bone torn off where the periosteum covering the bone and the [[cortical bone]] are tightly bound together) and "bones on both the proximal and distal sides of a single joint are affected, especially at the knee".<ref name="Caffey J 1972 161–9"/> Infants may display irritability, [[failure to thrive]], alterations in eating patterns, [[lethargy]], [[vomiting]], [[seizure]]s, bulging or tense [[fontanel]]s (the soft spots on a baby's head), increased size of the head, altered breathing, and dilated [[pupil]]s. ==Risk factors== 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 financial troubles, are other risk factors for aggression and impulsiveness in caregivers.<ref name=pmid11433079/> Both males and females can cause SBS.<ref name=pmid11433079/> 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== 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 web | url=http://www.medscape.com/viewarticle/515880 | title=Shaken Baby Syndrome | access-date=2011-04-27 | publisher=[[Journal of Forensic Nursing]] | url-status=live | archive-url=https://web.archive.org/web/20140305145648/http://www.medscape.com/viewarticle/515880 | archive-date=2014-03-05 }}</ref> which can raise [[intracranial pressure|pressure inside the skull]] and damage delicate brain tissue, although witnessed shaking events have not lead to such 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=2016-10-26 |website=www.sbu.se |publisher=Swedish Agency for Health Technology Assessment and Assessment of Social Services |isbn=978-91-85413-98-0 |pages=9–15 |language=en |access-date=2017-06-08 |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=2017-06-06 |url-status=live}}</ref> 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" /> ===Force=== There has been controversy regarding the amount of force required to produce the brain damage seen in SBS. There is broad agreement, even amongst skeptics, that shaking of a baby is dangerous and can be fatal.<ref>{{cite journal|author=The Royal College of Pathologists |title=Report Of A Meeting On The Pathology Of Traumatic Head Injury In Children |url=https://www.rcpath.org/Resources/RCPath/Migrated%20Resources/Documents/S/sbs_meeting_report_final.pdf |url-status=dead |archive-url=https://web.archive.org/web/20130602182505/http://www.rcpath.org/Resources/RCPath/Migrated%20Resources/Documents/S/sbs_meeting_report_final.pdf |archive-date=2013-06-02 }}</ref><ref>{{cite journal|vauthors=Findley KA, Barnes PD, Moran DA, Squier W |title=Shaken Baby Syndrome, Abusive Head Trauma, and Actual Innocence: Getting It Right |journal=Houston Journal of Health Law and Policy |date=April 30, 2012 |ssrn=2048374}}</ref><ref>{{cite journal|author=Squier W|title="Shaken Baby Syndrome" and Forensic Pathology|journal=Forensic Science, Medicine and Pathology|volume=10 |issue=2 |pages=248–250 |doi=10.1007/s12024-014-9533-z|pmid=24469888|year=2014|s2cid=41784096}}</ref> A biomechanical analysis published in 2005 reported that "forceful shaking can severely injure or kill an infant, this is because the cervical spine would be severely injured and not because subdural hematomas would be caused by high head rotational accelerations... 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 for structural failure of the cervical spine. Furthermore, shaking cervical spine injury can occur at much lower levels of head velocity and acceleration than those reported for SBS."<ref>{{cite journal|author=Bandak FA|title=Shaken Baby Syndrome: A biomechanical analysis of injury mechanisms|volume=151|issue=1|pages=71–79|date=2005|doi=10.1016/j.forsciint.2005.02.033|pmid=15885948|journal=Forensic Science International}}</ref> Other authors were critical of the mathematical analysis by Bandak, citing concerns about the calculations the author used concluding "In light of the numerical errors in Bandak’s neck force estimations, we question the resolute tenor of Bandak’s conclusions that neck injuries would occur in all shaking events."<ref>{{Cite journal|author=Margulies S |title=Shaken baby syndrome: a flawed biomechanical analysis |journal=Forensic Science International |volume=164 |issue=2–3 |pages=278–9; author reply 282–3 |date=December 2006 |pmid=16436323 |doi=10.1016/j.forsciint.2005.12.018|name-list-style=vanc|author2=Prange M|author3=Myers BS|display-authors=3|last4=Maltese|first4=Matthew R.|last5=Ji|first5=Songbai|last6=Ning|first6=Xinguo|last7=Fisher|first7=Jacob|last8=Arbogast|first8=Kristy|last9=Christian|first9=Cindy}}</ref> Other authors critical of the model proposed by Bandak concluding "the mechanical analogue proposed in the paper may not be entirely appropriate when used to model the motion of the head and neck of infants when a baby is shaken."<ref>{{Cite journal|vauthors=Rangarajan N, Shams T |title=Re: shaken baby syndrome: a biomechanics analysis of injury mechanisms |journal=Forensic Science International |volume=164 |issue=2–3 |pages=280–1; author reply 282–3 |date=December 2006 |pmid=16497461 |doi=10.1016/j.forsciint.2005.12.017}}</ref> Bandak responded to the criticism in a [[letter to the editor]] published in ''Forensic Science International'' in February 2006.<ref name="Bandak F">{{Cite journal| author=Bandak F | title=Response to the Letter to the Editor | journal=Forensic Science International | volume=157 | issue=1 |date=December 2006 | doi=10.1016/j.forsciint.2006.01.001 | pages=282–3}} which refers to<br>{{Cite journal|author=Margulies S |title=Shaken baby syndrome: a flawed biomechanical analysis |journal=Forensic Science International |volume=164 |issue=2–3 |pages=278–9; author reply 282–3 |date=December 2006 |pmid=16436323 |doi=10.1016/j.forsciint.2005.12.018|name-list-style=vanc|author2=Prange M|author3=Myers BS|display-authors=3|last4=Maltese|first4=Matthew R.|last5=Ji|first5=Songbai|last6=Ning|first6=Xinguo|last7=Fisher|first7=Jacob|last8=Arbogast|first8=Kristy|last9=Christian|first9=Cindy}}</ref> ==Diagnosis== 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/> It is unclear how useful [[subdural haematoma]], [[Retinal haemorrhage|retinal hemorrhages]], and [[encephalopathy]] are alone at making the diagnosis.<ref name="Insufficient evidence for 'shaken b">{{cite journal |last1=Lynøe |first1=N |last2=Elinder |first2=G |last3=Hallberg |first3=B |last4=Rosén |first4=M |last5=Sundgren |first5=P |last6=Eriksson |first6=A |date=July 2017 |title=Insufficient evidence for 'shaken baby syndrome' - a systematic review. |journal=Acta Paediatrica |volume=106 |issue=7 |pages=1021–1027 |doi=10.1111/apa.13760 |pmid=28130787 |doi-access=free}}</ref> <gallery> File:AbusiveheadtraumaBonewindowsNo.png|A skull fracture from abusive head trauma in an infant File:SkullFracAHTLtMark2.png|3D CT reconstruction showing a skull fracture in an infant File:SkullFracAHTMark.png|3D CT reconstruction showing a skull fracture in an infant </gallery> ===Triad=== While the findings of SBS are complex and many,<ref>{{cite journal | doi=10.2214/AJR.14.14191 |pmid = 25905929|volume=204 |issue = 5| title=Abusive Head Trauma: A Review of the Evidence Base | journal=American Journal of Roentgenology | pages=967–973|year = 2015|last1 = Greeley|first1 = Christopher Spencer}}</ref> they are often incorrectly referred to as a "triad" for legal proceedings; distilled down to [[retinal hemorrhage]]s, [[subdural hematoma]]s, and [[encephalopathy]].<ref>{{cite journal | doi=10.1007/s12024-014-9540-0 |pmid = 24532195| volume=10 |issue = 2| title="Shaken baby syndrome" and forensic pathology | journal=Forensic Science, Medicine, and Pathology | pages=253–255|year = 2014|last1 = Greeley|first1 = Christopher Spencer|s2cid = 207365843}}</ref> SBS may be misdiagnosed, underdiagnosed, and overdiagnosed,<ref>Report questioning shaken baby syndrome seriously unbalanced http://www.aappublications.org/content/36/5/1.2</ref> and caregivers may lie or be unaware of the mechanism of injury.<ref name=pmid11433079>{{Cite journal|title=Shaken baby syndrome: rotational cranial injuries-technical report |journal=Pediatrics |volume=108 |issue=1 |pages=206–10 |date=July 2001 |pmid=11433079 |doi=10.1542/peds.108.1.206 |author1= American Academy of Pediatrics Committee on Child Abuse and Neglect|doi-access=free }}</ref> Commonly, there are no externally visible signs of the condition.<ref name=pmid11433079/> Examination by an experienced [[ophthalmologist]] is critical in diagnosing shaken baby syndrome, as particular forms of ocular bleeding are strongly associated with AHT<ref>{{Cite web|title=Shaken Baby Syndrome Resources |url=http://www.aao.org/education/library/statements/shaken_baby.cfm#ocular |publisher=American Academy of Ophthalmology |url-status=dead |archive-url=https://web.archive.org/web/20061001032144/http://www.aao.org/education/library/statements/shaken_baby.cfm |archive-date=2006-10-01 }}</ref> [[Magnetic resonance imaging]] may also depict retinal hemorrhaging<ref>{{cite journal |pmid=23568702 | doi=10.1007/s00234-013-1180-7 | volume=55 | issue=7 | title=Susceptibility weighted imaging depicts retinal hemorrhages in abusive head trauma. | date=Jul 2013 | journal=Neuroradiology | pages=889–93 | pmc=3713254 | author1=Zuccoli G | author2=Panigrahy A | author3=Haldipur A | author4=Willaman D | author5=Squires J | author6=Wolford J | author7=Sylvester C | author8=Mitchell E | author9=Lope LA | author10=Nischal KK | author11=Berger RP}}</ref> but is much less sensitive than an eye exam. Conditions that are often excluded by clinicians include [[hydrocephalus]], [[sudden infant death syndrome]] (SIDS), [[epilepsy|seizure disorders]], and [[infectious disease|infectious]] or [[congenital disease]]s like [[meningitis]] and [[metabolic disorder]]s.<ref name="Oral">{{Cite web| author=Oral R | title=Intentional head trauma in infants: Shaken baby syndrome | publisher=Virtual Children's Hospital |date=August 2003 | url=http://www.vh.org/pediatric/provider/pediatrics/shakenimpactsyndrome/ | archive-url=https://web.archive.org/web/20050214084615/http://www.vh.org/pediatric/provider/pediatrics/shakenimpactsyndrome/ | archive-date=2005-02-14 | format=Archived | access-date=2006-10-09}}</ref><ref>{{cite journal |vauthors=Togioka BM, Arnold MA, Bathurst MA, etal | year = 2009 | title = Retinal hemorrhages and shaken baby syndrome: an evidence-based review | journal = J Emerg Med | volume = 37 | issue = 1| pages = 98–106 | doi=10.1016/j.jemermed.2008.06.022| pmid = 19081701 }}</ref> [[CT scan]]ning and [[magnetic resonance imaging]] are used to diagnose the condition.<ref name=pmid11433079/> Conditions that often accompany SBS/AHT include classic patterns of skeletal fracturing (rib fractures, corner fractures), injury to the [[cervical spine]] (in the neck), retinal hemorrhage, [[cerebral hemorrhage|cerebral bleed]] or [[atrophy]], [[hydrocephalus]], and [[papilledema]] (swelling of the [[optic disc]]).<ref name="Miehl"/> The terms ''non-accidental head injury'' or ''inflicted traumatic brain injury'' have been used in place of "abusive head trauma" or "SBS".<ref name="Minns">{{Cite journal|vauthors=Minns RA, Busuttil A |title=Patterns of presentation of the shaken baby syndrome: Four types of inflicted brain injury predominate |journal=BMJ |volume=328 |issue=7442 |pages=766 |date=March 2004 |pmid=15044297 |pmc=381336 |doi=10.1136/bmj.328.7442.766}}</ref> === Classification === The term abusive head trauma (AHT) is preferred as it better represents the broader potential causes. The US [[Centers for Disease Control and Prevention]] identifies SBS as "an injury to the skull or intracranial contents of an infant or young child (< 5 years of age) due to inflicted blunt impact and/or violent shaking".<ref>{{cite journal|author=Parks, SE |author2=Annest JL |author3=Hill HA |author4=Karch DL |year=2012 |title=Pediatric Abusive Head Trauma: Recommended Definitions for Public Health Surveillance and Research |url=https://www.cdc.gov/violenceprevention/pub/pediatricheadtrauma.html |url-status=dead |archive-url=https://web.archive.org/web/20141208183557/http://www.cdc.gov/violenceprevention/pub/pediatricheadtrauma.html |archive-date=2014-12-08 }}</ref> In 2009, the [[American Academy of Pediatrics]] recommended the use of the term AHT to replace SBS, in part to differentiate injuries arising solely from shaking and injuries arising from shaking as well as trauma to the head.<ref>[http://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/Abusive-Head-Trauma-A-New-Name-for-Shaken-Baby-Syndrome.aspx Abusive Head Trauma: A New Name for Shaken Baby Syndrome] {{webarchive|url=https://web.archive.org/web/20141103083316/http://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/Abusive-Head-Trauma-A-New-Name-for-Shaken-Baby-Syndrome.aspx |date=2014-11-03 }}</ref> The [[Crown Prosecution Service|Crown Prosecution Service for England and Wales]] recommended in 2011 that the term ''shaken baby syndrome'' be avoided and the term ''non accidental head injury'' (''NAHI'') be used instead.<ref>[http://www.cps.gov.uk/legal/l_to_o/non_accidental_head_injury_cases/ Non Accidental Head Injury Cases (NAHI, formerly referred to as Shaken Baby Syndrome Prosecution Approach] {{webarchive|url=https://web.archive.org/web/20131206165646/http://www.cps.gov.uk/legal/l_to_o/non_accidental_head_injury_cases/|date=December 6, 2013}}</ref> === Controversy === Efforts to create doubt about AHT include the mischaracterization and replacement of the complex diagnostic process by a near mechanical determination based on the “triad” — the findings of subdural hemorrhage, retinal hemorrhage and encephalopathy.<ref>{{Cite journal |last=Narang |first=Sandeep K. |date=2011 |title=A Daubert Analysis of Abusive Head Trauma/Shaken Baby Syndrome |url=http://dx.doi.org/10.2139/ssrn.1919054 |journal=SSRN Electronic Journal |doi=10.2139/ssrn.1919054 |issn=1556-5068}}</ref> This critique has been sensationalized in the mass media in an attempt to create the appearance of a “medical controversy” where there is none.<ref>{{Citation |title=Shaken Baby Syndrome |url=http://dx.doi.org/10.1007/springerreference_180578 |work=SpringerReference |place=Berlin/Heidelberg |publisher=Springer-Verlag |access-date=2022-03-10}}</ref> The straw man “triad” argument ignores the fact that the AHT diagnosis typically is made only after careful consideration of all historical, clinical and laboratory findings as well as radiologic investigations by the collaboration of a multidisciplinary team.<ref name=":1" /> ===Differential diagnosis=== ====Vitamin C deficiency==== Some authors have suggested that certain cases of suspected shaken baby syndrome may result from [[vitamin C]] deficiency.<!-- --><ref name="ClemetsonCAB">{{Cite journal | author = Clemetson CAB | title = Capillary Fragility as a Cause of Substantial Hemorrhage in Infants | journal = Medical Hypotheses and Research | volume = 1 | issue = 2/3 | pages = 121–129 | url = http://www.journal-mhr.com/PDF_Files/vol_1_2/1_2N3_PDFs/1_2N3_5.pdf | date = July 2004 | access-date = 2009-05-19 | url-status = dead | archive-url = https://web.archive.org/web/20090304190227/http://www.journal-mhr.com/PDF_Files/vol_1_2/1_2N3_PDFs/1_2N3_5.pdf | archive-date = 2009-03-04 }}</ref><!-- --><ref>{{Cite book| author= Johnston, C.S. | title= Ascorbic Acid; Biochemistry and Biomedical Cell Biology | volume=25 | chapter=Chapter 10) The Antihistamine Action of Ascorbic Acid | year=1996 | page=189 | publisher= Plenum Press | isbn=978-0-306-45148-5}}</ref><!-- --><ref>{{Cite journal|vauthors=Majno G, Palade GE, Schoefl GI |title=STUDIES ON INFLAMMATION : II. The Site of Action of Histamine and Serotonin along the Vascular Tree: A Topographic Study |journal=The Journal of Biophysical and Biochemical Cytology |volume=11 |issue= 3|pages=607–26 |date=December 1961 |pmid=14468625 |pmc=2225127 |doi=10.1083/jcb.11.3.607}}</ref> This contested hypothesis is based upon a speculated marginal, near scorbutic condition or lack of essential nutrient(s) repletion and a potential elevated histamine level. However, symptoms consistent with increased [[histamine]] levels, such as low blood pressure and allergic symptoms, are not commonly associated with [[scurvy]] as clinically significant vitamin C deficiency. A literature review of this hypothesis in the journal ''[[Pediatrics International]]'' concluded the following: "From the available information in the literature, concluded that there was no convincing evidence to conclude that vitamin C deficiency can be considered to be a cause of shaken baby syndrome."<ref>{{Cite journal|vauthors=Fung EL, Nelson EA |title=Could Vitamin C deficiency have a role in shaken baby syndrome? |journal=[[Pediatrics International]] |volume=46 |issue=6 |pages=753–5 |date=December 2004 |pmid=15660885 |doi=10.1111/j.1442-200x.2004.01977.x|s2cid=35179068 }}</ref> The proponents of such hypotheses often question the adequacy of nutrient tissue levels, especially vitamin C,<!-- --><ref>{{Cite journal|author=Dettman G |title=Factor "X", sub-clinical scurvy and S.I.D.S. Historical. Part 1 |journal=The Australasian Nurses Journal |volume=7 |issue=7 |pages=2–5 |date=March 1978 |pmid=418769}}</ref><!-- --><ref>{{Cite journal|vauthors=Kalokerinos A, Dettman G |title=Sudden death in infancy syndrome in Western Australia |journal=The Medical Journal of Australia |volume=2 |issue=1 |pages=31–2 |date=July 1976 |pmid=979792|doi=10.5694/j.1326-5377.1976.tb141561.x |s2cid=34061797 }}</ref> for those children currently or recently ill, bacterial infections, those with higher individual requirements, those suffering from environmental challenges (e.g. allergies), and perhaps transient vaccination-related stresses.<!-- --><ref>{{Cite book| author=Institute of Medicine (IOM) | title= Adverse Effects of Pertussis and Rubella Vaccines | chapter=Chapter 6 Evidence Concerning Pertussis Vaccines and Other Illnesses and Conditions -- Protracted Inconsolable Crying and Screaming | chapter-url=http://newton.nap.edu/books/0309044995/html/165.html | year=1991 | page=165 | publisher=The National Academies Press | isbn=978-0-309-04499-8}}</ref> At the time of this writing, infantile scurvy in the United States is practically nonexistent.<ref>{{Cite journal|author=Lee RV|title=Scurvy: a contemporary historical perspective |journal=Connecticut Medicine |volume=47|issue=10 |pages=629–32, 703–4 |year=1983 |pmid=6354581}}</ref> No cases of [[scurvy]] mimicking SBS or [[sudden infant death syndrome]] have been reported, and scurvy typically occurs later in infancy, rarely causes death or intracranial bleeding, and is accompanied by other changes of the bones and skin and invariably an unusually deficient dietary history.<ref>{{Cite journal|author1=Weinstein M |author2=Babyn Phil |author3=Zlotkin S |title=An Orange a Day Keeps the Doctor Away: Scurvy in the Year 2000 |journal=Pediatrics |volume=108 |issue=3 |pages=e55 |year=2001 |pmid=11533373 |doi=10.1542/peds.108.3.e55|doi-access=free }}</ref><!-- --><ref>{{Cite journal|author=Rajakumar K|title=Infantile Scurvy: A Historical Perspective |journal=Pediatrics |volume=108 |issue=4 |pages=e76 |year=2001 |pmid=11581484|doi=10.1542/peds.108.4.e76|doi-access=free }}</ref> In one study vaccination was shown not associated with retinal hemorrhages.<ref>{{Cite journal|author=Binenbaum G|title=Evaluation of Temporal Association Between Vaccinations and Retinal Hemorrhage in Children|journal=JAMA Ophthalmol|volume=133|issue=11 |pages=1261–1265 |year=2015|quote=Vaccination injections should not be considered a potential cause of retinal hemorrhage in children, and this unsupported theory should not be accepted clinically or in legal proceedings.|doi=10.1001/jamaophthalmol.2015.2868|pmid=26335082|pmc=4910821}}</ref> ====Gestational problems==== 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=484–92 |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, 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|author=Looney CB |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=535–41 |date=February 2007 |pmid=17179400 |doi=10.1148/radiol.2422060133|name-list-style=vanc|author2=Smith JK|author3=Merck LH|display-authors=3|last4=Wolfe|first4=H. M.|last5=Chescheir|first5=N. C.|last6=Hamer|first6=R. M.|last7=Gilmore|first7=J. H.}}</ref>{{verification needed|date=July 2015}}<!-- Need to verify that these sources support the specific claim that "Gestation problems ... can also mimic SBS", otherwise this is section WP:SYN and should be removed. --> ==Prevention== Interventions by neonatal nurses including giving parents information about abusive head trauma, normal infant crying and reasons for crying, teaching how to calm an infant, and how to cope if the infant was inconsolable may reduce rates of SBS.<ref name="pmid25137601">{{cite journal |vauthors=Allen KA |title=The neonatal nurse's role in preventing abusive head trauma |journal=Advances in Neonatal Care |volume=14 |issue=5 |pages=336–42 |year=2014 |pmid=25137601 |pmc=4139928 |doi=10.1097/ANC.0000000000000117 |type=Review}}</ref> ==Treatment== Treatment involves monitoring [[intracranial pressure]] (the pressure within the skull), draining fluid from the [[cerebral ventricles]], and, if an [[intracranial hematoma]] is present, draining the blood collection.<ref name="Miehl"/> ==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>Perkins, Suzanne. (2012). An Ecological Perspective on the Comorbidity of Childhood Violence Exposure and Disabilities: Focus on the Ecology of the School. Psychology of Violence. 2. 75-89. 10.1037/a0026137.</ref><ref>Keenan Heather T, Runyan DK, Marshall SW, Nocera MA, & Merten DF (2004). A population-based comparison of clinical and outcome characteristics of young children with serious inflicted and noninflicted traumatic brain injury Pediatrics, 114(3), 633–639. [PubMed: 15342832]</ref> The most frequent neurological impairments are learning disabilities, seizure disorders, speech disabilities, [[hydrocephalus]], [[cerebral palsy]], and visual disorders.<ref name="Oral"/> ==Epidemiology== Small children are at particularly high risk for the abuse that causes SBS given the large difference in size between the small child and an adult.<ref name=pmid11433079/> SBS usually occurs in children under the age of two but may occur in those up to age five.<ref name=pmid11433079/> ==History== In 1971, [[Norman Guthkelch]] proposed that [[whiplash injury]] caused subdural bleeding in infants by tearing the veins in the subdural space.<ref>{{Cite journal|author=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=556–61 |date=November 1999 |pmid=10703491 |pmc=1297429|doi=10.1177/014107689909201105 }}</ref><ref>[http://www.argumentcritique.com/uploads/1/0/3/1/10317653/guthkelch_lw.pdf Integrity in Science: The Case of Dr Norman Guthkelch, ‘Shaken Baby Syndrome’ and Miscarriages of Justice By Dr Lynne Wrennall] {{webarchive|url=https://web.archive.org/web/20150309043634/http://www.argumentcritique.com/uploads/1/0/3/1/10317653/guthkelch_lw.pdf |date=2015-03-09 }}</ref> The term "whiplash shaken infant syndrome" was introduced by Dr. [[John Caffey]], a pediatric radiologist, in 1973,<ref>{{cite journal |url=http://pediatrics.aappublications.org/cgi/content/abstract/54/4/396 |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 |access-date=2011-04-30 |url-status=live |archive-url=https://web.archive.org/web/20100313182616/http://pediatrics.aappublications.org/cgi/content/abstract/54/4/396 |archive-date=2010-03-13 |date=October 1974 |last1=Caffey |first1=John |pmid=4416579 }}</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|author=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=161–9 |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/> ==Legal issues== 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>Forensic Science in Criminal Courts: Ensuring Scientific Validity of Feature-Comparison Methods (p. 23) {{cite web |url=https://obamawhitehouse.archives.gov/sites/default/files/microsites/ostp/PCAST/pcast_forensic_science_report_final.pdf |title=Archived copy |access-date=2016-12-31 |url-status=live |archive-url=https://web.archive.org/web/20170120233219/https://obamawhitehouse.archives.gov/sites/default/files/microsites/ostp/PCAST/pcast_forensic_science_report_final.pdf |via=[[NARA|National Archives]] |work=[[Office of Science and Technology Policy]] |archive-date=2017-01-20 }}</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>Cuellar M. Causal reasoning and data analysis: Problems with the abusive head trauma diagnosis. Law, Probability and Risk, 2017; 16(4): 223–239. doi:10.1093/lpr/mgx011</ref> A proposed clinical prediction rule with high sensitivity and low specificity, to rule out Abusive Head Trauma, has been published.<ref>Pfeiffer H, et al. External Validation of the PediBIRN Clinical Prediction Rule of Abusive Head Trauma. Pediatrics, 2018; 141(5): e20173674. doi:10.1542/peds.2017-3674</ref> In July 2005, the Court of Appeals in the [[United Kingdom]] 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 |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 |year=2007 |pmid=<!--none found--> |doi=10.1186/cc5576 |pmc=4095469 }}</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| title=Shaken baby convictions overturned | url=https://www.theguardian.com/child/story/0,,1533200,00.html | work=Special Reports | date=July 21, 2005 | publisher=Guardian Unlimited | access-date=2006-10-15}}</ref> The court did not believe the "unified hypothesis", proposed by British physician J. F. Geddes and colleagues, as an alternative mechanism for the subdural and retinal bleeding found in suspected cases of SBS.<ref name="Leeuw07"/> The unified hypothesis proposed that the bleeding was not caused by shearing of subdural and retinal veins but rather by cerebral [[hypoxia (medical)|hypoxia]], increased [[intracranial pressure]], and increased pressure in the brain's blood vessels.<ref name="Leeuw07"/> The court reported that "the unified hypothesis [could] no longer be regarded as a credible or alternative cause of the triad of injuries": subdural haemorrhage, retinal bleeding and [[encephalopathy]] due to [[hypoxemia]] (low blood oxygen) found in suspected SBS.<ref name="Leeuw07"/> On January 31, 2008, the Wisconsin Court of Appeals granted Audrey A. Edmunds a new trial based on "competing credible medical opinions in determining whether there is a reasonable doubt as to Edmunds's guilt." Specifically, the appeals court found that "Edmunds presented evidence that was not discovered until after her conviction, in the form of expert medical testimony, that a significant and legitimate debate in the medical community has developed in the past ten years over whether infants can be fatally injured through shaking alone, whether an infant may suffer head trauma and yet experience a significant lucid interval prior to death, and whether other causes may mimic the symptoms traditionally viewed as indicating shaken baby or shaken impact syndrome."<ref>{{Cite news| title=Court of Appeals decision - State of Wisconsin v. Audrey A. Edmonds | url=http://caselaw.lp.findlaw.com/scripts/getcase.pl?court=wi&vol=2008%5C31696&invol=2 | work=Wisconsin Court Opinions | date=January 31, 2008 | publisher=Findlaw | access-date=2009-09-25}}</ref><ref>[http://www.nacdl.org/uploadedfiles/files/resource_center/topics/post_conviction/findley_presentation.pdf Keith A. Findley Co‐Director, Wisconsin Innocence Project Clinical Professor, University of Wisconsin Law School ''Litigating Postconviction Challenges to Shaken Baby Syndrome Convictions'' ] {{webarchive|url=https://web.archive.org/web/20141215000746/http://www.nacdl.org/uploadedfiles/files/resource_center/topics/post_conviction/findley_presentation.pdf |date=2014-12-15 }}</ref> In 2012, A. Norman Guthkelch, the neurosurgeon often credited with "discovering" the diagnosis of SBS,<ref name="npr.org">{{cite web |url=https://www.npr.org/2011/06/29/137471992/rethinking-shaken-baby-syndrome |title=Rethinking Shaken Baby Syndrome |access-date=2015-05-30 |url-status=live |archive-url=https://web.archive.org/web/20150526055135/http://www.npr.org/2011/06/29/137471992/rethinking-shaken-baby-syndrome |archive-date=2015-05-26 }}</ref> published an article "after 40 years of consideration," which is harshly critical of shaken baby prosecutions based solely on the triad of injuries.<ref name="globalwrong.files.wordpress.com">{{cite web |url=https://www.law.uh.edu/hjhlp/volumes/Vol_12_2/Guthkelch.pdf |title=Archived copy |access-date=2013-01-15 |url-status=live |archive-url=https://web.archive.org/web/20141207111213/http://globalwrong.files.wordpress.com/2013/01/guthkelch-an-preface-to-narang-hous-j-health-law-poly-2012.pdf |archive-date=2014-12-07 }}</ref> Again, in 2012, Dr. Guthkelch stated in an interview, "I think we need to go back to the drawing board and make a more thorough assessment of these fatal cases, and I am going to bet . . . that we are going to find in every - or at least the large majority of cases, the child had another severe illness of some sort which was missed until too late."<ref>{{cite web |url=http://onsbs.com/2014/08/20/conversations-with-dr-a-norman-guthkelch/ |title=Conversations with Dr. A. Norman Guthkelch |access-date=2014-09-24 |url-status=live |archive-url=https://web.archive.org/web/20140919224037/http://onsbs.com/2014/08/20/conversations-with-dr-a-norman-guthkelch/ |archive-date=2014-09-19 |date=2014-08-20 }}</ref> Furthermore, in 2015, Dr. Guthkelch went so far as to say, "I was against defining this thing as a syndrome in the first instance. To go on and say every time you see it, it's a crime...It became an easy way to go into jail."<ref>{{cite news|url=https://www.nytimes.com/video/us/100000003906982/retro-report-voices-the-lawyer.html?playlistId=1194811622182|title=The Nanny Murder Trial: Retro Report Voices: The Lawyer|work=New York Times|access-date=14 September 2015|url-status=live|archive-url=https://web.archive.org/web/20150915041225/http://www.nytimes.com/video/us/100000003906982/retro-report-voices-the-lawyer.html?playlistId=1194811622182|archive-date=15 September 2015}}</ref> On the other hand, Teri Covington, who runs the National Center for Child Death Review Policy and Practice, worries that such caution has led to a growing number of cases of child abuse in which the abuser is not punished.<ref name="npr.org"/> In March 2016, [[Waney Squier]], a paediatric neuropathologist who has served as an expert witness in many shaken baby trials, was struck off the medical register for misconduct.<ref>{{cite web |url=http://www.mpts-uk.org/static/documents/content/Waney_Marian_Valerie_SQUIER_21_March_2016.pdf |title=Archived copy |access-date=2016-04-04 |url-status=dead |archive-url=https://web.archive.org/web/20160416053904/http://www.mpts-uk.org/static/documents/content/Waney_Marian_Valerie_SQUIER_21_March_2016.pdf |archive-date=2016-04-16 }}</ref> Shortly after her conviction, Dr. Squier was given the "champion of justice" award by the International Innocence Network for her efforts to free those wrongfully convicted of shaken baby syndrome.<ref>Oxford doctor Waney Squire vows to fight suspension over 'shaken baby' trial evidence {{cite web |url=http://www.oxfordmail.co.uk/news/14469215.Oxford_doctor_struck_off_over_evidence_in__shaken_baby__court_cases_vows_to_fight_suspension/ |title=Oxford doctor struck off over evidence in 'shaken baby' court cases vows to fight suspension |access-date=2016-05-06 |url-status=live |archive-url=https://web.archive.org/web/20160810201908/http://www.oxfordmail.co.uk/news/14469215.Oxford_doctor_struck_off_over_evidence_in__shaken_baby__court_cases_vows_to_fight_suspension/ |archive-date=2016-08-10 }}</ref> Squier denied the allegations and appealed the decision to strike her off the medical register.<ref>{{citation |title=Shaken baby sceptic begins appeal |url=https://www.bbc.com/news/uk-england-oxfordshire-37688263 |access-date=2016-10-24 |publisher=BBC |url-status=live |archive-url=https://web.archive.org/web/20161025055202/http://www.bbc.com/news/uk-england-oxfordshire-37688263 |archive-date=2016-10-25 |work=BBC News |date=2016-10-18 }}</ref> As her case was heard by the [[High Court of England and Wales]] in October 2016, an open letter to the ''British Medical Journal'' questioning the decision to strike off Dr. Squier, was signed by 350 doctors, scientists, and attorneys.<ref>{{citation |title=Should Waney Squier have been struck off over shaken baby syndrome? |date=17 October 2016 |first=John |last=Sweeney |url=https://www.bbc.com/news/health-37672451 |publisher=BBC |access-date=2016-10-24 |url-status=live |archive-url=https://web.archive.org/web/20161025051953/http://www.bbc.com/news/health-37672451 |archive-date=2016-10-25 }}</ref> On 3 November 2016, the court published a judgment which concluded that "the determination of the MPT is in many significant respects flawed".<ref>{{cite web |url=https://www.judiciary.gov.uk/wp-content/uploads/2016/11/squier-v-gmc-protected-approved-judgment-20160311-2.pdf |title=Case No: CO/2061/2016 Approved Judgement |date=3 November 2016 |access-date=2016-11-04 |url-status=live |archive-url=https://web.archive.org/web/20161104205435/https://www.judiciary.gov.uk/wp-content/uploads/2016/11/squier-v-gmc-protected-approved-judgment-20160311-2.pdf |archive-date=2016-11-04 }}</ref> The judge found that she had committed serious professional misconduct but was not dishonest. She was reinstated to the medical register but prohibited from giving expert evidence in court for the next three years.<ref>{{cite web |date= 3 November 2016 |url=https://www.bbc.co.uk/news/health-37861618 |title=Shaken baby evidence doctor reinstated |publisher=BBC |website=BBC News|access-date=2016-11-04 |url-status=live |archive-url=https://web.archive.org/web/20161104130431/http://www.bbc.co.uk/news/health-37861618 |archive-date=2016-11-04 }}</ref> The [[Louise Woodward case]] relied on the "shaken baby syndrome". == References == {{Reflist}} == External links == {{Medical resources | DiseasesDB = <!-- no direct topic --> | ICD10 = {{ICD10|T74.1}} | ICD9 = {{ICD9|995.55}} | ICDO = | OMIM = | MedlinePlus = 007578 | eMedicineSubj = | eMedicineTopic = | MeSH =D038642 }} * Centers for Disease Control and Prevention - [https://web.archive.org/web/20141208183557/http://www.cdc.gov/violenceprevention/pub/pediatricheadtrauma.html Abusive head trauma] {{Neurotrauma}} {{DEFAULTSORT:Shaken Baby Syndrome}} [[Category:Neurotrauma]] [[Category:Child abuse]] [[Category:Infancy]] [[Category:Syndromes]] [[Category:Wikipedia medicine articles ready to translate]]'