Shaken baby syndrome and the legal perspective

Abstract

Shaken baby syndrome (SBS) is defined by the presence of a triad of findings (subdural hemorrhage [SDH], retinal hemorrhages [RH], and hypoxic-ischemic encephalopathy [HIE]) in the absence of scalp and/or skull fracture that indicate head injury in an infant or young child caused by violent shaking. While some authorities accept the triad as diagnostic of SBS, there is some skepticism by other experts, creating some controversy. The core evidence shows that shaking alone is not as frequently fatal as are blunt impacts of the head. It is apparent that, in some instances, shaking itself can cause fatal head injury. Although short falls rarely cause fatal head injury with the triad, an overlap between the clinicopathological findings of SBS and short falls can be seen, which sometimes seems inseparable. In the majority of accidental and nonaccidental fatal head injury cases studied, the infants became immediately unconscious at the time of incident. If not immediately unconscious, only a brief lucid interval with symptoms is present followed by progressive deterioration. Subject to few exceptions, the majority of infants who acutely collapse with the triad have a head injury. Therefore, it is important for the forensic pathologist to keep an open mind, acknowledging the existence of both traumatic and non-traumatic causes of the triad, in the differential diagnosis. Although many sources indicate that shaking causes characteristic RH, there is also contrary evidence showing that so-called characteristic RH can have causes other than shaking. Due to such persistent controversies, there is no uniform consensus on the reliability of diagnosing SBS simply from the presence of RH.