Shaken baby syndrome:
Recognizing and responding to a lethal danger
By Thomas A. Nakagawa, MD, and Edward E. Conway, Jr., MD, MS
Inflicted head trauma is disturbingly common in infants and carries a poor prognosis. Know what to look for and when to suspect abuse.
Head trauma related to nonaccidental injury is a leading cause of morbidity and mortality in infants and children.1 Eighty percent of deaths of children under 2 years of age result from nonaccidental head trauma,2 and homicide is a leading cause of death in children younger than 1 year. Abusive head trauma, which often involves violent shaking and impact injury, results in an estimated 1,500 hospitalizations each year. Many of the victims have permanent neurologic damage, and more than 25% die from injury related to violent shaking.3
Initial descriptions of injuries caused by shaking date to 1946, when Caffey described long-bone fractures in infants suffering from chronic subdural hematomas.4 In 1971, Guthkelch noted the association between subdural hematomas and whiplash injuries in infants and described the possible mechanism of injury.5 In 1974, Caffey reported a constellation of findings in infants without evidence of external trauma that included subdural hemorrhage, retinal hemorrhage, and metaphyseal fractures. He termed them the whiplash shaken infant syndrome (WSIS), which we now know as shaken baby syndrome (SBS).6
SBS is a serious form of child maltreatment that describes a group of unique symptoms resulting from violent shaking. It most often involves children under 1 year of age, with peak incidence between 6 weeks and 6 months of age. Boys tend to be affected slightly more often than girls. Older childen also may suffer injuries related to violent shaking, and fatal injuries have been reported even in adults who have been shaken.7,8
Infants who are abused are usually in the care of a single perpetrator for a short period when their injuries occur. Many victims have suffered prior abuse and lack signs of external trauma, and their injuries go unrecognized because of the diverse presentation of symptoms (Table 1). Life-threatening complications, such as respiratory embarrassment or cardiopulmonary arrest, in a previously healthy infant with no explanation for the severity of symptoms are a common presenting scenario.
TABLE 1
Common presenting findings associated with SBS |
| Apnea Bulging fontanel Fever History of minor trauma Irritability Lethargy Poor feeding Seizures Staring episodes Vomiting |
The classic triad of injuries related to violent shaking includes intracranial bleeding, cerebral edema, and retinal hemorrhages. They result from repetitive acceleration, deceleration, and rotational forces. Since Caffey's original description of WSIS, much interest and research has focused on the mechanisms of injury related to violent shaking and its effects on the immature nervous system of the infant. Although debate continues about damage caused by shaking versus impact, shaking any child is considered abuse, and the evaluation should focus on injury to the brain.
Common histories and presenting complaints
Crying is the most common event that precipitates violent shaking. Frustration, unrealistic expectations of the child, social stressors, and careless disregard for the child's safety contribute to the caretaker's inability to cope with the precipitating event, resulting in injury to the child. The perpetrator grabs the infant by the shoulders or under the arms and shakes the child violently, causing the head to move back and forth rapidly (Figure 1). The perpetrator may then leave the baby alone in hopes that the baby will recover, or the perpetrator may conclude that shaking resolved the problem or discomfort that caused the infant to cry.
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The clinical presentation of infants who have been shaken ranges from subtle findings such as irritability, vomiting, and poor feeding to—in severe or lethal cases—seizures, respiratory distress, and manifestations of cerebral edema with intracranial hypertension, including hemodynamic instability, respiratory depression, and coma. The wide range of findings, which can mimic other disease processes, results in misdiagnosis of many cases of inflicted head trauma. Jenny and colleagues reported that 31.2% of confirmed abusive head trauma cases were missed on initial presentation, and many infants sustained additional injury because of the delay in diagnosis.9
A high degree of suspicion, inability to explain the degree of injury, or a reported mechanism of injury that is inconsistent with the physical findings should alert the health-care professional to possible inflicted injury. Bruising in any nonambulatory child should raise suspicion of abusive trauma and prompt an investigation. If symptoms go unrecognized or treatment is delayed, apnea leading to hypoxia and eventual cardiac arrest can occur. Treatment delay and prolonged hypoxic insult contribute to the poor neurologic outcome associated with nonaccidental traumatic head injury. Although the exact timing of such injuries can be difficult to estimate, an infant with a serious head injury shows signs of neurologic deterioration almost immediately.1
How shaking causes injury
The central nervous system develops continually from birth, and the brain grows rapidly, reflecting maturational processes, including dendritic growth and myelination. At birth, the infant has approximately 1 billion neurons, each of which may produce up to 15,000 synapses. Most of these synapses develop during the first three years of life, which explains the poor outcome of infants who suffer nonaccidental injury during this crucial developmental period.
Infants have a high risk of injury from violent shaking for several anatomic reasons. An infant's head is the largest part of the body, comprising 10% to 15% of body weight, compared to 2% to 3% for adults. The brain is enclosed in a skull that is thin, pliable, and unossified. The nonfused sutures and open fontanels facilitate movement of the infant's head through the birth canal and permit rapid brain growth during the first few years of life. Weak neck muscles allow the head to move in multiple directions if left unsupported. The combination of a large head and weak neck muscles makes the infant particularly susceptible to acceleration-deceleration injuries. The lack of myelination and higher water content of the infant brain further increase the risk of shearing injury from acceleration-deceleration forces.
As the unsupported head of the infant is shaken violently, much like a cherry on a stem, linear and rotational forces are applied to the brain. These forces stretch and tear bridging vessels, causing subarachnoid or subdural bleeding (Figure 2), and lead to axonal injury. Linear forces result in retinal hemorrhages as blood vessels are literally sheared away from the retina. Compression of the chest may impede venous drainage from the head and neck, elevating intraretinal pressure and contributing to retinal bleeding.10 The perpetrator may throw the infant into the crib or bed, causing cerebral contusion or skull fractures when the infant's head hits a solid surface (Figure 3).
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Click here to view full-size graphic
Compression of the cervical spine during shaking or impact injury damages the spinal cord (Figure 4). Infants are vulnerable to spinal cord injury because of their large head, weak underdeveloped paraspinous and neck musculature, shallow and horizontally oriented cervical facets, large subarachnoid space, and elastic underdeveloped ligaments. Spinal cord injury may be difficult to document; the infant may exhibit apnea or vasomotor collapse similar to spinal shock.
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Shake injuries result from tremendous forces similar to those generated by high-speed motor vehicle crashes. The forces produced by violent shaking have been estimated to be greater than 9 gravitational forces (G forces), which are acceleration forces pulling against the body as the plane of motion changes. The forces are magnified (almost 50-fold) if the head suddenly decelerates and impacts a stationary object.11 New, unpublished evidence from biomechanical models presented at the Fourth National Conference on Shaken Baby Syndrome in 2002 suggests that the extent of these forces actually may be underestimated.
The forces exerted during violent shaking are much greater than those associated with playful activities. Falls from beds, sofas, and changing tables are commonly reported as causes of infant trauma, but studies show that falls from heights of fewer than four feet rarely result in significant injury.12–14 Repetition of the shake injury is common. Although shaking may last only a few seconds, substantial damage can occur in that brief period. Levitt and colleagues point out that anyone who has worked with 8- to 10-lb weights held at arm's length realizes that fatigue occurs quickly; most shaking probably lasts 20 seconds or less, but as many as 40 to 50 shakes may occur during that time.15
Although some medical professionals believe that impact is required to produce the traumatic brain injury associated with violent shaking, shaking alone can cause serious injury or death.16–18 Violent shaking with or without impact identifies child abuse.
Characteristic clinical findings
Retinal hemorrhages, subdural or subarachnoid bleeding, and cerebral edema are characteristic of SBS. These findings, alone or in combination, help the clinician identify injury related to violent shaking. Imaging studies of the head may show subdural or subarachnoid bleeding, diffuse axonal injury, and associated cerebral edema, or older injuries such as subdural effusions.
Subdural and subarachnoid hemorrhage. Subdural hemorrhage (SDH) is the most common acute intracranial injury seen in SBS and results from tearing of the bridging veins, which pass from the cortical surface to the dural venous sinuses (Figure 5, reproduced in the print issue with permission from Nakagawa TA, Skrinska R: Improved documentation of retinal hemorrhages using a wide-field digital ophthalmic camera in patients who experienced abusive head trauma. Arch Pediatr Adolesc Med 2001;155:1149 ). These veins stretch and tear as the brain moves within the cranial cavity in response to acceleration, deceleration, and rotational forces. SDHs are evident in approximately 90% of cases and are most often located over the cerebral convexities. SDH can be unilateral or bilateral, and the blood tends to extend into the posterior interhemispheric fissure on both sides of the falx cerebri.
Subarachnoid hemorrhages (SAH) are located between the brain and the thin subarachnoid membrane located directly above the surface of the brain. Bleeding is caused by the same mechanism as SDH—the bridging veins tear during violent shaking. The location and quantity of SDH and SAH do not correlate with the force, velocity, or site of impact to the head.
Diffuse axonal injury (DAI) is a sensitive marker of acceleration-deceleration damage sustained during shaking or impact. The long, poorly myelinated axonal fibers tear during violent shaking, and neurotransmission may be delayed or totally lost. Susceptible areas are located in the subcortical-parasagittal white matter, corpus callosum, periventricular areas, and dorsolateral quadrants of the brainstem. Injury to the periventricular and brainstem regions is associated with abnormal neurologic function and rapid loss of consciousness.
Intracranial hypertension. Much of the insult to the infant's brain from shaking occurs when intracranial hypertension develops as a result of delayed treatment following injury. The Monro-Kellie hypothesis states that the cranial vault contains a fixed volume consisting of three components—brain (80%), blood (10%), and cerebrospinal fluid (CSF, 10%)—which are encased by the thick inelastic dura and the semi-rigid cranium. These compartments exist in a state of equilibrium, and if the volume of one increases, the volume of one or both of the other compartments must decrease to maintain equilibrium within the cranial vault. Craniocerebral trauma accompanied by a hematoma or cerebral edema results in loss of compliance or buffering capacity, and intracranial pressure (ICP) begins to rise to dangerous levels as the hematoma expands or cerebral edema progresses. Failure to recognize these changes, or a delay in treatment, can lead to cerebral infarction or herniation. Uncontrolled cerebral edema results in malignant intracranial hypertension and death.
Retinal hemorrhages. Unilateral or bilateral retinal hemorrhages are a common finding in abusive head trauma, occurring in 50% to 90% of infants who are violently shaken.19 Violent shaking is increasingly recognized as the key element in producing hemorrhagic retinopathy.20 The hemorrhages result from linear acceleration-deceleration forces that shear the vitreous humor (which is more adherent in children) away from the retina as the head moves unsupported during shaking.
Shearing forces can cause splitting of the retina (retinoschisis), a unique feature of SBS.10,20 Retinoschisis in children is very specific for shaking and has not been described with any other disease processes.
The hemorrhagic retinopathy associated with SBS tends to produce diffuse hemorrhages in multiple layers throughout the retina, extending to the ora serrata (Figure 6, reproduced in the print issue with permission from Nakagawa TA, Skirnska R: Improved documentation of retinal hemorrhages using a wide-field digital ophthalmic camera in patients who experience abusive head trauma. Arch Pediatr Adolesc Med 2001;155:1149). Compression of the chest during violent shaking may result in venous stasis, further disrupting the integrity of the retinal vessels. Although some authorities believe that retinal hemorrhages alone may not be diagnostic of SBS, their presence clearly reinforces the diagnosis, especially when accompanied by intracranial injuries. Optic nerve sheath hemorrhages found on post-mortem examination are a marker for shaking injury as well.20
Retinal hemorrhages also can result from significant trauma, such as that resulting from high-speed motor vehicle accidents, carbon monoxide poisoning, vasculitis and coagulation disorders, leukemias, infection, increased ICP, metabolic diseases, and cardiopulmonary resuscitation (CPR). However, the distribution and extent of hemorrhages from such causes is clearly different from bleeding associated with violent shaking. Retinal hemorrhages associated with CPR are small and punctate, confined to the posterior pole of the retina, and occur rarely.21 Retinal hemorrhages in children caused by increased ICP are uncommon and, usually, not severe or extensive.20 Moreover, brain edema alone is insufficient to cause retinal or other ocular hemorrhages.
Retinal hemorrhages have been reported in children with aneurysms, arteriovenous malformations, and arachnoid cysts. These hemorrhages are rare, tend to be limited to the posterior pole, and do not have the diffuse appearance of hemorrhages seen in shaken babies.22
Retinal hemorrhages are a common finding in newborns, occurring more often from vacuum-assisted delivery and spontaneous vaginal delivery; hemorrhages from caesarean section delivery are rare.23 Most hemorrhages associated with childbirth are intraretinal, and typically resorb by seven to 10 days of age, although they may persist for as long as 30 days. Emerson and colleagues concluded that intraretinal hemorrhages in infants older than 1 month are not likely to be related to birth trauma, based on their findings that newborns with retinal hemorrhages had no preretinal hemorrhages or vitreous blood and only rarely had isolated subretinal hemorrhages.23
It is essential to involve a pediatric ophthalmologist in documenting retinal hemorrhages. Abusive head trauma can be missed because other health-care providers fail to recognize retinal findings.24 Accurate documentation by free-hand drawings or digital or film photography of hemorrhages is important for diagnosing SBS and should be included in the evaluation of any child whom it is believed may have suffered nonaccidental trauma.25 Photographic images may play a crucial role in the medical-legal aspects of abusive head trauma.
Rib fractures
Infants who have sustained abusive head trauma also may have rib fractures. Rib fractures associated with accidental trauma are rare and require significant force to produce—such as direct chest wall trauma from motor vehicle crashes—because the elastic and more flexible chest wall of infants allows for greater compression without injury. Fractures caused by abusive trauma tend to be posterolateral and may be of different ages.26 Forces applied by the perpetrator's hands and fingers when an infant is grabbed and shaken compress the rib cage, resulting in lateral rib fractures or posterior fractures at the point of insertion to the spine (Figure 7, reproduced in the print issue with permission from Lauridson J, Levin A, Parrish R: Animated Graphic Demonstration of Shaken Baby Syndrome (CD-ROM). Ogden, Utah: National Center on Shaken baby Syndrome, 2000). Fractures may occur more often in the left posterior chest because right-hand dominance is more common than left-hand dominance. Lateral and posterior rib fractures tend to be pathognomonic of child abuse, although they do not occur in all cases. Anterior rib fractures are rare and are usually associated with direct trauma to the chest.
Birth trauma resulting from high birth weight and traumatic delivery has been postulated as a cause of rib fractures in infants, but studies have disproved this supposition.27 Cardiopulmonary resuscitation also has been implicated as a cause for rib fractures. Many critically ill children receive CPR and have no evidence of rib fractures, however, including children with osteogenesis imperfecta.28–30 More important, CPR does not cause posterior rib fractures.
The history usually reveals a mechanism of trauma, such as a direct blow or compression injury to the chest. Accidental injury does not cause posterior rib fractures. If such fractures exist, a traumatic mechanism consistent with the injury is usually noted. Occasionally, we see children in the pediatric intensive care unit who have been backed over by a motor vehicle and have sustained only soft tissue injury with no rib fractures. Rib fractures in infants without a history of significant trauma are highly suggestive of abuse and warrant further investigation.
Skeletal disease such as osteogenesis imperfecta type II can result in fractures, but such fractures tend to involve the long bones and are accompanied by generalized osteoporosis. Other findings such as blue sclera, hearing deficits, dental problems, and frequent fractures also may be noted.
Acute fractures can be difficult to visualize. A skeletal survey and follow-up radiographs can help identify skeletal trauma. Radionuclide bone scans also may be useful in revealing occult fractures. Radiographs should always be reviewed by a pediatric radiologist.
Other trauma-related problems
Bleeding abnormalities are a known complication of head trauma.31 Intracranial hemorrhage from abusive head trauma has been attributed to post-traumatic coagulopathy when, in fact, the coagulopathy is the direct result of the injury to the brain. Coagulation profiles should be obtained and followed in all children who have sustained a head injury.
Infants who have sustained CNS injury also may develop hypothermia. Hypothermia occurs from several mechanisms, including heat loss from the large body surface area of infants, CNS dysfunction resulting in central mediated vasodilation, altered cardiac output, and environmental factors such as exposure.
A poor prognosis
The outcome of SBS is far worse than that of accidental trauma, often because of hypoxic ischemic injury caused by cerebral edema and intracranial bleeding. Delay in immediate treatment following the injury further compromises the infant's chance for a meaningful neurologic recovery.
Mortality rates range from 15% to 38%.32 Infants who survive severe injury may be left profoundly neurologically impaired, suffering from cortical blindness, seizures, hydrocephalus, and learning disabilities, or they may be institutionalized in a persistent vegetative state. Children who sustain minor injuries may have minimal neurologic damage.
Perpetrators: Who and why
There is no specific profile of the perpetrator who violently shakes an infant. Any adult-sized person is capable of inflicting injury on a small baby or child. Although siblings or other children may be implicated in causing physical trauma to an infant, it is extremely unlikely that a child could pick up an infant weighing one third to one half of his or her own body mass and generate enough force to cause significant injury by violent shaking.
Starling reported that male caretakers are more likely to abuse an infant.33 In fatal cases, however, the incidence of male and female perpetrators was equal. A higher incidence of abuse among military families has been attributed to high stress, low pay, and isolation.34 Unpublished data compiled by Nakagawa of confirmed cases of SBS during an 11-year period show a significant increase in abusive head trauma cases in military families coinciding with the return of personnel from military deployments (Figure 8).
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Injury to infants 6 to 8 weeks of age is related to several factors. During this time, mothers may be returning to work, support systems for the family begin to diminish, and fathers or male caretakers are left with the infant for short periods. These factors, aggravated by sleep deprivation and a caretaker who has had little opportunity to care for the infant, can be a lethal combination.
Investigating possible abuse
Child abuse cases are emotionally challenging for all health-care providers involved. It is important to remember that each member of the team has a specific responsibility. Whether the presentation is in the office or emergency department, the physician must first identify suspected or apparent abuse and report the case to social services, child protective services, and local authorities. A high index of suspicion is necessary. If abuse is not contemplated, cases will be missed. When abuse is suspected, each member of the health-care team must determine whether the history is consistent with the injury.
Health-care workers must remain objective and identify the case, not the family, as suspicious. They are charged with providing treatment to the child and supporting the family, not determining who injured the child. Documentation of physical findings by drawings or photographs and written records of conversations are crucial to successful identification and prosecution of the perpetrator in cases of inflicted head trauma.
A call to undertake preventive measures
Children from all backgrounds can be victims of abuse. Caffey advocated massive educational campaigns to reduce the number of children injured by violent shaking, and suggested that one third of the mentally handicapped population may have been habitually shaken as infants.7 Although preventable, injury from violent shaking continues to increase even as medical awareness of this traumatic condition grows. Identification of high-risk families, especially those in which abuse has occurred previously, is paramount to prevention.
It goes without saying that today's children are the future. Children should be protected—by teaching parents and other caretakers that, when a caretaker is frustrated, the safest place for an inconsolable infant is the crib, not in that person's arms. After placing the child in the crib, the caretaker should seek help in dealing with the crying child from friends or family members. Regional and national educational campaigns can have a profound impact on reducing the number of cases of inflicted head trauma in children.35
Children continue to be victims in our society instead of valued members—in part, because fabricated and fantastic stories of injury continue to be accepted and not challenged as explanations of severe child abuse. Mechanisms of injury must always be considered and consistent with the injuries sustained by the child. In cases of head trauma, shaking, with or without impact, identifies child abuse. Tougher punishment for crimes committed against children is needed to keep perpetrators from abusing other children.
Education is key
Much has been learned about mechanisms of traumatic brain injury and SBS since the first descriptions more than 50 years ago. Yet the outcome remains poor, without exception, for severely injured infants because of hypoxic ischemic insult. Biochemical mediators have been identified, and current research is seeking ways to improve identification of victims who have sustained nonaccidental head trauma.
The focus, however, needs to be on prevention. Educating young parents and caretakers is essential to prevent the devastating injuries that continue to affect infants and children in epidemic numbers. Only through aggressive education can we hope to reduce injuries and improve outcomes.
REFERENCES
1. Duhaime AC, Christian CW, Rorke LB, et al: Nonaccidental head injury in infants—The "shaken-baby syndrome." N Engl J Med 1998;338:1822
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13. Williams RA: Injuries in infants and small children resulting from witnessed and corroborated free falls. J Trauma 1991;31:1350
14. Reiber GD: Fatal falls in childhood. How far must children fall to sustain fatal head injury? Report of cases and review of the literature. Am J Forensic Med Pathol 1993;14:201
15. Levitt CJ, Smith WL, Alexander RC: Abusive head trauma, in Reece RM (ed): Child Abuse: Medical Diagnosis and Management. Philadephia, Lea & Febiger, 1994, pp 1–22
16. Gilliland MG, Folberg R: Shaken babies—Some have no impact injuries. J Forensic Sci 1996;41:114
17. Alexander R, Sato Y, Smith W, et al: Incidence of impact trauma with cranial injuries ascribed to shaking. Am J Dis Child 1990;144:724
18. Hadley MN, Sonntag VK, Rekate HL, et al: The infant whiplash-shake injury syndrome: A clinical and pathological study. Neurosurgery 1989;24:536
19. Green MA, Lieberman G, Milroy CM, et al: Ocular and cerebral trauma in nonaccidental injury in infancy: Underlying mechanisms and implications for paediatric practice. Br J Ophthalmol 1996;80:282
20. Levin AV: Ophthalmology of shaken baby syndrome. Neurosurg Clin N Am 2002;13:201
21. Odom A, Christ E, Kerr N, et al: Prevalence of retinal hemorrhages in pediatric patients after in-hospital cardiopulmonary resuscitation: A prospective study. Pediatrics 1997;99:E3
22. Clark RS, Orr RA, Atkinson CS, et al: Retinal hemorrhages associated with spinal cord arteriovenous malformation. Clin Pediatr (Phila) 1995;34:281
23. Emerson MV, Pieramici DJ, Stoessel KM, et al: Incidence and rate of disappearance of retinal hemorrhage in newborns. Ophthalmology 2001;108:36
24. Kivlin JD, Simons KB, Lazoritz S, et al: Shaken baby syndrome. Ophthalmology 2000;107:1246
25. Nakagawa TA, Skrinska R: Improved documentation of retinal hemorrhages using a wide-field digital ophthalmic camera in patients who experienced abusive head trauma. Arch Pediatr Adolesc Med 2001;155:1149
26. Feldman KW, Brewer DK: Child abuse, cardiopulmonary resuscitation, and rib fractures. Pediatrics 1984; 73:339
27. Nadas S, Gudinchet F, Capasso P, et al: Predisposing factors in obstetrical fractures. Skeletal Radiol 1993; 22:195
28. Bush CM, Jones JS, Cohle SD, et al: Pediatric injuries from cardiopulmonary resuscitation. Ann Emerg Med 1996;28:40
29. Spevak MR, Kleinman PK, Belanger PL, et al: Cardiopulmonary resuscitation and rib fractures in infants. A postmortem radiologic-pathologic study. JAMA 1994; 272:617
30. Sewell RD, Steinberg MA: Chest compressions in an infant with osteogenesis imperfecta type II: No new rib fractures. Pediatrics 2000;106:E71
31. Hymel KP, Abshire TC, Luckey DW, et al: Coagulopathy in pediatric abusive head trauma. Pediatrics 1997;99:371
32. American Academy of Pediatrics Committee on Child Abuse and Neglect: Shaken baby syndrome: Rotational cranial injuries—Technical report. Pediatrics 2001; 108:206
33. Starling SP, Holden JR, Jenny C: Abusive head trauma: The relationship of perpetrators to their victims. Pediatrics 1995;95:259
34. Gessner RR, Runyan DK: The shaken infant: A military connection? Arch Pediatr Adolesc Med 1995;149:467
35. Dias MS: Inflicted head injury: Future directions and prevention. Neurosurg Clin N Am 2002;13:247
DR. NAKAGAWA is associate professor of anesthesiology and pediatrics, Wake Forest University School of Medicine, and director, pediatric critical care medicine, Brenner Children's Hospital and North Carolina Baptist Hospital, Winston-Salem, N.C.
DR. CONWAY is professor of clinical pediatrics and acting chairman, Milton and Bernice Stern Department of Pediatrics, Albert Einstein College of Medicine, and chief, division of pediatric critical care, Beth Israel Medical Center, New York, N.Y.
The authors have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.
KEY FACTS
About shaken baby syndrome
• Shaken baby syndrome (SBS) results from violent acceleration-deceleration forces that cause brain injury in children
• SBS is not caused by playful bouncing
• SBS is not accidental trauma
• Short falls, from less than four feet, do not result in the type of injury seen in SBS
• No period of lucidity follows injury caused by violently shaking an infant. Injured infants and children show signs of head trauma almost immediately
• SBS is not caused by vaccinations
• Posterior rib fractures are a marker for child abuse
• Diffuse hemorrhagic retinopathy is a sign of abusive head trauma
Thomas Nakagawa, Edward Conway. Shaken baby syndrome: Recognizing and responding to a lethal danger. Contemporary Pediatrics March 2004;21:37.
