BMJ  2004;328:767 (27 March), doi:10.1136/bmj.328.7442.767


Patterns of presentation of the shaken baby syndrome Subdural and retinal haemorrhages are not necessarily signs of abuse

EDITOR-The "serious data gaps, flaws of logic, and inconsistency of case
definition" shown up by the evidence based case report of the shaken baby
syndrome (p 754) and highlighted in the accompanying editorials (pp 719 and
720) will be of interest to the many parents who over the past 10 years
have maintained that they have been wrongly accused and convicted of
causing their children's injuries.1-3

Furthermore, the recent evidence emphasised by Geddes and Plunkett that
trivial falls and other minor injuries can give rise to the allegedly
characteristic signs of subdural and retinal haemorrhages is consistent
with a triad of possible alternative explanations for shaken baby syndrome.
This triad has emerged from an analysis of 98 parental accounts reported to
the support group the Five Percenters, each of the three being compatible
with a distinct type of neuropathology.

The first is minor trauma (37% of cases). This group gives a history of
minor trauma (such as a fall from a bed or sofa) with either immediate loss
of consciousness or delayed presentation of an acute subdural bleed and
retinal haemorrhages. This is in line with the recently reported series
from the United States of independently witnessed minor falls resulting in
an acute intracranial bleed, the retinal haemorrhages being caused by a
sudden rise in retinal venous pressure as in Terson's syndrome.4

The second is birth injury (29% of cases). The clinical presentation in the
second group is quite different. There is a general period of variable
length of non-specific symptoms such as vomiting and lethargy warranting
repeated medical consultations until computed tomography shows the presence
of a chronic subdural haemorrhage. The most likely aetiology is a subdural
bleed at birth, which, though usually associated with prematurity or a
difficult labour, can follow a normal delivery.5

The third is respiratory arrest (22% of cases). In this group the
precipitating event is suggestive of respiratory arrest-often followed by
attempts at resuscitation-that could result in the subdural and retinal
haemorrhages characteristic of hypoxic encephalopathy. The findings that
severe traumatic brain damage is not, as previously thought, present in
these cases contradicts the assumption that such injuries could only have
been induced by violent shaking.6

A fourth type of presentation, epileptiform seizures (12%) is presumably
secondary to underlying intracranial disease-and is thus uninformative
about possible aetiology.

These three patterns of clinical events-in the absence of other
circumstantial evidence for non-accidental injury-offer a more credible
explanation than shaken baby syndrome for the presence of subdural and
retinal haemorrhages. It should be noted that shaking has never been
directly observed or proved to cause such injuries but is rather an
inference based on (contested) theories of biomechanics.7 By contrast,
consistent parental testimony tallies with descriptions from independent
witnesses. Furthermore, each pattern of clinical events is consistent with
a distinctive type of neuropathology of acute subdural, chronic subdural,
or the thin subdurals of hypoxic encephalopathy.

While we recognise the limitations of the volunteered parental testimony on
which this analysis is based, the same triad of presentations-designated as
acute encephalopathic, idiopathic subdural, and hyperacute presentation-has
also been independently identified from an extended database of cases of
suspected non-accidental injury (see previous letter).8 These findings
necessarily raise disturbing questions about the validity of the opinions
expressed by medical experts in the courts. They warrant further, urgent,
and appropriate scientific investigation.

James LeFanu, general practitioner

Mawbey Brough Health Centre, London SW8 2UD

Rioch Edwards-Brown, director

The Five Percenters, PO Box 23212, London SE14 5WB

Competing interests: JLeF-none declared. RE-B is director of a voluntary
organisation providing advice, information, and support to parents who
state that they have been wrongly accused of shaken baby syndrome. Neither
she nor any individual in the organisation has any financial competing

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