Triad of Doubt – the shaken baby syndrome

The hypothesized shaken baby syndrome triad.

Dr. John Caffey, often credited with “discovering” shaken baby syndrome, hypothesized that by shaking a child, “[s]pecial lacerating stresses are thus applied to the cerebral bridging veins at the fixed sites of their attachment to the walls of the sagittal sinuses”[1] causing subdural hemorrhage.   Dr. Norman Guthkelch, also credited with discovering the hypothesis, “postulated that whiplash forces caused subdural hematomas by tearing cortical bridging veins”.[2] Proponents further hypothesized that shaking caused immediate symptoms producing brain “injury referred to as shearing injury or diffuse axonal injury.”[3] Dr. Alex Levin, a leading advocate of the shaking hypothesis claimed that macular retinoschisis has never been described in children due to any entity other than SBS so its presence is diagnostic.”[4] Thus “the neuropathological triad of subdural and retinal haemorrhages and acute encephalopathy was termed the ‘shaken baby syndrome’ (SBS)”[5].

From “clearly definable” to “controversy” in eight years

In 2001, the American Academy of Pediatrics declared the shaken baby syndrome hypothesis to be a “clearly definable form of child abuse”.[6] According to the American Academy of Pediatrics, the presence of subdural and/or retinal hemorrhage in a child under the age of one year created “a presumption of child abuse”[7].  In other words, in the context where “[e]xternally visible injuries are often absent”[8] abusive shaking should be presumed without more than the presence of subdural and/or retinal hemorrhage.   That “[s]ubarachnoid and subdural hemorrhages should be appreciated as markers of brain displacement by angular force and the possibility of accompanying diffuse axonal injury”[9], was the position taken by shaking hypothesis proponents.   In other words, in the presence of subdural or subarachnoid hemorrhage (the marker), traumatic brain injury can be inferred without actual evidence of trauma to the brain (the presumption).

In 2001, doubt about the validity of the shaken baby hypothesis was gathering momentum[10].   By 2009, the American Academy of Pediatrics admitted that, despite the fact that medical and scientific “advances have improved our understanding of the range of mechanisms that contribute to brain injury”, “controversy remains.”[11] There is no controversy that impact causes subdural hemorrhage and brain injury, the only “controversy” is whether shaking can.   As a result of the doubt and controversy, the American Academy of Pediatrics recommended the use of the “term ‘abusive head trauma’ rather than a term that implies a single injury mechanism, such as shaken baby syndrome”.   Since it is not controversial that impact causes subdural hemorrhage and brain injury, the shift in terminology away from shaken baby syndrome is a recognition of the controversy of the shaking mechanism in cases where there is minimal evidence of impact to the child.  In less than a decade the American Academy of Pediatrics went from declaring the shaken baby hypothesis a “clearly definable form of child abuse” to a conceding the hypothesis to be a “controversy” and avoiding use of the term “shaken baby syndrome”.

Doubt 1 – Subdural hemorrhage – from trauma or leaky blood vessels?

One of the conundrums of the shaken baby hypothesis was, if the cortical bridging veins were sheared off from shaking as hypothesized, why was there so little blood in these thin film subdural hemorrhages?    The brain swelling response in these infants seems disproportionate to the relatively minor amount of subdural hemorrhage, if one assumes the small subdural hemorrhages are caused by trauma.  In 2007, a prominent proponent of the shaking hypothesis recognized the conundrum “occurs uniquely in infants and toddlers [and] more likely reflects their age-dependent brain response to combined stresses rather than reflecting a single, specific mechanism or circumstance of injury.”[12] In 2009, a groundbreaking article rediscovered the anatomy of the dura, anatomy that had been forgotten with the advent of CT and MRI imaging technology[13].  A rich vascular network that supplies and drains blood from the dura, and leaks blood under certain natural non-traumatic circumstances, is the likely source of much of the “subdural” bleeding that proponents of shaking presumptively attributed to trauma.   The source of the thin film subdural hemorrhage was better explained by leaky blood vessels, rather than by the presumption of trauma.

Doubt 2 – Brain injury and shearing diffuse axonal injury – trauma or not enough oxygen?

Shaking, it was hypothesized, sheared brain axons in a pattern distributed diffusely throughout the brain rather than in one particular location, as would be expected in impact trauma.  According to the hypothesis, shaking caused diffuse axonal injury (DAI) thus accounting for shaken baby syndrome symptoms of “an immediate decrease in the level of consciousness (either lethargy or unconsciousness); respiratory irregularity, difficulty, or apnea; and frequently seizures”[14] sometimes leading to death.  Thus, according to the hypothesis, the caregiver present with the child at the onset of symptoms became the presumptive perpetrator.  In 2001 a pair of seminal papers announced findings made possible by new pathological techniques that, in autopsies of cases of hypothesized shaking, the brain did not show torn axons or diffuse axonal injury[15].    By 2010, even one of the foremost shaking advocates conceded that, “[i]t is becoming increasingly clear from both neuroimaging studies and post-mortem analyses of fatal cases that the widespread cerebral and axonal damage in cases of [shaking] are, in fact, ischemic [from inadequate blood flow] rather than directly traumatic in nature.”[16]

Doubt 3 – Retinal hemorrhage and retinoschisis – from cardinal and pathognomonic to controversy and doubt.

Proponents of the hypothesis increasingly came to rely on the retinal hemorrhage leg of the triad as evidence surfaced that the other two triad legs were not supported by science or medicine.  Proponents of the shaking hypothesis assert that “[r]etinal hemorrhages are a cardinal manifestation of abusive head injury characterized by repeated acceleration–deceleration with or without blunt impact (Shaken Baby syndrome).[17] In 2000, one leading shaking proponent boldly declared, macular[18] “retinoschisis has never been described in children due to any entity other than SBS so its presence is diagnostic.”[19] In 2004 and 2006 the medical literature reported macular retinoschisis in non-shaking circumstances.[20] The shaken eye corollary to the shaken baby hypothesis is based on traction between the vitreous of the eye and the retina, or vitreoretinal traction, which is more pronounced in infants than adults.   In 2002 the shaken eye corollary to the shaken baby hypothesis was characterized as “biomechanically improbable”[21] and by 2009, whether vitreoretinal traction played any role in causing retinal hemorrhage was characterized as “controversy”[22].  New case reports continue to surface clearly demonstrating that the eye findings Dr. Levin boldly declared in 2000 as “diagnostic” of shaking is simply not true.

With so much Doubt – Prosecutions continue unabated.

Despite the controversy over shaking as a mechanism for subdural hemorrhage and retinal hemorrhage, and a complete retreat from the hypothesis that subdural hemorrhage was a marker for diffuse axonal injury, prosecutions of the caregiver present at the onset of symptoms in alleged shaken baby cases continues unabated.  The proponents of the shaken baby hypothesis, have simply reformulated the hypothesis and its associated presumptions and follow a different triad.  “Children who are otherwise healthy and have no history of trauma … who present with subdural hemorrhage and unexplained skeletal injuries, … or severe retinal hemorrhages generally are presumed by most physicians to have a non-accidental mechanism of injury.”[23] [24]

The new triad includes “unexplained” fractures

The new triad is subdural hemorrhage, retinal hemorrhage and “unexplained” fractures.   Proponents of the shaken baby hypothesis advise, “[e]vidence of other injuries, such as bruises, rib fractures, long-bone fractures, and abdominal injuries, should be meticulously searched for and documented.”  If the initial exam fails to reveal any evidence of trauma, proponents further urge “[r]epeated physical examinations may reveal additional signs of trauma.”  In search of “unexplained” fractures, according to the American Academy of Pediatrics, a “skeletal survey of the hands, feet, long bones, skull, spine, and ribs should be obtained as soon as the infant’s medical condition permits” and “a skeletal survey should be repeated after 2 weeks to better delineate new fractures that may not be apparent until they begin to heal (a process that does not become radiologically apparent for 7–10 days).”

Fractures that are not fractures

The search for “additional signs of trauma” other than subdural or retinal hemorrhage, implies subdural and retinal hemorrhage are, by definition, traumatic.  The search for “other signs of trauma” leads to some situations where fractures that do not exist are interpreted from the imaging and used to support a shaken baby diagnosis.   It is not unusual for “possible” and “suspected” skull, rib, tibia, fibula, ulna and radius fractures to be interpreted from imaging when there are no such fractures.  In cases where true fractures or pseudofractures[25] (bone findings that appear to be fractures but are not) are present, the presumption of abuse often prevents a genuine search for a metabolic cause of subdural hemorrhage or “unexplained” fractures.

Simply hypotheses, not proven medical or scientific facts

According to Dr. Norman Guthkelch, the pediatric neurosurgeon often credited with first advancing the hypotheses, the shaken baby syndrome hypothesis and its associated shaken eye hypothesis are “simply hypotheses, not proven medical or scientific facts” and that it is not reasonable to “infer shaking (or any other form of child abuse) from a finding of retino-dural hemorrhage of infancy”[26].

What should you do if falsely accused?

Immediately obtain a competent attorney who understands the medicine, science and controversies surrounding the hypothesis of shaken baby syndrome.   Most attorneys will advise you not to speak with the police and that you should consult with an attorney prior to allowing yourself to be interviewed, questioned or interrogated.    Most states mandate that doctors report suspected child abuse and immunize doctors and other medical professionals for reporting abuse and cooperating with or conducting their own child abuse investigation.   If the doctors are negligent, share confidential information with police or child protective services, and if they do not believe the caregiver’s account of what happened, they likely have immunity from liability in a civil lawsuit against them by the parent.  In most cases, the doctors to whom parents bring their child, to find out what happened to their child, become the caregiver’s accuser.

If you have been charged criminally, have had your children taken away, signed a safety plan, or are being investigated for allegedly abusing a child, you may want to consult with Mr. Freeman about your case.  Mr. Freeman practices law in Pennsylvania and New Jersey.  Mr. Freeman has also consulted in criminal and family court cases across the United States (outside of Pennsylvania and New Jersey)  and in Canada.  You can contact Mr. Freeman at mark@markdfreemanlaw.com or 1-800-580-0084.

This webpage is offered for informational purposes only and does not constitute legal advice. You should consult an attorney to obtain legal advice in your case.


[1] Caffey J. The whiplash shaken infant syndrome: manual shaking by the extremities with whiplash induced intracranial and intraocular bleeding, linked with permanent brain damage and mental retardation. Pediatrics 1974;54:396– 403.

[2] American Academy of Pediatrics, Committee on child abuse and neglect, Shaken baby syndrome: Rotational cranial injuries – technical report, Pediatrics, 2001 108, 1, 206–210.

[3] Case ME, Graham MA, Handy TC, Jentzen JM, Monteleone JA, for the National Association of Medical Examiners Ad Hoc Committee on Shaken Baby Syndrome. Position paper on fatal abusive head injuries in infants and young children. Am ] Forensic Med Pathol 2001 ;22: 112-122.

[4] Levin AV. Retinal haemorrhage and child abuse. In: David TJ, editor. Recent advances in paediatrics, No. 18. London: Churchill Livingstone, 2000:151–219.

[5] Finnie JW, Manavis J, Blumbergs PC, Diffuse neuronal perikaryal amyloid precursor protein immunoreactivity in an ovine model of non-accidental head injury (the shaken baby syndrome); Journal of Clinical Neuroscience 17 (2010) 237–240 citing American Academy of Pediatrics Committee on Child Abuse and Neglect. Shaken baby syndrome: inflicted cerebral trauma. Pediatrics 1993;92:872–5.

[6] American Academy of Pediatrics, Committee on child abuse and neglect, Shaken baby syndrome: Rotational cranial injuries – technical report, Pediatrics, 2001 108, 1, 206–210.

[7] Id.

[8] Id.

[9] Case ME, Graham MA, Handy TC, Jentzen JM, Monteleone JA, for the National Association of Medical Examiners Ad Hoc Committee on Shaken Baby Syndrome. Position paper on fatal abusive head injuries in infants and young children. Am ] Forensic Med Pathol 2001 ;22: 112-122.

[10] Although the shaken baby hypothesis had never been accepted in the bioengineering scientific community, prosecutors, child protection agencies and much of the medical community had accepted the hypothesis.  (See Duhaime AC, Gennerelli TA, Thibault LE, Bruce DA, Margulies SS, Wiser R. The shaken baby syndrome. A clinical, pathological, and biomechanical study. J Neurosurg. 1987;66:409–415.  The forces generated by shaking are “well below the injury range”; and Prange MT, Coates B, Duhaime A-C, Margulies SS: Anthropomorphic simulations of falls, shakes and inflicted impacts in infants. J Neurosurg 99:143-150, 2003. “In addition, there are no data showing that the [force] experienced during shaking … is sufficient to cause SDHs (SudDural Hemorrhages) or primary TAIs (Traumatic Axonal Injuries) in an infant.”  Perhaps the precipitating event of the public awareness and debate about the validity of the hypothesis was the 1997 trial of Louise Woodward, a British nanny accused of shaking young Matthew Eappen.  Although Louise Woodward was convicted by a jury, the Judge’s lenient sentence led to a firestorm of public criticism by the proponents of the shaken baby hypothesis of any doubt about the hypothesis.

[11] Christian CW, Block R Committee of Child Abuse and Neglect, American Academy of Pediatrics: Abusive head trauma in infants and children. Pediatrics  2009; 123:1409-1411.

[12] Duhaime AC, Durham S (2007) Traumatic brain injury in infants: the phenomenon of subdural hemorrhage with hemispheric hypo- density (“big black brain”). Prog Brain Res 161:293–302

[13] Mack J, Squier W, Eastman JT (2009) “Anatomy and Development of the Menings: Implications for Subdural Collections and CSF Circulation.” Pediatr Radiolog. Mar 39(3) 200-210

[14] Case ME, Graham MA, Handy TC, Jentzen JM, Monteleone JA, for the National Association of Medical Examiners Ad Hoc Committee on Shaken Baby Syndrome. Position paper on fatal abusive head injuries in infants and young children. Am ] Forensic Med Pathol 2001 ;22: 112-122.

[15] Geddes J et al., Neuropathy of Inflicted Head Injury in Children: I. Pattern of Brain Damage, Brain 2001; 124(7):1290-1298.  Geddes J et al., Neuropathy of Inflicted Head Injury in Children: II. Microscopic Brain Drain Injury in Infants, Brain 2001; 124(7):1299-1306.

[16] Dias MS. The Case for Shaking. In: Jenny C, editor. Child Abuse and Neglect. Elsevier Saunders; 2010.

[17] Wyngnanski-Jaffe T, Morad Y, Levin AV, Pathology of retinal hemorrhage in abusive head trauma, Forensic Sci Med Pathol (2009) 5:291–297 DOI 10.1007/s12024-009-9134-4

[18] In his writings, Dr. Alex Levin almost universally substitutes the word “macular” for “traumatic” essentially equating “macular retinoschisis” with “traumatic retinoschisis”.

[19] Levin A. Retinal haemorrhage and child abuse. In:David T, ed. Recent Advances in Paediatrics. London, England: Churchill Livingstone; 2000:151-219.

[20] Lantz PE, Sinal SH, Stanton CA, Weaver RG Jr. Perimacular retinal folds from childhood head trauma. BMJ. 2004;328(7442): 754 –756; Lueder GT, Turner JW, Paschall R: Perimacular retinal folds simulating nonaccidental injury in an infant. Arch Ophthalmol  2006; 124:1782-1783

[21] Ommaya AK, Goldsmith W, Thibault L. Biomechanics and neuropathology of adult and paediatric head injury. Br J Neu- rosurg. 2002;16(3):220–242

[22] Clarke, MP, Controversy: Vitreoretinal traction is a major factor in causing the haemorrhagic retinopathy of abusive head Injury? – No, Eye (2009) 23, 1761–1763; doi:10.1038/eye.2009.200; published online 7 August 2009Levin AV, Controversy: Vitreoretinal traction is a major factor in causing the haemorrhagic retinopathy of abusive head Injury? – Yes, Eye (2009) 23, 1758–1760; doi:10.1038/eye.2009.199; published online 7 August 2009

[23] Rorke-Adams L, Duhaime AC, Jenny C, Smith WL, Head Trauma; In: Child Abuse, Medical Diagnosis and Management, 3rd Edition; Christian CW, Reece RM, Editors(2009), American Academy of Pediatrics.

[24] “Shaken baby syndrome is characterized by the triad of skeletal injury, intracranial hemorrhage, retinal hemorrhage, or a combination thereof, usually in the absence of external signs of injury.” Schloff S, Mullaney PB, Armstrong DC, et al. Retinal findings in children with intracranial hemorrhage. Ophthalmology. 2002; 109:1472–6.  See discussion below on the new triad.

[25] One type of fracture that proponents of the shaken baby hypothesis consider diagnostic of abuse is the Classic Metaphyseal Lesion (CML).  CMLs are typically found in the growth plate of long bones and exhibit none of the healing phases characteristic of other bone fractures.  There are some doctors who doubt CMLs are fractures at all and are, according to the doctor most credit with “discovering” CMLs, characterized as “resembling” and “indistinguishable” from rickets, “similar” to bone dysplasias, “simulate” and “difficult to distinguish from” from developmental bone variants.  Kleinman PK, Problems in the diagnosis of metaphyseal fractures, Pediatr Radiol (2008) 38 (Suppl 3):S388–S394 DOI 10.1007/s00247-008-0845-6.   In short, CMLs are likely “normal developmental variants and dysplastic changes that may be confused” and misdiagnosed as child abuse.   Due to the epidemic of vitamin d insufficiency, it is thought that many CMLs are simply infantile rickets misdiagnosed as abusive fractures, particularly in infants under six months of age.

[26] Guthkelch, AN, Problems of infant retino-dural hemorrhage with minimal external injury; 12 Hous. J. Health L. & Policy 209 (Nov. 28, 2012).

  • Mark Freeman is an attorney that got involved in defending those accused of shaking a child when a close friend was charged with child abuse for allegedly shaking his son.
  • After spending hundreds of hours investigating, reading medical journal articles and speaking with doctors from around the country about shaken baby syndrome, Mark confirmed with science what he knew in his heart, that his friend was innocent and that the doctors were wrong.
  • Since that first case, Mark has vigorously defended innocent parents of false charges of child abuse, regained custody of children for innocent parents and has defended innocent parents of criminal charges. Mark is now pursuing civil rights lawsuits in cases where false accusations of child abuse resulted in the violation of parents' civil rights.
  • Mark is licensed to practice law in Pennsylvania and New Jersey and consults with local attorneys in other states. Email Mark at mark@markdfreemanlaw.com or call Mark at: 1-800-580-0084