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Shaken Baby Syndrome Shaken Baby Syndrome (SBS) is a term used to describe a constellation of injuries and the mechanism of abuse that causes these injuries. The major signs of SBS are subdural and/or subarachnoid hematomas(bleeding in the membranes that cover the brain), retinal hemorrhages (bleeding in the back of the inner surface of the eyes) and little or no sign of external injury. In some cases there are broken ribs and fractures of the skull. The broken ribs are caused by the manner in which the child is held around the rib cage during the shaking. The fractured skull is caused by the head striking an object during the shaking. The brain injury is caused by an individual who shakes a an infant, usually under the age of two years, severely back and forth. Infants who are less than two do not have fully developed neck muscles and so the head can be whiplashes back and forth. Because these young infants' brains do not yet fill the entire brain cavity or skull, the brain becomes bruised as it literally bounces back and forth and rotates inside the skull as the baby is shaken. The rapid acceleration, deceleration and rotation of the brain also tears the bridging veins that cover its surface, which accounts for hematomas, or bleeding in the brain. The combination of surface bruising and the hematomas ultimately lead to cerebral edema, or swelling of the brain. Not all infants die from SBS but if the swelling of the brain cannot be controlled, the brain tissue deteriorates when it runs out of space to swell within the skull. It is usually the cerebral edema or brain swelling that leads to death. If the child does not die, brain damage and mental retardation are common as a result of the edema. The original medical research article on SBS was written by Dr. John Caffey and was entitled "The Whiplash Shaken Infant Syndrome: Manual Shaking by the Extremities With Whiplash-Induced Intracranial and Intraocular Bleeding, Linked With Residual Permanent Brain Damage and Mental Retardation", Pediatrics Vol. 54 No 4 October 1974. Battle Of The Experts There rarely are witnesses to abusive shaking; therefore, the case is usually a matter of attempting to re-create what occurred by using medical descriptions and analyses of the injuries. The opinions of these professionals, however, can be contradictory because no one has sufficient scientific data in this area: it is not possible or ethical to create a controlled study that measures the effects of shaking on a real infant's brain. Unfortunately, opinions are sometimes based on personal biases when there is no scientific information available. Such is the case with many child advocacy experts. Accidental Injury Child advocacy experts claim that SBS injuries can never be caused by a fall. This is based on the idea that a short fall cannot create the necessary acceleration/ deceleration forces that bruise and tear brain tissue. But this is not always the case. Studies on artificial brains subjected to falls have shown that the acceleration/ deceleration forces are forty times greater when the head is suddenly stopped by an object than when the head is shaken in mid air. Government statistical reviews of children who have suffered short distance falls show skull fractures, sub-dural hematomas and sub-arachnoid hematomas. In addition, autopsies of automobile accident victims have described some of these same injuries. It is possible, then for the brain to be damaged by an accidental fall or sudden, accidental impact. For that reason, when a parent claims that an accident occurred, the defense attorney must place into evidence all research data showing that the injuries that the child sustained are consistent with the parent's version of the accident. One of the serious problems with SBS is that researchers have not actually seen a child being shaken and then done an autopsy to study and measure the injuries. Without scientific studies to guide child advocacy experts, SBS is open to exaggerated claims about how violent the shaking must be in order to cause the injuries in any given case. Descriptions of a child having to fall from a third story window or having to be slammed against a wall while swung by its feet have an enormous emotional effect on a jury. Moreover, such unsubstantiated and unscientific stories interfere with the jury's fair determination as to whether or not the injury was an accident, caused by another caretaker, and whether or not the defendant is guilty of manslaughter, second-degree murder or first-degree murder. Timing Of The Injuries The Shaken Baby Syndrome is one area of child abuse in which our office does not detect bias for accusing one gender over another. A mother or a female babysitter is just as likely to be charged with child physical abuse or murder as is a husband or male babysitter. The person that is charged is normally the individual who was caring for the child when the symptoms first became evident. Child advocacy experts believe that the SBS injuries are so severe that the symptoms of such trauma would be immediately apparent, making it impossible for anyone to claim that an injured child appeared normal when it came into his or her care. In other words, there is no time delay between inflicting the trauma and observing it. Nothing could be further from the truth. In the cases that our office has handled, prosecution witnesses on cross examination have attempted to claim that their research supports their theory that there is no time delay between injury and symptoms. When our researchers analyzed the studies that the child advocacy experts named, they did not find any evidence to support the non-time delay theory. In fact, the main study that we were directed to stated that there could be a delay between the time of the injury and the time of the symptoms due to the fact that it takes time for a two-year old's brain to swell and fill the cavity space. And still a number of child advocacy experts continue to make these unsubstantiated claims in published papers, despite the lack of any scientific evidence to support their opinions. Our researchers have found numerous studies that strongly support a delay between injury and symptom, and not minutes, but many hours. And if there can be a delay of numerous hours between the time of injury and the time of the symptoms, then it is also possible that several people could have been involved in caring for the child. Therefore, there are other people who should be investigated-not just the individual who was with the child at the time the symptoms first appeared-in order to determine how and when the child sustained such life- threatening physical trauma. The most important research supporting the delay of time between injury and symptoms follows: Delayed Deterioration Following Mild Head Injury in Children by J.W. Snoek, J.M. Minderhoud, and J.T. Wilmink, Department of Neurology and Neuroradiology, University Hospital, PO Box 30.01, 9700 RB Groningen, The Netherlands. published in Brain (1984) 107, 15-36 Early detection of delayed traumatic intra-cranial hematomas using near-infrared spectroscopy, by Shankar P. Gopinath, M.D. and others, University of Pennsylvania, Philadelphia, Pennsylvania, J. Neurosurg./ Vol. 83, September 1995 Head-Injury Patients who talk and deteriorate into coma Analysis of 211 cases studied with computerized tomography, by Ramiro D. Lobanto, MD, and others, Complutense University, Madrid, Spain, J. Neurosurg./ Volume 75/August 1991 Patients Who Talk and Deteriorate, by Gaylan L. Rockswold, MD and Paula J. Pheley, RN, Annals of Emergency Medicine 22:6 June 1993 The National Traumatic Coma Data Bank, Part 2: Patients who talk and deteriorate: Implications for treatment by Lawrence F. Marshall, M.D. and others, UC San Diego, San Diego Medical Center, San Diego, California, J. Neurosurg./ Volume 59/ August 1983 The Time Interval Between Lethal Infant Shaking and Onset of Symptoms, A Review of the Shaken Baby Syndrome Literature, by Marcus B. Nashelsky, M.D. and Jay D. Dix, M.D. , Am. Jur Forensic Med and Path, Vol 16, No. 2, 1995 Conclusions A Shaken Baby Syndrome case is extremely difficult to prepare and present to a jury. The cost for the necessary experts is staggering because most of the evidence relies on medical expert testimony and medical research papers. The most serious problems, however, are 1) insufficient research, and 2) the inaccessibility of supporting research. First of all, one simply cannot shake a baby in a lab with monitors on the baby to see what damage is done to the brain and body. And secondly, supporting studies are often difficult to find or sometimes written in other languages requiring translation. These two factors enable the child advocacy expert to substitute his or her own personal or political beliefs for fact. Even the educated public is not familiar with head trauma studies or the complexities of Shaken Baby Syndrome. Therefore, the role of the defense team is to teach the jury the difference between scientific research and the opinions of an advocate. Finally, the defense must educate the jury members on the actual state of knowledge with regard to brain trauma so they can determine the truth of the child's injuries-and the innocence or guilt of the defendant.
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