Shaken baby syndrome

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Shaken baby syndrome
ICD-9 995.55
MedlinePlus 000004

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]

Overview

Shaken baby syndrome (SBS) is a form of child abuse that is thought to occur when an abuser violently shakes an infant or small child, creating a whiplash-type motion that causes acceleration-deceleration injuries. The injury is estimated to affect between 1,200 and 1,600 children every year in the USA.[1] A remarkable feature of SBS is the typical lack of external evidence of trauma. The combination of shaking with striking of the infant against a hard object is sometimes termed the shaken impact syndrome.

The concept of SBS was initially described in the early 1970s, based on a theory and a wide variety of circumstances by Dr. John Caffey, a radiologist, as well as Dr. Norman Guthkelch, a neurosurgeon.[2][3]

SBS, a major cause of mortality in infants, is often fatal and can produce lifelong disability from neurological damage. Up to 50% of deaths related to child abuse are reportedly due to shaken baby syndrome.[4] About 25% to 30% of infant victims with SBS die from their injuries.[citation needed] Nonfatal consequences of SBS include varying degrees of visual impairment (e.g., blindness), motor impairment (e.g. cerebral palsy) and cognitive impairments.

Signs and symptoms

The signs associated with inflicted SBS include retinal hemorrhages, petechiae (small, pinpoint hemorrhages) on the body or face, multiple fractures of the long bones, and subdural hematomas.[5] These signs have evolved through the years as the accepted and recognized signs of child abuse and the shaken baby syndrome. Additional effects of SBS are diffuse axonal injury, oxygen deprivation and swelling of the brain, which can raise intracranial pressure and damage delicate brain tissue.

Most victims of SBS are under one year old. Victims of SBS may display irritability, failure to thrive, alterations in eating patterns, lethargy, vomiting, seizures, bulging or tense fontanels, increased size of the head, altered respirations, and dilated pupils.[6] Medical professionals strongly suspect shaking as the cause of injuries when a baby or small child presents with retinal hemorrhage, fractures, soft tissue injuries or subdural hematoma, that cannot be explained by accidental trauma or other medical conditions. No alternative condition mimics all of the symptoms of SBS exactly, but those that must be ruled out include hydrocephalus, sudden infant death syndrome (SIDS), seizure disorders, and infectious or congenital diseases like meningitis and metabolic disorders.[7]

Fractures of the vertebrae and ribs may also be associated with SBS. Although several bone disorders may also cause increased vulnerability to fractures, they can be distinguished from inflicted trauma by other characteristic alterations of the bones, by gene tests, and by the absence of corroborative evidence of abuse. The principal disorders known to cause increased susceptibility to fracture without other obvious evidence of bone abnormality are the various moderate-severity forms of osteogenesis imperfecta.[8] Although bone disease of prematurity, rickets due to vitamin D deficiency,[9] Scurvy (vitamin C deficiency),[10][11] copper deficiency and Menkes disease can increase fracture susceptibility, the bone disease is accompanied by additional evidence allowing it to be easily distinguished from abuse in nearly all cases.[12][13][14] In addition to Barlow's Disease[15][16][17] or scurvy,[18][19][20][21] a number of medical conditions,[22] including malformations,[23] premature infants,[24] can mimic SBS, even before birth.[25][26][26][27][28]

Examination by an experienced ophthalmologist is often critical in diagnosing shaken baby syndrome, as particular forms of ocular bleeding are quite characteristic of this condition.[29]

Some medical experts assert that "no case studies have ever been undertaken to probe even a partial list of possible confounding variables/phenomena, such as the presence of intracranial cysts or fluid collections, hydrocephalus, congenital and inherited diseases, infection, coagulation disorders and venous thrombosis, recent immunizations,"[30] medications, birth-related brain injuries,[31] "or recent or remote head trauma. Until and unless these and probably many more factors are evaluated, it is inappropriate to select one mechanism only and ignore the rest of the potential causes."[32]

In 2005, a review of several ophthalmology studies and their findings concerning "inflicted childhood neurotrauma" (SBS) was published in the UK, in the quarterly ophthalmology publication Focus.[33] One of the studies "found a correlation between intra-ocular bleeding, anterior optic nerve haemorrhage and subdural haematomas. Post mortem findings of vitreous traction at the apex of retinal folds and the edge of dome shaped haemorrhages and retinoschisis gives some supporting evidence that vitreous forces may cause this shearing damage. There is no adequate model to test this experimentally, so this remains hypothesis, not established fact."[34]

The main scientific finding of two additional studies[35][36] from the Focus article "was that in cases of retinal haemorrhages with thin film subdurals and in the absence of other injuries that the pathological finding is more commonly that of hypoxic ischaemic encephalopathy rather than diffuse axonal injury. Regardless of the recent debate the observational evidence to date remains that children with non accidental injury may have no visible retinal haemorrhages, whilst non accidental injury and birth are the only circumstances in which multiple retinal haemorrhages in differing layers of the retina have been accurately documented."[33]

The following references documented cases of retinal hemorrhages from accidental head trauma[37] a videotaped minor fall,[38] osteogenesis imperfecta[39] indicating that shaking is not the only possible cause of injury. According to one author, "the presence of retinal hemorrhages is neither necessary nor sufficient for the diagnosis of child abuse."[40] A postvaccinial ocular syndrome was reported as early as 1948,[41] recent papers have been published concerning the occlusion of central retinal vein after hepatitis B vaccination,[42] "The compounding effects of anoxia or hypoxia, anemia, thrombocytopenia, mild coagulopathy, obstruction of retinal venous flow, or possible age-related anatomic variations in the retinal vasculature are not well understood."[43]

Anatomy and pathophysiology

People under the age of three years are especially susceptible to brain damage from shaking.[43] This is due to several anatomical factors. Their heads are bigger and weigh more with respect to their bodies than adults' heads, and their neck muscles are weak and cannot prevent violent motions.[44] Infants' brains are not myelinated; myelin sheaths form in childhood and are complete in adolescence. The brain water content is reduced as neurons gain myelin during development, so babies have a greater percentage of brain water than adults do.[45] Because of this higher water content, children's brains are softer and are much more susceptible to acceleration-deceleration injuries and diffuse axonal injury.[45]

Rotation injury is especially damaging and likely to occur in shaking trauma.[7] The type of injuries caused by shaking injury are usually not caused by falls and impacts from normal play, which are mostly linear forces.[7]

Rotation injury is also referred to as diffuse axonal injury (DAI). A report in 2001, reviewed the brains of 37 infants aged 9 months or less, all of whom died from inflicted head injuries, and 14 control infants who died of other causes. Axonal damage was identified using immunohistochemistry for ß-amyloid precursor protein. The observation that the predominant histological abnormality in cases of inflicted head injury in the very young is diffuse hypoxic brain damage, not DAI, can be explained in one of two ways: either the unmyelinated axon of the immature cerebral hemispheres is relatively resistant to traumatic damage, or in shaking-type injuries the brain is not exposed to the forces necessary to produce DAI.[36] Apparently a critical point was missed or overlooked in a paper published in 1968[46] concerning the results of bioengineering study in conjunction with the U.S. Department of Transportation. This experiment showed, qualitatively, that rotation alone could indeed produce intracranial injury, though it was not shown quantitatively that human beings could generate the required rotational acceleration by manual shaking. This critical omission was not addressed until 19 years later, when it was shown quantitatively that impact was required to generate adequate force. Guthkelch, Caffey, and others either were not aware of, or disregarded, this critical missing piece of information. In the intervening years, and even up to the present, numerous references are made to infants sustaining inflicted brain injury by manual shaking. Yet no laboratory proof of this possibility has ever been put forth. In fact, the available experimental evidence began as far back as 1943, addressed directly in 1987[47] and reproduced in 2003,[48] seems to indicate the contrary.[49][50][51]

"The assessment of the mechanical causation of injury requires training and experience in Injury Biomechanics, a distinct discipline not taught in medical school. Lack of education and experience in Injury Biomechanics, amongst other factors, has led in practice to the proliferation and propagation of inaccurate and sometimes erroneous information on SBS injury mechanisms in the literature." A recent biomechanical experiment in 2005, demonstrated that "forceful shaking can severely injure or kill an infant, this is because the cervical spine would be severely injured and not because subdural hematomas would be caused by high head rotational accelerations. Furthermore, shaking cervical spine injury can occur at much lower levels of head velocity and acceleration than those reported for the SBS. These findings are consistent with the physical laws of injury biomechanics as well as our collective understanding of the fragile infant cervical spine from (1) clinical obstetric experience, (2) automotive medicine and crash safety experience, and (3) common parental experience. We have determined that an infant head subjected to the levels of rotational velocity and acceleration called for in the SBS literature, would experience forces on the infant neck far exceeding the limits for structural failure of the cervical spine. Furthermore, shaking cervical spine injury can occur at much lower levels of head velocity and acceleration than those reported for the SBS.[52]

In 2004, a Scottish database collected data for five years on cases of suspected non-accidental head injury diagnosed after a multiagency assessment and included cases with uncoerced confessions of perpetrators and criminal convictions. Several patterns appeared allowing the categorization of the cases into four predominant types: Hyperacute encephalopathy (6% of all cases); Acute encephalopathy (53% of cases (SBS)); Subacute non-encephalopathic presentation (19% of cases); Chronic extracerebral presentation (22% of cases). Infants can be traumatically injured in many ways, and many instances are unwitnessed. Thus the generic term non-accidental head injury or inflicted traumatic brain injury is occasionally used in preference to shaken baby syndrome, which implies a specific mechanism of injury.[53] An earlier detailed neuropathological study was publish in the UK in 2001, which included immunocytochemistry for microscopic damage.[35]

Prognosis

SBS kills about one third of its victims and permanently and severely disables another third.[7] Problems resulting from SBS include learning disabilities, seizure disorders, speech disability, hydrocephalus, behavioral problems, cerebral palsy, and visual disorders.[7]

Prevention

Prevention is similar to the prevention of child abuse in general. New parents, babysitters, and other caregivers should be warned about the dangers of shaking infants. Crying is a common trigger for creating irritation and frustration in the caregiver. Some experts have advised that caregivers need strategies to cope with their own frustrations; for example, they should be reminded that they are not always responsible when babies cry.

SBS as a medicolegal concept

The legal import of shaken baby syndrome varies according to circumstances, often involving child welfare and criminal investigations. Such investigations determine whether children are judged safe to remain in their parents / caregivers' care, and whether an individual may be charged with assault, child endangerment, or homicide.

Since the inception of "whiplash shaking" evolving into SBS, the concept has been the subject of criticism by some scientists and jurists for years.

In April 2006, a Daubert hearing (a mini-trial within a trial, conducted before the judge only, not the jury, over the validity and admissibility of expert opinion testimony) was conducted concerning the admissibility of proposed medical and scientific evidence in a Kentucky Circuit Court case.[51] A Grand Jury had indicted the defendant of first-degree criminal abuse by violently shaking a child. The Defendant alleges that the child's medical records indicate that the only significant injury for the victim was a subdural hematoma and retinal hemorrhaging and there was no significant bruising, fractures, or evidence of impact. The Commonwealth's case was based upon the theory of shaken baby syndrome.

The Court after hearing expert testimony and reviewing the evidence, issued the following conclusion and opinion: "The Court can further conclude that based on the medical signs and symptoms, the clinical medical and scientific research communities are in disagreement as to whether it is possible to determine if a given head injury is due to an accident or abuse. Therefore, the Court finds that because the Daubert test has not been met, neither party can call a witness to give an expert opinion as to whether a child's head injury is due to a shaken baby syndrome when only the child exhibits a subdural hematoma and bilateral ocular bleeding. Either party can call a witness to give an expert opinion as to the cause of the injury being due to shaken baby syndrome, if and only, the child exhibits a subdural hematoma and bilateral ocular bleeding, and any other indicia of abuse present such as long-bone injuries, a fractured skull, bruising, or other indications that abuse has occurred."

The trial court's ruling is not considered binding legal precedent. The Commonwealth of Kentucky has appealed the ruling to the state's intermediate appellate court..[54]

In the Summer of 2006 a review of the Shaken Baby Syndrome and the Shaken Impact Syndrome was published in the Military Law Review. This legal review contains an extensive examination of the divergent views of the scientific literature, in addition to examining the divergent views of the legal parameters involving a trial. [55]

In July of 2005, the Court of Appeals in the United Kingdom reversed or reduced three convictions of SBS, finding that the classic triad of retinal hemorrhage, subdural hematoma, and acute encephalopathy are not 100% diagnostic of SBS and that clinical history is also important.[56] In their ruling, they upheld the clinical concept of SBS but dismissed two cases and reduced the sentence on a third based on their individual merits. In their words: "Whilst a strong pointer to NAHI [non-accidental head injury] on its own we do not think it possible to find that it must automatically and necessarily lead to a diagnosis of NAHI. All the circumstances, including the clinical picture, must be taken into account." The term "non-accidental trauma'" was suggested instead of "SBS" in the March 27, 2004 edition of the British Medical Journal[53]

Alternative hypotheses

An additional, alternative explanation for some incidents contemplated as shaken baby syndrome has been proposed. This explanation suggests that a vitamin C deficiency may sometimes play a role in the pathogenesis of shaken baby syndrome,[57][11][58][59][60] citing that the current SBS pathology determination may be seriously flawed or incomplete[44][61][62] This contested hypothesis is based upon a speculated marginal, near scorbutic condition or lack of essential nutrient(s) repletion and a potential elevated histamine level.[17][5][63][64][65][66][67]

The proponents of such hypotheses often question the adequacy of nutrient tissue levels, especially vitamin C,[68][69][70] for those children currently or recently ill, bacterial infections, those with higher individual requirements, those suffering from environmental challenges (e.g. allergies), and perhaps transient vaccination related stresses.[71] However, no cases of scurvy mimicking SBS or crib death have been reported, and scurvy typically occurs later in infancy, rarely causes death or intracranial bleeding, and is accompanied by other changes of the bones and skin and invariably an unusually deficient dietary history.

A number of medical personnel recommend that all SBS pathology determinations should include vitamin C repletion history and histamine/vitamin C levels. Additional medical recommendations for the use of vitamins and nutrients as a preventive measure, particularly vitamin C, should be used especially for children with known, projected or suspected stresses/conditions (vaccines) that may deplete certain nutrients.[72][73][74]

Although a Barlow’s disease variant (infantile scurvy) may be the most common disease, other diagnoses such as fragile bone disease, hemorrhagic disease of the newborn (vitamin K deficiency) and glutaric aciduria type 1 must also be considered. Gestational problems affecting both mother and fetus, the birthing process, prematurity and nutritional deficits can accelerate skeletal and hemorrhagic pathologies that can also mimic SBS, even before birth.[57][25][26][26][27] These views are not widely known, utilized or explored in conventional medicine. Nevertheless, favorable court rulings[51] and evidentiary commentary on flawed SBS determinations have been demonstrated by biomechanical studies over the years.[50][47][48][49][75][52][76]

In addition, it has been suggested that severe adverse reactions to vaccinations may be an alternative cause of SBS. [77][78]

See also

  • Louise Woodward - was famously convicted of killing Matthew Eappen in 1997 by shaking baby syndrome.
  • Alan Yurko - sentenced to life in prison + 10 years (1998) without parole for the murder of his son, supposedly due to shaking baby syndrome. "Bad Science" from the "Orlando Weekly" (2003) [3]. Case was vacated on second appeal and Alan Yurko was subsequently released from prison on August 27, 2004 [4]. Information on Case of Alan Yurko - Shaken Baby Syndrome [5]
  • C. Alan B. Clemetson
  • Child abuse

Footnotes

  1. ↑ National Center for Injury Prevention and Control (7th September 2006). "Child Maltreatment: Fact Sheet". Centers for Disease Control and Prevention (CDC). Check date values in: |date= (help)
  2. ↑ Caffey J (1972). "On the theory and practice of shaking infants. Its potential residual effects of permanent brain damage and mental retardation". Amer J Dis Child. 124: 161–169. - in Archives of Pediatrics & Adolescent Medicine
  3. ↑ David TJ (1999). "Shaken baby (shaken impact) syndrome: non-accidental head injury in infancy" (PDF). J R Soc Med. 92 (11): 556–61. PMID 10703491.
  4. ↑ Montelenone JA, Brodeur AE. (1994). Child maltreatment, a clinical guide and reference. GW Medical Publishing. St Louis.
  5. ↑ 5.0 5.1 Clemetson CAB (2006). "Caffey Revisited: A Commentary on the Origin of "Shaken Baby Syndrome."" (PDF). J Am Phys Surg. 11 (1): 20–1. Unknown parameter |month= ignored (help)
  6. ↑ Types of brain injury: Shaken baby syndrome. Brain Injury Association of America. Retrieved on September 24, 2007.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Oral R (August 2003). "Intentional head yrauma in infants: Shaken baby syndrome" (Archived). Virtual Children's Hospital.
  8. ↑ "Fast Facts on Osteogenesis Imperfecta". Osteogenesis Imperfecta Foundation. August 2005.
  9. ↑ Chudgar P. "Radiology In Rickets". Pediatric Oncall - Child Health Care.
  10. ↑ Chudgar P. "Radiology In Scurvy". Pediatric Oncall - Child Health Care.
  11. ↑ 11.0 11.1 Scheibner V (2001). ""Shaken Baby Syndrome Diagnosis on Shaky Ground."" (PDF). “Journal of the Australasian College of Nutritional and Environmental Medicine”. 20 (2): 5–8, 15. Unknown parameter |month= ignored (help)
  12. ↑ Paterson C, Burns J, McAllion S (1993). "Osteogenesis imperfecta: the distinction from child abuse and the recognition of a variant form". Am J Med Genet. 45 (2): 187–92. PMID 8456801. Unknown parameter |month= ignored (help)
  13. ↑ Paterson C (June 5, 2004). "Bone diseases that lead to false allegations of non-accidental injury". NCHR's Symposium "Corruption and miscarriages of justice in child care cases" in Gothenburg, Sweden.
  14. ↑ Paterson C (2003). "Radiological features of the brittle bone diseases" (Abstract). Journal of Diagnostic Radiography and Imaging. 5: 39–45. doi:10.1017/S1460472803000075.
  15. ↑ "Möller-Barlow Disease". Who Named It.
  16. ↑ ""Medical History - Infantile scurvy: the centenary of Barlow's disease"" (PDF). British Medical Journal. 287. December 17, 1983.
  17. ↑ 17.0 17.1 Clemetson CAB (2004). "Was it "shaken baby" or a variant of Barlow's disease?" (PDF). J Am Phys Surg". 9: 78–80.
  18. ↑ Hess, A. (1920). Scurvy Past and Present. J.P. Lippincott Company. Philadelphia and London. 1920.
  19. ↑ Rothschild B, Sebes J. "Scurvy". eMedicine.com.
  20. ↑ Suman R, Dabi D (1998). "Scurvy-An Unusual Cause of Proptosis?". Indian Pediatrics. 35: 915–6.
  21. ↑ Sloan B, Kulwin D, Kersten R (1999). ""Scurvy causing bilateral orbital hemorrhage."" (Abstract). Arch Ophthalmol. 117 (6): 842–3. PMID 10369606. Unknown parameter |month= ignored (help)
  22. ↑ Rutty GN, Smith CM, Malia RG (199). "Late-form hemorrhagic disease of the newborn: a fatal case report with illustration of investigations that may assist in avoiding the mistaken diagnosis of child abuse". Forensic med Pathol. 20 (1): 48–51. PMID 10208337. Unknown parameter |month= ignored (help)
  23. ↑ Beraud C, Sobotska F, Cret E. (1975). "Osseous scurvy in an 11-month-old infant. Radiological course". J Radiol Electrol Med Nuc. 56 (6–7): 527–30. PMID 1177197. Unknown parameter |month= ignored (help)
  24. ↑ Fledelius HC (2005). "Retinal haemorrhages in premature infants: a pathogenetic alternative diagnosis to child abuse". Acta Ophthalmologica Scandinavica. 83 (4): 424–427. Unknown parameter |month= ignored (help)
  25. ↑ 25.0 25.1 Cushing H (2000). "Reprint of "Concerning Surgical Intervention for the Intracranial Hemorrhages of the New-born" (1905)". Child's Nervous System. 16 (Classics in Pediatric Neurosurgery): 484–492. PMID 11007498.
  26. ↑ 26.0 26.1 26.2 26.3 Williams Obstetrics (1997). "Chapter 20". Diseases and Injuries of the Fetus and Newborn. 20. Appleton & Lange, Stamford, CT. pp. page 997-998. ISBN 0-8365-9638-X.
  27. ↑ 27.0 27.1 Looney CB, et.al (2007). "Intracranial Hemorrhage in Asymptomatic Neonates: Prevalence on MR Images and Relationship to Obstetric and Neonatal Risk Factors". Radiology. 242: 535–541. PMID 17179400.
  28. ↑ Position Statement: Fetus and Newborn Committee, Canadian Paediatric Society (CPS) (2001). ""Routine screening cranial ultrasound examinations for the prediction of long term neurodevelopmental outcomes in preterm infants."". Paediatrics & Child Health". 6 ((1)): 39–43.
  29. ↑ "Shaken Baby Syndrome Resources". American Academy of Ophthalmology.
  30. ↑ Devin F, Roques G, Rodor P and Weiller PJ. (1996). ""Occlusion of central retinal vein after hepatitis B vaccination."". “Lancet”. 347 (9015): 1626. PMID 8667894. Unknown parameter |month= ignored (help)
  31. ↑ Schoenfeld MD, Buckman G, Nissenkorn MD, Cohen S, Ben-Sira I, Ovadia J. (1985). ""Retinal Hemorrhages on the Newborn Following Labor Induced by Oxytocin or Dinoprostone."". Arch Opthalmol. 103 (7): 932–4. PMID 3860196. Unknown parameter |month= ignored (help)
  32. ↑ Leestma J (2006). ""Shaken Baby Syndrome": Do Confessions by Alleged Perpetrators Validate the Concept?" (PDF). J Am Phys Surg. 11: 14–6.
  33. ↑ 33.0 33.1 Newman W (2005). "Inflicted Childhood Neurotrauma - Non Member Update Contribution" (PDF). "Focus" - Occasional Update From The Royal College of Ophthalmologists. 80 (33). Unknown parameter |month= ignored (help)
  34. ↑ Green MA, Lieberman G, Milroy CM, Parsons MA (1996). "Ocular and cerebral trauma in non-accidental injury in infancy: underlying mechanisms and implications for paediatric practice". Br J Ophthalmol. 80 (4): 282–7. PMID 8703874. Unknown parameter |month= ignored (help)
  35. ↑ 35.0 35.1 Geddes J, Hackshaw A, Vowles G, Nickols C, Whitwell H (2001). "Neuropathology of inflicted head injury in children. I. Patterns of brain damage". Brain. 124 (Pt 7): 1290–8. PMID 11408324. Unknown parameter |month= ignored (help)
  36. ↑ 36.0 36.1 Geddes J, Vowles G, Hackshaw A, Nickols C, Scott I, Whitwell H (2001). "Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants". Brain. 124 (Pt 7): 1299–306. PMID 11408325. Unknown parameter |month= ignored (help)
  37. ↑ Lantz P E, Sinal S H, Stanton C A and Weaver, Jr R G (2004). "Perimacular retinal folds from childhood head trauma". BMJ. 328 (7442): 754–6. PMID 15044292. Unknown parameter |month= ignored (help)
  38. ↑ Goldsmith W, Plunkett J (2004). "Review: A biomechanical analysis of the causes of traumatic brain injury in infants and children". Am J Forensic Med Pathol. 25 (2): 89–100. PMID 15166757. Unknown parameter |month= ignored (help)
  39. ↑ Ganesh A, Jenny C, Geyer J, Shouldice M, Levin AV. (2004). "Retinal hemorrhages in type I osteogenesis imperfecta after minor trauma". Ophthalmology. 111 (7): 1428–31. PMID 15234150. Unknown parameter |month= ignored (help)
  40. ↑ Aryan1 HE, Ghosheh FR, Rahul Jandial R, Levy1ML (2005). "Retinal hemorrhage and pediatric brain injury: etiology and review of the literature". J Clin Neurosci. 12 (6): 624–31. PMID 16115547. Unknown parameter |month= ignored (help)
  41. ↑ Rosen E (1948). "A postvaccinial ocular syndrome". Am J Ophthalmol. 31: 1443–53.
  42. ↑ Devin F, Roques G, Disdier P, Rodor F, Weiller PJ. (1996). "Occlusion of central retinal vein after hepatitis B vaccination syndrome". Lancet. 347: 1626. PMID 8667894. Unknown parameter |month= ignored (help)
  43. ↑ 43.0 43.1 Forbes BJ, Christian CW, Judkins AR, Kryston K. (2004). "Inflicted childhood neurotrauma (shaken baby syndrome): ophthalmic findings". J Pediatr Ophthalmol Strabismus. 41 (2): 80–8. PMID 15089062. Unknown parameter |month= ignored (help)
  44. ↑ 44.0 44.1 Patel N and Moorjani B (2007). ""Neonatal injuries in child abuse."". eMedicine.com.
  45. ↑ 45.0 45.1 Singh J and Stock A. 2006. Head Trauma. Emedicine.com. Retrieved on September 23, 2007.
  46. ↑ Ommaya AK, Faas F, Yarnell P (1968). "Whiplash injury and brain damage: an experimental study". JAMA. 22 (204(4)): 285–9. PMID 4967499.
  47. ↑ 47.0 47.1 Duhaime A, Gennarelli T, Thibault L, Bruce D, Margulies S, Wiser R (1987). "The shaken baby syndrome. A clinical, pathological, and biomechanical study". J Neurosurg. 66 (3): 409–15. PMID 3819836.
  48. ↑ 48.0 48.1 Prange M, Coats B, Duhaime A, Margulies S (2003). "Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants". J Neurosurg. 99 (1): 143–50. PMID 12854757. Unknown parameter |month= ignored (help)
  49. ↑ 49.0 49.1 Uscinski R (2004). "The Shaken Baby Syndrome" (PDF). J Am Phys Surg. 9 (3): 76–7. Unknown parameter |month= ignored (help)
  50. ↑ 50.0 50.1 Ommaya A, Goldsmith W, Thibault L (2002). "Biomechanics and neuropathology of adult and paediatric head injury". Br J Neurosurg. 16 (3): 220–42. PMID 12201393. Unknown parameter |month= ignored (help)
  51. ↑ 51.0 51.1 51.2 Commonwealth Of Kentucky VS. Christopher A. Davis. "Case No.04-CR 205" (PDF). Greenup Circuit Court.
  52. ↑ 52.0 52.1 Bandak F (2005). "Shaken baby syndrome: a biomechanics analysis of injury mechanisms". Forensic Sci Int. 151 (1): 71–9. PMID 15885948. Unknown parameter |month= ignored (help)
  53. ↑ 53.0 53.1 Minns R, Busuttil A (2004). "Patterns of presentation of the shaken baby syndrome: four types of inflicted brain injury predominate". BMJ. 328 (7442): 766. PMID 15044297. Unknown parameter |month= ignored (help)
  54. ↑ Commonwealth v. Christopher A. Davis, Kentucky Court of Appeals, 2006-CA-002237 [1]
  55. ↑ Lt. Colonel MD Ramsey (2006). ""A Nuts And Bolts Approach To Litigating The Shaken Baby Or Shaken Impact Syndrome."" (PDF). Military Law Review - US Department of Army Pamphlet. 27-100-188: 1–37. ISSN 0026-4040. Unknown parameter |month= ignored (help)
  56. ↑ "Shaken baby convictions overturned". Special Reports. Guardian Unlimited. Thursday July 21, 2005. Check date values in: |date= (help)
  57. ↑ 57.0 57.1 Clemetson CAB (2004). "Capillary Fragility as a Cause of Substantial Hemorrhage in Infants."" (PDF). Medical Hypotheses And Research. 1 (2/3): 121–129. Unknown parameter |month= ignored (help)
  58. ↑ Hess, A. (1920). Scurvy Past and Present. J.P. Lippincott Company. Philadelphia and London. 1920.
  59. ↑ ""Medical History - Infantile scurvy: the centenary of Barlow's disease"" (PDF). British Medical Journal. 287. December 17, 1983.
  60. ↑ Rajakumar K (2001). ""Infantile Scurvy: A Historical Perspective"" (PDF). Pediatrics. 108: 76.
  61. ↑ Ricci LR and Botash AS. ""Pediatrics, Child Abuse."". eMedicine.com.
  62. ↑ Fung ELW, Sung RYT, Nelson EAS, Poon WS (2002). "Unexplained subdural. hematoma in young children: is it always child abuse?". "Pediatr. Int.". 44 (1): 37–42. Text " doi:10.1046/j.1442-200X.2002.01500.x" ignored (help); Unknown parameter |month= ignored (help)
  63. ↑ Johnston, C.S. (1996). "Chapter 10) The Antihistamine Action of Ascorbic Acid". Ascorbic Acid; Biochemistry and Biomedical Cell Biology. 25. Plenum Press. pp. page 189. ISBN 978-0-306-45148-5.
  64. ↑ Johnston C S, Martin L J, and Cai X (1992). "Antihistamine effect of supplemental ascorbic acid and neutrophil chemotaxis". J Am Coll Nutr. 11 (2): 172–6. PMID 1578094. Unknown parameter |month= ignored (help)
  65. ↑ Majno G, Palade GE (1961). "I. The effect histamine and serotonin on vascular permeability. An electron microscopic study" (PDF). J Biophys Biochem Cytol. 11 (3): 571–605. PMID 14468625. Unknown parameter |month= ignored (help)
  66. ↑ Majno G, Palade GE, Schoefl GI. (1961). "II. The site of action of histamine and serotonin along the vascular tree: a topographic study" (PDF). J Biophys Biochem Cytol. 11 (3): 607–626. PMID 14468625. Unknown parameter |month= ignored (help)
  67. ↑ Gore I, Fujinami T, Shirahama T. (1965). "Endothelial changes produced by ascorbic acid deficiency in guinea pigs". Arch Pathol. 80 (2): 371–376. PMID 5319838. Unknown parameter |month= ignored (help)
  68. ↑ Dettman G (1978). "Factor "X", sub-clinical scurvy and S.I.D.S. Historical. Part 1". Australas Nurses J. 7 (7): 2–5. PMID 418769. Unknown parameter |month= ignored (help)
  69. ↑ Kalokerinos A (1978). "The sudden infant death syndrome. Part 2. Definition. Further clinical observations". Australas Nurses J. 7 (7): 6–8. PMID 418769. Unknown parameter |month= ignored (help)
  70. ↑ Kalokerinos A, Dettman A (1976). "The sudden infant death syndrome in Western Australia". Med J Aust. 2 (1): 31–32. PMID 979792. Unknown parameter |month= ignored (help)
  71. ↑ Institute of Medicine (IOM) (1991). "Chapter 6) Evidence Concerning Pertussis Vaccines and Other Illnesses and Conditions -- Protracted Inconsolable Crying and Screaming". Adverse Effects of Pertussis and Rubella Vaccines. The National Academies Press. pp. page 165. ISBN 0-309-04499-5.
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  73. ↑ Lendon H. Smith, MD and Joseph Hattersley (August 30, 2000). The Infant Survival Guide: Protecting Your Baby from the Dangers of Crib Death, Vaccines and Other Environmental Hazards. Smart Publications; 1st edition. ISBN-10: 1890572128 - ISBN-13: 978-1890572129.
  74. ↑ Lendon H. Smith, MD (January 25, 1998). How to Raise a Healthy Child. M. Evans and Company, Inc. ISBN-10:0871318229 - ISBN-13:978-0871318220.
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  76. ↑ Bandak F (10 February 2006). "Response to the Letter to the Editor". Forensic Sci Int. 157 (1). doi:10.1016/j.forsciint.2006.01.001. which refers to
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  77. ↑ Buttram HE (2001). "Shaken Baby Syndrome or Vaccine-Induced Encephalitis?". Medical Sentinel. 6 (3): 83–89. Unknown parameter |month= ignored (help)
  78. ↑ Goodwin J (2000). "Was It Murder Or A Bad Vaccine?". Redbook. 6: 158–175. Unknown parameter |month= ignored (help)

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