Shaken baby syndrome

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Shaken baby syndrome
Classifications and external resources
ICD-9 995.55
MedlinePlus 000004
eMedicine topic list

Shaken baby syndrome (SBS) is a form of child abuse affecting between 1,200 and 1,600 children every year in the USA.[1] SBS encompasses a variety of outcomes that are attributed to shaking an infant or small child. The concept of SBS was initially described in the early 1970's, based on a theory and a wide variety of circumstances by Dr. Caffey, a radiologist. [2][3]

SBS is thought to occur when an abuser violently shakes an infant, creating a whiplash-type motion that causes acceleration-deceleration injuries. SBS is a specific type of non-accidental trauma (physical child abuse). 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.

SBS, a major cause of mortality in infants, is often fatal and can produce lifelong disability from neurological damage. About 25% to 30% of infant victims with SBS die from their injuries. Nonfatal consequences of SBS include varying degrees of visual impairment (e.g., blindness), motor impairment (e.g. cerebral palsy) and cognitive impairments. Direct costs of child maltreatment (judicial, law enforcement, and health system responses to the maltreatment) are estimated at $24 billion each year while indirect costs (long-term economic consequences of child maltreatment) exceed an estimated $69 billion annually in the USA (2001).[1]

Contents

[edit] 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. [4] 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 1 year old. SBS infants 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 (BIAUSA). Medical professionals strongly suspect shaking as the cause of injuries when a baby or small child presents with retinal hemorrhage, fractures or soft tissue injuries, 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. [5]

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,[6]. Although bone disease of prematurity, rickets due to vitamin D deficiency,[7] Scurvy (vitamin C deficiency),[8][9] 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.[10][11][12] In addition to Barlow's Disease[13][14][15] or scurvy,[16][17][18][19] a number of medical conditions, [20] including malformations[21] can mimic SBS, even before birth.[22] 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,[23] medications, birth-related brain injuries,[24] 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." [25]

Examination by a experienced ophthalmologist is often critical in diagnosing shaken baby syndrome, as particular forms of ocular bleeding are quite characteristic of this condition. “Most eye injuries in childhood are by other children or by accident, however a significant portion of eye injuries in childhood result from physical abuse by adults. Approximately 4 to 6 percent of abused children have ocular findings from apparent abuse. The most common ocular manifestation of shaking injury, present in a large majority of cases, is retinal hemorrhage. Retinal hemorrhages occur in approximately 80 percent of cases and may be more common and severe in children who present with more severe neurologic injury, although this is not necessarily the case. Retinal hemorrhages vary from none to extensive, often extending to the very edge of the retina (the ora serrata) and may be dramatically asymmetric or unilateral. Intracranial injury in shaken infants almost always includes subdural hematoma, typically bilateral over the cerebral convexities or in the interhemispheric fissure. Evidence of subarachnoid bleeding is also often apparent. In many cases, cerebral parenchymal damage is manifest on neuroimaging, acutely as edema, ischemia, or contusion and in later stages as atrophy. In addition, retinal and vitreous hemorrhages and nonhemorrhagic changes, including retinal folds and traumatic retinoschisis, are characteristic of SBS.” [26]

In 2005, an independent review of prominent ophthalmology studies and their findings concerning "Inflicted Childhood Neurotrauma" (SBS) was published in the UK, in the quarterly ophthalmology publication "Focus".[27] 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.” [28]

The main scientific finding of two additional studies [29][30] 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.” [27]

The following references documented cases of retinal hemorrhages from accidental head trauma [31] a videotaped minor fall, [32] osteogenesis imperfecta [33] indicating that shaking may not be the only cause of injury, Noting, “the presence of retinal hemorrhages is neither necessary nor sufficient for the diagnosis of child abuse.” [34] “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.” [35]

[edit] Anatomy and pathophysiology

Several anatomical factors make infants susceptible to brain damage. 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 (Patel and Moorjani, 2005). Infants' brains are not myelinated; myelin sheaths form in childhood and are complete in adolescence. The cerebrospinal fluid (CSF), or brain water, content is reduced as neurons gain myelin during development, so babies have a greater percentage of CSF than adults (Stock and Singer, 2004). Because of this higher water content, children's brains are softer and are much more susceptible to acceleration-deceleration injuries and diffuse axonal injury, including the axons of the respiratory control center (Stock and Singer, 2004). Infants also have a larger subarachnoid space than young adults, and so the veins traversing the space are in greater danger of being torn during violent movement of the head, causing subdural hematoma (Patel and Moorjani, 2005).

Rotation injury is especially damaging and likely to occur in shaking trauma. [5] The type of injuries caused by shaking injury are usually not caused by falls and impacts from normal play, which are mostly linear forces. [5]

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." [30] "Apparently a critical point was missed or overlooked in a paper published in 1968 [36] "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" [37] "and reproduced in 2003," [38] "seems to indicate the contrary." [39][40][41]

"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."[42]

The following is part of a letter to the editors in 2006, reponding to criticism of the reported velocity values as being too high, in the previously mentioned biomechanical experiment in 2005. "Since SBS is referred to in the literature as causing "acceleration/deceleration" brain injury, my approach was to directly analyze these accelerations applied for the time course of shaking. I chose a range that includes the highest values of accelerations reported because had I chosen lower values, the analysis would simply exclude the cornerstone mechanism of SBS and therefore, would be rendered moot. In other words, lower values would not be sufficient to activate the customary mechanism of rupturing bridging veins that SBS solely depends on for producing SDH. This of course, is the mechanism garnered for SBS from experiments where the head of a primate was potted in a metal cylinder constrained for acceleration/deceleration along a prescribed arc in a prescribed time frame."[43]

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); 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. [44] An earlier detailed neuropathological study was publish in the UK in 2001, which included immunocytochemistry for microscopic damage. [29]

[edit] Prognosis

SBS kills about one third of its victims and permanently and severely disables another third.[5] Problems resulting from SBS include learning disabilities, seizure disorders, speech disability, hydrocephalus, cerebral palsy, and visual disorders.[5]

[edit] 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.

[edit] SBS as a medical/legal concept

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. [45] 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."

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. [46] 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[47]


[edit] Nutriture hypothesis

It has been suggested that vitamin C deficiency (scurvy) may account for some of the prosecuted cases of SBS or infant death because it can cause increased fragility of bones and skin. 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.

[edit] 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 by shaking baby syndrome."Bad Science" from the "Orlando Weekly" (2003) [1]- Vacated on second appeal 2004. Information on Case of Alan Yurko - Shaken Baby Syndrome [2]

[edit] Footnotes

  1. ^ a b National Center for Injury Prevention and Control (7th September 2006). Child Maltreatment: Fact Sheet. Centers for Disease Control and Prevention (CDC). Retrieved on 2006-10-09.
  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. ^ Clemetson CAB (Spring 2006). "Caffey Revisited: A Commentary on the Origin of "Shaken Baby Syndrome."" (PDF). J Am Phys Surg 11 (1): 20-1.
  5. ^ a b c d e Oral R (August 2003). Intentional Head Trauma In Infants: Shaken Baby Syndrome (Archived). Virtual Children's Hospital. Retrieved on 2006-10-09.
  6. ^ Fast Facts on Osteogenesis Imperfecta. Osteogenesis Imperfecta Foundation (August 2005). Retrieved on 2006-10-12.
  7. ^ Chudgar P (2001-01-13). Radiology In Rickets. Pediatric Oncall - Child Health Care.
  8. ^ Chudgar P (2001-01-13). Radiology In Scurvy. Pediatric Oncall - Child Health Care.
  9. ^ Scheibner V (Aug 2001). ""Shaken Baby Syndrome Diagnosis on Shaky Ground."". “Journal of the Australasian College of Nutritional and Environmental Medicine” 20 (2): 5-8,15.
  10. ^ Paterson C, Burns J, McAllion S (Jan 15 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.
  11. ^ 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.
  12. ^ Paterson C (2003). "Radiological features of the brittle bone diseases" (Abstract). Journal of Diagnostic Radiography and Imaging 5: 39-45. DOI:10.1017/S1460472803000075.
  13. ^ Möller-Barlow Disease. Who Named It.
  14. ^ (December 17, 1983) "“Medical History - Infantile scurvy: the centenary of Barlow's disease”" (PDF). British Medical Journal 287.
  15. ^ Clemetson CAB (2004). "Was it "shaken baby" or a variant of Barlow's disease?" (PDF). J Am Phys Surg" 9: 78-80.
  16. ^ Hess, A. (1920). Scurvy Past and Present.. J.P. Lippincott Company. Philadelphia and London. 1920.
  17. ^ Rothschild B, Sebes J. Scurvey. eMedicine.com.
  18. ^ Suman R, Dabi D (1998). "Scurvy-An Unusual Cause of Proptosis?". Indian Pediatrics 35: 915-6.
  19. ^ Sloan B, Kulwin D, Kersten R (Jun 1999). ""Scurvy causing bilateral orbital hemorrhage."" (Abstract). Arch Ophthalmol 117 (6): 842-3. PMID 10369606.
  20. ^ Rutty GN, Smith CM, Malia RG (Mar 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.
  21. ^ Beraud C, Sobotska F, Cret E. (Jun-Jul 1975). "Osseous scurvy in an 11-month-old infant. Radiological course.". J Radiol Electrol Med Nuc. 56 (6-7): 527-30. PMID 1177197.
  22. ^ 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. Retrieved on 2006-10-12.
  23. ^ Devin F, Roques G, Rodor P and Weiller PJ. (Jun 8 1996). ""Occlusion of central retinal vein after hepatitis B vaccination."". “Lancet” 347 (9015): 1626. PMID 8667894.
  24. ^ Schoenfeld MD, Buckman G, Nissenkorn MD, Cohen S, Ben-Sira I, Ovadia J. (Jul 1985). ""Retinal Hemorrhages on the Newborn Following Labor Induced by Oxytocin or Dinoprostone."". Arch Opthalmol 103 (7): 932-4. PMID 3860196.
  25. ^ Leestma J (2006). ""Shaken Baby Syndrome": Do Confessions by Alleged Perpetrators Validate the Concept?" (PDF). J Am Phys Surg 11: 14-6.
  26. ^ Shaken Baby Syndrome Resources. American Academy of Ophthalmology.
  27. ^ a b Newman W (Spring 2005). "Inflicted Childhood Neurotrauma - Non Member Update Contribution" (PDF). "Focus" - Occasional Update From The Royal College of Ophthalmologists 80 (33).
  28. ^ Green MA, Lieberman G, Milroy CM, Parsons MA (Apr 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.
  29. ^ a b Geddes J, Hackshaw A, Vowles G, Nickols C, Whitwell H (Jul 2001). "Neuropathology of inflicted head injury in children. I. Patterns of brain damage.". Brain 124 (Pt 7): 1290-8. PMID 11408324.
  30. ^ a b Geddes J, Vowles G, Hackshaw A, Nickols C, Scott I, Whitwell H (Jul 2001). "Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants.". Brain 124 (Pt 7): 1299-306. PMID 11408325.
  31. ^ Lantz P E, Sinal S H, Stanton C A and Weaver, Jr R G (Mar 2004). "Perimacular retinal folds from childhood head trauma.". BMJ 328 (7442): 754-6. PMID 15044292.
  32. ^ Goldsmith W, Plunkett J (Jun 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.
  33. ^ Ganesh A, Jenny C, Geyer J, Shouldice M, Levin AV. (Jul 2004). "Retinal hemorrhages in type I osteogenesis imperfecta after minor trauma.". Ophthalmology 111 (7): 1428-31. PMID 15234150.
  34. ^ Aryan1 HE, Ghosheh FR, Rahul Jandial R, Levy1ML (Oct 2005). "Retinal hemorrhage and pediatric brain injury: etiology and review of the literature.". J Clin Neurosci. 12 (6): 624-31. PMID 16115547.
  35. ^ Forbes BJ, Christian CW, Judkins AR, Kryston K. (Mar-Apr 2004). "Inflicted childhood neurotrauma (shaken baby syndrome): ophthalmic findings.". J Pediatr Ophthalmol Strabismus. 41 (2): 80-8. PMID 15089062.
  36. ^ Ommaya AK, Faas F, Yarnell P (1968). "Whiplash injury and brain damage: an experimental study.". JAMA 22 (204(4)): 285-9. PMID 4967499.
  37. ^ 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.
  38. ^ Prange M, Coats B, Duhaime A, Margulies S (Mar 2003). "Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants.". J Neurosurg 99 (1): 143-50. PMID 12854757.
  39. ^ Uscinski R (Fall 2004). "The Shaken Baby Syndrome" (PDF). J Am Phys Surg 9 (3): 76-7.
  40. ^ Ommaya A, Goldsmith W, Thibault L (Jun 2002). "Biomechanics and neuropathology of adult and paediatric head injury.". Br J Neurosurg 16 (3): 220-42. PMID 12201393.
  41. ^ Commonwealth Of Kentucky VS. Christopher A. Davis. Case No.04-CR 205 (PDF). Greenup Circuit Court. Retrieved on 2006-10-13.
  42. ^ Bandak F (Jun 30 2005). "Shaken baby syndrome: a biomechanics analysis of injury mechanisms.". Forensic Sci Int 151 (1): 71-9. PMID 15885948.
  43. ^ 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
    Marguliesa S, Prangeb M, Myersc B, Maltesed M, Jie S, Ningf X, Fisherg J, Arbogasth K and Christianh C (24 January 2006). "Letter to the Editor: Shaken baby syndrome: A flawed biomechanical analysis". Forensic Sci Int.. DOI:10.1016/j.forsciint.2005.12.018.
  44. ^ Minns R, Busuttil A (Mar 27 2004). "Patterns of presentation of the shaken baby syndrome: four types of inflicted brain injury predominate.". BMJ 328 (7442): 766. PMID 15044297.
  45. ^ Commonwealth Of Kentucky VS. Christopher A. Davis, Greenup Circuit Court CASE NO.04-CR 205
  46. ^ "Shaken baby convictions overturned", Special Reports, Guardian Unlimited, Thursday July 21, 2005. Retrieved on 2006-10-15.
  47. ^ Minns R, Busuttil A (27 March 2004). "Patterns of presentation of the shaken baby syndrome -- Four types of inflicted brain injury predominate". BMJ 328: 766. DOI:10.1136/bmj.328.7442.766.- provides links to Editorials and a Clinical review

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