There is an ongoing debate in the scientific literature about the biomechanics, histopathology, prevalence, and pathophysiology of the constellation of cranial and ocular findings referred to as the Shaken Baby Syndrome

22 victims of SBS.9 Duhaime et al. also advocated, based on available biomechanical data from subhuman primates, that shaking alone was not enough to cause the SBS findings. Duhaime’s findings were, however, disputed by other studies, and the concept of SBS as a purely shaking based phenomenon remained.10,11 A more serious challenge to the prevailing beliefs about SBS was provided by numerous studies in the early 1990’s that disputed the diagnostic nature of many of the syndrome’s findings. Principal among these were ophthalmologic findings such as extensive subretinal, intraretinal, and preretinal hemorrhages. Even more specific findings such as folding of the retina around the macular region (perimacular retinal folds) and the separation of any of the retinal layers in the region of the macula (traumatic macular retinoschisis) were challenged. Although the differential diagnosis of retinal hemorrhages in infancy is quite broad, including hemorrhages from the birthing process as well as hemorrhages due to coagulopathies, retinal hemorrhages were not considered likely in short distance accidental falls.12 This was important because the most common history for SBS victims as given by the parent or guardian was one of an accidental household fall. The finding of retinal hemorrhages in these supposed accidental cases would point to shaking as the true cause of the injury.13 However, studies finding that retinal hemorrhages could be found after Cardio Pulmonary Resuscitation (CPR) raised concerns that children unconscious due to reasons other than abuse could be wrongly deemed to have been abused.14,15 Although retinal hemorrhages were no longer pathognomonic for SBS, numerous studies reconfirmed the high prevalence of SBS in infants with retinal hemorrhage.12,13,16,17 Other studies questioned the finding that CPR can cause retinal hemorrhages or indicated that CPR retinal hemorrhages, which are typically small punctate hemorrhages, were easily distinguishable from the characteristic pattern of SBS retinal hemorrhages which consisted of extensive, often confluent, hemorrhages found in subretinal and preretinal regions as well as extensively throughout the layers of the retina.18,19 Thus, despite many challenges, by the turn of the century, a somewhat uniform picture of SBS had emerged. Infants, usually below the age of two but sometimes up to the age of five, presenting with histories of accidental trauma who had little evidence of external head injury but who suffered form subdural and retinal hemorrhages were quickly scrutinized for the possibility of SBS if no other obvious causes, such as a severe coagulopathy, were found.20