title: Fatal head injury in children younger than 2 years in New York City and an overview of the shaken baby syndrome.
abstract: BACKGROUND
  Shaken baby syndrome is a controversial topic in forensic pathology. Some forensic pathologists state that shaking alone is insufficient to explain death and that an impact must have occurred even if there is no impact site on the head.
  
  
  OBJECTIVE
  To examine a large cohort of fatal, pediatric head injuries for patterns of specific autopsy findings and circumstances that would support or dispute pure shaking as the cause of death.
  
  
  METHODS
  We retrospectively reviewed 59 deaths due to head injuries in children younger than 2 years certified in our office during a 9 year period (1998-2006). The review included autopsy, toxicology, microscopy, neuropathology, and police and investigators' reports.
  
  
  RESULTS
  There were 46 homicides, 8 accidents, and 1 undetermined death from blunt-impact injury of the head. In 10 (22%) of the homicides, there was no impact injury to the head, and the cause of death was certified as whiplash shaking. In 4 (40%) of these 10 deaths, there was a history of shaking. In 5 (83%) of the other 6, there was no history of any purported accidental or homicidal injury. All 8 accidental deaths had impact sites. Of the 59 deaths, 4 (6.7%) had only remote injuries (chronic subdural hematomas, remote long bone fractures) that were certified as undetermined cause and manner. These 4 deaths were excluded from the study.
  
  
  CONCLUSIONS
  We describe a subset of fatal, nonaccidental head-injury deaths in infants without an impact to the head. The autopsy findings and circumstances are diagnostic of a nonimpact, shaking mechanism as the cause of death. Fatal, accidental head injuries in children younger than 2 years are rare.
authors.affiliation: Office of Chief Medical Examiner, New York, NY 10016, USA. jgill@ocme.nyc.gov
authors.forename: James R
authors.initials: JR
authors.lastname: Gill
authors.forename: Lara B
authors.initials: LB
authors.lastname: Goldfeder
authors.forename: Vernon
authors.initials: V
authors.lastname: Armbrustmacher
authors.forename: Andrea
authors.initials: A
authors.lastname: Coleman
authors.forename: Hernando
authors.initials: H
authors.lastname: Mena
authors.forename: Charles S
authors.initials: CS
authors.lastname: Hirsch
mesh_terms: D001921:Brain / Q000473:pathology; D002423:Cause of Death; D006801:Humans; D007223:Infant; D009519:New York City; D012189:Retrospective Studies; D038642:Shaken Baby Syndrome / Q000401:mortality* / Q000473:pathology; D014949:Wounds, Nonpenetrating / Q000401:mortality*