Repeated whiplash shaking of infants can cause brain damage and permanent disabilities. Subdural hematomas, retinal hemorrhages, and bone fractures are common injuries seen in abused infants. While shaking is sometimes used by caregivers to correct minor misbehaviors, the evidence suggests this practice can have severe unintended consequences and should be avoided.

1. ' "Pr
rtN4 -
Atiguat.19721;
,
•
Vol 124 N o 2
Abrah
.
.„ •
e Its Potential Residual ,•E ,.„..,•• •••,,„,
••
of 0 . t r # 0 4 p i i t
t
9 • ••, ••••••• • • , ,•1
, l
. •S i * i t i : • ' D O
.
J
B e .
0
•l i i t e ,
4
- • r n a g e : • c 0s
:t :
:
in 1946 of the paient infant : : ; • M O k i
stress öf
r y n t i rb * e t • „nct c
4
genie vaalcil;umenaornZhogpentiv:sehlkpilgh?;
e
s f
•
syneir:§00';',*4esci7ihecl t 0 , 1 : ; • : : I t e . i
r
:n e •
• oftenh d i s t „r ti b u t
i
:monthsS ), younger, whtods u t f : 9
s yx o r
:t(P th e combination4o f subdural
i R a fi g •
tiom a n t s , p Ibone lesions
i h
ie n rf
o matomas and characteristic bone ;
hi •
o n ITS m u s t
h
1 e d 3, •
r
b a t During the last 25(..years
lcsLons' t
:
: C
p b e i n _
e
e a r t g a n t : l i a k e y i d e ri e ; ' ,
s t e d i
t
;
b circumstantial, has gradual* a6;:'
:sad a t a
f
cumuIateCivhick:: suggests': tb4,.:::the'
b o t by " , M
§
b
i
; u
iibused infants are common .
whli4lObiabaking.:•,::: and je rkin g
.
i
t boneg
: k
o
rc
a taisr0100.10,4):•;*.01; aa.;.the'eerehro:'
l ue s' te t
the o f
,
t s : , •
:
vascatArte0Oti§; • t
se r 1 o 1 4 4 ' 0 ; c i t 4 e •
s
•
n
,
the mo s t c ommon cause o f
t
,
,tle I u
011: iPlic at ic k pl r
ma n d
a t t e riS ! , t
, g9#0;YAWeinvite your agOnt,ion,!,tn.•
h e evidence which supports our con-
the .
o toh a ts: ; , : : : t h :
L•
m s
cept
,
d a r
jerkmg o f t i n t s a re frequently E
t lash-shaking is practiced, commonly in, e
,
f
pathogenic and
: t v h i O a s h 4 o fh e t l
t a Wide variety of Weis; Under a wide i
I qf e
: a a
permanent d a ma g e t o i n f a n t i l e
. variety of circumstances, by a ' n
ea- kIng,a n variety of person's, for a 'ytride,jrai:iey„,
m t lia t : iii. o p iit ia lly,
:b
d out
,
of ireasons:
o
s c4 1 :r : , w de,, m
d sn it i n
,
a fOi', h e
: T repeated WhiPlaahahakinge,f,' fragments
0 re : : fants and young' children is to correct :d irea
,i -
iig 3eceivedi$ g:publication,Apr il 12 1972
1 : a 0 o q ii, cfor mn o s
n ,r a : ' , Minor miabeh av ion Such sh ikings are • a c n
and p i i * t h e departments of radiology :and pel t tt m .t r taes 'pemae;,to,irrtchkip i
ffee- h e
s s , ac
diatiiii;:School of Medicine, University of Pitts-
generally
c oparents : and 'physicians. :If , s h et e ' r ,
u1-
41 a . both
; r, o
c
a !
bilitli,"faiid the Children's Hospital of Pittsburgh,
c r .,.• ;
Pittsburgh
n m o u r / of th e pathogenie,' signifi- r r i sa t t t
concept
,,o m s
c n c 1h:,:tniesla.no pus
n gr1I _ : tadt '2 sl
haS i t r t c
pacnh s
- 6ee e i h :Oa e
d Read as the Tenth Annual Abraham Jaeabl', o n of whiplash-shaking, is valid, it
cance e e
ue # i i i i k
Aiiy)**FlOaaaif before.:: the 121st annual :con
e follows a l r tio e to'r no'sal m',com
i d e r that the prevention o f such r0 , o 'u tnhonrIt,reoseedr s m ,
tsheass s 'ale7wttbsu le
/ f od's e b n ce ta
1n e n ,
h:e a
e l e
n
o
s t
v m o
sReprint requests to chi l dr en' ; H ospi
S a. ) t i anc i § shaking and jerking might substan- o t':IdW
e d a:anor o
p weto' t i
Ince r y t i 1 r vu
v fia91)
as1
l1om,,nslsio a n d oin rme n c . ' s
:e. o t t i o : : n n ala s
itially reduce the incidence o f brain e ln6onihqnv' V
. . Traumatica
o
Pittsburgh 125 De Sete Si, Pittsburgh 15212:
sO t ; : . , l ar i q
cA r e vdamagee and mental retardatien. The , • P sav segment r fo o (
c u l only e c n v t
minal
n t nm t i e s T1
Y:
1
:1
- Cs4 fM e W
: o c rvemr h e . t
t 2 al 4 Psee:skeibs e l tr peo
- .W 0 ,
ie a 7 u o p lv r
etei y s e
e
n
te::'
t2 fhf s
wit " 1i c9 t i 2
i e
aoi al
Amer Dip ,Philci/VoI,124,, Aug'1972' u s Damage from WhiplaskShaking•of 'Iirifant0Caffey 1 6 1
a sareteari s h
o
.0 e
M
,
3
r c ti tching,
e r r 312
4
d i c e tlioehrr
h 9es' : e . e
Y n l
a 1 b s d b
e ' 66 e s rdo
e xl 1 " '
- a
A s 3 r h y
,r u f r y tsi:
e
T l
s o , e u a p ofli

2. F-U 11'
-
•••„•••••
• •
• ,, , • ,
: - , s u p e• i •
spicuous o f all t i anmatic lesions in imposed on the haft, but after four
growing bonesl l t y ea d most con- -
U s u a h Tny are not
lg
te
rs
a
y
e
ht
fracture-dependent They develop due : W
to traction-rupture of the abundant .. . . . : : : • ' •
normal p e rf O ra t in g " : ; b lo o d ;
.: The entrapped subperiosteal b1oo
0
which course througif.,thelettotieal•Valt t t;then::gradually resorbeci The n a 444
-
-: : : v e s s e li, . •l e . . :
and distribition of these lesions
440t.no c
„ullary cavity and -ivIlicli'•047.0.:,0'0„.iier•Oct...47:•;':,. : be best explained on the basis of i1 ( i-
- 4 a n ?1
the junction • .0.10:„Inten.a:',..:'•e'cike",:of ., V
h ii ' : ' a-
"• . ti0k4r0t,f,0*d.;*gi*iithOperiostetlm
e
••:,• • :
, . '(4 ••
V
-•••
tof "04kO4
: . joint:
,,_•,•.••••• blood •internal• to• tne perieetetiM' :: its vessels, and thefp, i a n„l e„4 t pg
• : • • •• • • „ , , r On„n ag iz 'ilAilp it .
1
i -
V
••••butextern41
i . whipla •_
.: 4 h e
, ithe Periosteurn.off;:.the•••wall
t h 0 , .
extremities andh s h a 1
N
,h
d
a
e ,
able: distances and I o
- :h distribution can be , : - satisf
, t er t h e i r
ce
teallImatp.mas•Of vanable sizes and # eih ed -
o ernt , i* c a
ii
n a t on theebasis actoi i1y _et:;
••• :;••:, . •••'
•• . : n
•• ehappa„ m4
b plained u r of•,_ •its
vrect s h
n
)
w
o
l
b
(
e
r
t
:'!,fOr.; •
l • ••analogous. bones. _ •••••••tivo'artriS a n Severaltobservers have noted
- in •• ,•• " • • • : la. the ",• •••••••,:•••,• r • t o
. • ;
• 'legs;„ or they affeet, bones in the aims.• o c i art e d " , d i f f t i s e l S cO r
-
i la
: O f t- •e n e :4 '
and forearms: • •••• ••„.„: : • : n some o f : ' : . . . t 1
metaphyseal fr ag- e Or::: •• • ••••••••• : • ••
t h •,i the*e • ••• •
••
s .
Fre- UPrt a infants Th is has -
: only ,
abused - P suggestod i 4
k•.'xcessively fragile,:brittle, ,chalk-like
.e -
. O
: -
quently i rn y o l y e
m ,: ,
Celaticationi (pzc) on the proximal ti de of , t, o s- _
. A T ec!Mp'
e .•r:.o
thQkneei in the femur and the distal side of a the distal.. p r o x i m a l ' ' , sides o f
. th e m e t i
h i : bonesIto * e . i , U
W. 1 1
s
r
the tibia of a patient 4, months;ii, • ,••_ -• „ ointl
, _•
," . b 0 . • , • •_•,•- ) •:: ' .
•:,l .
geh . ,ohS y 0 i0 s
fi St y nc , lappear radiographically :a 4 : ,
r rn t , l b e 1 :
'i o f . . . . .s: . :l 1 t i o n O S ' i § f
. mination:disclosed, 1 1
2n , ' ' , • , ; )voven pat-
r -:
- .
t , , , , • a M OsPi e a ,
• •r • . • , 0a d i o l o g
S t t ho S h a ; t S
O m 1
, , • , , ' • , ,
ee
e ::• . . o n s : O
e
,: i , i : , ha i. s' t s
0e exces-
b :• o :t phe :: • •
• • • F
,i ; : ' • • • : , ' ar- ' ': '':•;•- ' ' •- " ''''sive :n I '°
.- , newly•
r pf o
:,. i , : ; f o r i n e d ' : r i n i t t; i . ' e o' : : .c i
.i : , V n• 0. e c
.
v_, : a l under the perlosteOrn" f5 a
,: :
ks .1 4 n t
e
hp: .Fig::• b r o u s ly •
l.rnur,& with . , O e
. 5 A - :
_ e. : _ curve:::,.;..:::::„: :: : : :.: ,„.::,;:.. ,.,;,: .:::• :::: .;:t,...„ : ,: : ; ,: .::.;,,..:: : .,. : „.„.;•,....:, :, ,:,...:•::::::":•;' ! " '„, _D•:• " . " '• . • • „! ; , : , l. *. 1 1 thickeningsn -
s(___;;;..,,;.:::::;:.; :., , d line (arri74/4/s
:,
opaque: ?...:. , ,
„ s
, tom " 4 *i: , : in g ls of
e ,l i
.
,:,.,„-•, -
iap • oe 0i
; - :i the external s u b p e riu S t
-e rg:f r-A r n l
) .. O io „
ris n;t s l i ti y a fi n e . nn n i g i
•4
•t
, :: n
e S y
r u po r i m p o s e d or ,l , r o s:pi U . The epiphyseaLOSSift
i s
sm m e b o t l' h . ea1 ,,,ii
:tos n. _ n
to t h o a yt c
e -,- !s i •• , •—• ,,
•
T r u m a t i 444,611 :ie cs e n -
': ,'-'• ' T h e sclerotic. shafts are
-d e. t r
w
.e e „
i p O .
l . !
- -•••-_1 s t0 ;:ro n g e r than nortriallSh44ts.
,#0 -
l's i .c he
t
;n m, e , ni
k
' •::„ - • ,
,
) ap i p h y s
li n - . , , :e TraumatictmetaphySeal:::!•.:eilpptut.,: is -
•::: o f h ef• • , , „ ,,_ -
„e .
.io d : li ep
,.• • d us e to traumatic obstructive:;ipPrY,: to
•e ms l
,fo
i a
, y.
e .hthe epiphyseal :
a ,. .
d e. e f e :
1t
-t d h . „, fdboring r i o l e s plate. . . .
acr t e cartilage
„.
',h g _ t, s - * -
e
e a:
, r i ;•
' t ' '•ei t n , "loop7,, d e . o r, Miie e !
taphyseal
- f
eto stretching ', and••!ciio#onSiOn.,:;O
,g e 4
•p . :l :'-fvtii aumatie i n v O l i i
:• - .
;
.: p, i
i rh s ' , e o: . .l h o . .
1o h •a
. r :,..: e.. fl..these .l e s i o n S-
ofi:Ahe
,l '
io : r , e the t , :
:n : r on.a#U cca u„sa l: ': h a . ••• , , ':,O •,,,,,
: • ssi: •„ :,
.v y
, f " s
,l t . : :t ; C,• •
m s; *•„4 u e t h o : , e ] t t re n
squeezing
0
a ' •,•,: .:g r e : , l ' : h O S t l
•i. si
: h. : t
a -a- h
i sailant's hands, and „whiplash-shaking
:
e n i ei f„:n e , t F i l -
!,s
;- e, : : r :qei,.tinfant's ; ' , M e - ,
the 1 , , :
. 1 e . o,S :
• i , Despite the fa 4 n t..0 .'
,i, a.
:o t :
d o- t
,
t M ia:l4hrOn 'di i .tg l y , ' ,
; t en ie, i
1: l .
,n i, h
r u.physicians o tol,apprepia,t,tho,-
hl : a d .
. e
:,
tsignificande...;
-a ".
,
, b
1 m
o n. ol . t...,:;Pt4 't0 -
• f- o ; B o
:. younger infants, and
•-
a :
:, ', i u dh• • ' „h ,
l
? a e '• ::::'•,. .•. ,y : '-,
:•
l: f
i • • , - :,..,:,.• :,
z n n :",:k'S :
,
, l, _ • d -- e- n1 * .n d
! i:. :
q g •••„•,,••••••••••,„••„
o
-n p1 • ..,..,..,•:,„,:••••••••• • ,•• • ••• • • • • • , - ,-A • u 2
7
9
1
g d ::
..ing• t h:e ,: : : •
,,• Brain Damage. From Whiplash-Shaking of Infants/Caffc
,
l ; ,e
i:::of
ve : • 4 : • ,
• z , b :w :ia
,e :'. .i.g ,
t
-o e: .
, c
o
- . i::::, :-
(;
,as
" -
i f A:
• . n
' l i,e : O g ,
::
Jih
:: f :
s f
e
- : j:: ! , • • • : :

3. because she whined (2) A girl , 4 years, of
iper- ageW Shaken violently because Of inces-
as
four e sant crying : .(3) A, girl 4', months Of ,age;was
new some and,At,thp,„ same time, the most sig- shaken faUlly' during Which
,
f
Rind iufi banged
, h e ragainst, the crib
h e a d , ye
tm a. whe
ca iplaSh141 a
wr s a s
counted i n k t fi g ' A t n i b i f - 4 1 s
)d is
- na
. t •
ture - o 31(THREE CAs -
0r
M0 , * nt fote l , * Y o y , : ' i l l ' O d 4 mont swiss explained 'cOnvulsioni, and
h t's
h,
can ported a n t
0, liit l
4t fever • His mother Was • too shocked
ndi- maimed I t VtlieriAtiiiiii.a;;Iier,idrlof eight.
,
. h
t k
0t h , t 7lO Og :O,V I 4 y
years, V9s
era- , a i n i ea r l,. : and t heir blood vessels
4antile brains
I n
0
i
;: , and e ndied, ,three days later Eventuall
a k he
iA
,
- ,
These assaults all occurred in the homes of
;ules sh l n l p
, fii f a a t s :
I p•p e r - mi d d l i 4n 4 n S s i
a t d
y4 O ,
a 1
s
thehm her•aclinitiecl thatshehad shak
m
i ot
the
u
1l parents, who provided expert medical:
. a u several times t6 f r o p t
b , •" c h o -
d
do
, en to death" cltirine a violent Pit'roXYM' of
Og 5 WYd : : •- h i g h . i k „ ; . - t 4 4 1
n1 n n ? iing
rcoughing StiP ,ha t t e mp t e d " c l e a r his
61,I a
the caree n
. )y (4
;heir f
services 1 4 . '
i
.; throat': and he went into convulsions
l
b
ex- 7
demand n
o',' jp e d i ' b t . 0 0 0 S , .
:lowing the Shaking. ( 2) ', A boy, 6 m onths
ns :
.
: 'edt , 00; t ed. V e
. 5 for bein
tion
e0 4 began to vomit and cnnVulSe., There
old,
pact f c , Sarc t
6
.
; P
awere no external signs of head injury but
infant
. u s charges Both parents d o c t o r s
g
a 0t 'l n g ,
p: ia e r . : : :
t
n
:0 u , • - ;hemorrhages were seen in both
)
tretinal
appareiltlY:Jliakitilegnfidence in her in one
.
"
ee x t r a
r
, lodder fundi. Subdural hematornas were
insto.4e4d..Wkin),i,ited back by the par-
.
b au
v g
e
ents , i
opa7i C t s ee c o n d infant
h
: atreated surgically:, (3) -
Qifle i t i lhad shaken their first child to death_
;
Ate :f jt e r
g n
4 . , patient's twin brother came to the hos-
this ,
v a
, n
O tA
1 e w andunexplained broken femur. fragmentst ; both ends •of pz0
tAf t ,tef , ?inf ant W found dead without
. n l tpital1 Fig 3.L.,11nexplamod
a
e
.
as o r with ,
f a y
-like u
y aVdt adt pry oShortly thereafter, the first twin returned, -
s
d t ipn
M m1 ; persistent subdural hematomal By
•with , : y•
s tures) of the left femur with fine thin
2ent p l444'
P - t( rn p m a t i c
auO p
n i d a t e r , nal thickenings of its cortex which 1:0Iiee_sent
ex- ,:
p
abubble up " I 0004 him tin and tried to
,
a time bruises had appeared,on both
elthis , r a c
f f r a c t u r
n t o!, 5. ))14,; p,: .,441: ).do-anything
aI nhe.1 0
, e forearms, which fitted the pads' in the • o
0 lget e
k o :o :T: 4 whis e
tAe a c P i a t i a to o * p r ,..p f
twxongyy,Ne i
: i o
a fingers and thumbs,' cif': the , examiner's the distal t h e two ,i;:',Shafts;
-
pat- - e
o n ;4
tsuccumbed unexpectedly, she admitted
o fbands,' where the boy's forearms had
t
s these'lesienS;indieafe'•:that the infant
ates
b
, h: a
:ces, h s S he O .
s
(
o h .
that .
t egripped by his assailant during t
h Eventually, the mother admitted that l
r,ponths) had been 'splidd by hoth,
,
e
rous e e r P a ti e n ts
h e
h
liecropsisliselcided'.,tranmatie'brain injury.
:
g i e u t i tra l i y : : h
n
ing, s h a k
he
x and her husband "might have shaken
B a
h n w she d
r nt seand maiming two others. When these -
04 e!
:
s
f
• c
ihim when he cried, at night "' Guthkelch rvent his t d :
raü d
.
1 n a d M xt t e d '
e
admissions became t o the commu-
o i iopines' that ,a.• "good shaking" is f elt by Si*..:WOqns;latOi;:;itiftftsIv:iIti'VOluera'?,!Oine
l; :
tBritish parents to be more socially accept: 'r adius and Oink iff.the: SOlidlifOiO4fn. were
ed- o
i. l , in a d , g in disclosed that ten additional
nitYPEirenta
- s y h m , ,n fl t r a t e d : :
t e o
4 k ll l: had been significantly injured by
n n i
infants g h able, and physically lefts dangerous, than de o s
c , eh : r e
v
thin nurse
t e 7
rO 3, ; . , O
of r weeks wass ai d
Y, y
h i m a blows or punches to the head. : , : to have suddenly de
44V
e Tile primar d ExAmhz 4 (ONE C A s E ) . tf a d il o gar S r :
t * a
veloped unexplained swelling,
t r r a
, : described radiographic bone lesions caused
eu t k
i Iy o p n
i - iS 1 .inaA ttii .g j! * g k : hours latei' i.' 4) 4diatr i-
4 fi . d l
and fever. ,Twelve ln e e
O l #
4
h4Y.:heOn':,yiolent::. whiplash shaking and byK e m p e
the repeatedeparental shaking of a pre-
. f o r
e t ieian diagnosed g s t e o r n S r e l i t i s :
g o
eiC8diaiit.e:Whiplash;'•Pennding on the back maturely born twin girl of 7 months; who because o f p o i n t
:
ly r §c e
d a l
had been abused by the mother since the -and ; 0 . 0 § 0 4 a
during burping One is amazed that she
o d : , O tslight fever a n d
: i 9
second month of life. She was shaken while ,a . .,re n d e i
t
,
s h a ,, t
k
0n
satt4l*thiS Much.better-than7aVerage so-
o
;
k i n
gripped by the legs and held inverted. Mul- y l e begun. e y t o S i showecUOUld,On
rwas
:
. nkO
Radiographs
ciat,and
a a t medical' milieu for eight years. I t tiple massive involucra and several me- fracture fragments at,::th0:;.1.PlYPt,',* one
g t
i ,
g likely that she did not realize the full .a e l ,sh: 0 :i *e§ ; !
n
Srei s (
g45i is lc
a taphyseal avulsions developed In her fe- tproximal tibial metapnysis w n t q l
e
„
— murs and tibias. n * e l: Later films showed ; the evolution
*
trauma
pOW4r. and violence generated in her shak-
k ls : i-
t
an k X EXAM 5 (ONE C A s E )
PLE o a longf:;tratiMati,inYnitiOtn*.Offiis
of
4.0 i
oo u i n d wha tn .d : d ie
k iC e
the t
;(2,33Ab), and was said to have had very
d scribed compression fractures of vertebral b
,-- tibia, e ,
th nf
lart,Onands',,Il.be last infant she shook to
h bodies iin c h uinfant, which were believed rthe 19.tki day;',..
Sw s one k m .
.
s ma
idOft,thi:WOignftd:.:497 k g (11 lb). Had the
e n
!l
l
to be due to whiplash-shaking.
l u .i. . prior to the.aPPearandS.Of the SWAing
mjust
,
.
frnOkneetishanOnhy a caretaker of corre- EXAMPLE 6 ( T H R E E CA S E S ) . —W e h a v e :
' d examples of protective jerking
e - a the n o she had E
of knee,
s, h leg and jerked;her M
t t •e h h o t t ; t
• n f
iSOncling, W ght.,.1. and :•strength, the mon-
ei found two the a
g
a a
a n would haye weighed 21 times her
ster and one of repeated sibling whiplash-shak- e e hfrom falling y g a hard wood floor
t ye r' , r a n onto
f O 'e A! Wa s;
her
-
h
n ing. We have encountered two patients in , t; ) W ab t s f fi d i
sthe:same time she had, fallen,forwatd*ith
tweight or 2 , 2 2 6 kg. (5,000 113)
bs . y •t I,
s u
n ; ,
t. a n d whom a single, sudden, violent jerk of one .ther and onto her ThdPedietricianWtaitill
iWOnIct;hayOlhaid',the s
. . ,g . :
t O
a women
srengt h.
t : extremity apparently produced metaphy- T in
.
S 1 # 4 0 C t ,
#.0 a'AT,44py,,2:(Fpn*CAsEs):.:LWeston seal avulsions and traumatic involucra. (1) rO c h r i
a
d t r a u nn d . ' • b e e a u d e
of
rwith the frequency of feYeranctileuko-
'h f and Pollock'. report: low cases of
o 2 1 A boy, 41/2 months old, had always been
Steele d
p6 : a tn r o n g a t e c y
e t
.
täJ ,s
epathOgenie:Shaking,in battered babies (1) well until his mother grabbed him by one e : h O , after traumatic,. ,iiitdrnal!,:[....;:lieinor-
cytosis '
p ,
: forearm and yanked him upward to pre- a l,
y :
rhage.t. (3): This boy of 8 months had had
ar e iiilgirl2W,::Yeara old,' was shaken violently
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tT t
:
e
a Me l Wa S t t f t f 4 i n i l i a r
c ,
t
i Pis Child/Vol 1 2 4 , Brain Damage From Whiplash-Shaking of Infaidts/Caffey 1
fey' r et
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o
g ,
s na
t
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h Aug 1 9 7 2 ,
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