Aims: (1) To identify whether infants and young children admitted to hospital with subdural haematomas (SDH) secondary to non-accidental head injury (NAHI), suffer from apnoea leading to radiological evidence of hypoxic ischaemic brain damage, and whether this is related to a poor prognosis; and (2) to determine what degree of trauma is associated with NAHI. Methods: Retrospective case series (1992-98) with case control analysis of 65 children under 2 years old, with an SDH secondary to NAHI. Outcome measures were presenting symptoms, associated injuries and apnoea at presentation, brain swelling or hypoxic ischaemic changes on neuroimaging, and clinical outcome (KOSCHI). Results: Twenty two children had a history of apnoea at presentation to hospital. Apnoea was significantly associated with hypoxic ischaemic brain damage. Severe symptoms at presentation, apnoea, and diffuse brain swelling/hypoxic ischaemic damage were significantly associated with a poor prognosis. Eighty five per cent of cases had associated injuries consistent with a diagnosis of non-accidental injury.Conclusions: Coma at presentation, apnoea, and diffuse brain swelling or hypoxic ischaemia all predict a poor outcome in an infant who has suffered from SDH after NAHI. There is evidence of associated violence in the majority of infants with NAHI. At this point in time we do not know the minimum forces necessary to cause NAHI. It is clear however that it is never acceptable to shake a baby.

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The research on which this paper is based aimed to identify the social and legal consequences when young children sustain a suspected non-accidental subdural haemorrhage; and to examine the clinical and social factors that impact on clinical referral decisions. Data were collected from medical, social services, police and court files for information on the management of children with these injuries by various agencies in the South West of England and South Wales. Data were collected on the case management of young children from time of presentation to hospital through to referral to police and social services. The paper shows that children who are most at risk of shaking injuries are likely to be very young babies between 3 and 5 months of age. They are most likely to come from deprived households where parental stability is weak and where social support for the carers is limited. Referral of children by paediatricians to child protection agencies is not always carried out in cases where coexisting signs indicate a strong reason for referral. It is recommended that paediatricians and other clinicians involved in the care of young children should embark on a multidisciplinary process of assessment and training in the identification of non-accidental head injury in very young children and babies, to reduce their risk of future harm.

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