Objective. Abusive head trauma is the most common cause of morbidity and mortality in physically abused infants. Effective prevention requires the identification of potential perpetrators. No study has specifically addressed the relationship of the perpetrators of abusive head trauma ("shaken baby syndrome") to their victims. The objectives of this study were to identify the abusers and their relationship to victims in these cases.

Methods. We reviewed the medical charts of 151 infants who suffered abusive head trauma to determine the perpetrator of the abuse. Caretakers were classified by level of certainty: confession to the crime, legal actions taken, or strong suspicion by the staff. The relationship of abusers to victims was analyzed.

Results. Male victims accounted for 60.3% of the cases. Twenty-three percent of the children died, although death rates for boys and girls did not vary significantly. Male perpetrators outnumbered females 2.2:1, with fathers, step-fathers, and mothers' boyfriends committing over 60% of the crimes. Fathers accounted for 37% of the abusers, followed by boyfriends at 20.5%. Female baby-sitters, at 17.3%, were a large, previously unrecognized group of perpetrators. Mothers were responsible for only 12.6% of our cases. All but one of the confessed abusers were with the child at the time of onset of symptoms.

Conclusions. Our data suggest male caretakers are at greater risk to abuse infants. Baby-sitters are a concerning risk group, because they represent a significant proportion of abusers, and they more easily escape prosecution. In addition, no prevention efforts have been directed at baby-sitters. These statistics could help change the focus of efforts to prevent abusive head trauma.

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