OBJECTIVE:Children born extremely preterm (EPT) vary greatly regarding academic outcomes, underscoring the need to investigate subgroups in large representative samples. This study aimed to (1) examine academic outcomes in EPT children versus full-term controls and (2) examine the role of maternal education, child sex, maternal origin, cognitive ability and the presence of attention deficit hyperactivity disorder (ADHD) or autism spectrum disorder (ASD) diagnosis. DESIGN:National cohort study. SETTING:Sweden. PATIENTS:12-year follow-up of a cohort study, the Extremely Preterm Infants in Sweden Study, including children born EPT (n=449) and full-term controls (n=365). OUTCOME MEASURES:Data on school grades (mathematics, Swedish and English) and special education school attendance were obtained from registers. EXPOSURE:EPT group versus controls and subgroup analyses within the EPT group. RESULTS:Compared with full-term controls, children born EPT more often attended special education schools (13.6% vs 0.5%; OR 28.5 (95% CI 6.9 to 117.5)) and those attending mainstream school more often received at least one failing grade (32.3% vs 5.2%; OR 8.7 (95% CI 5.2 to 14.5)). Of children with gestational age (GA) ≤23 weeks, 39% attended mainstream school and passed all three core subjects, compared with 65% of those born at 26 weeks (OR 0.34 (95% CI 0.17 to 0.62)). Among EPT children attending mainstream education, low GA, low maternal education, cognitive impairment and ADHD/ASD diagnosis increased the risk of poor academic achievement. CONCLUSIONS:EPT birth was associated with poor academic achievement, but the risk varies substantially within the EPT group, primarily based on cognitive impairment, ADHD/ASD diagnosis and maternal education. However, the risk of poor academic achievement among children born EPT remained after adjusting for confounders and mediators.

OBJECTIVES:We assessed the prevalence of neurodevelopmental disabilities (NDDs; cognition, cerebral palsy, vision/hearing, epilepsy), attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), developmental coordination disorder (DCD), behavior problems, and multimorbidity in a national cohort of children born extremely preterm (EPT, <27-week gestation) to provide a comprehensive understanding of the challenges faced by children born EPT in early adolescence. METHODS:All infants born EPT in Sweden from April 2004 through March 2007 were enrolled in the Extremely Preterm Infants in Sweden Study (EXPRESS). Of 492 survivors at age 12 years, 462 were assessed alongside 373 term-born controls. Standard instruments were used to assess cognition, motor function, and behavior. Parents completed a structured health questionnaire. Diagnoses were obtained from national health registers. RESULTS:Compared with controls, children born EPT exhibited significantly higher rates of moderate/severe NDD (37.4% vs 4.6%), ASD (14.9% vs 2.41%), ADHD (21.2% vs 8.9%), DCD (29.4% vs 5.7%), and behavioral problems (35.3% vs 8.13%; all P < .001). Of children born EPT with no/mild NDD, 8.3% (24/289) were diagnosed with ASD and 14.5% (24/289) with ADHD, and of those with moderate/severe NDD, 26.0% (42/289) were diagnosed with ASD and 32.4% (56/173) with ADHD. Of children born EPT with moderate/severe NDD, 59% exhibited at least 2 co-occurring disabilities/disorders, and in those with no/mild disabilities, comorbidity was 24.9%. In the total EPT cohort, 57.4% were free from moderate/severe NDD and ASD, and 42.0% were free from ASD, ADHD, and DCD. CONCLUSIONS:By age 12 years, a large proportion of children born EPT faced challenges because of NDD, ASD, ADHD, DCD, multimorbidity, and behavioral problems, necessitating multidisciplinary follow-up.

PURPOSE:The Extremely Preterm Infants in Sweden Study (EXPRESS) followed a national cohort of extremely preterm born (EPT, i.e. <27 weeks) children until 12 years of age. This study aimed to investigate the longitudinal development of visual acuity (VA) in children born EPT, explore the predictive value of early visual assessments, and evaluate risk factors for visual impairment at the age of 12 years. METHODS:All 462 children born EPT in Sweden during April 2004-March 2007, and surviving to age 6.5 years, and full-term born matched controls were invited to participate in the 12-year follow-up. VA was assessed at 12 years and the results were compared with values at 2.5 and 6.5 years. RESULTS:At age 12, 332 (72%) EPT survivors and 189 controls were examined. The mean VA in the EPT group was lower than in the control group (1.15, 95%CI [1.12-1.19] vs. 1.33, 95% CI [1.29-1.37]). Fifteen (4.5%) EPT had visual impairment. The examination at age 2.5 failed to identify most of them, while the examination at 6.5 could predict the final visual outcome at 12. Risk factors for visual impairment were low gestational age, moderate and severe intraventricular haemorrhage, treatment-requiring retinopathy of prematurity, cerebral palsy, and cognitive disability. CONCLUSION:In this national cohort, the VA outcome at age 12 was lower in children born EPT than full-term controls. As eye examination at 2.5 years did not reliably identify visual impairment, clinical risk factors should be considered in the screening of children born EPT to early identify the visually impaired.

BACKGROUND:Optic pathway glioma (OPG) is a feared complication to neurofibromatosis type 1 (NF1) since it can cause visual impairment in young children. The main goal of screening is to detect symptomatic OPGs that require treatment. Optical coherence tomography (OCT) has been suggested as a tool for detection of neuro-retinal damage. AIMS:To investigate whether the ganglion cell layer assessed by OCT is a reliable measure to identify and detect relapses of symptomatic OPGs in children with NF1. METHODS:Children (3-6 years) with NF1, with and without known OPG and children with sporadic OPG (S-OPG) resident in the Stockholm area, were invited and followed in a prospective study during a three-year period. Brain magnetic resonance tomography (MRI) had been performed in children with symptoms of OPG. Outcome measures were VA in logMAR, visual field index (VFI), average thicknesses of the ganglion cell-inner plexiform layer (GC-IPL), and peripapillary retinal nerve fiber layer (pRNFL). RESULTS:There were 25 children with MRI-verified OPG and 52 with NF1 without symptomatic OPG. Eyes from NF1 patients without symptoms of OPG showed significantly better results in all four analyzed parameters compared to eyes with NF1-associated OPG. Mean GC-IPL measurements seemed stable and reliable, significantly correlated to pRNFL (correlation coefficient (r) = 0.662, confidence interval (CI) = .507 to .773 p<0.001), VA (r = -0.661, CI = -7.45 to -.551, p<0.001) and VFI (r = 0.644, CI = .452 to .774, p<0.001). GC-IPL measurements were easy to obtain and acquired at considerably younger age than pRNFL (5.6±1.5 vs 6.8±1.3; p<0.001). CONCLUSIONS:The mean GC-IPL thickness could distinguish well between eyes with OPG and eyes without symptomatic OPG in children with NF1. As thinning of GC-IPL assessed with OCT could indicate underlying OPG, it should be included in the screening protocol of children with questionable VA measurements and in particular in children with NF1.

This study investigates whether optical coherence tomography (OCT) could add useful information in the examination of children with optic pathway glioma (OPG) at high risk of developing vision loss. For this purpose, the relationship between ganglion cell-inner plexiform layer (GC-IPL) thickness and visual function, evaluated with tests of visual acuity (VA) and visual field (VF), as well as tumor site according to magnetic resonance imaging (MRI), were examined in a geographically defined group of children with OPG.METHODS:Children aged <18 years with OPG underwent ophthalmic examination including VA, VF (Zeiss HFA perimetry) and OCT imaging (Zeiss Cirrus HD-OCT).RESULTS:Out of 51 patients included, 45 provided 77 eyes with MRI-verified OPG, and 19 patients provided 25 eyes without OPG. Significant correlations were found between GC-IPL, VF and VA (p < 0.001). The GC-IPL pattern loss corresponded in 95% to VF defects and in 92% to MRI findings.CONCLUSIONS:Our study indicates that GC-IPL measures could serve as an early marker of vision-threatening changes related to OPG and as a valuable link between MRI and visual function tests. Thinning of GC-IPL and differences in topography between eyes are strong indicators of and predictive of vision loss related to OPG.

Objectives To characterize changes of foveal topography and microstructure of persisting foveal immaturity at 6.5 years of age in children born extremely preterm without retinopathy of prematurity (EPT-NoROP). Methods Images from previous optical coherence tomography examinations of 37 EPT-NoROP and 92 control eyes were selected from a regional cohort of the EXPRESS (Extremely Preterm Infants in Sweden) study. Thickness of ganglion cell + inner plexiform layer (GCL+), outer nuclear layer (ONL), retinal thickness (RT) at the foveal centre (FC), foveal depth (FD) and RT at the foveal rim were evaluated. Results Layer thickness of GCL+, ONL and RT was increased at FC in the EPT-NoROP group. More than two-thirds had thickness values above the control limit (control mean +2 SD) at FC (GCL + 68%, ONL 76%, and RT 68%), and 50% had reduced FD compared to controls. All parameters showed a high correlation within the EPT-NoROP group, whereas no or weaker correlation was seen in control eyes. The EPT-NoROP sub-groups, divided based on the control limit, did not differ in terms of associated factors such as gestational age, birth weight, visual acuity, and refraction. Conclusions Extreme prematurity without impact of ROP is associated with increased GCL + , ONL, and RT thickness at FC as well as reduced FD compared to full-term controls at age 6.5. This indicates that prematurity per se may have a profound effect on foveal anatomical maturation during the first months after birth. Our results suggest RT at FC to be a simple and useful measure of foveal anatomical immaturity.

Literature on the development of global motion and global form perception demonstrated their asynchronous developmental trajectories. However, former studies have failed to clearly establish the critical period of maturation for these specific abilities. This study aimed to analyze the developmental trajectories of global motion and global form discrimination abilities by controlling for basic visual functions and general cognitive ability and to present the global motion and global form normative scores. A sample of 456 children and adolescents (4-17 years of age) and 76 adults recruited from the Italian and Swedish general population participated in the study. Motion and form perception were evaluated by the motion coherence test and form coherence test, respectively. Raven's matrices were used to assess general cognitive ability, the Lea Hyvarinen chart test was used for full-and low-contrast visual acuity, and the TNO test was used for stereopsis. General cognitive ability and basic visual functions were strongly related to motion and form perception development. Global motion perception had an accelerated maturation compared with global form perception. For motion perception, an analysis of the oblique effect's development showed that it is present at 4 years of age. The standardized scores of global motion and form coherence tests can be used for clinical purposes. (c)psi 2021 Elsevier Inc. All rights reserved.

PURPOSE To investigate whether a questionnaire can identify cerebral visual impairment (CVI) in a group of 6.5-year-old children born extremely preterm (EPT) as accurately as direct assessments. METHODS This prospective population-based study included 120 children born before 27 weeks' gestational age (66 males; mean, 25.4 +/- 1.0 weeks) and 97 full-term controls (56 males; mean, 39.9 +/- 1.1 weeks) at the age of 6.5 years, as part of the Extremely Preterm Infants in Sweden Study (EXPRESS). A questionnaire for detection of CVI was evaluated and compared with visual, perceptual, and cognitive assessments. RESULTS Parents of children born EPT reported more CVI features than the parents of control children, with median sum scores of 25 (95% CI, 18.1-31.9) and 11 (95% CI, 8.813.2), respectively (P < 0.001), and a median difference of 14 (95% CI, 6.6-21.4). Low rates of reported CVI features were significantly associated with better results from direct assessments within the EPT group and with less pronounced differences compared to controls. CONCLUSIONS The questionnaire discriminated well between children born EPT and controls, and the scores were congruent with other evidence of visual, perceptual, and cognitive deficits. The easily used questionnaire compared favorably with direct assessment in identifying CVI in children born EPT and also provides valuable information to clinicians, and parents about the daily life problems associated with CVI.

Background The purpose was to study the macular ganglion cell- inner plexiform layer (GC-IPL) thickness in healthy 6.5 year- old Swedish children using Optical Coherence Tomography (OCT) and to study topography symmetry within eyes and between eye pairs. Methods A total of 181 eyes of 92 healthy children (39 girls, 53 boys) aged 6.5 and serving as a term-born control group in the Extremely Preterm Infants in Sweden Study (EXPRESS), were examined with Cirrus HD-OCT. Main outcome measures were average and minimum values of GC-IPL thickness of the device’s predefined macular sectors. Single sectors, combined sectors defined as superior and inferior hemispheres and temporal and nasal sectors were evaluated. Intra-individual GC-IPL thickness between eye pairs was analyzed. Visual acuity, refraction and general cognition were assessed and correlated to GC-IPL outcome. Results Eighty-five children completed the OCT examination and 155 out of 181 scans (86%) were analyzed. The mean average GC-IPL thickness was 85.9 μm (± 5.3; 5th and 95th percentiles were 76.0 and 94.6 μm). The mean minimum GC-IPL thickness was 83.6 μm (± 4.9; 5th and 95th percentiles were 75.4 and 92.3 μm). The difference in thickness between nasal and temporal sectors and between superior and inferior hemisphere sectors were less than 2 μm. The difference between average GC-IPL thickness and minimum GC-IPL thickness was 2.3 μm (± 1.9; 5th and 95th percentiles were 0.0 and 6.0 μm). The difference between the thickest and thinnest sector within eye was 6.4 μm (± 2.2; 5th and 95th percentiles were 3.0 and 10.0 μm). There was a moderate correlation in the difference between the nasal combined and the temporal combined sectors within eye pairs ( p < 0.0001, Spearman’s ρ 0.58). The average GC-IPL thickness was weakly positively correlated with SE (spherical equivalent; combined sphere and ½ cylinder) ( p = 0.031, Spearman’s ρ 0.23). Conclusions This study provides normative GC-IPL thickness values for healthy 6.5 year- old Swedish children. The GC-IPL thickness variations within eyes and within eye pairs are generally small. It could therefore be assumed that larger variations are sensitive markers of focal GC-IPL thinning due to damage to the primary visual pathways in children.

PURPOSE To analyze the ganglion cell layer and inner plexiform layer (GCL+) thickness in children born extremely preterm and control children. METHODS A study of 6.5-year-old children born before the gestational age of 27 weeks and age-matched controls. The GCL+ thickness and foveal depth (FD) were analyzed in a single optical coherence tomography B-scan. Association with neonatal risk factors and sex was investigated. Extremely preterm was divided into no, mild, and severe retinopathy of prematurity, retinopathy of prematurity treatment, and no, mild, and severe intraventricular hemorrhage. RESULTS Adequate measurements were obtained from 89 children born extremely preterm and 92 controls. Extremely preterm children had increased total (5 µm, P < 0.001) and central (21 µm, P < 0.001) GCL+ thickness and reduced FD (-53 µm, P < 0.001) compared with controls. Extremely preterm children receiving retinopathy of prematurity treatment had increased GCL+ thickness and reduced FD compared with other subgroups. Sex and gestational age were associated with increased central GCL+ thickness and reduced FD. Reduced total GCL+ thickness was associated with severe intraventricular hemorrhage. CONCLUSION Extremely preterm birth can cause incomplete extrusion of the GCL+ and reduced FD. Retinopathy of prematurity treatment, gestational age, and male sex were associated to increased central GCL+ thickness and reduced FD, while severe intraventricular hemorrhage was associated with reduced total GCL+ thickness.

Brain injuries due to abusive head trauma (AHT) in infants are not rare and they are probably under-diagnosed. Retinal hemorrhages (RH) constitute a cardinal symptom of AHT and AHT is the most common cause of RH in infants next to childbirth. Retinoschisis with or without retinal folds is highly suggestive of AHT and never seen secondary to childbirth. Bilateral extensive RH that are too numerous to count, multilayered and extending to the peripheral retina in infants < 3 years of age, in combination with brain injury and in absence of leukemia, ruptured brain aneurysm/AVM, fatal head crush or known severe accidental trauma must be considered to be caused by AHT in the absence of any other compelling factors. The ophthalmologist has an important role and a responsibility in describing the pattern of RH and in evaluating the likelihood of the diagnosis in the medical report and in communication with pediatricians and child protection team.

Idiopathic intracranial hypertension (IIH) is a disorder affecting both the pediatric and adult population. Investigations and treatments may differ considerably. There are no evidence-based guidelines for treatment. During a national multidisciplinary meeting in Stockholm January 2018 IIH experts from several Swedish regions met to discuss how to manage this patient group. These guidelines are based on this meeting and a review of current medical knowledge. To summarize: All patients should be investigated and treated for underlying factors that could be the cause of high intracranial pressure (ICP) (such as obesity, secondary causes such as intracranial tumors or other factors reported to affect ICP). When treating IIH the preservation of vision is crucial. Follow-up depends on visual status. In case of acute risk of visual impairment prompt surgical intervention must be considered. Symptomatic treatment of headache is recommended.

Thirty children with cerebral palsy (CP) and 22 typical developing (TD) were tested with 3D-gait analysis. At turning, trunk rotation was larger in CP2 (GMFCS II) than in TD and CP1 (GMFCS I), and head flexion was larger in CP3 (GMFCS III) than TD. Maximum head and trunk flexion values during the entire trial were larger in CP3 than in the other groups, and trunk flexion was larger in CP2 than in TD. Trial time increased with GMFCS-level. Less trunk rotation than TD and CP1 reflects spatial insecurity in CP2, which in CP3 is compensated by the walker. The flexed head and trunk in CP3 and trunk in CP2 may reflect deficits in proprioception and sensation requiring visual control of the lower limbs.

This study evaluated the contributions of various prenatal and postnatal predictive factors to a documented high prevalence of ophthalmological abnormalities in children aged 6.5 years who were born extremely preterm. We carried out a prospective population-based study of all children born in Sweden at a gestational age of 22 + 0 to 26 + 6 weeks based on the Extremely Preterm Infants in Sweden Study. The main outcome measures were a combined score of visual impairment, refractive errors and strabismus at 6.5 years of age. Models of univariate and multivariable regression were used to analyse potential prenatal and postnatal predictive factors at different clinically relevant time-points from one minute after birth to 30 months. We focused on 399 known extremely preterm survivors and compared them to 300 full-term controls. Significant antecedents for ophthalmological abnormalities included prematurity per se , retinopathy of prematurity that required treatment, severe bronchopulmonary dysplasia and cerebral palsy. Severe intraventricular haemorrhage was no longer a significant risk factor when we adjusted it for the 30-month cognitive and neuromotor development outcomes. This time-course risk analysis model showed a changing panorama of significant risk factors for ophthalmological abnormalities in children aged 6.5 years who were born extremely preterm.

This study aimed to explain the relationship between visual-motor integration (VMI) abilities and extremely preterm (EPT) birth, by exploring the influence of perinatal variables, cognition, manual dexterity and ophthalmological outcomes. This was part of the population-based national Extremely Preterm Infant Study in Sweden (EXPRESS) study. We studied 355 children, born at a gestational age of <27 weeks from April 2004 to March 2007, and 364 term-born controls. At six-and-a-half years of age, we assessed VMI, cognitive function, motor skills and vision. VMI impairment was classified as <−1 standard deviation (SD). The mean (SD) VMI score was 87 (±12) in preterm children compared to 98 (±11) in controls (p < 0.001). VMI impairment was present in 55% of preterm infants and in 78% of children born at 22–23 weeks. Male sex and postnatal steroids showed a weak association with poorer visual-motor performance, whereas low manual dexterity and cognitive function showed a stronger association. Poor VMI performance was common in this EXPRESS cohort of children born EPT. Its strong association to cognition and manual dexterity confirms that all of these factors need to be taken into account when evaluating risks in preterm born children.

Objectives This exploratory study aimed to investigate associations between neonatal brain volumes and visual–motor integration (VMI) and fine motor skills in children born extremely preterm (EPT) when they reached 6½ years of age. Setting Prospective population-based cohort study in Stockholm, Sweden, during 3 years. Participants All children born before gestational age, 27 weeks, during 2004–2007 in Stockholm, without major morbidities and impairments, and who underwent MRI at term-equivalent age. Main outcome measures Brain volumes were calculated using morphometric analyses in regions known to be involved in VMI and fine motor functions. VMI was assessed with The Beery-Buktenica Developmental Test of Visual–Motor Integration—sixth edition and fine motor skills were assessed with the manual dexterity subtest from the Movement Assessment Battery for Children—second edition, at 6½ years. Associations between the brain volumes and VMI and fine motor skills were evaluated using partial correlation, adjusted for total cerebral parenchyma and sex. Results Out of 107 children born at gestational age <27 weeks, 83 were assessed at 6½ years and 66/83 were without major brain lesions or cerebral palsy and included in the analyses. A representative subsample underwent morphometric analyses: automatic segmentation (n=34) and atlas-based segmentation (n=26). The precentral gyrus was associated with both VMI (r=0.54, P=0.007) and fine motor skills (r=0.54, P=0.01). Associations were also seen between fine motor skills and the volume of the cerebellum (r=0.42, P=0.02), brainstem (r=0.47, P=0.008) and grey matter (r=−0.38, P=0.04). Conclusions Neonatal brain volumes in areas known to be involved in VMI and fine motor skills were associated with scores for these two functions when children born EPT without major brain lesions or cerebral palsy were evaluated at 6½ years of age. Establishing clear associations between early brain volume alterations and later VMI and/or fine motor skills could make early interventions possible.

Aim: This study evaluated the contributions of various prenatal and postnatal predictive factors to a documented high prevalence of ophthalmological abnormalities in children aged 6.5 years who were born extremely preterm. Methods: We carried out a prospective population-based study of all children born in Sweden at a gestational age of 22 + 0 to 26 + 6 weeks based on the Extremely Preterm Infants in Sweden Study. The main outcome measures were a combined score of visual impairment, refractive errors and strabismus at 6.5 years of age. Models of univariate and multivariable regression were used to analyse potential prenatal and postnatal predictive factors at different clinically relevant time-points from one minute after birth to 30 months. Results: We focused on 399 known extremely preterm survivors and compared them to 300 full-term controls. Significant antecedents for ophthalmological abnormalities included prematurity per se, retinopathy of prematurity that required treatment, severe bronchopulmonary dysplasia and cerebral palsy. Severe intraventricular haemorrhage was no longer a significant risk factor when we adjusted it for the 30-month cognitive and neuromotor development outcomes. Conclusion: This time-course risk analysis model showed a changing panorama of significant risk factors for ophthalmological abnormalities in children aged 6.5 years who were born extremely preterm.

Purpose: To assess the macular thickness in 6.5-year-old children born extremely preterm (EPT) in comparison with children born at term and to investigate risk factors associated with the macular thickness in the preterm group. Methods: A population-based study of 6.5-year-old children born before the gestational age of 27 weeks and age-matched control subjects. Macular assessments with optical coherence tomography were performed, and the results were compared with neonatal risk factors and sex. Results: Adequate optical coherence tomography measurements were obtained from 134 children born EPT (mean gestational age of 25 weeks [range 23–26]) and 145 control subjects. The mean (range) of central macula thickness was significantly increased (P < 0.001) in the EPT group (right eyes: 282 μm [238–356], left eyes: 283 μm [229–351]), compared with the control group (right eyes: 249 μm [208–293], left eyes: 248 μm [207–290]). A multiple linear mixed model analysis of the EPT group revealed gestational age, retinopathy of prematurity, and male gender as important risk factors for an increased macular thickness. The macular thickness decreased by 3.9 μm per gestational week, when adjusted for retinopathy of prematurity and sex. Conclusion: Extremely preterm birth constitutes a substantial risk factor for a thick central macula, even when adjusted for retinopathy of prematurity and male gender.

In this issue of Acta Paediatrica, Professor Alex Levin, Director of the Pediatric Ophthalmology and Strabismus Service at Wills Eye Hospital (PA, USA), expresses relevant concerns 1 about a report produced by the Swedish Agency for Technology Assessment of Health and Social Services (SBU) 2 and summarised in a paper by Lynøe et al. 3. He also provides necessary input on the importance of the morphology and distribution of retinal haemorrhages in diagnosing different causes of retinal bleedings. SBU undertakes independent assessments of methods used in health, medical, dental and social services and services provided to persons with certain functional disabilities. In a recently published report, SBU evaluated the hypothesis that a triad of subdural haematoma, retinal haemorrhages and encephalopathy is always caused by traumatic shaking and concluded that there is insufficient evidence to support such hypothesis 2, 3. For paediatricians, paediatric ophthalmologists and radiologists caring for infants who are admitted to hospital with seizures, coma or other serious symptoms and are found to have subdural haematoma and retinal haemorrhages, it is well known that these signs may have various aetiologies of which one is shaking. Possible abuse must be considered if the history taking, laboratory results and radiological investigations fail to identify alternative causes. The SBU report concludes that there is only limited evidence that shaking of an infant can cause the triad signs, in contrast with the numerous reports describing such lesions in victims of verified shaking. It is unfortunate that the SBU panel neither included a paediatrician nor a paediatric ophthalmologist with experience of child abuse to facilitate a correct interpretation of the cited papers. The SBU report recommends ambitious research programmes which will take many years to perform and which will never reveal the true probability that an infant with certain signs and symptoms has been shaken given the difficulties in proving that shaking has occurred. The report offers no recommendations on how to handle infants with the above-mentioned signs. It is already evident to those caring for these infants that not all cases with the triad signs have been shaken. So what are the implications of this report for our patients, their parents and caregivers? If it is considered questionable that shaking may cause brain and eye haemorrhages, should we then refrain from reporting such cases to social authorities? Is it the opinion of SBU that no investigations of possible child abuse should be performed in cases with these signs, when medical work-up has failed to find an alternative plausible aetiology? The authors of the SBU report are concerned about the risk of overdiagnosing shaken baby syndrome, due to a presumed biased view among the medical professions that the triad signs always result from shaking. We do not share this concern, and we do not acknowledge that such a bias exists. The alternative aetiologies for the triad signs are well known to experienced paediatricians and paediatric ophthalmologists. Professor Alex Levin is right to be concerned about this report 2. In addition, he provides necessary input on the importance of morphology and distribution of retinal haemorrhages in the differential diagnoses between different causes of retinal bleedings. To miss a diagnosis of child abuse can result in continued trauma and even death.