bmj.com Rapid Responses for Geddes and Plunkett, 328 (7442) 719-720

Rapid Responses to:

EDITORIALS:
J F Geddes and J Plunkett
The evidence base for shaken baby syndrome
BMJ 2004; 328: 719-720 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

will anyone listen now?: s m latta (26 March 2004)

The Problem As I See It: John A Vater (27 March 2004)

It is about time: Lois Herlihy (27 March 2004)

There is a Light at the End of the Tunnel: Belinda A Moran (28 March 2004)

Re: The Problem As I See It: CA Johnson (28 March 2004)

Re: It is about time: Debbie A. Grater (29 March 2004)

Optimal evaluation of suspicious head injury in infants and young children: terence g donald (29 March 2004)

another facet of the nanny state exposed: Chris Destree (29 March 2004)

SBS Persecution: Lisa M Mullenax (1 April 2004)

Re: Optimal evaluation of suspicious head injury in infants and young children: Heather Lohr (1 April 2004)

The evidence base for shaken baby syndrome: C. Alan B. Clemetson, M.D., New Orleans, Louisiana 70125 (6 April 2004)

Shaken baby syndrome or another diagnosis?: Anne Marie Oudesluys-Murphy, Annemarie van Rossum (7 April 2004)

Retinal haemorrhages remain an important physical sign in the diagnosis of non accidental injury: Michael P clarke, Professor David S.I. Taylor, Professor Gordon Dutton, Ian Christopher Lloyd, Brian Fleck, Lucilla Butler, Richard Bonshek. (Members of Ophthalmology Child Abuse Working Party) (11 April 2004)

Retinal haemorrhages and SBS. Fact or Fantasy?: Michael D Innis (13 April 2004)

Re: Retinal haemorrhages remain an important physical sign in CONJECTURING the diagnosis of non accidental injury: L. Travis Haws (13 April 2004)

The Editorials on shaken baby syndrome, BMJ 27th March 2004: Jeanne E Bell, James Lowe (19 April 2004)

Re: The Editorials on shaken baby syndrome, BMJ 27th March 2004: Michael Innis (20 April 2004)

Refuting established medical beliefs also requires evidence: Timothy Jaspan, Richard Bonshek, Norman McConachie, Jonathan Punt, Nina Punt, Jane Ratcliffe (20 April 2004)

Potential problems with autopsy based studies.: Hilary Butler (22 April 2004)

Re: Refuting established medical beliefs also requires evidence: Heather Lohr (22 April 2004)

Re: Re: Refuting established medical beliefs also requires evidence: Michael D Innis (23 April 2004)

Re: The appliance of science?: Michael P Mackey, N/A (24 April 2004)

Re: Refuting established medical beliefs also requires evidence: Michael D Innis (27 April 2004)

Re: Refuting established medical beliefs also requires evidence: Mark Struthers (28 April 2004)

Re: Refuting established medical beliefs also requires evidence--seeing the vast amounts of evidence requires glasses on an open mind: L. Travis Haws (23 May 2004)

"Shaken Baby", or Barlow's Disease Variant?: C. Alan B. Clemetson, M.D., New Orleans, LA 70125 (19 June 2004)

Clemetson Syndrome: F. Edward Yazbak (23 June 2004)

Re: "Shaken Baby", or Barlow's Disease Variant?: abram hoffer (24 June 2004)

Patience instead of Anger and Condemnation: Dr. Herbert H. Nehrlich (25 June 2004)

K comes after C and H in SBS: F. Edward Yazbak (25 June 2004)

Clemetson's work: Keith B Taylor (5 July 2004)

Re: Clemetson's work: Michael D Innis (6 July 2004)

Re: Clemetson's work: Theo H Fenton (6 July 2004)

Re: Re: Clemetson's work: Hilary Butler (7 July 2004)

Re: Re: Clemetson's work: Heather Lohr (7 July 2004)

Re: Re: Clemetson's work: C. Alan B. Clemetson, M.D. (7 July 2004)

Re: Re: Clemetson's work: Michael D Innis (7 July 2004)

Please tell me that was a joke: L. Travis Haws (7 July 2004)

Re: Re: Re: Clemetson's work: Ed Cooper (8 July 2004)

Re:Re:Re:Re: Clemetson's Work: C. Alan B. Clemetson, M.D. (9 July 2004)

Clemetson's work is not at the end of a mouse.: Hilary Butler (9 July 2004)

Re: Re: Re: Re: Clemetson's work: Michael D Innis (9 July 2004)

Re: Re:Re:Re:Re: Clemetson's Work: Ed Cooper (14 July 2004)

Ed Cooper's response: John Stone (16 July 2004)

Subdural Haemorrhage/Effusion � are low velocity falls or other minor impacts to the head a factor in the aetiology?: Chris J Hobbs, Anne-Marie Childs (7 August 2004)

Re: Subdural Haemorrhage/Effusion - misdignosed: Michael D Innis (9 August 2004)

�Shaken baby� conviction overturned. The case of Alan Yurko: Mark Struthers (7 September 2004)

Re: �Shaken baby� conviction overturned. The case of Alan Yurko: Andrew L. Schlafly (8 September 2004)

Re: Re: �Shaken baby� conviction overturned. The case of Alan Yurko: Heather Lohr (9 September 2004)

Re: Subdural Haemorrhage/Effusion � are low velocity falls or other minor impacts to the head a factor in the aetiology?: L. Travis Haws (14 September 2004)

Re: Re: Re: Clemetson's work: Michael D Innis (14 September 2004)

The case of Alan Yurko - A clarification: Anthony R Cox (16 September 2004)

Re: The case of Alan Yurko - A clarification: Mark Struthers (17 September 2004)

Toxic histaminaemia: C. Alan B. Clemetson, M.D. (28 September 2004)

the current evidence base - make believe?: Heather Lohr (12 October 2004)

Re: the current evidence base - make believe?: L. Travis Haws (13 October 2004)

A sacrificial lamb on the vaccination altar?: Jenny L Robertson (13 October 2004)

Re: A sacrificial lamb on the vaccination altar?: Michael D Innis (14 October 2004)

Subdural haematomas in infants: C. Alan B. Clemetson, M.D. (22 October 2004)

Re: Errors in the diagnosis of child abuse: Michael D Innis (10 December 2004)

Errors in the diagnosis of child abuse: C. Alan B. Clemetson, M.D. (21 December 2004)

Has any progress been made?: Heather Lohr (31 March 2005)

Re: Has any progress been made?: Michael D Innis (1 April 2005)

will anyone listen now? 26 March 2004

s m latta,
director
po16
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Re: will anyone listen now?

It is long overdue these issues were raised. Shaken baby syndrome or is it now known as shaken impact baby syndrome? was seen for what it is a lot of opinion will very little scientific basis.
We are told it is made up of three medical signs. Retinal bleeding, brain bleeding and fractures and or any other physical signs of abuse.
Retinal bleeding has long been known to be caused through many reasons one of which is abuse. Birth trauma, hematological problems, short falls, lack of oxygen are others but not all.
Bleeding to the brain, lack of oxygen, birth trauma,falls and abuse are just a few reasons for this that are at present known. This is an area of which a lot more investigation needs to be implimented prior to pointing the finger of abuse. It is simply not known just how great a force of shaking is required to caue bleeding to the brain.
Fractures- It is not know what force is required to cause fractures in babies. In court we have heard by selfmade radiological court experts that is is a force that amounts to the same as an adult standing or stamping on a baby. Said many times but i have yet to find the scientifict or medical papers to back this up. A number of clinical non abuse reasons can be found for calcificaton on bones. It has been known that radiologists will say that fractures cannot be caused through CPR and later have pathologists say that this is possible (T Patel Trial). It has also been known that radiologists will find fractures, parents charged, children taken into care and then later it is found that there were in fact no fractures. Charges dropped and children returned.
The simple fact is that there is simply not enough known about shaken baby syndrome. Not enough to send people to prison off the back of it.
The protection of children is paramount, this must include the protection of emotional well being, false accusations and the effects of this on a family must also be taken into account.
Police, social services and the medical world need to look at each case with open eyes. Medical history and family background must all be looked at in detail prior to pointing the finger of abuse.
Is it helpful that training CD roms are used on how to prosecute parents for SBS, these are used by social services and the police. This simply can not be right, each case needs to be looked at. The death of a baby when the parents can not explain why is no reason to think murder first rather than anything else off of the back of the SBS thinking that can not back itself up with science.
If other reasons are the cause of ill health or death then lets get some funding into finding why, to avoid ill health or death.
Child abuse is a sad reality and this is not lost on me, i just think that it is easy to say a set of symptoms are abuse when it is clear that medicine still has many grey areas. The above are just three of them.
Competing interests: None declared

The Problem As I See It 27 March 2004

John A Vater,
Barrister
2, Harcourt Buildings, Temple, London
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Re: The Problem As I See It

Clearly some parents shake their children. Clearly some parents inflict serious impact injuries upon their children. In both circumstances, we know that sdh and retinal haemorrhages are likely consequences. My concern is this:
1) Just because we know that, in the absence of very significant impact, shaking can cause these injuries, it does not follow, as a matter of logic as much as anything else, that whenever we see these injuries there must be a shaking component in the absence of a history of very significant impact, accidental or otherwise;
2) It seems probable that a number of children can suffer sdh and retinal haemorrhages which go undetected, and resolve without further complication. That must be so if it is right that symptoms of these injuries are sometimes non - specific. In my job I very frequently hear pathologists say that they find sdh in children at post - mortem which were not contributory to death and were previously occult;
3) We think we know that shaking produces the rotational forces required to cause sdh. What we do not know (and cannot know in view of 2)) is what other mechanisms can cause the requisite rotational forces;
4) I remain unclear as to what causes retinal haemorrhage in these shaking cases. If (as would seem likely to me as a poor, ignorant lawyer) the most likely cause is also rotational forces (and it is a matter of common sense that some shakes whilst causing sdh will not cause retinal haemorrhages, just as, as a matter of common sense, there will be some shakes that cause neither injury), then 3) applies;
5) It seems to me (again, through a glass darkly) that it must follow there is a real possibility that these injuries can be caused by other events, perhaps creating rotational forces, perhaps not. Some of these injuries will go undetected, some of them will not. The problem with the injuries which are detected is that, even if a parent has an explanation for it, in the current climate that explanation is unlikely to be accepted unless it involves very significant impact and/or a shaking component. As a consequence, a Court is likely to find, on the medical evidence alone (since as a matter of law a Court is not permitted to believe a parent in preference to a doctor in these circumstances)that the injuries were caused by shaking, and that case becomes another statistic which is used in other cases in support of the shaking theory;
6) The protestation one often hears that the wards would be full of children with sdh and retinal haemorrhage if they were caused other than by shaking or serious impact just isn't a valid one. That has to be so where it is likely that there are children in whom these injuries go undetected, and it must be so where the likelihood is that, where the injuries are detected, a parent's story is unlikely to be believed in the absence of serious impact and/or shaking;
7) All too often, one finds doctors not even considering whether an explanation proffered by a parent might have created the necessary forces because it does not involve a shaking component. That is quite the wrong approach (which should be: what happened in this case? Not: because in the other hundred cases I have done there was a shake therefore this too must be a shake) and is based on what is, in the absence and impossibility of experimentation on babies and in view of the above, an article of faith which is as susceptibe to proof and reason as a belief in God;
8) Watching doctors squabble is a seriously unedifying sight which I have witnessed a number of times in the context of these cases. The disrespect with which non "orthodox" views are treated (from certain physicians on the one hand to pressure groups on the other) is both surprising and unnecessarily defensive. The same is true of the increasing complaint that doctors will simply give up as expert witnesses: in the Court arena the only reason for fear is if an opinion is based more on dogma than good science.
My real fear, as a specialist member of the family Bar, is that there is increasing polarisation in the various views about how these injuries are caused. The job of the Court is to decide cases on the best evidence. If the best evidence is to become based upon dogma, either way, then the real losers will be children: some deliberately harmed and removed from their parents, others not deliberately harmed and still removed from their parents. More seriously, there will be children who suffer because NAI has gone undetected and/or unproved. Frankly, I don't care for the sort of rather bad tempered rivalry I see when this topic arises for discussion, or when I go to lectures or seminars. I don't care for incidents of shaking being rather emotively described as "attacks" upon children (as I heard more than once today in a seminar on the topic). I don't care for the press being "banned" from the lecture I went to today because of the fear that the reporting would not be balanced (why not invite them for free, especially in view of the sensationalism of the last few months?) What I do care about, however, is putting a Court in the right position to take critical decisions about the future of children, whichever side of a case I happen to represent. That involves a debate of a number of competing interests. In these sorts of cases we are utterly dependent upon objective medical advice and opinion: that in turn depends upon hearing all sides of every argument.
Competing interests: None declared

It is about time 27 March 2004

Lois Herlihy,
none
33029
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Re: It is about time

All of us living this nightmare are grateful for professionals who devote their work to helping the wrongfully accused and convicted. I have spent a lot of time reviewing this article as well as the other ones in this issue. We have lived with this since 2000 and will continue to do so until the US government looks into this bogus diagnosis and theory. thank you for this eye opening article
Competing interests: None declared

There is a Light at the End of the Tunnel 28 March 2004

Belinda A Moran,
parent
10221 Goldenbrook Way, Tampa,Florida USA 33647
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Re: There is a Light at the End of the Tunnel

As Richard Clark stated We failed the victims of 911. The victims of false allegations of SBS have also been failed by the medical profession, law enforcement, and child protective services. There is an absolute rush to accuse rather than seek differential diagnosis as the cause of the infant's illness. They can ruin your life in two minutes and are not even held accountable for their erroneous findings! The money that was spent on our defense would have been better spent on our son's rehabilitation. What a waste of money on some doctor's lack of experience, ego, or just plain stupidity!
Competing interests: None declared

Re: The Problem As I See It 28 March 2004

CA Johnson,
Parent
LA9
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Re: Re: The Problem As I See It

John A Vater's letter echoes many of my own concerns. I would like to pick up just one line and run with it:
"... as a matter of law a Court is not permitted to believe a parent in preference to a doctor in these circumstances."
Bear with me while I think out of the box for a moment. Why is this so? Why is the word of a parent, who may have witnessed the incident which caused a child's injury with their own eyes, and who knows for certain whether they abused their child or not, considered less valid than the opinion of a doctor who did not see the incident and relies on mere interpretation?
I know that people sometimes lie. The point is that people also tell the truth, and interpretative opinions can be quite wrong. Is it a measure of the courts' quasi-religious view of medical science that the opinion of an expert witness carries *more* weight than the word of a witness of fact.
Even more, the opinion of the expert witness also outweighs the family's medical history, support of friends, neighbours and relatives, and evidence of a normal, non-abusive home.
It must be a measure of the law's deference to science that police, social services and courts take this view. If so, perhaps the medico-legal system is lagging behind a more general feeling that scientific interpretations should be regarded with more skepticism. Society does not defer as it once did. Good science tries to break its own theories, and the public better understands this now. Scientific dogma is of no more value than religious dogma, and far less reliable than the word of an average parent and citizen. Perhaps we should scrutinize our expert witnesses to see they have not become a paid priesthood instead.
Competing interests: None declared

Re: It is about time 29 March 2004

Debbie A. Grater,
none
19464
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Re: Re: It is about time

I want to say thank you to these doctors who are defending us against these false allegations.This article is great!! I have been researching many articles since I became a victim of these false allegations in 2000.
I hope now that people wake up and realize this is shaken baby syndrome is just a theory and has never been proven to be a true medical diagnosis.
Competing interests: None declared

Optimal evaluation of suspicious head injury in infants and young children 29 March 2004

terence g donald,
Paediatric Forensic Physician, Head Child Protection Unit
women's & Children's Hospital, Adelaide, South australia
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Re: Optimal evaluation of suspicious head injury in infants and young children

Editor- The case report �Perimacular retinal folds from childhood head trauma� reported by Lantz et al1 is important to both publish and comment upon.
In my view, from what they have presented, the authors are quite correct in condemning those who asserted that the child had been a victim of the �shaken baby syndrome�.
Cases such as this are important to report because they help accurately establish the patterns of injury which may result from known mechanisms. However,the case report still falls short of the ideal, which is to have an incident of injury reported by an independent person by whom it has been witnessed. This case had no such witness but there was sufficient information available from the site visit and analysis to support the view that the child had almost certainly suffered the fatal head injury from the television falling onto his head. Such extensive site visits and reconstructions of events are far too rare in the investigation of injury, even when the injury may have been inflicted. Site evaluations may, as in the reported case, provide essential information to the forensic physician whose opinion assists the police and, in child protection cases, the statutory welfare agency investigation.
Before the publication of this case report perimacular folds or traumatic retinoschisis (which remains a rare finding) had only been described in infants and young children who were considered to have been victims of child abuse, predominantly the �shaken baby syndrome�(references cited by Lantz et al1). The evidence base that does exist in relation to perimacular folds or traumatic retinoschisis, as referenced by Lantz et al is that such an ocular condition only results from severe trauma involving high forces. Such severe trauma has been considered, by some, to only occur to infants who have been shaken. This case report supports the severe trauma hypothesis but can�t discount that shaking may produce an equivalent level of intracranial damage.
Unfortunately there is often an inadequate level of rigor in reaching the diagnosis of the shaken baby syndrome. For example, the diagnosis of the shaken baby syndrome often seems to be based solely on the presence of extensive retinal haemorrhages and recent subdural haematomas. There is no attempt made in many cases to follow a systematic diagnostic approach, suitable for forensic purposes, or to seek out and evaluate the material available from site assessments and police interviews. Clearly this is not good practice, and the diagnosis in such cases is unlikely to withstand a vigorous challenge in court.
The comment by Geddes and Plunkett on the Lantz et al case report states that those diagnosing the 'shaken baby syndrome' often ignore the 'short distance fall literature' (particularly the work of Plunkett3) and the �morphologically minor� structural damage found in the brain of �abused infants who die� (Geddes� work4,5). However, the fact that infants and young children do experience unexplained life threatening head injury of suspicious aetiology, is not addressed by them.
Plunkett�s study �Fatal pediatric head injuries caused by short- distance falls�3 clearly demonstrated that children have died after falling a short distance, but the forces were still high. It is inappropriate, based on that study, to argue that a baby could suffer a fatal head injury from rolling off a bed from 35 cms, but that is the implication in the editorial. Plunkett�s study does support more thorough investigation of unexplained or suspicions head injury in infants and young children, but as mentioned in the second editorial (Harding, Risdon and Krous6), none of the head injury victims in that study were less than 12 months of age, which is when inflicted head injury is most common.
Also, the Geddes and Plunkett2 editorial fails to mention that just under one third of infants who were subsequently considered to have evidence of abusive head trauma had no history of head injury provided at their initial presentation, and their condition was initially mis- diagnosed7. This means that in one third of cases the carers either didn�t know or were not telling what happened to their child. How would Geddes and Plunkett incorporate this information into their editorial without suggesting that such injuries occur spontaneously?
Geddes�4,5 work, which is also quoted in the first editorial, asserts that �neuropathological studies have shown that abused infants do not generally have severe traumatic brain injury and that the structural damage associated with death may be morphologically mild�. However, review of the original paper reveals that the cases Geddes studied were identified as victims of inflicted head injury most often by a multidisciplinary case conference. None were identified by the account of an independent witness. In other words who knows what percentage of the study group had actually suffered inflicted head injury? This does not discount the value of the neuropathological observations reported by Geddes but it throws serious doubt on her conclusions which relate the neuropathology to inflicted head injury.
I suggest that the main issue which arises from the Lantz et al case report and the two editorials is whether there is any useful purpose served in the continued use of the diagnosis �shaken baby syndrome�? The question in such cases is not �Has this baby been shaken?' but �What mechanism(s) could have caused the injury patterns present and are those mechanisms accounted for by the explanation provided (by either carer or witness)?'.
I believe that the task that has to be addressed in infants and young children who present with �(an) acute encephalopathy, with subdural and retinal haemorrhages, occurring in a context of inappropriate or inconsistent history and commonly accompanied by other apparently inflicted injuries� (Editorial, Harding, Risdon and Krous6) is to ensure that an optimal forensic assessment occurs. This includes establishing the full range of injuries, both overt and covert, that involve the head and brain as well as the limbs, trunk and skeleton. The assistance of the police is necessary to ensure that any explanation provided can be followed up and if possible validated. Also, police involvement ensures that injury site visits are properly conducted.
This approach ensures that mis-diagnosis or incorrect attribution of physical and investigation findings to an inflicted cause, including the �shaken baby syndrome� are minimised.
1. Lantz P, Sinai S, Stanton C, Weaver R. Perimacular retinal folds from childhood head trauma: Case report with critical appraisal of current literature. BMJ 2004;328: 754-6.
2. Geddes J F, Plunkett J The evidence base for shaken baby syndrome. BMJ 2004 328: 719-720.
3. Plunkett J. Fatal pediatric head injuries caused by short-distance falls. Am J Forensic Med Pathol 2001;22: 1-12.
4. Geddes JF, Hackshaw AK, Vowles GH, Nickols CD, Whitwell HL. Neuropathology of inflicted head injury in children. I. Patterns of brain damage. Brain 2001;124: 1290-8.
5. Geddes JF, Vowles GH, Hackshaw AK, Nickols CD, Scott IS, Whitwell HL. Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants. Brain 2001;124: 1299-306.
6. Harding B, Risdon RA, Krous HF. Shaken baby syndrome. BMJ 2004 328: 720-721.
7. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. JAMA. 1999 Feb 17;281(7):621-6. Erratum in: JAMA 1999 Jul 7;282(1):29
Competing interests: None declared

another facet of the nanny state exposed 29 March 2004

Chris Destree,
staff grade a&E
winchester
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Re: another facet of the nanny state exposed

the creation of ill defined "syndroms" is all the rage in order to justify ever more intrusions into people's privacy by the state. the pharmaceutical industry created "female sexual dysfnction" in order the sell more viagra and the creation of "shaken baby syndrom" is nothing but an attempt to create a raison d'etre for nosy social workers. all in an attempt to justify nanny state interference - and the waste of funds on these people, of course. gladly this one has been exposed for what it is - a lot more still have to be exposed.
Competing interests: None declared

SBS Persecution 1 April 2004

Lisa M Mullenax,
Educator
16131
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Re: SBS Persecution

We are blessed to have physicians like Dr. Geddes and Dr. Plunkett. False accusations of Shaken Baby Syndrome are becoming commonplace in our society today. As a result, numerous innocent child carers are being wrongly accused and convicted. Children are being victimized and stripped away from the family unit. Incompetent treating physicians rapidly skirt from their blatant medical malpractice. I know this from personal experience.
It is time that this 'junk science' be exposed for what it truly is. There are numerous physicians that have tirelessly dedicated their time assisting those falsely accused of these heinous SBS allegations. To these special doctors, we can not praise enough. They are the noble physicians who are truly making a difference. These honorable physicians are not afraid to go against the status quo. Instead, they seek the TRUTH and question a theory that has no validity behind it. They recognize that numerous innocent families are being routinely victimized due to lack of thorough medical investigation. I commend these physicians, scientists, and bio-mechanic experts for their dedication. They will never fully know how much their work means - especially to the falsely accused and their families.
Competing interests: Falsely Accused

Re: Optimal evaluation of suspicious head injury in infants and young children 1 April 2004

Heather Lohr,
parent
16652
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Re: Re: Optimal evaluation of suspicious head injury in infants and young children

"However, review of the original paper reveals that the cases Geddes studied were identified as victims of inflicted head injury most often by a multidisciplinary case conference. None were identified by the account of an independent witness. In other words who knows what percentage of the study group had actually suffered inflicted head injury?"
Excuse me, but the lack of an independent witness to verify inflicted head trauma has not stopped thousands of allegations of child abuse by doctors. How many cases of shaken baby syndrome come complete with a independent witness? Is this the criteria for the diagnosis of inflicted head trauma? Or does this standard only apply when trying to invalidate Geddes study?
I know of one independently witnessed case of shaken baby syndrome. It wasn't witnessed by a human who could be prone to emotion, etc. It was witnessed by a hidden video camera and was flashed across the news media throughout the United States. Find this baby and do a study on the traumatic brain injuries suffered. If you can find any. This was after all a textbook demonstration of the biomechanics of SBS. Funny thing is this child had NO INJURIES by report.
I can't believe the implication that Geddes study might not be valid because of the lack of an independent witness. Perhaps the same conclusion could be reached for the diagnosis of Shaken Baby Syndrome. It is after all an untested, unproven, unwitnessed hypothesis.
Thank you Dr. Geddes and Dr. Plunkett for bringing attention to the controversy surrounding this diagnosis.
Competing interests: None declared

The evidence base for shaken baby syndrome 6 April 2004

C. Alan B. Clemetson, M.D.,
Professor Emeritus, Tulane University School of Medicine
5844 Fontainebleau Drive,
New Orleans, Louisiana 70125
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Re: The evidence base for shaken baby syndrome

It is gratifying to know that more and more paediatricians, neurologists, ophthalmologists, and pathologists are questioning the tenet that retinal petechiae and subdural haemorrhages are always indicative of child abuse, or shaken-baby syndrome.
It is, however, disturbing to note that few, if any, of these physicians seem to be interested in considering the possibility of capillary fragility in these infants. They do not even deem it necessary to estimate blood histamine and plasma ascorbic acid levels, which may often provide the correct diagnosis.
See Clemetson, C.A.B. Barlow's disease. Medical Hypotheses 2002;59:52 -56.
Competing interests: None declared

Shaken baby syndrome or another diagnosis? 7 April 2004

Anne Marie Oudesluys-Murphy,
consultant paediatrician
Medisch Centrum Rijnmond-Zuid, 3075 EA, Rotterdam , The Netherlands,
Annemarie van Rossum
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Re: Shaken baby syndrome or another diagnosis?

We read the recent papers and editorials on the shaken baby syndrome with great interest (1,2,3). These discuss the possible aetiology of this disorder, but fail to address the differential diagnoses which need to be taken into account when confronted with a baby with the findings of acute encephalopathy accompanied by subdural and retinal haemorrhages. In view of not only the medico-legal, but also the diagnostic and possible therapeutic aspects, we wish to draw attention to other disorders which may mimic the shaken baby syndrome.
In the first place coagulation disorders may have a similar presentation (4). They need to be investigated and, if present, treated urgently. A second disorder which may present in an identical manner to the shaken baby syndrome is hemophagocytic lymphohistiocytosis (HLH) (5,6). In a recent article Rooms et al. (5) report 3 cases showing that presentation of this disorder may be indistinguishable from the shaken baby syndrome. This rare disorder is caused by an abnormal proliferation of histiocytes in tissues and organs. It usually presents with fever, hepatosplenomegaly, pancytopenia, hypertriglyceridemia and coagulation disorders. However, it may also present with central nervous system manifestations ranging from irritability to encephalopathy and coma.
Clinical findings include retinal and intracranial haemorrhages. When untreated this disorder is fatal. Optimal treatment consists of allogeneic bone marrow transplantation and cytotoxic and immunosuppressive therapy.
The presence of anaemia, thrombocytopenia, abnormal liver enzymes and hepatosplenomegaly as well as coagulation disorders should raise suspicions of HLH. More extensive investigations including bone marrow aspiration, T2 weighted MRI scan of the brain, triglyceride and serum ferritine levels will be necessary to confirm the diagnosis.
As shown in the papers and ensuing correspondence in your journal, the impact for all concerned, of the diagnosis of shaken baby syndrome is enormous (7,8). Therefore it is essential that other possible causes are eliminated before this diagnosis is pronounced.
1. Geddes JF, Plunkett J. The evidence base for shaken baby syndrome. BMJ 2004;328:719-720
2. Harding B, Risdon RA, Krous HF. Shaken baby syndrome. BMJ 2004;328:720- 721
3. Lantz PE, Sinal SH, Stanton CA, Weaver Jr RG. Perimacular retinal folds from childhood head trauma. BMJ 2004;328:754-756
4. Vorstman EB, Anslow P, Keeling DM, Haythornwaite G, Bilolikar H, McShane MT. Brain haemorrhage in five infants with coagulopathy. Arch Dis Child 2003; 88: 1119-21
5. Rooms L, Fitzgerald N, McClain KL. Hemophagocytic lymphohistiocytosis masquerading as child abuse: presentation of three cases and review of central nervous system findings in hemophagocytic lymphohistiocytosis. Pediatrics 2003;111:e636-40
6. Hallahan AR, Carpenter Pa, O�Gorman�Hughes DW, Vowels MR, Marshall GM. Haemophagocytic lymphohistiocytosis in children J. Paediatr Child Health 1999; 35: 55-9
7. Minns RA, Busuttil A. Four types of inflicted brain injury predominate. BMJ 2004;328:766
8. LeFanu J, Edwards-Brown R. Subdural and retinal haemorrhages are not necessarily signs of abuse. BMJ 2004;328:767
Competing interests: None declared

Retinal haemorrhages remain an important physical sign in the diagnosis of non accidental injury 11 April 2004

Michael P clarke,
Reader in Ophthalmology
University of Newcastle upon Tyne,
Professor David S.I. Taylor, Professor Gordon Dutton, Ian Christopher Lloyd, Brian Fleck, Lucilla Butler, Richard Bonshek. (Members of Ophthalmology Child Abuse Working Party)
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Re: Retinal haemorrhages remain an important physical sign in the diagnosis of non accidental injury

The Ophthalmology Child Abuse Working Party has produced guidelines about the significance of retinal haemorrhages as a clinical sign in the diagnosis of non accidental injury1, in which we pointed out the non-specific nature of retinal haemorrhages as an isolated clinical sign in infants with accidental injury, non-accidental injury and cases in which retinal haemorrhage is a feature of other pathology. A revised version of this guidance is in press. Physical abuse of infants occurs. Retinal haemorrhages remain a valuable physical sign in the diagnosis of abuse, but they are not pathognomonic and need to be evaluated in the context of other injuries. The circumstance of an infant who has sub-dural and retinal haemorrhage alone needs to be evaluated with caution, but despite media speculation2, there is little sound evidence that trivial trauma may result in profound changes in the brain and eye. Many such children many have evidence of other injuries, and most of these children have suffered severe trauma, but we agree that in the light of current evidence, it remains uncertain whether they all have. Measured, scientific debate in this field can be overwhelmed by emotional response and the criminal court processes involved in the prosecution of suspected abuse. The development of a classification which does not infer causation in the absence of sufficient proof is necessary. The terms 'Non-Accidental Injury' and 'Shaken Baby Syndrome' have been applied when a diagnosis of Child Abuse is suspected, but this may be taken to mean that the diagnosis is established. We propose that these terms should be reserved for use only after a case has been proven and that the following classification clarifies the situation in new cases of infants with brain and/ or retinal haemorrhage:- Category 1. Injury. - A. Cause established. B. Cause unknown. Category 2. Suspected injury Category 3. No injury (The clinical signs are due to other pathology.) It is essential that a correct differentiation between accidental injury, non-accidental injury and alternative diagnoses is established in every case.
1. Child abuse and the eye. The Ophthalmology Child Abuse Working Party. {Eye(1999);13:3-10} 2. http://www.bbc.co.uk/pressoffice/proginfo/pdfs/tv/week1 3/bbctvwk13_mon.pdf
Competing interests: The authors have served as paid expert witnesses in court cases relating to suspected non accidental injury.

Retinal haemorrhages and SBS. Fact or Fantasy? 13 April 2004

Michael D Innis,
Director Medisets International
Home 4575
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Re: Retinal haemorrhages and SBS. Fact or Fantasy?

Editor,
The Shaken Baby Syndrome (SBS) is receiving renewed attention by the Ophthalmology Child Abuse Working Party (OCAWP) deciding to develop new �guidelines� for the diagnosis of retinal haemorrhages associated with intracerebral haemorrhages.
The first essential of their endeavour should be to establish the validity of the diagnosis of SBS. Does such a condition exist or is it the diagnosis of those who �think dirty� when unable to explain a particular group of signs and symptoms in a child?
Of 21 cases of alleged child abuse sent to me for my opinion from four countries including the UK, USA and Australia, 16 had retinal, intracerebral and other haemorrhages with or without fractures.
All 16 were either vaccinated within 21 days of the onset of their symptoms or had documented evidence of a haemostatic, liver or nutritional disorder. All had a history of Apnoea at the onset of their symptoms.
If the OCAWP seek to guide the profession on the distinction between accidental and non-accidental retinal haemorrhages they must first document a SINGLE case of retinal haemorrhages associated with intracerebral haemorrhages that did not occur within 21 days of being vaccinated and had no evidence of a haematological, liver or nutritional disorder,
Since the authors declare they have served as expert witnesses in suspected non-accidental injury they will obviously have a number of cases upon which they can draw to produce just ONE ADEQUATELY INVESTIGATED CASE of SBS with none of the features mentioned above.
If between them they cannot produce a single case they should admit that the concept of Shaken Baby Syndrome is an aberration unworthy of inclusion in the Medical lexicon.
Michael D Innis MBBS; DTM&H; FRCPA; FRCPath.
Competing interests: I have served as a paid witness in court cases relating to suspected Non-accidental Injury.

Re: Retinal haemorrhages remain an important physical sign in CONJECTURING the diagnosis of non accidental injury 13 April 2004

L. Travis Haws,
Dentist
DFC 12860 West Cedar Drive Lakewood, CO 80228
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Re: Re: Retinal haemorrhages remain an important physical sign in CONJECTURING the diagnosis of non accidental injury

Editor: I believe Clarke et al. meant to say that retinal hemorrhages "remain" an important physical sign while using CONJECTURE to diagnose "non-accidental" injury, especially when there are no other signs of trauma. Then again, if one considers stretching of the periosteum or "traumatic" rib fractures that don't result in internal injuries or pain upon every breath (or pain elicited by palpation during numerous well and sick pediatric physical examinations) "signs" of trauma, then perhaps it is not conjecture, but is clear and defined???
Clarke et al. state that "despite media speculation2, there is little sound evidence that trivial trauma may result in profound changes in the brain and eye". Did they forget about the studies by Plunkett, Aoki and Masuzawa, Hall, Berney, Greenes and Schutzman, Di Rocco and Velardi, Canestri and Monzalli, Wissow and Wilson...(1,2,3,4,5,6,7,8�) Some of this "trivial" trauma was videotaped or witnessed by multiple witnesses. As well, some of these cases provided very detailed descriptions of the "trivial" falls biomechanics... Is that not sound? Maybe they just aren't aware of these articles, so are naive to such things? Although, you would hope they are aware of all the literature, as Clarke et al. are "Members of Ophthalmology Child Abuse Working Party".
Conversely, the research supporting the triad "signs" of SBS diagnosis, such as subdural hemorrhage, retinal hemorrhages and encephalopathy have been shown to have serious flaws by Donohoe, Barnes and Lantz et al. (9, 10, 11) In addition, there is not one witnessed case (even videotaped and broadcast recently in Florida) of shaken baby syndrome producing such injuries. The short fall studies commonly cited by the SBS proponents are by Helfer, Chadwick and Williams. (12,13,14) Unfortunately, these authors forget to tell us, and more importantly the courts, that the data is severely limited. There is no discussion of the biomechanics of the falls, the behaviors prior during and following the falls, the part of the body impacted, differences among impacted surfaces, did something brake the fall, was it a free fall, was it translational or rotational...? Maybe they feel that biomechanics is irrelevant. Yet, despite this they conclude and correlate (as pre-conceived?) that it is extremely rare to have serious injury following "trivial" falls. And immediately assume that all caretakers are fabricating stories in such instances regardless of birth and prior histories, lab tests, recent vaccinations/illnesses... Nor are these in-depth histories commonly sought.
I do agree, however, that "trivial" trauma rarely is serious, otherwise we wouldn't have enough hospitals, would be an extinct race, or 94 percent of us would be incarcerated. But that does not mean it does not occur. It could be very likely that it is these rare events that are being charged as abuse, due to false dogmatic assumptions, in many cases. Everyone knows "freak" accidents and injuries happen from apparently benign events. On the flip side, some people have very malignant traumatic episodes and survive unscathed despite all reasoning thereof. Another study frequently cited by the child "experts" is by Nimityongskul, and even in that study it cautions that "a direct fall of a child's head onto a concrete surface from a height as low as 1 ft can produce an impact force of 160g, which could be fatal...a 3 ft' fall onto packed earth has the same force." (15)
The child "experts" unfounded assumptions, conclusions and generalized correlations based on such weak data, despite equivalent contradictory data or pathologies...has lead to unethical testimony in court. Testimony, that to acquire a severe head injury it requires a high speed car crash, a multi-story fall, or violent shaking with or without impact (dependent upon blunt trauma evidence). The television toppling case by Lantz et al. is much less force than a multi-story fall or high speed car crash. Yet, as stated by Plunkett and Geddes, these examples are routinely testified as the minimum force required! (16) Even worse, some of these authors (i.e. Chadwick and Krous) have written in text books and journals regarding irresponsible medical testimony. (17) I'm not sure if these �experts� writings about testifying represents the kettle calling the pot black, or just the inability to look in the mirror? Do what we say, not what we do?
Why is it that child protection "experts" so readily discard and justify contradictory evidence, call it unfounded, refute the scientific claims of their data being weak, flawed (basically not useful) and then proceed to claim their diagnosis as pathognomonic in a court of law? Is it arrogance? Is it because they are "tight" with the authorities and media that allows this unproven junk science to continue? A position of power (we say so, and therefore it is) and cash that allows it to continue despite protest...at least until the protests are loud enough? When will the truth be sought, by unbiased science, prior to hypotheses outcomes being determined even before gathering the data or peer review (i.e. outcome determinative)? How long will it take to intervene in the future before theories of MSBP, SBS, Flat Earth, Salem Witches, Satanic Ritual Abuse, NAI...become engrained dogma and countless lives are ruined before the junk is sniffed out? When and what will it take to hold those proclaiming such theories, as certainty, accountable? To charge them with abuse of authority, negligence, mal-practice, defamation of character, slander, malfeasance...?
The statement by Clarke et al. should be rephrased, more correctly, to "despite child "expert", courtroom and media belief in SBS, it is still extremely controversial and currently "remains" a dogma that is weakly supported by quality science�and its very existence is now in doubt�.
1) Plunkett J. Fatal pediatric head injuries caused by short-distance falls. Am J Forensic Med Pathol 2001;22: 1-12.
2) Aoki N, Masuzawa H. Infantile acute subdural hematoma. Clinical analysis of 26 cases. J Neurosurgery 1984;61:273-80.
3) Hall JR, Reyes HM, Horvat M. The mortality of childhood falls. J Trauma 1989;29:1273.
4) Berney J, Froidevaux AC, Favier J. Pediatric head trauma: influence of age and sex. II. Biomechanical and anatomo-clinical correlations. Childs Nerv Syst 1994;10:517-23.
5) Greenes DS, Schutzman SA. Occult intracranial injury in infants. Ann Emerg Med 1998;32:680-6.
6) Di Rocco C, Velardi F. Epidemiology and etiology of craniocerebral trauma in the first two years of life, in Eds Head Injuries in teh Newborn and Infant. New York: Springer-Verlag, 1986;125-39.
7) Canestri G, Monzali GL. Cranial injuries in childhood. Clinico- statistical data on patients hospitalized in a 5-year period. Minerva Pediatr 1970;22:1687-9.
8) Wissow, LS, Wilson, MH. The use of consumer injury registry data to evaluate physical abuse. Child Abuse and Neglect. 1988;12:25-31.
9) Donohoe M. Evidence-Based Medicine and Shaken Baby Syndrome. American Journal of Forensic Medicine and Pathology 2003; 24: 239-42.
10) Barnes P. Ethical Issues in Imaging Nonaccidental Injury: Child Abuse. Topics in Magnetic Resonance Imaging 2002; 13; 85-94.
11) Lantz P, Sinai S, Stanton C, Weaver R. Perimacular retinal folds from childhood head trauma: Case report with critical appraisal of current literature. BMJ 2004;328: 754-6.
12) Helfer RE, Slovis RL, and Black M, Injuries resulting when small children fall out of bed. Pediatrics 1977 60: 533-535.
13) Chadwick DL, Chin S, Salerno CS, et al., Deaths from falls in children: How far is fatal? J Trauma 1991 13:1353-55.
14) Williams RA, Injuries in infants and small children resulting from witnessed and corroborated falls. J Trauma 1991 13:1350-52.
15) Nimityongskul P, Anderson L. The Likelihood of Injuries When Children Fall Out of Bed, - Journal of Pediatric Orthopedics 1987 7: 184- 186.
16) Geddes J, Plunkett J. The evidence base for shaken baby syndrome- We need to question the diagnostic criteria. BMJ 2004;328:719-20
17) Chadwick D, Krous H. Irresponsible testimony by medical experts in cases involving physical abuse and neglect of children. Child Maltreatment 1997 Vol.2 No.4:313-21
Competing interests: Know the Falsely Accused

The Editorials on shaken baby syndrome, BMJ 27th March 2004 19 April 2004

Jeanne E Bell,
Professor of Neuropathology
Pathology (Neuropathology), Alexander Donald Building, Western General Hospital, Edinburgh, EH4 2XU,
James Lowe
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Re: The Editorials on shaken baby syndrome, BMJ 27th March 2004

Editor - The editorials on shaken baby syndrome (BMJ 27th March 2004) are timely and address an important topic. The arguments are presented both for and against invoking this label as an explanation for the triad of subdural and retinal haemorrhages with encephalopathy in an infant, when the carer has provided an apparently inadequate history. Both editorials have called for the development of an evidence base to support more robust prosecution of alleged perpetrators.
How is this evidence to be gathered? (1,2) The difficulties are highlighted by Harding et al (2). Given that the history may be unreliable if not witnessed, evidence relating to infant head injury requires a careful pathology comparison of babies displaying the triad with a variety of age matched infants dying of other conditions including definite accidental head injury. Two contentious issues are central to the success of such a study. First, whole brain retention is necessary for detailed neuropathological examination but may be resisted by families. Second, while it is considered mandatory to seek the agreement of families to undertake research on post mortem organs and tissues, it is not appropriate to seek the agreement of parents under suspicion of perpetrating a crime. Neuropathologists are committed to the thorough investigation of all categories of brain disorders and to seeking the agreement of families for such activities to take place. Few matters can be as pressing as the need to undertake research in the shaken baby syndrome, both to protect those wrongly accused and to bring those guilty to justice.
Changes now pending in UK legislation relating to post mortem practice have caused us considerable concern. In Coroners� post mortem examinations, where no consent is required to retain organs and tissues, authority only exists for restricted use of material to establish the cause of death. There is no authority to use such retained material for research, audit or teaching. While the Human Tissue Bill 2004 (3) does not specifically cover material initially retained under the authority of a Coroner it seems intended to apply to uses beyond establishing the cause of death.
The question of research on human material legitimately retained in Coroners� investigations of criminal cases is in urgent need of debate. It will never be possible to obtain informed consent for research from family members who have been implicated in causing harm to a child. There is a need to look at all cases, not just a select few. There is a need to avoid bias in selection. How will this be achieved in the setting of the Human Tissue Bill that has placed informed consent as its main guiding principle?
Unless a mechanism to conduct such research is included in the Human Tissue Bill presently under consideration by Parliament, vital research that needs to be conducted in the setting of retained organs and tissues from accidental and non-accidental deaths in children will be seriously compromised.
We are strong advocates for the need for consent in relation to research on retained human tissues. Can this requirement be negated in the context of a Coroner�s investigation of sudden death in childhood, provided that there is appropriate ethical oversight?
In Scotland, the matter of post mortem-related research is subject to public consultation along with a range of related issues and with a specific allusion to research in cases of homicide or infanticide where it may be inappropriate to seek research consent in the accepted way (4). These matters require urgent debate and resolution in England and Wales before the Human Tissue Bill is enacted.
Yours sincerely
Professor Jeanne E Bell
Professor & Honorary Consultant in Neuropathology
Professor James Lowe
Professor & Honorary Consultant in Neuropathology
References
Geddes JF & Plunkett J. The evidence base for shaken baby syndrome. BMJ 2004; 328: 719-720.
Harding B, Risdon RA, Krous HF. Shaken baby syndrome. BMJ 2004; 328: 720-721.
The Human Tissue Bill, 2004: http://www.parliament.the-stationery- office.co.uk/pa/cm200304/cmbills/049/2004049.htm
Independent Review Group on Retention of Organs at Post Mortem. Report on Phase 3, November 2003. http://www.scotland.gov.uk/library5/health/romp3-00.asp
Competing interests: Conflict of Interest Prof. Lowe and Prof Bell both undertake post mortem examinations for Legal authorities as well as consented post mortem examinations.

Re: The Editorials on shaken baby syndrome, BMJ 27th March 2004 20 April 2004

Michael Innis,
Director Medisets International
Home 4575
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Re: Re: The Editorials on shaken baby syndrome, BMJ 27th March 2004

Editor,
Professors Bell and Lowe rightly state, �few matters can be as pressing as the need to undertake research in the shaken baby syndrome, both to protect those wrongly accused and to bring those guilty to justice�
To protect those wrongly accused I suggest the following principles be adopted:
1. Accept as true the history given by the parent. There is no logical reason to reject a history of an �Apparent Life Threatening Event� [1] or Illness following Immunization [2]
2.A thorough investigation is needed to exclude a defect in Haemostasis [3]
3.A thorough investigation of the Nutritional status of the infant is imperative [4]. Determine the level of the Serum Albumin and Blood Urea Nitrogen and essential amino acids if necessary.
4.Liver Function Tests are needed to corroborate the tests for Haemostasis.[5]
5. Test for deficiency of Vitamin C [6] to exclude Infantile Scurvy.
In all sixteen cases in which Retinal and Subdural Haemorrhages, with or without fractures that have been brought to my attention one or other of the above conditions was present but wrongly interpreted or simply ignored.
The reluctance of the Medical Profession to acknowledge their part in the distress they have caused families by their spurious diagnosis of Shaken Baby Syndrome is what hampers research into the lesions found in these infants. It is regrettable and shameful that they have in some instances misled Judges and Juries.
Shaken Baby Syndrome should take its place alongside the Witches of Salem in the History of Jurisprudence. I�m sure the learned Professors would agree. But if not then perhaps they could document a SINGLE case of the so-called Shaken Baby Syndrome which did not follow Vaccination within 21 days and in which no Nutritional of Haematological defect was present.
Michael Innis
Reference:
1. Discovery Health � Apparent Life Threatening Event and GERD (Google search)
2. Torch WC, Diphtheria-pertussis-tetanus (DPT) immunization: A potential cause of the sudden infant death syndrome (SIDS). Amer. Academy of Neurology, 34th Annual Meeting, Apr 25 - May 1, 1982),
3. Innis MD Retinal haemorrhages and SBS. Fact or Fantasy? http://bmj.com/cgi/eletters/328/7442/719#56438, 12 Apr 2004
4. Kalokerinos A. Every Second Child. Foreword by Linus Pauling. Thomas Nelson (Australia) Limited 1981 Keats Publishing Inc
5. Williams WJ. Beutler E. Erslev AJ. Lichman MA HEMATOLOGY FOURTH EDITION McGRAW HILL PUBLISHING COMPANY New York p1511 and p 1534
6. Clemetson CAB. Vaccinations, Inoculations and Ascorbic Acid The Journal of Orthomolecular Medicine 1999;Vol 14: 137 � 142
Competing interests: I have been paid for giving evidence on this subject.

Refuting established medical beliefs also requires evidence 20 April 2004

Timothy Jaspan,
Consultant Neuroradiologist
Imaging Centre, University Hospital, Nottingham NG7 2UH,
Richard Bonshek, Norman McConachie, Jonathan Punt, Nina Punt, Jane Ratcliffe
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Re: Refuting established medical beliefs also requires evidence

Sir, With regard to the leader by Geddes and Plunkett1, we should like to make the following points:
1. We do not doubt the sincerity of Geddes and Plunkett with regard to the issues underlying the debate centred upon the �shaken baby syndrome�. We trust that they do not doubt the sincerity of the very many health care professionals, social service workers and police who are engaged in the difficult and emotionally charged atmosphere surrounding childcare work. We do not like or use the term �SBS�. We feel that this is a pejorative, emotive and unhelpful term to describe children who have suffered a traumatic head injury unexplained by known medical conditions or explanations provided by their carers. We suggest the term inflicted shaking/impact injury.
2. We deeply regret that Drs Geddes and Squier chose to express their views on the BBC programme on the 29th March in a wholly unchallenged, deeply biased and flawed analysis of this highly complex issue.2 The programme made reference to the BMJ editorial of Geddes and Plunkett implying that their opinions were accepted fact without making reference to the editorial of Harding, Risdon and Krous in the same issue.3 The fact that Geddes research has been fundamentally challenged by many experts in the field and that the hypotheses are not accepted by many of the researchers and clinicians involved in child abuse work was conveniently ignored for the purposes of the programme.4
3. The underlying contention of Geddes, Plunkett and Squier is that a significant proportion of infants who suffer subdural haematomas and retinal haemorrhages do so as a consequence of minor or no injury. Their thesis is that these children suffer a profound hypoxic-ischaemic insult, possibly due to milk-aspiration-induced-laryngospasm or brainstem dysfunction secondary to trivial brainstem injury, resulting in brain swelling, raised intracranial pressure and consequent intradural haemorrhage.5,6
4. The lack of a scientifically validated model for the �SBS� is frequently used to criticise the large majority of the medical profession who view such injuries as being inflicted (deliberately or not). However, an infant succumbing to the sudden infant death syndrome (SIDS) or other medical causes of an acute and overwhelming hypoxic-ischaemic insult in the early months of life would be expected, by the theory of Geddes et al., to be particularly vulnerable to developing subdural haematomas and retinal haemorrhages. Yet this group of infants displays a remarkable absence of subdural and retinal haemorrhage in most, if not all, cases.
5. Geddes and Plunkett, and Squier, decry the absence of evidence, but deny a population based study that demonstrated that inflicted head injury was very probably the cause of 82% of cases of subdural haematoma in the first two years of life when prematurity, infection and neurosurgical interventions were excluded7. They also deny a population based study of injury in the first six months of life that demonstrated that minor accidents had trivial outcomes, and that no intracranial harm came from low-level falls8.
6. In the discussion between pathologists concerning this syndrome, it is often forgotten that the large majority of infants who suffer inflicted head injuries survive. The typical scenario is an infant admitted in either a collapsed state or exhibiting varying degrees of encephalopathy.9 In a large proportion of these cases, retinal haemorrhages are identified on examination of the eyes and CT scans taken on admission typically demonstrate multiple, small subdural haematomas, yet there is little or no cerebral swelling. In many of these children, subsequent CT and MRI examinations do not show evolution of hypoxic- ischaemic injury. If these children have not suffered a significant hypoxic-ischaemic insult and there is no evidence of a predisposing illness or propensity to develop these injuries, it must be suspected in the absence of any credible explanation that the retinal haemorrhages and subdural haematomas are the consequence of inflicted injury.
7. In many infants who present with typical, thin, posterior parafalcine and posterior fossa subdural haematomas and retinal haemorrhages, the imaging features on CT and MRI examinations are identical in infants who have multiple skeletal fractures, bruising and other features of abuse in comparison with those infants without such markers. Yet the thesis of Geddes et al. propounds two separate models for the intracranial and ocular findings, being 1) trauma or 2) an unknown and unexplained insult or event. It is highly unlikely that inflicted trauma occurs at an �all or nothing level� � it is much more likely that there is a spectrum of traumatic injury resulting in varying degrees of consequential intracranial injury.
8. Neuropathologists are becoming increasingly involved in legal proceedings concerning the large proportion of infants who do not succumb to this injury complex. This includes a recent case in which the father admitted shaking his child during transient loss of temper on two separate occasions, resulting in the sole findings of subdural haematomas and retinal haemorrhages. Notwithstanding this admission, the neuropathological opinion maintained that the injuries sustained were not the consequence of inflicted injury but some other non-traumatic aetiology.
9. We are not on a crusade to vilify and convict parents. Our deeply held concerns are to maintain the health and welfare of infants who are at the most vulnerable stage of their lives. To deny that abusive head injury causes subdural and retinal haemorrhages carries the potential of leaving infants vulnerable to further inflicted injury, long term physical, emotional or intellectual impairment or, sadly, in a not insignificant number of cases, death in the first year of life. It also does nothing to assist any perpetrator towards rehabilitation.
Yours sincerely,
Tim Jaspan
Consultant Neuroradiologist
Imaging Centre, University Hospital, Nottingham NG7 2UH
Richard E Bonshek
Consultant Paediatric Ophthalmologist
Academic Department of Ophthalmology, Royal Eye Hospital, Manchester
Norman S McConachie
Consultant Neuroradiologist
Imaging Centre, University Hospital, Nottingham, NG7 2UH
Jonathan Punt
Retired Paediatric Neurosurgeon
PO Box 6016, Keyworth, Nottingham NG12 5RP
Nina Punt
Independent Researcher
PO Box 6016, Keyworth, Nottingham, NG12 5RP
Jane M Ratcliffe
Consultant Intensive Care Physician
Intensive Care Unit, Royal Liverpool Children�s Hospital, Liverpool
References
1. Geddes JF, Plunkett J. The evidence base for shaken baby syndrome. BMJ 2004;328:719-720
2. Real Life. BBC 1, 29th March 2004
3. Harding B, Risdon RA, Krous HF. Shaken baby syndrome. BMJ 2004;328:720- 721.
4. Punt J, Bonshek RE, Jaspan T, McConachie NS, Punt N, Ratcliffe JM. The �unified hypothesis� of Geddes et al is not supported by the data. Pediatric Rehabilitation (in print).
5. Geddes JF, Vowles GH, Hackshaw AK, Nickols CD, Scott IS, Whitwell HL. Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants. Brain 2001; 124:1299-1306
6. Geddes JF, Tasker RC, Hackshaw AK, Nickols CD, Adams GGW, Whitwell HL et al. Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in �shaken baby syndrome�? Neuropathol Appl Neurobiol 2003;29:14-22
7. Jayawant S, Rawlinson A, Gibbon F, Price J, Schulte J, Sharples P, Sibert J, Kemp AM. Subdural haemorrhages in infants: population based study. BMJ 1998;317:1558-61.
8. Warrington SA, Wright CM, ALSPAC Study Team. Accidents and resulting injuries in premobile infants: data from the ALSPAC study. Arch Dis Child 2001;85:104-7.
9. Minns RA, Busuttil A. Four types of inflicted brain injury predominate. BMJ 2004;328:766.
Competing interests: All authors except NP have provided expert medical reports to the Courts, and have received payment for so doing

Potential problems with autopsy based studies. 22 April 2004

Hilary Butler,
freelance journalist
Tuakau 1892, New Zealand
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Re: Potential problems with autopsy based studies.

Dear Sir,
With regard to Professor Bell's suggestion of retaining brains from many different potential etiology to do a study to establish a factual basis for shaken baby syndrome, there is a key problem that the suggestion fails to mention.
The assumption is made that autopsies are accurate and would solve the problem of "definition".
However, analysis of many cases that I have been peripherally involved in, has shown that the key problem with the case has most often been the autopsy itself.
Shearing can be caused by incorrect removal of the brain by pathologists. Therefore there should be MRI scans of the brain prior to removal as well as while the patient is in hospital.
Many autopsies I have reviewed, have suffered from a raft of either errors, or absence of crucial evidence, examples of which, would be lack of bacteriology, toxicology... inedequate sampling, insufficent slides, and even basic issues such as incorrect head measurements, incorrect race, reports on tissue that wasn't there at autopsy, and things such as the spine being removed from the body the wrong way. Some autopsies only had some of these deficiencies. A few had all of these and more besides.
Some of these pathoologist reports I have seen, I have been told, are now used by a well known International medical teacher in order to illustrate how NOT to do an autopsy.
In order for any study to have any credibility, we need assurances that the pathologists involved are more competantly trained than many of the pathologist reports upon which well-known cases have hinged in the past, and are being hinged on now.
Hilary Butler.
Competing interests: None declared

Re: Refuting established medical beliefs also requires evidence 22 April 2004

Heather Lohr,
parent
Huntingdon, PA 16652, USA
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Re: Re: Refuting established medical beliefs also requires evidence

Here we go again. The population studies you cite so freely are based on nothing more than assumption. That is the point that is being made and that is the point you all refuse to see.
Right from the start of this nonsense, assumption has been piled upon assumption and it is leading no where. Several of us who have responded in the BMJ have asked for a clearly defined case of shaken baby syndrome or as you put it inflicted shaking/impact injury. We have yet to see it.
It does not take inflicted trauma to equal impact! How many parents and caregivers have gone to prison still claiming the child was injured in a fall or from a banged head? Regardless of what any study may say or not say, trivial falls have killed infants, toddlers, juveniles, teenagers, adults and of course the elderly. In fact trivial falls causing potentially fatal head injuries have been well cited in the elderly. Let's expand on this just a bit. Why would the elderly be more susceptible to head injury from falls? Ahhh, I can recall reading about something called atrophy ... the brain shrinks as people age. What is the major battle cry of SBS proponents. Ahhh, again I seem to recall that an infants brain doesn't fill the skull and is free to move back and forth when shaken. Now let's put that into an easy equation even the simplest of us can understand:
Elderly with smaller brain + seemingly trivial fall = possible fatal head injury.
Infant with smaller brain + seemingly trivial fall = possible fatal head injury.
Now that makes sense to me and whole lot of other people.
Population studies would of course follow the current dogma that trivial falls can't cause these symptoms in infants and toddlers so IF these symptoms were seen in an infant or toddler following a trivial fall it would immediately be ruled as inflicted shaking or impact injury and would be excluded from any study.
As human beings we are still individuals. No one on this earth is the same of any other person. Identical twins don't have the same thoughts. When a child presents with an illness you cannot ASSUME that because you saw another child last week with similar symptoms, the new presenting child must have the same thing. This is exactly what happens when an infant presents with subdural hemorrage and retinal hemorrhage (or even just one of those). Well we see this all the time. It is the "classic" shaken baby syndrome. We don't need to do coagulation tests. We don't need to do metabolic tests. We don't need to do cultures. We don't need genetic studies. Damned is the family with a child who has a "rare" disorder that can present with these symptoms. We see reports all the time of these under appreciated disorders that are diagnosed in a few babies after the accusations have already been made, or worse upon the death of the child. What do they tell the parents when that happens? "Ooops!?" Got a baby in cardiac arrest? Well since it's shaken baby syndrome we don't even need so much as an ekg or an echo to see if something might actually be wrong with the heart to cause cardiac arrest.
Let's evaluate the statement about SIDS deaths and children dying from other hypoxic events. Hummmmmmm. Seems to me that if a child presents with a subdural and retinal hemorhages then it "is shaken baby." So if a child who died of SIDS or some other hypoxic event had these symptoms we just wouldn't know about it because they would no longer be labeled as SIDS deaths, etc. They just became the latest murder deaths.
Parents are damned! Help the parent who has a child with these symptoms because doctors will never investigate anything further and will move right along to their "document the injuries" mentality. You will be left helpless and targeted and your children will be ripped from you. You may go to prison or worse for something that just didn't happen because assumptions have led to this. The medical community should be ashamed to have accepted this in the first place 30 years ago based on the speculation given. To have picked it up and carted it around like an Olympic torch is even more shameful.
The lack of differential diagnosis is astounding! As long as these dogma-based assumptions continue children will die from what you call sbs. No educational programs are going to help. The reason is that the dogma- based asumptions are wrong. And until doctors and researchers face that possibility and begin objective studies nothing can be done to save the lives of these children and the lives of the parents and caregivers who have been falsely accused.
Competing interests: None declared

Re: Re: Refuting established medical beliefs also requires evidence 23 April 2004

Michael D Innis,
Director Medisets International
Home 4575
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Re: Re: Re: Refuting established medical beliefs also requires evidence

Editor,
Ms Heather Lohr points out that in spite of being repeatedly challenged to document a single authenticated case of Shaken Baby Syndrome or Shaking/Impact Injury no one has been able to do so.
All they are required to do to convince Judges, Juries and those of us who regard the condition as a spurious diagnosis is present a case which:
1.Was not vaccinated within 21 days of the onset of symptoms [1]
2.Was shown to have a normal Coagulation/Haemostatic System.[2]
3.Had no evidence of malnutrition, and was not artificial fed or premature, since these factors predispose to fractures.[3]
The frequent occurrence of fractures in these children is explained by Dr Paterson�s discovery of Temporary Brittle Bone Disease and as Ms Lisa Blakemore-Brown says should not automatically be equated with abuse.[4]
If the numerous Paediatricians, Ophthalmologists, Radiologists and Pathologists who have given evidence in Courts in the UK, USA and Australia are unable to document a single properly investigated case there is good reason to abandon the diagnosis.
And as Ms Lisa Blakemore-Brown says, � all responsible professionals, Judges and politicians will recognise that this is very serious iatrogenic child abuse on a grand scale and will immediately seek to prevent such abuse continuing in the system, and will put in place funding for the research to prevent and ameliorate such damage.�
Michael Innis
Reference:
1.Innis MD. Retinal haemorrhages and SBS. Fact or Fantasy. Rapid Responses 13th April 2004
2.Clemetson CAB Shaken Baby Syndrome of Scurvy. Journal of Orthomolecular Medicine 2002 vol 17 No 4 p 193 �196
3.Paterson CR, Burns J, McAllion SJ Osteogenesis Imperfecta:The distinction from Child Abuse and the Recognition of a Varient form. (1993) Amer J Med Genetics 45:187 -192
4.Blakemore-Brown L. ?Fractures = abuse? Rapid Response 21st April 2004
Competing interests: I have been paid for giving evicence in Court

Re: The appliance of science? 24 April 2004

Michael P Mackey,
N/A
Manchester M3 3NE,
N/A
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Re: Re: The appliance of science?

Sir,
The letter by Jaspan, Punt and others, (the authors), could provoke a number of reactions, but should prompt critical analysis of both of its content and tone.
"SBS" is hardly a pejorative term in itself. Any suggestion that it is, arises from the fact that there have been so many criticisms of the science on which it is based. Those criticisms have been aired, not only in the pages of medical journals, but also in the criminal courts.This area of medical research has been the central issue in a number of high profile prosecutions. Many misunderstandings have arisen, because doctors, learned though they may be, are neither learned, nor indeed particularly well versed in the law and its objectives.
There is a world of difference between proffering a diagnosis and giving so called expert opinion. In repsonse to the authors:
1) Child care is a hugely difficult and emotionally charged area. That fact should operate to underline the need for an objective reasoned approach. It seems to be proffered as an excuse for error. That can't be acceptable.
2) A virtual symbiosis between the police and certain groups within the profession means that one side in the SBS debate constantly finds itself allied exclusively with the prosecution in crimina