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Pathological diagnosis based on the triad, but where is the scientifc evidence to back it up?
- Heather J Lohr (29 March 2004)
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SBS Articles - Quality Research or Dogma?
- Tracy L. Emblem (29 March 2004)
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Changes of Season
- L. Travis Haws (30 March 2004)
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The SBS Myth
- Michael D Innis (4 April 2004)
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Logic and Biomechanics in Shaken Baby Syndrome diagnosis
- Robert D Murdoch (27 October 2004)
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New Scientist and new science
- Penny Mellor (8 February 2009)
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Heather J Lohr, parent 16652
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First I want to thank the BMJ for not only making its content free to all (for the time being) but for allowing us the opportunity to voice our opinions. In response to the Harding, Risdon and Krous piece concerning the disgnosis of shaken baby syndrome I am much concerned that they cannot see the "whole picture." "The basic triad should have all the necessary features for confident diagnosis and the conclusion that undue force has been applied." By citing opinion pieces and reports which would clearly fall in the time frame of Mark Donahoe's recent review of the literature, it is clear that they refuse to admit the basis of their conclusions is weak and getting weaker everyday. Even in the light of the revelation that retinal findings that were previously attributed to violent shaking are not necessarily caused by such they continue to spout the "typical" war cry of the "classic" shaking baby syndrome victim. The parallels drawn in conclusions of the study by the Wake Forest University team and of Mark Donahoe on the available literature should be enough to make any medical servant take pause. The recent reports by Geddes et al, Plunkett and even Duhaime (I did note the lack of inclusion of her lastest report published in 2003) lead the reader to agree that indeed we don't know what is happening. Can you truly claim that an unwitnessed accidental fall is sbs in light of the findings of the past several years? We have seen the proof that falls can generate sdh and rh and glocal brain swelling. We have evidence that hypoxic injuries can also cause similar bleeding in infants who have not suffered trauma. Clearly the evidence is indicating that there may indeed be a likelihood that trauma may not be a factor in infantile subdural hemorrhage and that the retinal findings may most likely be related to the intercranial pathology not a sign of rotational acceleration/deceleration. I just read a report "Frequency and natural history of subdural haemorrhages in babies and relation to obstetric factors" that showed a shocking number of infants with asymtomatic sdh following the birth process. Some have used this report to try to dispel birth injury claiming that since the sdh in these nine infants resolved by four weeks then ALL sdh seen after four weeks cannot be attributed to birth injury. I read the report and saw nine very fortunate infants with diagnosis made which clearly affect their everyday handling and care. Continuing to say that rotational/deceleration causes these findings without having the evidence to back it up is not going to make this an accurate diagnosis. In light of the recent evidence it has become clear that nonviolent etiology may be indicated and certainly needs to be investigated. Competing interests: None declared |
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Tracy L. Emblem, Attorney 205 W. 5th Ave., Suite 105, Escondido, CA 92025
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I am a research attorney who represents a man who was falsely accused of murder in 1983. I have been researching shaken baby and fatal head injury articles for the past four years. I feel I must respond to the Harding, Risdon, Krous editorial that stands for the proposition that Shaken Baby Syndrome is a valid scientific medical diagnosis and cites to Case ME, Graham, MA, Handy TC, Jentzen JM, Monteleone JA, Position paper on fatal abusive head injuries in infants and young children. (Am J Forensic Med Pathol 2001:22: 12-122.) Harding, et al. do not disclose that the Case, et al. position paper did NOT pass peer review. According to the AJFMP Editor's note on page 1056: "The manuscript was reviewed by three reviewers on the Board of Editors of the American Journal of Forensic Medicine and Pathology. They believed that while it was worthy of publication, it should not be published as a position paper because of the controversial nature of the subject." The NAME (National Association of Medical Examiners) Board nonetheless voted to publish the paper. Was there a conflict of interest? While the Am J Forens Med Pathol does not have a written conflict-of- interest statement, the American Journal of Forensic Science, a similar publication although with a broader audience, does. According to the American Journal of Forensic Science website, (adapted from the International Committee of Medical Journal Editors Statement on Conflict of Interest): "A conflict of interest for a given manuscript exists when a participant in the peer-review and publication process--author, reviewer, or editor--has ties to activities that could inappropriately influence his/her judgment, whether or not judgment is in fact affected....Public trust in the peer-review process and the credibility of published work depend in part on how well conflict of interest is handled during writing, peer review, and editorial decision making. Bias can often be identified and eliminated by careful attention to the scientific methods and conclusions of the work." At least two of the "paper" authors, Case and Graham, were on the NAME Board of Directors at the time the paper was published in the journal despite being rejected through peer review. Coincidentally, all of the paper's authors except Case are members of the Helfer Society. (See www.helfersociety.org/Members.htm) Dr. Krous is also currently listed as a "Helfer" member, as are many of the SBS proponent authors, such as Drs. Alexander, Chadwick, Christian, Dias, Feldman, Hymel, Jenny, Kleinman, and Levin. The U.K’s Sir Roy Meadow is also an honorary lifetime Helfer member. Many of the Helfer members speak at the various National Center on Shaken Baby conferences and other SBS oriented conferences. In advocating the existence and science of the syndrome, they routinely cite to another Helfer’s article. Is there a competing interest here? The time has come to critically evaluate the biomechanics of head injury in children instead of blindly adopting articles written by the child protection oriented physicians. The medical, scientific and legal communities must closely examine whether there is a competing interest and whether these articles involve qualitative research and studies. Tracy Emblem, Esq. Competing interests: None declared |
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L. Travis Haws, Dentist DFC 12860 West Cedar Drive Lakewood, CO 80228
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According to Harding, Risdon and Krous, the "triad" is defined, in their opening statement as, "acute encephalopathy with subdural and retinal haemorrhages, occurring in a context of inappropriate or inconsistent history and commonly accompanied by other apparently inflicted injuries." This definition of the triad is loaded with inconsistencies. All that one needs to do is review the literature. First of all, Caffey's original work, that is frequently cited as the keystone of the SBS theory...yes, it is still a theory, is full of inconsistencies. Caffey first proposes that the trio of symptoms/signs is subdural hemorrhage (SDH), retinal hemorrhage (RH) and fractures of the long bones or ribs. Then the trio of signs changes to SDH, RH and no external signs of abuse. (1,2) Then in 1974, the triad is bilateral SDH, bilateral RH no external signs of abuse and evidence of periosteal traction of the long bones. (3) Caffey does mention that instances of picking an infant up by an arm or leg, “swinging” or tossing the infant through the air, during play, by the extremeties (a common mode of play for parents/care takers-emphasis mine) can cause the bone lesions or “traumatic involucra”. Infants shoulders have been known to dislocate from picking them up by an arm, so to assume that it requires violent shaking or slamming...to stretch the periosteum is beyond reason. Of interest, in 1974, Caffey's paper includes the description of necropsies on Baby's "H" and "K". Baby H had “skin normal, thymus large microscopic focal hemorrhages in the myocardium: pinkish cellular exudates in the pulmonary alveoli: small subcapsular laceration of the liver filled with fresh blood, liver capsule intact.” Caffey seems to neglect the information pointing to a differential diagnosis and focuses only on the brain and eye hemorrhages. Does he suppose the bleeding in the myocardium (heart) and pinkish cellular exudates in the alveoli (lung infection?) are irrelevant? It would be far fetched to attribute the myocardial hemorrhages to acceleration/deceleration, let alone the cellular exudates in the alveoli. Perhaps Krous and Harding can tell us how this fits into the "triad"? Baby K, as described by Caffey, basically had bleeding in the brain and spinal cord. Baby K’s eyes were not examined. There was no evidence of fractures. However, Baby K had “several small foci of atelectasis in the lungs” with signs of generalized cyanosis. “Infant turned grayish and died 2 hours after admission.” Why was there no consideration of the lung findings, possible pneumonia or obstruction to explain the atelectasis and generalized cyanosis (a sign of severe apnea or hypoxia)? Again, it seems rather important differential diagnosis information was neglected and the focus was solely on bleeding in the brain. The recent work by Geddes et al. accounts for the brain hemorrhages in light of severe hypoxia... Also, this infant only had clear evidence of one sign of the triad (SDH), but shaking was still assumed to be the diagnosis. The experimental evidence Caffey was greatly lacking came from Ommaya, and Ommaya in 2002, states that Caffey misinterpreted his results and their applicability to his theory. (9) In 1984, a study by Ludwig and Warman add that “the physical findings of tense or bulging fontanelle, head circumference greater than 90th percentile for age, and retinal hemorrhage strengthen the diagnosis”. (4) Ludwig and Wartman seem to be saying that a CT scan with bleeding in or upon the brain is the sole criteria for diagnosis, but that retinal hemorrhages and a swollen brain (bulging fontanelle) help strengthen the diagnosis. Thus, SDH = SBS, but hydrocephalus (bulging fontanelle and head circumference greater than 90th percentile) and RH help confirm the diagnosis. They state this without any consideration to the meaning of a head circumference greater than the 90th percentile and all of its implications to other differential diagnosis. They do not discuss long bone or rib lesions/fractures. Then in 1987, Duhaime et al. perform a biomechanical study that concludes shaking cannot generate enough force to meet the injury threshold to cause subdural hemorrhage and traumatic axonal injury. (5) Hence, the derivation of shaken baby/impact syndrome. To continually assume shaking has anything to do with the actual injury is difficult to comprehend. It’s like saying that if you jump up and down 9 times (shaking), and on the 10th jump you land on someone’s foot (impact) which results in you breaking your ankle; that the 9 prior jumps played a role in the ankle fracture. Had the other persons foot not come into play, numerous more jumps could have occurred without injury. The injury occurred at the moment when another’s foot was landed on, and had nothing to do with prior, non-injury producing, stresses. The ankle fracture would have likely occurred had the person landed on someone else’s foot on the first jump. Then in 1989, Zimmerman and Bruce follow this study up by stating that shaking alone cannot cause such injuries. They also state that “with pure shaking impact injury, evidence of other trauma is rarely found”. (6) Not according to Duhaime and the current letter by Krous and Harding who state extracranial signs of trauma are common. Which is it? If the proponents of SBS cannot even keep it straight, how is anyone else supposed to? Zimmerman and Bruce were not the only ones to say the other evidence of trauma is rarely found, just as Duhaime and Krous...are not the only ones to say it is commonly found. Then, in 2003, a study by Prange et al. concludes that “there are no data showing that the maximum change in angular velocity and peak angular acceleration of the head experienced during shaking and inflicted impact against unencased foam is sufficient to cause SDHs or primary TAIs in an infant”. (7) This REPEATS the earlier data that shaking alone cannot cause subdural hemorrhage or traumatic axonal injury (this would seem to be supported by the hypoxic injury found by Geddes that the axonal injury is not trauma related). In addition, to result in SDH, it seems to require a hard impacting surface. So, why do many alleged SBS cases lack evidence of impact (the differential diagnoses is a completely different paper)? Wouldn't an impact from a multi-story fall or high speed car crash (that's what the "experts" tell us causes SDH or RH...that or shaking) leave significant signs of impact? To conclude, as you can see, the SBS "triad" changes with the seasons...the seasons of data. The child abuse "experts" clothe the "triad" depending upon the weather/season. How does Harding and Krous propose the incongruent history given by caretakers be confirmed? That all caretakers of children with a SDH get a polygraph? Maybe the SBS docs should be interrogators instead of physicians? Who's story wouldn't change after ten interrogations, threats, promises of leniency if you confess... Furthermore, I speculate that many investigators routinely change statements around? We know the "experts" won't accept any history beyond a multi-story fall or high speed MVA to account for SDH or RH despite all the evidence to the contrary...(i.e. Lantz's 14 month old television tragedy, Geddes work, Plunkett's eye witnessed "trivial" falls, Duhaime's shaking work...and that is just the tip of the iceberg). I would assume that Harding, Risdon and Kraus added trauma to the neck and spinal cord as a result of the work by Geddes et al, and Ommaya et al. (8,9) Yet, both SDH and RH also occur during birth pretty frequently and now we see them with a television toppling over onto one's head. To further conclude, This is why I propose a new mechanism or feature for the, what is now known as, shaken baby/shaken impact syndrome. I propose that hitherto and henceforth, the syndrome be called shaken/slammed/SQUASHED baby syndrome. Squashing coming from the biomechanics of birth, TV compressing one's head... Call it squeezed, compressed, squished...whatever you like. That's it folks SBS is now characterized as first shaking, then slamming and if that doesn't work, then the head is squeezed between two hands like it's in a vice. Don't you see it, it's clear, definable, pathognomonic and beyond a reasonable doubt or medical certainty??? But then again, the world might actually be flat afterall, too? L. Travis Haws 1)Caffey J. On the Theory and Practice of Shaking Infants. American Journal of Diseases in Childhood 1972; 124:161-9. 2)Caffey J. The parent-infant traumatic stress syndrome: (Caffey-Kempe Syndrome), (Battered Babe Syndrome). Amer J Radiol 1972; 114:218-29. 3)Caffey J. The whiplash shaken infant syndrome: manual shaking by the extremities with whiplash-induced intracranial and intraocular bleedings, linked with residual permanent brain damage and mental retardation. Pediat 1974; 54:396-403. 4)Ludwig S, Warman M, Shaken Baby Syndrome: A Review of 20 Cases. Annals of Emergency Medicine Feb. 1984; 104-7. 5)Duhaime A. et al., The Shaken baby syndrome. A clinical, pathological, and biomechanical study. J Neurosurg 1987; 66:409-415. 6)Bruce DA, Zimmerman RA. Shaken impact syndrome. Pediatric Annals 1989; 18:482-494. 7)Prange M. et al. Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants. Journal of Neurosurgery 2003 99: 143-150. 8)Geddes J. F. et al., Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in ‘shaken baby syndrome’? Neuropathology and Applied Neurobiology 2003; 29; 14-22. 9)Ommaya A., Goldsmith W., Thibault L., Biomechanics and neuropathology of adult and paediatric head injury. British Journal of Neurosurgery 2002 16(3): 220-242. Competing interests: Know The Falsely Accused |
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Michael D Innis, Director Medisets International Home 4575
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Editor, Regarding the question of the Shaken Baby Syndrome (SBS) Drs Harding, Risdon and Krous state, “a need exists for an impartial and intelligent assessment, but how may this be achieved in practice?” I suggest that since the role of vaccines in SBS has been questioned [1,2,3,4,5] the history should start with the question, “when was the child last vaccinated?” Of the 20 reports I have on the subject: 9 were vaccinated between 0 – 21 days prior to the onset of their signs and symptoms. Apnoea, Subdural and Retinal haemorrhage, Cutaneous bruising and “fractures”. 8 had documented evidence of abnormal Haematological or Liver Function Tests (LFTs) and Nutritional defects. 3 were incompletely documented. This is proof that the administration of vaccines is one cause, repeat one cause, of the so-called Shaken Baby Syndrome since it demonstrates that SBS was confined to the period LESS THAN 21 DAYS AFTER THE VACCINE WAS ADMINISTERED (the period in which hypersensitivity reactions are expected to occur). With the enormous number of persons accused, and for that matter imprisoned, it should not be an impossible task for those believing in the existence of SBS to negate this deduction by presenting documented evidence of the condition occurring AFTER the 21 day post vaccine period, having excluded haemorrhagic, liver and nutritional disorders. The Medical Profession should be looking for evidence of deficiency of Vitamin C induced by Immunization [5] and for Immune Complexes and other tell-tale signs of Hypersensitivity to Vaccines. It is time to change the name from ‘Shaken Baby Syndrome’ to ‘Adverse Vaccine Reaction’ in those cases in which the condition follows the administration of a vaccine within 21 days Iatrogenic Misadventure would be another label worth considering for the vaccine induced cases. The haematological and nutritional cases should be appropriately designated. Vitamin K Deficiency Bleeding (VKDB) or Barlow’s Disease would probably cover most of them. Finally, the safety of vaccines can be assured by doing what Kalokerinos did in the Australian Outback - administer Vitamin C before immunizing the infant and ensure the adequacy of Vitamin K.. Reference: 1.Kalokerinos A Every Second Child. With a Foreword by Linus Pauling. Keats Publishing. Inc New Canaan, Connecticut. 1981. 2.Goodwin J Was It Murder Or A Bad Vaccine. Redbook Magazine September 2000:158-175 Statement of Amici Curiae in support of Alan Yurko. 3.Scheibner V. Shaken Baby Syndrome. The Vaccination Link. Nexus Aug- Sep (31)1993 4.Clemetson CAB. Vaccinations, Inoculations and Ascorbic Acid. The Journal of Orthomolecular Medicine 1999 vol 14 p 137 – 142 5.Clemetson CAB Shaken Baby Syndrome or Scurvy. Competing interests: I have given evidence for the accused |
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Robert D Murdoch, physician Murdoch Family Physicians, P.A., 4632 Vincennes Blvd. #104, Cape Coral, FL 33914 USA
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Whilst Drs. Brian Harding, R Anthony Risdon, and Henry F Krous were correct in stating that other signs should be observed in Dx of SBS, they kept returning to the "triad" as the core of the diagnosis. Each component of said triad has many possible causes. How can such a diagnosis be made based upon said triad except through dogma? The Geddes et al. study does show pictures of non-traumatic, massive SDH, it refers to macroscopic SDH's. It does state that several of the 50 non- traumatic cases studies had RH's. No human can inflict the G-forces by shaking, that is exerted on a passenger in a 40mph+ motor vehicle collision. In such an instance, adults and children whose heads do not impact the inside of the car generally have cervical injury. They just don't present with SDH, RH and DAI, unless they have head impact. I am interested to know why given the questionable critera currently used for SBS Dx, none of the cases using those criteria have been witnessed, and why they are in children only under 12 months as stated by Harding et al.. What changes when a child is over 12 months old? Do perpetrators suddenly choose not to shake one year olds? Robert Murdoch AP Competing interests: None declared |
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Penny Mellor, Campaigner medico/legal researcher Home WV9 5HX
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The pathologist challenging shaken baby syndrome Irene Scheimberg states the below: "I'm exploring all sorts of theories. My colleague Marta Cohen from Sheffield Children's Hospital and I have just published a paper with observations of our autopsy work on fetuses and babies over the last couple of years. We selected 55 cases - 25 late third trimester fetuses who died shortly before delivery and 30 newborns - who had haemorrhage within the membrane that covers and separates the two halves of the brain, and compared this with the level of brain hypoxia, or oxygen deficiency. We knew that none of these cases could possibly be inflicted trauma. We found that all those with severe brain hypoxia and half of those with moderate brain hypoxia had SDH. This is the same type of SDH that some people describe as specifically indicative of shaken baby syndrome. A similar pattern of haemorrhages has been described in the retinas of newborn babies dying of natural causes. We think that in these cases the haemorrhaging is caused by the hypoxia." [1] Asking for Risdon et al to apologise and accept they were wrong is probably asking too much, I hope that when they read the latest research they will, however, take note of it when deciding on causes of death. Ms Geddes wasn't so far off the mark was she? No doubt somebody is now going to claim that pregnant women were undertaking activities that bounced the unborn child around in order to harm them pre-birth, I'm not kidding either! It's a shame that neither the BMJ Group or The Lancet chose to publish these very important findings. At the moment babies suspected of having been shaken are administered powerful and potentially devastating anticonvulsants in large quantities upon admission to hospital, the doctors treating what they believe to be SBS - problem is, if it was a hypoxic event caused by any one of a number of conditions known to cause such an event, then the treatment itself could kill! [1] http://www.newscientist.com/article/mg20126931.800-the- pathologist-challenging-shaken-baby-syndrome.html?full=true Competing interests: I am and have been involved as part of a team researching medical records in alleged cases of SBS in both family and criminal cases |
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