Shaken Or Not: That Is The Question - F. Yazbak, MD, FAAP

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Shaken Or Not: That Is The Question

By Red Flags Columnist, F. Yazbak, MD, FAAP

On Dec. 3, The Royal Gazette newspaper in Bermuda published an

article by entitled ?Expert witness undisciplined.?

Apparently the country?s Court of Appeal ?quashed? a young father?s

earlier murder conviction and mandatory life sentence for killing his

six-month-old daughter and criticized the way a pediatrician

testified at the original trial, describing his performance as

?unduly theatrical and undisciplined.? The court then convicted the

young father of manslaughter and sentenced him to 10 years in prison.

According to the report, the pediatrician apparently shook a plastic

doll violently ?before smacking its head down on the witness box, and

is said to have then turned the doll over and done the same to the

other side of its head.?

The higher court decreed that ?Anyone who used the degree of violence

? against a six-month-old child could only have intended to cause at

least really serious harm. It no doubt formed the basis of the jury?s

decision to convict of murder rather than manslaughter.? The judges

added that the expert witness ?was wrong to act as he did. It was his

duty to give evidence in the least emotive way possible, particularly

in a case such as this where feelings were likely to run high. His

performance was, to say the least, unduly theatrical and

undisciplined.? They addedthat the ?evidence was out of line with

evidence received by the Court of Appeal in England, which has

accepted that a much lesser degree of force than that illustrated by

him is all that is required to produce a non-accidental head injury

to a child.?

The Bermuda case will not be discussed in full as its details are not

available, but general aspects of shaken baby syndrome (SBS) will be explored.

Dolls in Court

Dolls have been used extensively by pediatricians and psychologists

to question children and demonstrate how injuries occur. Their use in

sexual abuse cases is well known; so is the fact that the technique

has been both misused and abused.

Many will recall court scenes where large men, prosecutors or their

medical experts, are holding a rubber doll the size of a two-month

old baby around the upper torso and shaking it back and forth

vigorously to demonstrate to the judge and jury how the accused must

have shaken the injured or deceased infant.

The proponents of the SBS (and shaking ? impacting baby syndrome)

describe the injuries and how they occur usually as follows. ?When

someone forcefully shakes a baby, the child's head rotates about

uncontrollably because infants' neck muscles aren't well-developed

and provide little support for their heads. The violent movement

pitches the infant's brain back and forth within the skull, rupturing

blood vessels and nerves throughout the brain and tearing the brain tissue.

?The damage is even greater when the shaking ends with an impact ?

hitting a wall or a crib mattress, for example ? because of the

strong forces of acceleration and deceleration associated with an

impact. After the shaking, swelling in the brain can cause enormous

pressure within the skull,compressing blood vessels and increasing

overall injury to its delicate structure.? (1)

Since the 1970s, hundreds (maybe thousands) of adults have been

jailed because they were believed to have injured their babies or

killed them by shaking. Some of these convicted child abusers may

themselves have been beaten in prison, even murdered, because

everyone, including criminals, hates a child abuser.

There is obviously no doubt that some parents, babysitters and

guardians have tortured and killed innocent infants and children.

They should be severely punished if they are sane, and receive expert

psychiatric therapy if they are deranged.

There is also no doubt that many innocent young parents and

caregivers are in jail because they were unjustly accused of shaking

or shaking-impacting their children. At trial, the prosecution with

its might and resources usually parades expensive medical experts who

swear ? with authority ? that a big man can, indeed, cause subdural

and retinal hemorrhages in a small baby and even kill him or her

without visible external bruises and injuries, and with no prior

history of abuse. In most cases, the only crime the adult committed

was to be alone with the child when he or she stopped breathing, a

?sinister game of musical chairs? ? as one of our Australian

colleagues calls the situation.

In September, renowned neuropathologist J.E. Leestma published an

important review of the shaken baby syndrome in the American Journal

of Forensic Medicine and Pathology, the official publication of the

National Association of Medical Examiners. (2)

He stated in the abstract: ?The English-language medical case

literature was searched for cases of apparent or alleged child abuse

between the years 1969 and 2001. Three hundred and twenty-four cases

that contained detailed individual case information were analyzed

yielding 54 cases in which someone was recorded as having admitted,

in some fashion, to have shaken the injured baby. Individual case

findings were tabulated and analyzed with respect to shaking as being

the cause for the injuries reported. For all 54 admittedly

shaken-infant cases, the provided details regarding the shaking

incidents and other events are reported. Data in the case reports

varied widely with respect to important details. Only 11 cases of

admittedly shaken babies showed no signof cranial impact (apparently

free-shaken). This small number of cases does not permit valid

statistical analysis or support for many of the commonly stated

aspects of the so-called shaken baby syndrome.?

In other words, there were only 11 confirmed reports of infants or

children who had injuries that could be attributed to shaking and

only shaking in the complete English-language medical literature.

According to the Centers for Disease Control and Prevention (CDC) and

the National Center on Shaken Baby Syndrome (2005), ?Shaken baby

syndrome (SBS) is a form of child abuse affecting between 1,200 and

1,600 children every year. SBS is a collection of signs and symptoms

resulting from violently shaking an infant or child.? (3)

Some areas of the country seem to report more cases of SBS than

others and in certain states, medical centers with organized child

abuse teams somehow diagnose more cases than rural and community hospitals.

The ?Preventing Child Abuse? web site of The Children's Hospital

Medical Center in Denver, Colorado, features the following

information under ?Babies are Fragile.? ?Shaken Baby Syndrome is the

leading cause of death among child abuse cases in the United States.

The syndrome results from injuries received when someone vigorously

shakes an infant ? usually from 5 to 20 seconds. This can cause

severe brain injury and even death. In 2004, The Children?s Hospital

saw an average of one child a week with signs of Shaken Baby Syndrome

? the youngest just 2 weeks old.? (4)

In 2004, the population of Colorado was estimated at 4,301,261 ? or

1.5 percent of the entire population of the United States. The state

is 380 miles east to west and 280 miles north to south. It has high

mountains and snow in the winter. Even if every case of SBS in

Colorado was seen at Denver Children?s Hospital, 52 cases of Shaken

Baby Syndrome in one year would translate to a national incidence of

3,467 cases, almost three times the CDC figures.

According to a 2004 publication, a study conducted by the University

of North Carolina at Chapel Hill found that an estimated 50,000 cases

of shaken baby syndrome occur each year in the United States. Of that

number, 300 children die. (5)

It is obviously unlikely that the good people of Colorado and North

Carolina shake their children more frequently than in the rest of the

country or that the CDC and the National Center on Shaken Baby

Syndrome are underestimating the national number of cases of SBS.

Shaking and neck injury

Werner Goldsmith, PhD, former chair of the head injury model

committee at the National Institutes of Health and a professor at the

University of California, Berkeley and its 2001 Distinguished

Engineering Alumnus Award recipient, has stated unequivocally: " I am

absolutely convinced that in order to do serious or fatal damage to

an infant by shaking you have to have soft tissue neck

damage.? Goldsmith has calculated that a fall backward from three

feet onto a hard surface, like concrete, can produce nearly 180 Gs of

acceleration ? 180 times the force of Earth's gravity ? enough to

cause a subdural hematoma. Shaking a child once a second through a

range of one foot produces only 11 Gs, at the most. ?There is an

order of magnitude difference between shaking and falling,? he says,

?From the point of view of the brain, shaking is a much, much milder

form of braking than a fall.? To complicate matters, between five and

10 percent of children are born with undiagnosed subdural hematomas,

and 30 percent are born with retinal bleeding. ?If you get a rebleed,

you may get something that looks like shaken baby syndrome?. You

should be able to show neck damage to prove shaken baby syndrome.? (6)

In most of the cases I have reviewed, an MRI of the neck had been

ordered and every time, it was normal. Yet, in every one of those

cases, accusations were still made and charges were still filed.

There is no doubt that the ordering physicians would have considered

positive cervical findings as uncontestable proof of SBS and yet, not

one of those physicians has ever accepted a totally normal MRI of the

neck as proof of innocence and against shaking as demonstrated by

Goldsmith. It seems strange to send an infant near death into a tube

halfway across the hospital to get an expensive MRI and then to

ignore the results of that study.

Obviously everyone knows that a passenger in a stopped car (whether a

child or an adult) who is rear-ended by another car or truck going at

least 40 miles an hour is likely to suffer a severe whiplash injury

to the neck without brain damage, retinal bleeding and/or a brain hemorrhage.

A rush to judgment

As a rule, regardless of the history ? past and present ? the

symptoms and the laboratory findings, if an infant or a child is

discovered to have retinal hemorrhages and intracranial bleeding

(subdural hemorrhages or subarachnoid hemorrhages), the case is

immediately labeled ?shaken baby syndrome? and other diagnoses are

not even considered. Social Service is consulted and the Child Abuse

Team promptly endorses the notion that the infant must have been

shaken and the adult, who happened to be there at the time, must be

the perpetrator ? even when objective evidence of other causes is

glaring. From that moment on, the unfortunate parent is considered

guilty, till proven otherwise, which is not easy if he or she is poor

and uninformed.

Plunkett, a renowned forensic pathologist at Regina Medical

Center in Hastings, Minnesota, wrote in a 1998 letter to the American

Journal of Forensic Medicine and Pathology: ?Too many of my

colleagues (and most other physicians and almost the entire general

public) think our profession is the " whodunit " discipline. It is not.

Forensic pathology is the " what happened " specialty. When our focus

is on the ?who, " we forget the " what " or may consider it unimportant.

Worse, we may alter our explanation/interpretation of the " what " to

make it conform to our opinion of the " who. " The need to consider

alternative explanations ceases, doors to further inquiry close: Do

not go beyond, you will find nothing there. Objectivity fails because

we are forced to defend an advocacy role, be it for the state or for

the defendant. We must not forget that our only responsibility is to

bear witness within the limits of science.?

The most tragic thing about our present obsession with SBS is not

only that an innocent adult ends up in jail, but that often valuable

time is lost, appropriate investigations of the real causes are not

undertaken, the correct diagnosis is not even considered, and

important and urgent treatment is not provided to the infant who is

certainly innocent. Most often, trying to ?nail the guilty party,?

instead of focusing on helping the baby in the hospital, further

injures the infant and compromises recovery.

In March 2004, Plunkett co-authored a landmark editorial in The

British Medical Journal with British neuropathologist J. F. Geddes

titled ?The evidence base for shaken baby syndrome.? (7) I suggest

that interested Red Flags readers review that editorial because it is

certain to become a major reference on SBS.

Important Information

In the cases that I have reviewed, important events and findings

during the pregnancy and delivery have rarely if ever been considered

by the admitting staff. A thorough examination and analysis of every

detail is essential to discover the truth and arrive at a scientific

and not an impulsive diagnosis.

Radiological examinations should be judicious and carefully ordered.

Exposing the infant to an inordinate amount of irradiation and

sending him or her from the close observation of the intensive care

unit to the x-ray department repeatedly trying to prove that a distal

hair line fracture exists is immoral and borders on malpractice. Such

investigations can be done more appropriately when the child improves

and, by then, the presence or absence of a callus will clarify the diagnosis.

Laboratory examinations must include bleeding/clotting studies and

liver function tests in addition to the routine admission orders.

Sometimes, extensive testing may be required to assess nutritional

status, enzyme levels and liver, gut and kidney function. The results

should then be interpreted properly and the tests repeated to

demonstrate a trend ? if needed. The diagnosis of SBS should not be

made till all the results are considered.

On admission, blood should be drawn for a PIVKA -II test to rule out

late-onset hemorrhagic disease (8) and for a blood histamine and

serum vitamin C levels to rule out subclinical scurvy and histaminemia. (9)

Recent vaccinations

In addition to details of the recent past history including

illnesses, antibiotic use, exposures, feeding problems, etc., it is

essential to list and date vaccinations given in the 21 days

preceding admission. (10)

The following statement by Australian pathologist-hematologist and

SBS expert Innis summarizes his beliefs and is shared by many

of us now: ?They will have successfully demolished my explanation if

they can document a single case of shaken baby syndrome or ?inflicted

shaking/impact injury? (as they prefer to call it), which occurred

outside the 21-day period and in which a disorder of haemostasis,

nutrition or liver disease was convincingly excluded. I repeat, the

diagnosis of shaken baby syndrome or inflicted shaking/impact injury

is a proven figment of the imagination of some in the medical

profession and should be relegated to the scrap heap of history

before it causes any more shame to the profession and disaster to

innocent families. " (10)

Retinal hemorrhages

For more than 30 years, it has been assumed that the presence of

retinal hemorrhages in an unconscious child is ?evidence? of shaking

or shaking impacting. The unquestionable scientific fact is that

although retinal hemorrhages with or without intracranial bleeding

can occur after abuse, they are not seen only in cases of SBS.

In 1997, Rohrbach stated: ?Intraretinal hemorrhages alone are

typical, though not pathognomonic for the battered-child syndrome.?

Renowned neurosurgeon Uscinski recently wrote in the British

Journal of Neurosurgery (12) ?prior to 1972, the presence of retinal

hemorrhages was a diagnostic aid in detecting the presence of chronic

subdural hematoma in children, and has long been known among

neurosurgeons to reflect an abrupt increase in retinal venous pressure.?

There are three important statements about retinal hemorrhages:

1. The actual mechanism of retinal hemorrhages is unknown.

(Riffenburgh 1991)

2. There have been no controlled studies supporting a purely

mechanical etiology for retinal bleeding.

3. There is no agreement on what specific pattern or appearance

of retinal hemorrhages absolutely suggests inflicted trauma by shaking.

Retinal hemorrhages have been associated with asphyxia, hypoxia,

increased venous pressure and cerebral venous spasm. Studies by

i (1986) have shown that increasing intracranial pressure and

subarachnoid hemorrhage lead to retinal hemorrhages. In 1998,

Jayawant reported an 80 percent association between subdural

hemorrhages and retinal hemorrhages and postulated that retinal

hemorrhages are not independent risk predictors, but simply markers

of the extensiveness and severity of intracranial bleeding.

Retinal hemorrhages can occur with increased intracranial pressure

and following subarachnoid and other intracranial hemorrhages (Terson

Syndrome). A number of studies (Giangiacomo 1985, Weingeist 1986,

i 1986, ahn 1993, Poepel 1994) point out the similarities

between Terson's syndrome and the retinopathy of SBS. Retinal

hemorrhages have been reported following accidents, with infections,

with coagulopathies and bleeding disorders, in cases of vitamin C and

K deficiency, following a third of normal vaginal deliveries (Kaur),

and after vigorous cardiopulmonary resuscitation (Goetting).

Subdural hemorrhages

It is now almost always assumed that subdural hemorrhages in the

absence of a witnessed fall or injury are also an indication of child

abuse and the result of acceleration-deceleration by shaking or

shaking impacting.

This is not true.

Subdural hemorrhages are not exclusively the result of intentional

trauma and can be caused by a multitude of biomedical disorders.

Because of their open fontanels, young infants with a subdural bleed

may remain neurologically asymptomatic for some time. Babies with

subdural hemorrhages often have seemingly unrelated symptoms such as

crankiness, restless sleep, poor feeding, vomiting, and failure to thrive.

In a 1998 British retrospective study, Jayawant reported that 60

percent of the children with subdural hemorrhages, which he reviewed,

exhibited signs of other trauma (bruising, fractures, etc.). Duhaime

(1987), (1990) and Lancon (1998) reported that in cases of

severe cerebral damage and death, overt signs of trauma and abuse

were reported even more frequently.

Scientific documentation exists that subdural hemorrhage can and does

complicate many medical ? non-traumatic ? disease entities including

non-specific coagulopathies, coagulopathies secondary to bacterial

endotoxemia, certain enzyme defects, liver, blood and connective

tissue disorders.

Sometimes, the identification of a chronic, as well as an acute,

subdural hemorrhage makes the well-paid ?prosecution experts? jump to

the conclusion that this finding must mean recurrent abuse, when, in

fact, the opposite conclusion may be more appropriate. The simple

fact that the baby was well-cared for and had no visible external

injuries when seen repeatedly for routine pediatric care, while

having a subdural hemorrhage, is strong evidence against inflicted trauma.

When such cases are later reviewed with an open mind, other more

plausible non-traumatic causes are easily discovered and become the

basis for successful appeals.

The infant may have spontaneous and separate acute and chronic

subdural hemorrhages or may have a re-bleed in a chronic subdural

hemorrhage. The appearance of acute and chronic subdural hemorrhages

is different on CT-scans.

In 1977, Bergstrom et al reported: ?The histories reveal no new

traumas in association with onset of symptoms. Spontaneous rebleeding

may well explain the onset of symptoms as well as the attenuation

values being so much higher than those of CSF and serum.? (12)

Ommaya, Goldsmith and Thibault in a comprehensive review (22 pages,

126 references) published in 2002 in the British Journal of

Neurosurgery wrote: ?The five categories of CT imaging were as

follows: Layering type SDH hyperfibrinolytically active with a

highest tendency to rebleed. The mixed density type has also a high

tendency to rebleed but with lower hyperfibrinolytic activity.?(13)

Also in 2002, Uscinskiwrote: ?Rebleeding in subdural hematomas may

occur, with minimal or no trauma, owing to the nature of the

membranes and the process of resorption?. Common sense would seem to

indicate that not all the subdural hemorrhages in children are

inflicted injuries and prior to 1972 the presence of retinal

hemorrhages was a diagnostic aid in detecting the presence of chronic

subdural hematoma in children and has long been known among

neurosurgeons to reflect an abrupt increase in intracranial pressure.

Lastly, a simple point of consideration: When an adult presents with

a chronic subdural hematoma, abuse is rarely a diagnostic

consideration. Given the similar pathology of the subdural hematoma

in adults and children, why, logically, should the opposite be true

in a child? (11)

Conclusion:

Shaken or not: That certainly is the question.

" Injustice anywhere is a threat to justice

everywhere "

Luther King Jr.

References:

1. http://kidshealth.org/parent/medical/brain/shaken.html

2. Leestma, JE. Case analysis of brain-injured admittedly shaken

infants: 54 cases, 1969-2001. Am J Forensic Med Pathol. 2005 Sep;

26(3):199-212. PMID: 16121073

3. http://www.cdc.gov/ncipc/factsheets/cmfacts.htm

4. http://www.thechildrenshospital.org/pro/dep/detail.cfm?RecordID=1531

5.

http://www.armymedicine.army.mil/hc/healthtips/01/200406-07shakenbaby.cfm

6. http://www.berkeley.edu/news/media/releases/2001/11/27_baby.html

7. BMJ 2004;328:719-720 (March 27),

doi:10.1136/bmj.328.7442.719

http://bmj.bmjjournals.com/cgi/content/full/328/7442/719

8. Yazbak, F.E. K comes after C and H in

SBS. http://bmj.bmjjournals.com/cgi/eletters/328/7442/719#64501

9. Clemetson, C.A.B. " Shaken Baby " or Barlow's Disease

Variant? http://bmj.bmjjournals.com/cgi/eletters/328/7442/719#63250

10. http://bmj.bmjjournals.com/cgi/eletters/328/7442/719#57790

11. Uscinski, R. Shaken Baby Syndrome: fundamental questions.

Br J Neurosurg. 2002 Jun;16(3):217-9. PMID: 12201392

12. Bergstrom, M., son, K., Levander, B., Svendsen, P.

Computed tomography of cranial subdural and epidural hematomas:

variation of attenuation related to time and clinical events such as

rebleeding. J Comput Assist Tomogr. 1977 Oct; 1(4):449-55.

13. Ommaya AK, Goldsmith W, Thibault L. Biomechanics and

neuropathology of adult and paediatric head injury. Br J Neurosurg.

2002 Jun;16(3):220-42. PMID: 12201393