Does Shaken Baby Syndrome Really Exist?

Does Shaken Baby Syndrome Really Exist?  Source: Discover

…is important to clarify that DISCOVER is weighing the science behind the textbook definition of shaken baby syndrome, not delving into casework involving children who do display “external signs of abuse.” This article is about the evidence for and against a specific syndrome, not the vital importance of child abuse prevention.

The Centers for Disease Control and Prevention reports that as of 2005 there were between 1,200 and 1,600 confirmed SBS cases per year. While no official statistics are available on SBS prosecutions, Toni Blake of the American legal consulting firm 2nd Chair Services says that at least 2,000 to 3,000 lawyers and defendants have contacted her over the past decade to request assistance on SBS trials and appeals around the country. In 2007, she says, “we saw one of these cases overturned about once a month.”

 

As with baby Matthew Eappen in the Woodward case, SBS typically first presents itself when an infant is brought to a hospital or doctor’s office suffering a life-threatening condition such as convulsions, an inability to eat or to be awakened, or difficulty breathing. (SBS can also present with seemingly less serious symptoms, such as changes in feeding behavior.) The 2001 SBS textbook cites two studies (from the journals Annals of Emergency Medicine and Developmental Medicine and Child Neurology) showing that between 15 percent and 33 percent of SBS-symptomatic infants died, while one-third to one-half suffered permanent injury such as paralysis or mental retardation. Although many infants are hospitalized with life-threatening conditions, it is only on closer examination—CT or MRI scans of the infant’s head and ophthalmological examination of the infant’s eyes—that a diagnosis of shaken baby syndrome comes into play.

“The thing we pick up on most easily is the bleeding,” says Randell Alexander, chief of the division of child protection and foren­sic pediatrics at the University of Florida at Jacksonville College of Medicine. “You see intracranial bleeding, between the brain and the skull…and then the other thing you see in about 90 percent of the cases is retinal hemorrhages.”

Once a doctor says that an infant must have been shaken, it triggers a hunt for the shaker. In one diagnostic step, the legal system is brought to bear on the baby’s family and anyone else near the infant at the time of the supposed shaking.

The symptomatic triad of bleeding between the brain and skull (known as subdural or subarachnoid hematomas), bleeding behind the retinas, and brain swelling is both the core of an SBS diagnosis and the point of departure for the syndrome’s skeptics. The medical proof that shaking alone can cause these internal head injuries is questionable, the skeptics say, when many other things, from infections to malnutrition to falls onto a hard surface, are known to be causes of similar symptoms in infants.

One such skeptic testified for the prosecution in the Woodward case but later changed his stance. Pediatric neuroradiologist Patrick Barnes of Stanford University said in an e-mail interview, “It is known from case records that SBS is misdiagnosed/overdiagnosed. It is not only a problem in medicine but a problem in the justice system.”

 

…Uscinski traced medical citations in SBS research back to a 1968 study involving rhesus monkeys subjected to collisions and violent accelerations. Uscinski already knew the study—it had been conducted by his mentor, Ayub Ommaya, the very same colleague who had brought him into the Woodward case. Uscinski says the study yields no firm conclusions about the consequences of shaking monkeys or, for that matter, babies.

Despite his confidence in the existence of SBS, Newberger adds that he has consulted for the defense on two or three SBS cases in which, he says, a “juggernaut” develops. “The department of social services sends out a social worker,” he says, describing the usual procedure after a doctor reports a possible SBS case to the authorities. “If a parent does not know exactly what’s happening, very frequently the first conclusion is that they’re trying to hide something. And sometimes parents are racking their brains, coming up with one or two possibilities. Then it looks like they’re changing their stories. That can be used to damn them.”

The Haynes family of Rantoul, Illinois were caught in just such a juggernaut. In October 2005 the father, Neal, was charged in a civil case with shaking his then 3-month-old son, Jake (not his real name). Although not accused of shaking the baby, the mother, Christy, was also charged with abuse and neglect (for permitting the alleged shaking). Jake had been hospitalized three times over two months for fever, infection, difficulty breathing, and symptoms of seizures. He survived his third hospitalization and returned home healthy, with his parents. However, when emergency room doctors discovered retinal and subdural hemorrhages, they concluded that Jake’s medical problems must have stemmed from his being violently shaken.

 

In the Haynes case, Uscinski rendered a professional opinion that concluded, “There is no question but that [Jake] Haynes had a chronic subdural hematoma.” As a chronic (rather than acute) case, by definition the “hematoma had its genesis weeks or months earlier.” Uscinski suggested that baby Jake’s breech birth could have itself produced enough force on the brain to cause subdural bleeding. This kind of wound sometimes doesn’t heal and can go undetected for weeks or months, he says.

F. Edward Yazbak, a Massachusetts-based pediatrician, examined Jake’s medical records and wrote a 51-page report for the defense that pointed to other possible causes of baby Jake’s hemorrhages, including adverse reaction to his vaccinations, a vitamin C and K deficiency, and/or a toxic level of histamine in his blood.

By late December, following the ongoing case, the defense’s Yazbak learned about Jake’s enlarging head size—brought about, he concluded, by a subdural hematoma that was in fact bleeding again. “[Yazbak] said this child has got to see a specialist immediately,” Fischer says. “If it’s unchecked, he’ll die.” The lawyers called a meeting with state child protective services, petitioning for a second opinion on Jake’s condition. Ultimately he was sent to a hospital in St. Louis, where doctors operated on the hematoma and put in a shunt.

The doctors “had gotten into the routine that it was shaken baby syndrome,” Fischer says. “And they could not get out of that routine.”

“For the jury…the defense needs to prove what happened to this baby,” she says. “Unless you’ve got the money to hire top experts, you’re probably going to prison….It’s guilty until proved innocent.”

Cheri Landers, chief of the division of pediatric critical care at Kentucky Children’s Hospital in Lexington, says that if an infant were brought into the emergency room suffering seizures and was discovered to have a subdural hematoma and retinal hemorrhaging, she would want to ask the family about the background before rendering a diagnosis. “We would need to find out…was there any known trauma?” she says. According to Landers, a severe car accident, for instance, could explain subdural and retinal hemorrhages and consequent seizures. She points to a 1993 article in the journal Neurosurgery that examined the retinas of 140 children involved in car accidents. Two had hemorrhages, and both were in high-velocity side-impact crashes.

“When we discover no reason for the trauma,” she adds, “that is the point where we come to the conclusion that there is no reason for this other than shaking.” Landers cites a 2000 study in the journal Pediatrics that evaluated 19 Florida infants with subdural hemorrhages who were referred to the state’s child protective services in 1997. The authors selected nine of these cases and followed them up, reporting that every child was the victim of “inflicted injury, inappropriate infant handling, and/or high-risk social settings” such as a family with a history of domestic violence.

Neuropathologist Jan Leestma of Children’s Memorial Hospital in Chicago, who testified for the defense in the Woodward case, has come to a different conclusion. Leestma reviewed 324 apparent or alleged child abuse cases from 1969 to 2001 and published his results in a 2005 issue of the American Journal of Forensic Medicine and Pathology. Fifty-four of these cases involved shaking a baby. He found only 20 percent (11 cases) yielded no evidence of any impact to the baby’s skull—such as a fall from a changing table.

Thibault points to a 2003 study in the Journal of Neuro­surgery that used lifelike infant dolls with crash test dummy accelerometers inside their heads. A team of four bioengineers and neurologists from the Children’s Hospital of Philadelphia then simulated vigorous infant shakings—as might happen in an SBS case—as well as shakes that ended in an impact and drops from one-, three-, and five-foot heights.

The group concluded that shaking their model infants produced results “statistically similar” to one-foot falls onto concrete or a carpet pad or higher falls onto a foam mattress. These results were well below reported thresholds for causing the kind of intracranial bleeding observed in SBS babies, suggesting that shaking wasn’t enough to induce SBS.

“It’s drilled into people’s heads that shaking will kill these kids,” Kirk Thibault says. “I don’t know that shaking can’t kill a child. I assume you can probably shake a child to death. I have no idea…. What I specifically look at is whether shaking can cause loads [on the brain] that…can cause subdural hematomas. The flip side of that is people abuse kids,” Thibault says. But he adds, “You can’t simply categorically say this is all nonaccidental. I say one case at a time.”

Neurosurgeon Jean-Sébastien Raul, an assistant professor at the Institute of Legal Medicine at the University of Strasbourg in France, says he has a computer model of infant shaking that could help clarify the controversy. In a 2006 paper published in the International Journal of Legal Medicine, Raul concluded that, biophysically, shaking alone can produce the kinds of subdural hematomas that are seen in SBS cases.

Raul’s group drew from published properties of human baby brains and skulls and pig brains and skulls—markedly similar, he says, in biophysical properties. The group ran computer simulations that examined the behavior of veins that bridge the brain and the covering tissue surrounding the brain. Rupture of “bridging veins,” he says, is a known and well-understood cause of subdural hematomas.

Raul says he knows the 2003 Journal of Neurosurgery paper well but argues that the authors looked only at acceleration inside the skull. “We are looking at the relative motion between the brain and skull,” he says. It is this additional factor, he thinks, that produces the bleeding inside the shaken infant’s skull.

Thibault points out that Raul’s group conducted computerized experiments involving unknown situations without first confirming that their model could reproduce known experimental results. For instance, in 1984 Nobuhiko Aoki and colleagues at Nagoya University in Japan studied medical case records of infants who had fallen and hit their heads. Some had died, some had survived. All, Aoki said, had subdural hematomas and retinal hemorrhages and thus could potentially be seen as SBS cases. “You first have to [run your computer model] outside of the vacuum of your model,” Thibault says. “At least demonstrate that you can draw a line and say this is a threshold…and now I’m going to re-create every single one of Aoki’s falls.”

In July 2001 Coffee’s client was taking care of his 11-month-old son, Mike (not his real name), whom pediatrician Yazbak later described as suffering from “multiple medical problems” including malnutrition and possible blood coagulation deficiency. On July 10 Mike stopped breathing. According to Coffee, his client attempted CPR and called 911 before taking the child to a Las Vegas emergency room. Mike ultimately died on life support. Bruises were found on his abdomen and back, and paramedics had found a cut under his eyelid. Postmortem examinations revealed a subdural hematoma and retinal hemorrhaging.

With an existing criminal record that he feared would bias the trial, Coffee’s client opted to plead to shaking baby Mike. “I’m sure at some point during the failed attempt to resuscitate Mike, he was shaken, and as the local doctors were willing to testify that shaking caused the death, there wasn’t a problem getting the plea down,” Coffee said in an e-mail. In October 2007 Coffee’s client was sentenced to 10 years to life for second-degree murder.

Around the same time, the Wisconsin Law Review published a paper entitled “Shaken Baby Syndrome: Medical Uncertainty Casts Doubt on Convictions.” The paper’s author, Molly Gena, now a Milwaukee-based lawyer for Legal Action of Wisconsin, says her review of recent SBS decisions indicates the tide is beginning to turn.

“It started with the British cases,” Gena says, referring to a review ordered by the British attorney general, Lord Goldsmith, of 297 alleged child abuse cases, some of which were SBS convictions based only on the triad of internal symptoms: subdural hematoma, retinal hemorrhage, and brain swelling. In one case, R v. Harris, the court concluded that “the mere presence of the triad on its own cannot automatically or necessarily lead to a diagnosis of [SBS].”…

 

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