HOME: THE JOHN LAVERTY, JR. CASE-- FALSE SBS CHARGES, WRONGFUL CONVICTION & IMPRISONMENT

THE "SHAKEN BABY SYNDROME" MYTH: Why top scientists say it isn't possible to shake an infant hard enough to cause the symptoms used to diagnose SBS and the probable real causes

Questioning
The evidence base for shaken baby syndrome

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

BMJ 2004;328:719-720 (27 March), doi:10.1136/bmj.328.7442.719
Editorial
The evidence base for shaken baby syndrome
We need to question the diagnostic criteria

The phrase "shaken baby syndrome" evokes a powerful image of abuse, in which a carer shakes a child sufficiently hard to produce whiplash forces that result in subdural and retinal bleeding. The theory of shaken baby syndrome rests on core assumptions: shaking is always intentional and violent; the injury an infant receives from shaking is invariably severe; and subdural and retinal bleeding is the result of criminal abuse, unless proved otherwise.1 These beliefs are reinforced by an interpretation of the literature by medical experts, which may on occasion be instrumental in a carer being convicted or children being removed from their parents. But what is the evidence for the theory of shaken baby syndrome?

Retinal haemorrhage is one of the criteria used, and many doctors consider retinal haemorrhage with specific characteristics pathognomonic of shaking. However, in this issue Patrick Lantz et al examine that premise (p 754) and conclude that it "cannot be supported by objective scientific evidence."2 Their study comes hard on the heels of a recently published review of the literature on shaken baby syndrome from 1966 to 1998, in which Mark Donohoe found the scientific evidence to support a diagnosis of shaken baby syndrome to be much less reliable than generally thought.3

Shaken baby syndrome is usually diagnosed on the basis of subdural and retinal haemorrhages in an infant or young child,1 although the diagnostic criteria are not uniform, and it is not unusual for the diagnosis to be based on subdural or retinal haemorrhages alone.1 The website of the American Academy of Ophthalmology states that if the retinal haemorrhages have specific characteristics "shaking injury can be diagnosed with confidence regardless of other circumstances."4 Having reviewed the evidence base for the belief that perimacular folds with retinal haemorrhages are diagnostic of shaking, Lantz et al were able to find only two flawed case-control studies, much of the published work displaying "an absence of... precise and reproducible case definition, and interpretations or conclusions that overstep the data."2 Their conclusions are remarkably similar to those of Donohoe, who found that "the evidence for shaken baby syndrome appears analogous to an inverted pyramid, with a very small database (most of it poor quality original research, retrospective in nature, and without appropriate control groups) spreading to a broad body of somewhat divergent opinions."3 His work entailed searching the literature, using the term "shaken baby syndrome" and then assessing the methods of the articles retrieved, using the tools of evidence based inquiry. Reviewing the studies achieving the highest quality of evidence rating scores, Donohoe found that "there was inadequate scientific evidence to come to a firm conclusion on most aspects of causation, diagnosis, treatment, or any other matters," and identified "serious data gaps, flaws of logic, inconsistency of case definition."3

The conclusions of Lantz et al and of Donohoe make disturbing reading, because they reveal major shortcomings in the literature relating to a field in which the opportunity for scientific experimentation and controlled trials does not exist, but in which much may rest on interpretation of the medical evidence.5

If the concept of shaken baby syndrome is scientifically uncertain, we have a duty to re-examine the validity of other beliefs in the field of infant injury. The recent literature contains a number of publications that disprove traditional expert opinion in the field. A study of independently witnessed low level falls showed that such falls may prove fatal, causing both subdural and retinal bleeding.6 w2 A biomechanical analysis validates that serious injury or death from a low level fall is possible and casts doubt on the idea that shaking can directly cause retinal or subdural haemorrhages.7 w3 An important lucid interval may be present in an ultimately fatal head injury in an infant.8 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. 9 10 What is the relevance of the craniocervical injuries to corticospinal tracts, dorsal nerve roots, and so on that have been described?10 11 We do not know. What is the force necessary to injure an infant's brain? Again, we do not know.

While most abused children indisputably show the signs of violence, not all do. No one would be surprised to learn that a fall from a two story building or involvement in a high speed road traffic crash can cause retinal and subdural bleeding, but what is the minimum force required? "It is one thing clearly to state that a certain quantum of force is necessary to produce a subdural hematoma; it is quite another to use examples of obviously extreme force... and then suggest that they constitute the minimum force necessary."12

Research in the area of injury to infants is difficult. Quality evidence may need to be based on finite element modelling from data on infants' skulls, brains, and neck structures, rather than living animals. Any studies on immature animal models, if performed, will need to be validated against the known mechanical properties of the human infant. Pending completion of such studies, the reviews by Lantz and Donohoe are a valuable contribution and provide a salutary check for anyone wishing to cite the literature in support of an opinion. Their criticisms of lack of case definition or proper controls can be levelled at the whole literature on child abuse. If the issues are much less certain than we have been taught to believe, then to admit uncertainty sometimes would be appropriate for experts. Doing so may make prosecution more difficult, but a natural desire to protect children should not lead anyone to proffer opinions unsupported by good quality science. We need to reconsider the diagnostic criteria, if not the existence, of shaken baby syndrome.

J F Geddes, retired (formerly reader in clinical neuropathology, Queen Mary, University of London)
London (j.f.geddes@doctors.org.uk)

J Plunkett, forensic pathologist
Regina Medical Center, 1175 Nininger Road, Hastings, MN 55033, USA

Editorial p 720 Clinical review p 754 Letters p 766 Personal view p 775

Additional references w1-w3 are on bmj.com

Competing interests: JFG and JP have given evidence in criminal cases at the request of both the prosecution and the defence.

References

1. American Academy of Pediatrics Committee on Child Abuse and Neglect. Shaken baby syndrome: rotational cranial injuries—technical report. Pediatrics 2001;108: 206-10.[Abstract/Free Full Text]

2. 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.[Free Full Text]

3. Donohoe M. Evidence-based medicine and shaken baby syndrome. Part I: literature review, 1966-1998. Am J Forensic Med Pathol 2003;24: 239-42.[CrossRef][ISI][Medline]

4. American Academy of Ophthalmology. Shaken baby syndrome resources. www.aao.org/aao/education/library/shaken_baby.cfm (accessed 25 Feb 2004).

5. Milroy CM. Medical experts and the criminal courts. BMJ 2003;326: 294-5.[Free Full Text]

6. Plunkett J. Fatal pediatric head injuries caused by short-distance falls. Am J Forensic Med Pathol 2001;22: 1-12.[CrossRef][ISI][Medline]

7. Ommaya AK, Goldsmith W, Thibault L. Biomechanics and neuropathology of adult and paediatric head injury. Br J Neurosurg 2002;16: 220-42.[CrossRef][Medline]

8. Denton S, Mileusnic D. Delayed sudden death in an infant following an accidental fall. Am J Forensic Med Pathol 2003;24: 371-6.[Medline]

9. 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.[Abstract/Free Full Text]

10. 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.[Abstract/Free Full Text]

11. Shannon P, Smith CR, Deck J, Ang LC, Ho M, Becker L. Axonal injury and the neuropathology of shaken baby syndrome. Acta Neuropathol 1998;95: 625-31.[CrossRef][Medline]

12. People v Martinez, 51 P3d 1046 ( 2001) (R'hrg den. 2002) (cert. granted, 2002).

Related Articles

The evidence base for shaken baby syndrome: Meaning of signature must be made explicit
Mark Donohoe
BMJ 2004 329: 741. [Extract] [Full Text]

The evidence base for shaken baby syndrome: Response to editorial from 106 doctors
Robert M Reece
BMJ 2004 328: 1316-1317. [Extract] [Full Text]

Shaken baby syndrome
Brian Harding, R Anthony Risdon, and Henry F Krous
BMJ 2004 328: 720-721. [Extract] [Full Text]

Perimacular retinal folds from childhood head trauma
P E Lantz, S H Sinal, C A Stanton, and R G Weaver, Jr
BMJ 2004 328: 754-756. [Extract] [Full Text]

Patterns of presentation of the shaken baby syndrome: Four types of inflicted brain injury predominate
Robert A Minns and Anthony Busuttil
BMJ 2004 328: 766. [Extract] [Full Text]

Patterns of presentation of the shaken baby syndrome: Subdural and retinal haemorrhages are not necessarily signs of abuse
James LeFanu and Rioch Edwards-Brown
BMJ 2004 328: 767. [Extract] [Full Text]

Reluctance in child protection must be for several reasons
Ashok Beckaya
BMJ 2004 328: 767. [Extract] [Full Text]

Parents as well as children need protection
BMJ 2004 328: 775. [Extract] [Full Text]

This article has been cited by other articles:
(Search Google Scholar for Other Citing Articles)

* Hymel, K. P., Makoroff, K. L., Laskey, A. L., Conaway, M. R., Blackman, J. A. (2007). Mechanisms, Clinical Presentations, Injuries, and Outcomes From Inflicted Versus Noninflicted Head Trauma During Infancy: Results of a Prospective, Multicentered, Comparative Study. Pediatrics 119: 922-929 [Abstract] [Full text]
* Le Fanu, J (2006). Shaken baby syndrome.. Arch. Dis. Child. 91: 715-715 [Full text]
* Brookman, F., Nolan, J. (2006). The Dark Figure of Infanticide in England and Wales: Complexities of Diagnosis.. J Interpers Violence 21: 869-889 [Abstract]
* Le Fanu, J. (2005). Wrongful diagnosis of child abuse--a master theory. J. R. Soc. Med. 98: 249-254 [Full text]
* Spivack, B. (2004). Distinguishing Abusive from Accidental Head Trauma. AAP Grand Rounds 12: 47-47 [Full text]
* Donohoe, M. (2004). The evidence base for shaken baby syndrome: Meaning of signature must be made explicit. BMJ 329: 741-741 [Full text]
* Reece, R. M (2004). The evidence base for shaken baby syndrome: Response to editorial from 106 doctors. BMJ 328: 1316-1317 [Full text]
* LeFanu, J., Edwards-Brown, R. (2004). Patterns of presentation of the shaken baby syndrome: Subdural and retinal haemorrhages are not necessarily signs of abuse. BMJ 328: 767-767 [Full text]

Rapid Responses published:

will anyone listen now? 26 March 2004
s m latta,
director
po16

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 known 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
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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
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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’ work 4,5). 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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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 criminal trials. In those cases, the final arbiter is the jury, who are members of the public. Those, who strive to raise public awareness of concern, pursue a noble objective. The BBC programme made specific, limited reference to the Plunkett Geddes letter, which was published many weeks after the programme had been filmed. In a voice over, John Sweeney rightly referred to their recently published work. Further, whilst it is incorrect to suggest that the programme was unbalanced, (did we not have demonstrations of how doctors thought children might be shaken?), could this be a sustainable complaint,if any of the authors were approached for a contribution?

3) As far as I am aware, neither Squier , Geddes nor Plunkett suggest that no one ever abuses a child, nor do they deny that abusive head injury can cause subdural and retinal haemorrhages. They do question whether such findings can only be the result of malicious, sustained shaking. I understand their position to be that up to 18% of cases may be misdiagnosed with the consequent miscarriages of justice, which rightly have caused concern.

4) Contrary to popular belief, the courts do not say that whenever there is a dispute between doctors, cases should be abandoned. The position is that in some cases, there is overwhelming factual, or properly admitted circumstantial evidence to support an allegation of abuse. In others, the finding of abuse is agreed by all doctors. Those cases must be pursued. However, where there is no such supportive evidence, it's no longer thought to be appropriate to proceed on the sole basis of medical opinion, when there is a reputable challenge to that opinion.

5) The authors refer to a case, in which there had been an admission and "notwithstanding this admission the neuropathological opinion maintained the injuries were .....non traumatic". Such staggering misconception of trial procedures demonstrates the grave need for education of those, who are allowed to express opinions before juries. The evidence could only be led if the truth of the confession had been called into question. Even doctors should be aware that people do sometimes confess to that which they have not done. Have we all forgotten Stefan Kisko, who admitted the sexual assault and murder of an 11 year old girl, (following a difficult and emotionally charged enquiry)? Do the authors overlook the 17 years he spent in prison for a crime of which he was later found to be physically incapable? To base scientific opinion on the assumption that all confessions are true, demonstrates naivety of stupefying proportion.

6) No sensible observer would suggest a "crusade" to vilify or convict parents. Whether there is a desire to preserve medical dogma, which has wrongful conviction as a by-product, may be another matter.

7) The symbiosis of which I spoke earler could operate thus:investigators totally accept the SBS "hard line" theory. Where this results in conviction, the advocates of SBS might then claim that that conviction helps prove the theory. Does that happen?

8) It is regrettable that the authors chide Squier, Plunkett and Geddes for challenging "shaking" orthodoxy, when, in reality, this isn't the view of all the authors. Readers may be interested in sworn evidence, given in a recent trial: "the evidence regarding shaking alone is correctly criticised and probably the strongest evidence for it is people who acknowledge in non adversarial proceedings what they have done to a child". (Punt J: R v Latta Winchester Crown Court). So the position is "this child was shaken, because other parents have admitted shaking other children". Incidentally, perhaps the authors can tell us in which "non adversarial proceedings" these acknowledgements have been made? One assumes that those who regularly partake must know that care proceedings are adversarial. Truth may not be the only motive for "confession".

9) Perhaps doctors should take a step back - to proper medical research, in order that confidence in medical expertise might be restored and juries once more expect that it is objective, based on science and not reliant on virtual anecdotal evidence of supposed confessions. Most importantly, let's hope that experts are prepared to say "I'm not really sure", when that's the truth of the matter.

Sincerely, Mike Mackey Burton Copeland, Solicitors, 196Deansgate Manchester M3 3NE

Competing interests: The author is a defence solicitor, who has occasional experience of defending the innocent. He contributed to BBC "Real Story"
Re: Refuting established medical beliefs also requires evidence 27 April 2004
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Michael D Innis,
Director Medisets International
Home 4575w

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Re: Re: Refuting established medical beliefs also requires evidence

Editor,

Dr Jaspan et al [1] in criticising the leader by Geddes and Plunkett [2] declare “…it must be suspected in the absence of any credible explanation that the retinal haemorrhages and subdural haematomas are the consequence of inflicted injury.”

Evidently they do not accept immunization of the infant within 21 days prior to the onset of the haemorrhages as a “credible explanation” of those haemorrhages.

I have proved that immunization within this period is a cause, repeat A cause, of these haemorrhages (with or without fractures) in susceptible children [3] but it is obvious Jaspan et al; do not understand propositional calculus and have not been able to follow my argument.

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 scrap heap of history before it causes any more shame to the profession and disaster to innocent families.

Michael Innis

References:

1.Jaspan T, Bonshek R, McConachie N et al;Refuting established medical beliefs also requires evidence. Rapid Response April 20 2004

2 Geddes JF and Plunkett J The evidence base for shaken baby syndromeBMJ, Mar 2004; 328: 719 - 720.

3.Innis MD Proposed Name Change of Shaken Baby Syndrome. http://bmj.com/cgi/eletters/328/7442/766#56915, 17 Apr 2004

Competing interests: I have been paid for giving evidence in Court
Re: Refuting established medical beliefs also requires evidence 28 April 2004
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Mark Struthers,
GP
Bedfordshire, UK

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Re: Re: Refuting established medical beliefs also requires evidence

This strange, tawdry, nine-point tirade by Jaspan et al (the authors) against the editorial by Geddes and Plunkett deserves to be challenged again.

To start with, it suggests a distinct lack of imagination to propose that the term 'inflicted shaking/impact injury' may be more helpful in describing children who suffered a 'traumatic' head injury unexplained by known medical conditions or explanations provided by their carers. In their emotive use of words though, the authors leave no doubt as to where they're coming from, and of course, who could doubt the depth of their sincerity?

Geddes and Plunkett have done a great service and should be congratulated for highlighting the potential for diagnostic mistake and in their challenge to the validity of other belief systems in the field of infant injury. There must be some hope therefore that greater accuracy in the diagnosis of abuse will reduce the extent of injustice in the courts - on both sides of the equation.

Geddes and Plunkett did not deny that abusive head injury could cause subdural and retinal haemorrhages as the authors suggest in the ninth of their cardinal points. It is profoundly meretricious to say they did. Geddes and Plunkett merely challenged the idea that "shaking injury can be diagnosed with confidence regardless of other circumstances" - when retinal haemorrhages have certain characteristics.

The authors are not on a crusade to vilify and convict parents and yet the parallel between medical attitudes on SBS and the debacle over Munchausens Syndrome by Proxy and smothered babies is startling. Failure to accept diagnostic uncertainty and an inability to acknowledge that mistakes have been made, as well as the enormous damage that has been inflicted on the public trust in the medical profession does nothing to assist any perpetrator towards appropriate punishment and perhaps rehabilitation.

Competing interests: None declared
Re: Refuting established medical beliefs also requires evidence--seeing the vast amounts of evidence requires glasses on an open mind 23 May 2004
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L. Travis Haws,
Dentist
Lakewood CO USA 80228

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Re: Re: Refuting established medical beliefs also requires evidence--seeing the vast amounts of evidence requires glasses on an open mind

Editor: The letter by Jaspan et al. (the authors) is the ever- familiar response by the child protection "experts". That shaken baby syndrome is an “established” fact because we, the unregulated multi- disciplinary teams, say so. They even site to a case where the father admitted shaking, and still despite this admission, the neuropathologist maintained the subdural hemorrhages and retinal hemorrhages were of a non- traumatic etiology. The authors seem to take issue with the neuropathologist’s stance. Just because someone admits to shaking an infant does not mean it caused the injury to the brain, assuming that it was a traumatic injury at all, and not a natural process such as cortical venous thrombosis, dehydration, or meningitis. Jaspan et al. need to be reminded of the studies by Duhaime et al. and Prange et al. that demonstrated shaking doesn't generate enough force for concussion, let alone subdural hemorrhage or traumatic axonal injury. (1,2). Nor could they demonstrate enough force for such brain injury via inflicted impact against a padded surface as thin as 4 inches of unencased foam. (2) Wouldn’t the forceful violence (i.e. multi-story fall) the child protection “experts” claim is required leave serious signs of impact if the impact occurred on padding thinner than 4 inches, or even thicker than 4 inches?

They need to be reminded again that the literature that “established” their beliefs is seriously flawed, biased and opinion rather than evidence as shown by Donohoe, Barnes and Lantz et al. (3,4,5). Are the authors aware that the initial SBS work by Caffey was seriously flawed and biased? (6,7) Were complete birth histories or vaccination histories taken? Were all proper and necessary labs tests run to exclude other diagnoses? Despite these studies and the neuropathologist’s stance, Jaspan et al. still seem to believe (as "established"?) that shaking was the cause of the hemorrhages. Many of Caffey's cases didn't even have the "triad" of injuries (necropsies/descriptions of baby’s H and K) Harding, Risdon and Krous (9) elude to, but were still assumed to be "inflicted" whiplash cases. (7) If we have an established BELIEF based on non-science, all we have is nonsense. Houses built on weak foundations fall to the ground.

The American Academy of Ophthalmology Website has told us that perimacular retinal folds (PRF) or retinoschisis is characteristic of shaking injury REGARDLESS of other circumstances. (10) Now, that has also been shown to be wrong by Lantz et al. (5). There are so many holes in the all or nothing/pathognomonic/single entity "inflicted shaking/impact/SBS" hypothesis that it holds water as well as a sieve.

But we continue to hear the cry from the multidisciplinary child protection “experts" that the “majority” of the profession accepts the SBS hypothesis. It is still accepted as "established" truth, despite overwhelming evidence that it is unlikely to be correct, and no evidence other than repetition of the hypothesis and “confessions” to suggest that it is true. Doesn’t there need to be oversight of these “teams” by persons familiar with the psychology of a false confession; the limitations of injury dating by physical, radiological, or histochemical means; and the actual and known (not “hypothesized”) mechanisms of infant head injury? Doesn’t there need to be oversight of their pronouncements, since the diagnosis and opinions are largely protected from scrutiny by law? If there had been critical appraisal of Caffey’s hypothesis 30 years ago, maybe we wouldn’t be where we are today.

A group of Helfer members published a letter on-line and in Pediatrics after the Woodward acquittal appeal (11,12). Such oversight would inform (i.e. an editorial addendum) the public that this letter represents one side of a very controversial subject. Rather than letting it go unchallenged and potentially misleading thousands or millions of people. Why is the Woodward case any of their “outside-looking-in” business…or why were they so interested in the outcome? Is there something of interest to protect/preserve? Wherein the response letter it is stated “Indeed, the courtroom is not the forum for scientific speculation, but rather the place where only, according to the U.S. Supreme Court in Daubert vs. Merrill Dow, peer reviewed, generally accepted, and APPROPRIATELY [my emphasis] tested scientific evidence should be presented”. Just another instance of stones and glass houses as the courtroom/law is exactly how these multi-disciplinary teams “appropriately” tested and “established” the hypothesis (Caffey’s initial work stemmed from “confessions” of a nurse). (7) Caffey did, however, consider many other differential diagnosis that have since been ignored and thrown to the wolves. (8) The only appropriate experiments conducted conflict with the hypothesis and were not performed anywhere near a courtroom. Donohoe, Barnes and Lantz et al. explain the “appropriateness” of the remainder of the “establishing” literature. (3,4,5)

Jaspan et al. cite to a study and state 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 excluded". (13) What about the fact that as much as 9% of subdural hematomas can occur during birth. (14) Much less force than the testified to “triad” of a multi-story fall, high speed car crash or inflicted shaking/impact. As stated in a neonatology textbook, “subdural hemorrhage over the cerebral hemispheres occurring at the time of birth may be clinically silent, clinically apparent in the first few days after birth, or not apparent until as late as the sixth week of life. When this type of hemorrhage is manifested early, the signs are those of increasing intracranial pressure in the presence of jaundice or anemia. When an infant shows evidence of a convex subdural hematoma as late as the fourth to sixth week, there is usually an increasing head circumference, poor feeding or vomiting, failure to thrive, altered states of consciousness, and occasionally seizures”. (15) Does this explain some if not many of the children with a chronic SDH who do not become symptomatic until well after birth? Do these symptoms not encompass the checklist of symptoms described in much of the pro SBS literature? In practice, the SBS profession usually denigrates this claim: SDH + RH + cerebral edema = SBS, and any of the above combinations is still OK. The SBS child protection “experts” will tell us that these are indeed missed cases of abuse.

Chronic subdural hematomas can rebleed with little or no trauma. (16,17,18,19) SBS proponents and Helfer members Hymel, Jenny and Block report a case of an old subdural hematoma that had acute rebleeding from an apparent minor fall. Scattered intraretinal hemorrhages were found upon ophthalmologic examination. Hymel et al. state that the fall from a hospital bed “did not represent a clinically significant cranial deceleration event, [therefore] this young child did not suffer immediate loss of consciousness, apnea, seizure, hypotension, or prolonged traumatic coma”. However, this child did undergo “acute neurosurgical intervention. A large, acute subdural hematoma was evacuated, along with an older component of subdural hematoma”. Common sense tells anyone that without the emergency surgical evacuation of the large, acute SDH, the child would likely have lost consciousness and presented with seizure, apnea, hypotension and coma… Thus, this case supports rebleeding from minor trauma AND lucid intervals. Despite this, Hymel et al. go on to state that “Acute rebleeding within a chronic subdural collection during infancy may represent inflicted re-injury”. (20)

Regarding retinal hemorrhages, the same neonatology text states that “trauma at birth may result in retinal hemorrhage, hyphema, or vitreous hemorrhage…with a reported incidence of 2.6% to 50% of all births….the cause is most likely compression of the fetal head resulting in venous congestion [not inflicted acceleration/deceleration/impact]…hyphemas and vitreous hemorrhages usually result from misplaced forceps [direct trauma/compression--not whiplash]…during this time the infant should be handled gently and fed frequently to minimize crying and agitation…the prognosis is guarded; if resolution does not occur in 6 to 12 months, surgical correction should be considered”. (15) Again, birth is much less force than the testified to “triad” of a multi-story fall, high speed car crash or inflicted violent, non-neck-traumatizing, shaking/impact…

And it is convenient that the authors fail to discuss other potential mimics of apparent traumatic brain injury, including recent vaccinations (21,22), vitamin C deficiency (22,23), birth-related retinal hemorrhages (15,25,26,27), retinopathy of prematurity (28), surfactant therapy (29,30), external and internal hydrocephalus (31,32,33), metabolic diseases (34,35), bleeding disorders (36,37,38,39,40,41,42,43), cerebral venous thrombosis (44,45), anemia (46), hemophagocytic lymphohistiocytosis (47,48,49), disseminated vasculomyelinopathy/post-infection/post-vaccine (50), prematurity, vitamin deficiencies and temporary brittle bones (51), pneumonia/infectious diseases (52,53,54), and congenital malformations (55,56,57), among others.

What about “trivial” falls (58,59,60,61,62,63,64,65,66,67) or asymptomatic clinical presentation following minor head injury with concomitant intracranial injury/abnormal CT scans (68,69,70,71,72).

What about the predominance of hypoxic rather than traumatic axonal injury in Geddes’ studies? (73,74) What about her hypothesis that anoxia, rather than “violent trauma”, may be the source of brain injury in at least some of the infants thought to have inflicted trauma? (75) Geddes found histological evidence for isolated brain-stem damage in a number of the infants in her studies. However, where is the evidence for significant structural neck damage in any of these infants as discussed by Ommaya et al? (76) Why is cervical cord damage not part of the "accepted" triad? Common sense would tell anyone that severe neck and spinal cord trauma would be present if they have seen an SBS proponent shake a doll as they demonstrate to the jury in an “un-biased” all-or-nothing fashion. Any chiropractor could easily show us soft tissue injury in whiplash cases.

Jaspan et al. state that Geddes and Squier did a “biased” unchallenged television program. However, Dr. Randell Alexander, a “forensic pediatrician” from Atlanta and a Helfer Society member, was a featured participant. Chief Inspector Wheeler was asked to participate, but his superior did not allow it. The TV program pales in comparison to the constant and non-ending UNCHALLENGED, completely biased media coverage of SBS charges in the U.S. Dissemination of the unchallenged hypothesis is not limited to the media. SBS is taught as truth in our high-schools, universities, parenting classes, medical schools, and on billboards. The “never never shake a baby” campaign is an industry masquerading as science. In fact, the National Center on Shaken Baby Syndrome has a director of marketing, “life-like” infant dolls, investigator guide books for sale…among other things.

All one has to do is go to the National Center on Shaken Baby Syndrome to get an idea how the biased/unchallenged propaganda wheel works and how the child protection “experts” appropriately test the hypothesis in a courtroom. (77) At this year’s North American Conference on Shaken Baby Syndrome in Montreal, Quebec, Canada on September 12-15, 2004, we have a “forensic pediatrician” with no training or expertise in biomechanics, speaking about BIOMECHANICS and FORENSIC controversies! Where are the true biomechanic experts that have done the actual research? There is a “mock trial” at the same Conference that, according to the brochure, is being presented by defense and prosecution attorneys and experts. However, the attorneys are all prosecutors and the experts are all SBS proponents, Helfer members and co-signators to the Louis Woodward response letter. (12) Finally, at the same conference, there is an “Ask the Experts” presentation, where people are invited to bring questions to the “prestigious” panel of "experts" that consists of, guess who...that’s right…SBS proponents, Helfer members and Louis Woodward response letter co -signators. Where are the defense experts and attorneys as stated in the brochure? Where are the biomechanical experts that performed actual biomechanical experiments or the authors of research that conflicts with the SBS literature and explains alternative causes? Do you see a pattern? Why do the SBS proponents so readily ignore the existence of the biomechanical studies and alternative cause studies and/or invest so much time refuting such in mock trials and SBS proponent conferences, magazines... Is there something else, of great interest, to protect besides children?

Doesn’t protecting innocent families from false accusations/charges protect children? Doesn’t finding the true nature of many of these “classic” SBS cases protect children? Failure to do such IS domestic/child abuse.

Furthermore, why is it the burden of disbelievers to “disprove” the “established” belief in SBS? It is the responsibility of the SBS proponents the charge and unequivocally testify to prove, not on others to disprove. The responsibility lies with those accepting the hypothesis as truth, not with those who doubt it. Why do many child protection “experts” uncritically accept what they have been taught about injury mechanisms?? If I told you my hair turned purple and grew 5 mm from being whiplashed out of its follicle as I was shaken, would you believe me without expecting me to prove it? After all, it kind of makes sense…shaking and its centrifugal force lengthening my hair and causing the SDH to enter the hair follicles (through the skull fracture from the impact that Duhaime and Prange show needs to happen—and all this with no neck trauma). And if the data doesn’t agree with the hypothesis, then doesn’t the hypothesis need to be rejected or at least modified rather than manipulating the data to fit the hypothesis (i.e. selectively discarding or accepting certain data)?

Those who caution against uncritical acceptance of the SBS hypothesis do not challenge the fact that abuse MAY cause subdural hemorrhage brain injury. To suggest that they do, as does Jaspan et al., is dissembly. Geddes, Plunkett, Squier, and others challenge the effortlessness with which child protection "experts" arrive at conclusions and diagnoses with such profound societal and legal implications. This will likely continue until someone with the financial resources to fight has been accused, and is able to show that the Emperor has been wearing no clothes.

Jaspan et al. cite Harding, Risdon and Krous (9) to support their beliefs. However, although Harding et al stress the totality of findings or the “triad”, as recently as 2001, the American Academy of Pediatrics (AAP) Committee on Child Abuse and Neglect published a policy statement wherein is stated that "cerebral edema with subarachnoid hemorrhage may be the only finding" (78). How does this official position of the AAP correspond with the published opinion of Harding et al., one of whom (Krous) is a member of the AAP Committee on Child Abuse and Neglect?

L. Travis Haws

1)Duhaime A. et al., The Shaken baby syndrome. A clinical, pathological, and biomechanical study. J Neurosurg 1987; 66:409-415.

2)Prange M. et al. Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants. Journal of Neurosurgery 2003 99: 143-150.

3)Donohoe M. Evidence-Based Medicine and Shaken Baby Syndrome. American Journal of Forensic Medicine and Pathology 2003; 24: 239-42.

4)Barnes P. Ethical Issues in Imaging Nonaccidental Injury: Child Abuse. Topics in Magnetic Resonance Imaging 2002; 13; 85-94.

5)Lantz PE, Sinal SH, Stanton CA, Weaver RG Jr. Perimacular retinal folds from childhood head trauma. BMJ. 2004; 328:754-6. 6) http://bmj.bmjjournals.com/cgi/eletters/328/7442/720#55028

7)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.

8) Caffey J. On the Theory and Practice of Shaking Infants. American Journal of Diseases in Childhood 1972; 124:161-9.

9)Harding B, Risdon RA, Krous HF. Shaken baby syndrome. BMJ 2004;328:720-721.

10) http://www.aao.org/aao/education/library/shaken_baby.cfm#ocular

11)http://child-abuse.com/sbsletter.shtml

12)Chadwick DL, Kirshner RH, Reece RM, Ricci LR, Shaken baby syndrome: a forensic pediatric response [Letter]. Pediatrics 1998; 101:321 -3.

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21)Innis MD Proposed Name Change of Shaken Baby Syndrome. 17 Apr 2004 http://bmj.com/cgi/eletters/328/7442/766#56915

22)Scheibner V. Patterns of presentation of the "shaken baby" syndrome may not be caused by trauma at all. April 2004. http://bmj.bmjjournals.com/cgi/eletters/328/7442/766#55368

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27)Beratis NG, Varvariqou A, Katsibris J, Gartaganis SP. Vascular retinal abnormalities in neonates of mothers who smoked during pregnancy. J Pediatr 2000;136:760-66.

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31)Piatt JH. A Pitfall in the Diagnosis of Child Abuse: External Hydrocephalus, Subdural Hematoma, and Retinal Hemorrhages. Neurosurg Focus 1999:7(4).

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35)Nassogne MC, Sharrard M, Hertz-Pannier L, Armengaud D, Touati G, Delonlay-Debeney P, Zerah M, Brunelle F, Saudubray JM. Massive subdural haematomas in Menkes disease mimicking shaken baby syndrome. Childs Nerv Syst. 2002 Dec;18(12):729-31.

36)Chaou WT, Chou ML, Eitzman DV. Intracranial hemorrhage and vitamin K deficiency in early infancy. J Pediatr. 1984 Dec;105(6):880-4.

37)Suzuki K, Fukushima T, Meguro K, Aoki T, Kamezaki T, Saitoh H, Enomoto T, Nose T. Intracranial hemorrhage in an infant owing to vitamin K deficiency despite prophylaxis. Childs Nerv Syst. 1999 Jul;15(6-7):292-4.

38)de Tezanos PM, Fernandez J Perez Bianco PR. Update of 156 episodes of central nervous system bleeding in hemophiliacs. Haemostasis 1992 22(5). 259-267.

39)Furui T, Yamada A, Iwata K. Suburban Hematoma as a complication of hemostatic deficiency secondary to liver cirrhosis—a report of two cases. Neurolgia Medico-Chirurgica (Tokyo), 29(7):588-91.

40)Kolluri VR, Reddy DR, Reddy PK, Naidu MR, Kumari C. thrombocytopenia purpura: Case report. Neurosurgery 1986 19(4):635-36.

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43)Levin M, Kay JDS, Gould JD, Hjelm M, Pincott JR, Dinwiddie R, Matthew DJ, Haemorrhagic shock and encephalopathy: A new syndrome with a high mortality in young children. The Lancet July 9, 1983: 64-67.

44)Carvalho KS, Bodensteiner JB, Connolly PJ, Garg BP. Cerebral venous thrombosis in children. J Child Neurol. 2001 Aug;16(8):574-80.

45)Barron TF, Gusnard DA, Zimmerman RA, Clancy RR. Cerebral venous thrombosis in neonates and children. Pediatr Neurol. 1992 mar-Apr;8(2):112 -6.

46)Liao PM, Thompson JT. Opthalmic Manifestations of Virus-Associated Hemophagocytic Syndrome. Arch Opthalmol. 1991;109:777

47)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.

48)Hallahan AR, Carpenter Pa, O’Gorman–Hughes DW, Vowels MR, Marshall GM. Haemophagocytic lymphohistiocytosis in children J. Paediatr Child Health 1999; 35: 55-9.

49)Fitzgerald NE, McClain KL. Imaging characteristics of hemophagocytic lymphohistiocytosis. Pediatr Radiol 2003(33):392-401.

50)Reik L Jr. ‘Hypothesis’ Disseminated Vasculomyelinopathy: An Immune Complex Disease. Annals of Neurology 1980 Vol 7, No 4:291-96.

51)Amir J, Katz K, Grunebaum M, Yosipovich Z, Wielunsky E, Reisner SH. Fractures in Premature Infants. Journal of Pediatric Orthopedics 1988 Vol 8, No. 1: 41-44.

52)Baker AB, Noran HH. Changes in the central nervous system associated with encephalitis complicating pneumonia. Archives Internal Medicine. 1945;76:146-153.

53)Ogilvy CS, Chapman PH McGrail K. Suburban empyema complicating bacterial meningitis in a child: Enhancement of membranes with gadolinium on magnetic resonance imaging in a patient without enhancement on computed tomography. Surgical Neurology 1992 37(2);138-41.

54)Syrogiannopoulos GA, Nelson JD, McCracken GH Jr. Suburban collections of fluid in acute bacterial meningitis: A review of 136 cases. The Pediatric Infectious Disease Journal 1986 5(3):343-52.

55)Oikawa A, Aoki N, Sakai T. Ateriovenous malformations presenting as acute subdural hematoma. Neurological Research 1993 15(5):353-55.

56)O’Leary PM, Sweeny PJ. Ruptured intracerebral aneurysm resulting in a subdural hematoma. Annals of Emergency Medicine 1986 15(8):944-46.

57)Koc RK, Pasaoglu A, Kurtsoy A, Oktem IS, Kavuncu I. Acute spontaneous subdural hematoma of arterial origin: A report of five cases. Surgical Neurology 1997 Vol 47 No 1:9-11.

58)Plunkett J. Fatal pediatric head injuries caused by short-distance falls. Am J Forensic Med Pathol 2001;22:1-12.

59)Aoki N, Masuzawa H. Infantile acute subdural hematoma. Clinical analysis of 26 cases. J Neurosurgery 1984;61:273-80.

60)Hall JR, Reyes HM, Horvat M. The mortality of childhood falls. J Trauma 1989;29:1273.

61)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.

62)Greenes DS, Schutzman SA. Occult intracranial injury in infants. Ann Emerg Med 1998;32:680-6.

63)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.

64)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.

65)Wissow, LS, Wilson, MH. The use of consumer injury registry data to evaluate physical abuse. Child Abuse and Neglect. 1988;12:25-31.

66)Shane SA, Fuchs SM. Skull fractures in infants and predictors of associated intracranial injury. Pediatr Emerg Care. 1997 Jun;13(3):198- 203.

67)Browne GJ, Lam LT. Isolated extradural hematoma in children presenting to an emergency department in Australia. Pediatr Emerg Care. 2002 Apr;18(2):86-90.

68) Goldsmith W, Plunkett J, A Biomechanical Analysis of the Causes of Traumatic Brain Injury in Infants and Children. The American Journal of Forensic Medicine and Pathology. June 2004,Vol. 25 No. 2:89-100

69)Simon B, Letourneau P, Vitorino E, McCall J. Pediatric minor head trauma:indications for computed tomographic scanning revisited. J Trauma. 2001 Aug;51(2):231-7; discussion 237-8.

70)Mandera M, Wencel T, Bazowski P, Krauze J. How should we manage children after mild head injury? Childs Nerv Syst. 2000 Mar;16(3):156-60.

71)Stein SC, Young GS, Talucci RC, Greenbaum BH, Ross SE. Delayed brain injury after head trauma: significance of coagulopathy. Neurosurgery. 1992 Feb;30(2):16.

72)Ros SP, Cetta. Are skull radiographs useful in the evaluation of asymptomatic infants following minor head injury? Pediatr Emerg Care. 1992 Dec;8(6):328-30.

73)Hahn YS, McLone DG. Risk factors in the outcome of children with minor head injury. Pediatr Neurosurg. 1993 May-Jun;19(3):135-42.

74)Geddes JF, Hackshaw AK. Nickols CD, Whitwell HL. Neuropathology of inflicted head injury in children. I. Patterns of brain damage. Brain 2001;124: 1290-8.

75)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.

76)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.

77)Ommaya AK, Goldsmith W, Thibault L. Biomechanics and neuropathology of adult and paediatric head injury. British Journal of Neurosurgery 2002; 16(3):220-242.

78) http://www.dontshake.com/conferences/na/2004/programpdf.pdf

79)Committee on Child Abuse and Neglect. Shaken Baby Syndrome: Rotational Cranial Injuries—Technical Report. PEDIATRICS Vol. 108 No. 1:206-210.

Competing interests: Know the Falsely Accused and the Utter Devastation Heaped Upon Them and Their Families at the Hands of a Dogma
"Shaken Baby", or Barlow's Disease Variant? 19 June 2004
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C. Alan B. Clemetson, M.D.,
Professor Emeritus
5844 Fontainebleau Dr.,
New Orleans, LA 70125

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Re: "Shaken Baby", or Barlow's Disease Variant?

“SHAKEN BABY”, OR BARLOW'S DISEASE VARIANT?

The editorial by Geddes and Plunkett (1) is timely and very much to the point. Retinal petechiae and subdural haemorrhages do not always indicate trauma or child abuse. Fung et al (2) even suggest that the prevailing pathognomonic association between unexplained subdural haematoma, retinal haemorrhages, and a diagnosis of child abuse may be a self-fulfilling prophecy. It certainly seems to have become a self- propagating assumption.

It is my opinion that infantile scurvy, or a variant of it, still occurs today and can be mistakenly diagnosed as “shaken baby syndrome.” Most reports include a full panel of blood coagulation studies and full skeletal X-rays, etc.; but few, if any, discuss capillary fragility as a possible cause of retinal petechiae and the weakness of the bridging veins between the brain and the dura mater. Most physicians are probably unaware that there is a highly significant inverse relationship between plasma ascorbic acid and whole blood histamine levels in human adults. In a study of 437 outwardly normal men and women in Brooklyn NY in 1980, we found that three percent had markedly deficient plasma ascorbate levels (<0.2 mg/100 mL, or <11.4 µmol/L), associated with a four- to fivefold increase in the blood histamine concentration (3). The reason for this inverse relationship is that L-ascorbic acid is essential for the elimination of histamine by converting it to hydantoin-5-acetic acid and on to aspartic acid in vivo (4). Few physicians will be surprised to learn that blood histamine levels are increased by the injection of foreign proteins as inoculants and also during systemic infections (4). Both ascorbic acid depletion (5) and histamine excess (6) cause opening of the intercellular tight junction-gaps between the capillary and venular endothelial cells from which the bleeding of scurvy occurs.

No one wants to believe that infants today in the Western world could be vitamin C deficient; but dietary intake is only one of many causes of vitamin C depletion. Even the common cold can halve the leukocyte ascorbate content in the blood within 24 hours of its onset (7). Undoubtedly, the increased blood histamine concentration due to moderate ascorbate depletion can be elevated to a toxic level by inoculations or by infection.

Barlow’s disease, or infantile scurvy, was a well recognized disease among bottle-fed infants during the first 75 years of the 20th century, presenting as broken ribs, cerebral haemorrhages, retinal haemorrhages, and skin sores that would not heal. Today, the diagnosis of Barlow’s disease is rare. It seems that a variant of it still occurs and is diagnosed as “shaken-baby syndrome” -- a term which is becoming much too common. This new variant of Barlow’s disease should perhaps be called histaminaemia. It occurs earlier than classical scurvy, and often within two or three weeks following multiple inoculations, or following an infection.

We should all be cognizant of the seminal studies of Kalokerinos (8), who reported that deaths following inoculations in Australian aborigine infants could be prevented by the simple measure of providing a vitamin C supplement before their inoculations. Perhaps the aborigine children were unusually sensitive to the toxins, or toxoids, but they were also most probably ascorbate-depleted due to their chronic upper respiratory infections as reported. A review of the World literature (9) has shown a highly significant protective effect of vitamin C against morbidity and mortality following injection of a wide array of inoculants in animals. This beneficial effect was seen even in rats and mice, which make their own ascorbic acid in the liver. Clearly, they do not always make enough of it.

There was no suspicion of shaking among the nine infants with subdural haemorrhages and retinal petechiae reported by Fung et al (2002). We may therefore conclude that the haemorrhages may have been due to capillary fragility, which led to the delayed development, epilepsy, and four cases of spastic quadriplegia reported, -- i.e., very serious neurological damage.

It is of interest to recollect that retinal petechiae and incipient jaundice were indications for termination of pregnancy to prevent Wernicke’s haemorrhagic encephalopathy in women with excessive vomiting in pregnancy, until Lund and Kimble (10) of Madison WI, in 1943, reported, "Hyperemesis Gravidarum may lead to dangerously low levels of vitamin C. Clinical scurvy may appear. The retinal hemorrhages of severe hyperemesis gravidarum are a manifestation of vitamin C deficiency and are similar to petechial hemorrhages seen elsewhere. The hemorrhages cease after adequate therapy with vitamin C; henceforth they are not necessarily an indication for the use of therapeutic abortion."

Practical suggestions

1. No one should be indicted for “shaken-baby syndrome” unless there has been direct evidence of abuse. 2. Vaccinations or inoculations should be postponed for any infant who is premature, who has an upper respiratory infection, or who is ailing in any way. 3. We should ask ourselves whether it is wise to give as many as six inoculants, all at once, to infants at eight weeks of age. 4. Every infant should receive 500 mg of vitamin C powder or crystals, in fruit juice, to drink before inoculation. 5. Any infant showing severe reactions, such as convulsion or a high- pitched cry, should receive additional ascorbic acid by injection. 6. Plasma vitamin C and blood histamine analyses should become a routine part of the workup for severely ill infants.

C. Alan B. Clemetson, M.D. Professor Emeritus Tulane University School of Medicine 5844 Fontainebleau Drive New Orleans, LA 70125 Email: megcc2000@yahoo.com

References

1 Geddes JF, Plunkett J. Evidence base for shaken baby syndrome. BMJ 2004;328:719-20. 2 Fung ELW, Sung RYT, Nelson EAS, Poon WS. Unexplained subdural hematoma in young chi ldren. Is it always child abuse? Pediat Internat 2002;44:37-42. 3 Clemetson CAB. Histamine and ascorbic acid in human blood. J Nutr 1980;110:662-8. 4 Chatterjee IB, Majumder AK, Nandi BK, Subramanian N. Synthesis and some major functions of vitamin C in animals. Ann NY Acad Sci 1975;258:24- 47. 5 Gore I, Fujinami T, Shirahama T. Endothelial changes produced by ascorbic acid deficiency in guinea-pigs. Arch Pathol 1965;80:371-6. 6 Majno G, Palade GE. Studies on inflammation. 1. The effect of histamine and serotonin on vascular permeability. An electron microscopic study. J Biophys Biochem Cytol 1961;11:571-605. 7 Hume R, Weyers E. Changes in leukocyte ascorbic acid during the common cold. Scott Med J 1973;18:3-7. 8 Kalokerinos A. Every Second Child. Sydney: Thomas Nelson (Australia) Ltd, 1974. 9 Clemetson CAB. Vaccinations, inoculations and ascorbic acid. J Orthomol Med 1999;14:137-42. 10 Lund CJ, Kimble MS. Some determinants of maternal plasma vitamin C levels. Am J Obstet Gynecol 1943 46:635-47.

Competing interests: None declared
Clemetson Syndrome 23 June 2004
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F. Edward Yazbak,
Pediatrician, Director
TL Autism Research, Falmouth, Massachusetts 02540, USA

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Re: Clemetson Syndrome

In his remarks relative to the Geddes and Plunkett Editorial 1, Professor Clemetson 2 answers many questions that anyone who has reviewed cases of so-called “Shaken Baby Syndrome” (SBS) with an open mind, must have.

An indirectly related study by scientists at the National Human Genome Research Institute (NHGRI), The National Institute of Digestive and Kidney Diseases (NIDDK) -of our National Institutes of Health- and the University Of Pennsylvania School of Medicine and Children’s Hospital, appears relevant.3 Using mice with a defective Slc23a1 gene, which encodes the transporter protein that enables vitamin C to enter cells, the researchers discovered that ascorbic acid was not delivered from the blood through the placenta into the fetal tissues. The vitamin C-deprived mice died shortly after birth because of massive cerebral hemorrhage and complete respiratory failure, whether they were delivered normally after 21 days gestation, or earlier by Caesarian section (18.5 to 19.5 days) to avoid birth trauma.

It is well known that intracerebral hemorrhages, lung complications and respiratory failure are quite common in infants who are born prematurely, and are major causes of mortality and morbidity.

Vitamin C is an essential vitamin with superior anti-oxidant properties that can donate electrons to quench the free-radical inflammatory damage from toxins, injuries and infections. It is also a natural antihistamine that can limit and control sensitivity reactions and it helps in the healing of wounds and in the formation of collagen and bile.

During “stress periods” the usual daily-recommended dose of vitamin C, that is perfectly adequate in health, is just not enough to meet the increased demands. Particularly in premature, immature and “weakened” infants, the sudden significant stress in response to the concomitant administration of multiple antigens seems to render adequate reserves temporarily grossly inadequate.

Many parents and babysitters are in jail just because they were unfortunate enough to have been alone with a clearly at-risk baby who crashed a few days after receiving one or more vaccinations. While the triad of retinal hemorrhages, cerebral hemorrhages and fractured ribs and bones were previously required criteria for the diagnosis of SBS to be considered, some unfortunate and innocent adults are now being investigated and arrested because a baby in their care just had one of those findings. The Public Defender and one or two experts (willing to testify pro bono or for a symbolic fee) are often no match to the aggressive prosecutor and his or her parade of well-paid Professors in Medical Schools and “Experts in Shaken Baby Syndrome”.

In the cases I have reviewed, the mother had serious problems and complications during pregnancy and the baby was born prematurely or was small for gestational age. All babies had problems at or shortly after birth and were either on an apnea monitor or had used one. One had a prior "Life Threatening Event". Some had had intercurrent infections, had undergone septic workups or had received antibiotics. Each and every one of them had been recently vaccinated as reported by Innis.4 and not a single one had levels of Vitamin C and histamine checked.

Professor Clemetson has carefully discussed the retinal and cerebral hemorrhages of Vitamin C deficiency.

Prosecuting attorneys and their experts have used the finding of “multiple fractured ribs at different stages of healing”, as uncontestable evidence of recurrent abuse. It is time that fallacy is also laid to rest. It is unlikely to break a rib without any external evidence of direct trauma or demonstrable injury to the underlying pleura and lung. Breaking several ribs is even more unlikely. Breaking ribs one by one over a period of time, without anyone noticing and without evidence of internal and external injury, is statistically almost impossible.

According to Archie Kalokerinos, MD, 5 the decorated Australian researcher and expert on Vitamin C deficiency, one or more of the following can occur, in ribs and bones, without abusive injuries, when plasma levels of ascorbic acid are low a) Elevation of the periosteum with underlying hemorrhages b) Ossification of the underlying hemorrhages similar to what happens in hemorrhages near fracture sites c) Disorders of the epiphysis and breakdown collagen formation complicated by hemorrhages d) Separation of the epiphysis with resulting pathological fractures 5) Faulty collagen formation leading to weakening of the bones.

Vitamin C, even if taken in the recommended dosage, may be depleted by stresses to which the infant is exposed, including recurrent infections and multiple vaccinations: Adequate amounts of ascorbic acid in “Easy Times” become insufficient during “Red Alerts”.

Professor Clemetson’s contributions in the past and to the on-going discussion are considerable. As he suggests, all infants and children believed to be victims of “Shaking” and “Shaking and Impacting” should be routinely tested. Those with very low blood vitamin C and elevated serum histamine levels should be treated promptly and vigorously. I believe that these infants should be diagnosed as having “Clemetson Syndrome” and not inflicted trauma.

References 1) Geddes JF, Plunkett J. Evidence base for shaken baby syndrome. BMJ 2004;328:719-20.

2) Clemetson CAB. “SHAKEN BABY”, OR BARLOW'S DISEASE VARIANT? http://bmj.bmjjournals.com/cgi/eletters/328/7442/719 19 June 2004

3) http://www.nih.gov/news/pr/may2002/nhgri-01.htm Accessed June 21, 2004

4) Innis MD Retinal haemorrhages and SBS. Fact or Fantasy? http://bmj.bmjjournals.com/cgi/eletters/328/7442/719 13 April 2004

5) http://www.freeyurko.bizland.com/kalokerinos1.html Accessed June 21, 2004

Competing interests: I have reviewed the medical records of several cases of "SBS" and have received a nominal fee once.
Re: "Shaken Baby", or Barlow's Disease Variant? 24 June 2004
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abram hoffer,
private practice
Victoria BC. CAnada

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Re: Re: "Shaken Baby", or Barlow's Disease Variant?

I write to support Professor C.Alan B. Clemetson's et al(1) conclusions in his response to the Editorial by Geddes and Plunkett(2). I have known Professor Clemetson since the early 1950. when we were Professors at the University of Saskatchewan, Medical School in Saskatoon. I consider him one of the worlds foremost authorities on ascorbic acid, its clinical values, and its properties. His three volume series entitled Vitamin C(3) by CRC Press one of the best compilations of informtion about this important vitamins

His argument is that Shaken Baby syndrome can not scientifically be diagnosed unless ascorbic acid deficiency is ruled out by careful clinical and laboratory analysis as the signs and symptoms of scurvy in children may be similar or identical to those found in the Shaken baby syndrome. In my opinion his argument is based upon a careful, learned analysis of the evidence. His work should be available to courts that have to deal with this problem

My experience with vitamin C began in 1944 when I was a biochemist, expanded in 1952 when I began to study its effect in treating psychistric patients and was greatly expanded when I corroborated the earlier findings by E Cameron and L Pauling that it has value in the treatment of cancer. Over the decades I have become convinced that sub clinical scurvy is much more prevalent than most people think and that it should be always investigated when any condition similar to Shaken baby syndrome confronts us.

(1) Clemetson C. Alan B. et al "Shaken Baby"or Barlow's Disease Variant? BMJ Rapid response June 19,2004

(2) Geddes JF, Plunkett J. Evidence base for shaken baby syndrome. BMJ 2004;328:719-20

)3_ Clemetson C. Alan B. Vitamin C. CRC Press, Inc. Boca Raton, Florida, 1989

Competing interests: None declared
Patience instead of Anger and Condemnation 25 June 2004
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Dr. Herbert H. Nehrlich,
Private Practice
Bribie Island, Australia 4507

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Re: Patience instead of Anger and Condemnation

Needless to say, shaken baby syndrome is a tragedy. So are repressed memory and crib (cot) death. Anyone familiar with the work of Linus Pauling, Ian Cameron, Archie Kalokerinos, Robert Cathcart and Abram Hoffer will logically take the next step and read Professor Clemetson's writings (in case they haven't done so already).

Much has been said about Vitamin C, many positive things by those who had what it takes to use patience and their powers of observation to be able to experience the nature of this miraculous substance. There is no doubt about the constructive role that Ascorbic acid plays in many facets of our physiologies, and it matters little that this orphan drug is belittled, even ridiculed by those who either have ulterior motives or who are simply plain ignorant.

It was Victor Herbert who made fun of Pauling's 18 g/day Vitamin C habit and he showed very little good taste in the choice of his words but it was Kalokerinos who worked with Aboriginal children, providing tremendous help through Vitamin C, it was Klenner who courageously and singlehandedly stuck out his neck close to the unfriendly eyes of his medical peers and their waiting guillotines when he pioneered megadosing with vitamin C.

Cameron woke up Pauling to this unique substance and Hoffer looked at all of the evidence and was impressed.

And, if Hoffer is impressed and Professor Clemetson speaks out, people ought to listen.

There is NO ONE in the world today who knows more about ascorbates.

The history of medicine is, literally 'full of it', meaning full of mistakes, unfounded beliefs and hurtful therapies. Remember when mothers were the cause of Schizophrenia? When George Washington was finally 'put down' as a result of blood-letting? And, the history of medicine is also known to be vindictive, ready to jump to conclusion and gleefully enforce punishment. Haste has always been part of 'doctoring', in the past more by clinical necessity, today more out of the need to experience the high of overconfidence and to reap rewards. And it is the patient or their survivors who suffer the effects of humans practicing the art of healing. Perhaps patience is lacking, patience to study things thoroughly and not to fall for the temptation of quick assumptions, and patience to read the (admittedly considerably voluminous) writings of the scholars mentioned above.

Shaken baby syndrome is undoubtedly here to stay yet there is no doubt in my mind that the number of cases is wildly overstated. Could we look at the causes of the petechial and other haemorrhages before passing judgment?

The tools are available.

Competing interests: None declared
K comes after C and H in SBS 25 June 2004
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F. Edward Yazbak,
Pediatrician, Director
TL Autism Research, Falmouth, Massachusetts 02540

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Re: K comes after C and H in SBS

Professor Clemetson has described how sub-clinical Vitamin C deficiency, in addition to other causes of increased blood histamine, such as vaccinations and febrile illnesses, may produce findings similar to those of the so-called Shaken Baby Syndrome (SBS). He has also recommended that ascorbic acid and histamine levels be checked in every case where “Shaking” or “Shaking-Slamming” a baby is suspected.1

It has been proposed that infants have Clemetson Syndrome 2 if, in the absence of a convincing history and clear evidence of trauma, they have one or more of the following: retinal and intracerebral hemorrhages, bone or rib “fractures” or pathology, low plasma vitamin C and high blood histamine levels.

Vitamin K deficiency, like vitamin C deficiency, may play a role in the causation of the so-called “Shaken Baby Syndrome”.

Hemorrhagic Disease of the Newborn (HDN) or Vitamin K Deficiency Bleeding (VKDB) is a bleeding disorder caused by a deficiency of vitamin K and its dependent clotting factors (II, VII, IX and X). It is categorized as early, classical or late. In some series, up to 100% of cases of late- onset hemorrhagic disease of the newborn (LHDN) present with intracranial bleeding (84%-100% subdural, 37% -80% subarachnoid and 25%-40% intracerebral). 3

Risk factors for LHDN are no vitamin K prophylaxis, breastfeeding, prematurity, intra-uterine growth retardation, birth asphyxia, traumatic delivery, antibiotic therapy during the neonatal period, infective gastro- enteritis, malabsorption, liver disease and certain maternal medications including warfarin, phenytoin, barbiturates and isoniazid. 4, 5, 6. Most of these factors are fairly common in cases of so-called Shaken Baby Syndrome.

Babies are normally born with low levels of vitamin K. The prophylactic intra-muscular administration of vitamin K shortly after birth has been “routinely” recommended for decades and the early form of HDN has been practically eliminated. Because of safety concerns about intra-muscular Vitamin K, the oral route of administration has been advocated and used successfully in full term newborns for years.7

In 1992, Cornelissen et al, 8 conducted a randomized clinical trial to establish the effects of oral and intra-muscular administration of vitamin K at birth on plasma concentrations of vitamin K1, proteins induced by vitamin K absence (PIVKA-II), and clotting factors: They found that at the age of 3 months, PIVKA-II was detectable in 11.5% of infants and concluded that “repeated oral prophylaxis will be necessary to completely prevent (biochemical) vitamin K deficiency beyond the age of 1 month.”

In 1999, Rutty reported the case of a 9-week old male infant who was born at full term and received prophylactic IM vitamin K at birth and again in the community. 6 He was bottle-fed but had been seen repeatedly for failure to thrive. The baby had a 10-day history of vomiting and diarrhea before he was brought to a hospital emergency department unconscious and slightly jaundiced. A CT scan revealed right-sided subdural hematoma, midline shift and infarction of the right parietal lobe. The baby underwent a craniotomy and evacuation of the hematoma but did not survive beyond 24 hours. The autopsy confirmed the presence of the right subdural hematoma, bilateral retinal hemorrhages, hepatitis and chronic active gastritis. There was a single bruise in the midline of the chest.

A comprehensive hematological workup including a PIVKA test confirmed the diagnosis of LHDN.

Most of us in the field know of a parent or caretaker who is in jail only because he or she was alone with an infant who had a similar history and identical findings as that little boy.

SBS is not and must never be a “spot diagnosis”. In every suspected case, vitamin C and histamine levels must be obtained and a PIVKA test must be done, sooner rather than later.

The judicious administration of vitamin C and K, if indicated, could save the infant. If the baby expires, a positive PIVKA test on blood obtained on admission could save the parent.

I have yet to review a case where the above-suggested testing was done.

References

1. Clemetson CAB. “SHAKEN BABY”, OR BARLOW'S DISEASE VARIANT? http://bmj.bmjjournals.com/cgi/eletters/328/7442/719 19 June 2004

2. Yazbak FE. Clemetson Syndrome http://bmj.bmjjournals.com/cgi/eletters/328/7442/719 23 June 2004

3. Choo KE et al Hemorrhagic disease of the newborn and older infants: a study of hospitalized children in Kelantan, Malaysia. Ann Trop Paediatr 1994; 14:231-7

4. Nelson WE, Behrman RE, Kliegman RM, Arvin AM, eds. Nelson textbook of Pediatrics, 15th ed. Philadelphia:WB Saunders, 1996:504-5

5. Sutor AH, Dagres N, Niederhof H. Late form vitamin K deficiency bleeding in Germany. Klin Padiatr 1995;207:89-97

6. Rutty GN, Smith M, Malia RG. Late-Form Hemorrhagic Disease of the Newborn:A Fatal Case Report with Illustrations of Investigations that May Assist in Avoiding the Mistaken Diagnopsis of Child Abuse. Am J Forensic Med Path 1999;20(1):48-51.

7. Clark F, James EJP. Twenty-seven years of experience with oral vitamin K1 therapy in neonates. j ped 1995: 127 (2) 301-304

8. Cornelissen EA et al Effects of oral and intramuscular vitamin K prophylaxis on vitamin K1, PIVKA-II, and clotting factors in breast fed infants. Arch Dis Child. 1992Oct;67(10):1250-1254

Competing interests: I have reviewed the medical records of several cases of "SBS" and have received a nominal fee once.
Clemetson's work 5 July 2004
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Keith B Taylor,
Retired Physician
Ferry Cottage RH20 1PB

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Re: Clemetson's work

I have been aware of Clemetson's work and his thoughtful and logical suggestions concerning a possible cause for so called shaken baby syndrome.

He has proposed that elevated circulating levels of histamine as a consequence of acute Vitamin C deficiency, which are known to be associated with increased capillary fragility may be responsible for the retinal and intracranial bleeding seen in many of these unfortunate infants. Such bleeding occurs in infantile scurvy or Barlow's Disease without any excessive trauma, such as violent shaking.

On review of correspondence and publications over the past year on shaken baby syndrome I am surprised that these suggestions of Professor Clemetson have not been addressed more widely. In the UK the matter is still bedevilled by ex cathedra dogma, which is at least being challenged. Only in Australia does Clemetson's postulate seem to be given some credence.

Measuring bleeding times in infants at risk is technically difficult and at post mortem is impossible. Measurements of ascorbate in white cells or in plasma and of histamine in plasma are possible in infants deemed to be at risk (following inoculations or some significant infection). None of these tests can be done in those unfortunates who die. Clearly it will be necessary to overcome the problem by devising methods of identifying infants at risk. I am disappointed that no-one has discussed this. Meanwhile grieving parents and child minders throughout the world are being held under suspicion or even in prison.

Competing interests: None declared
Re: Clemetson's work 6 July 2004
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Michael D Innis,
Director Medisets International
Home 4575

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Re: Re: Clemetson's work

Editor, Dr Keith Taylor says, “Only in Australia does Clemetson's postulate seem to be given some credence.”

I suggest Professor Clemetson’s Hypothesis recorded in his papers ‘Vaccinations, Inoculations and Ascorbic Acid’ [1] Shaken Baby Syndrome or Scurvy [2] and Barlow’s Disease[3] should be compulsory reading not only for medical students and doctors but for Judges and Lawyers as well.

We may then see some sense in the Justice Systems of England, Australia and the USA in relation to the fabricated diagnosis ‘Shaken Baby Syndrome’.

Regrettably in Australia there is still widespread ignorance of Barlow’s Disease and its relation to Vaccines and Infections even though Dr Archie Kalokerinos made Australians aware of it more than a quarter of a century ago [4].

Innocent men and women are still being imprisoned here.

Michael Innis

References: 1.Clemetson CAB. Vaccinations, Inoculations and Ascorbic Acid Jour Ortho Mol Med 1999 vol 14 p137-142

2.Clemetson CAB Shaken Baby Syndrome or Scurvy Jour Ortho Mol Med 2002:vol 17, 193-196

3.Clemetson CAB Barlow’s Disease Med Hypoth{2002}: 59; 52-56

4.Kalokerinos A. EVERY SECOND CHILD 1974 Thomas Nelson (Australia) Limited

Competing interests: I have given evidence in one case of Infantile Scurvy but the accused was imprisoned.
Re: Clemetson's work 6 July 2004
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Theo H Fenton,
Consultant Paediatrician
Mayday University Hospital, Croydon CR7 7YE

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Re: Re: Clemetson's work

Even in Australia, Clemetson and Kalokerinos are viewed with considerable scepticism. See this Australian website, where the SBS links which refer to their work (published in obscure magazines) seem to lack any scientific rigour.

Competing interests: None declared
Re: Re: Clemetson's work 7 July 2004
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Hilary Butler,
freelance journalist
home 1892, NZ.

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Re: Re: Re: Clemetson's work

Dear Sir,

I cannot believe, that Theo H Fenton, Consultant Paediatrician, would give any credence to ratbags.com. (Or Quackwatch.com either for that matter, in case the thought crossed the mind.)

Anyone who knows anything about either of those sites, will be laughing throughout their day.

Until they realise that the day a paediatrician takes ratbags seriously, is the day that medicine is permanently doomed.

Hilary Butler.

Competing interests: None declared
Re: Re: Clemetson's work 7 July 2004
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Heather Lohr,
parent
Pennsylvania, USA 16652

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Re: Re: Re: Clemetson's work

The Web site referenced in the rapid response directed the reader to a thoroughly unprofessional site in which the owner appears to thrive on trashing anything he/she doesn't believe in. It's a confusing site in which I noticed a ticker of unfavorable "site reviews" posted proudly by the owner perhaps in an attempt to gain something?

Dr. Clemetson has simply suggested a few simple tests and safety measures which may ensure safety in infants who may be at risk when vaccinated. Several medical professionals wrote in his support. The Journal of Orthomolecular Medicine is not a magazine. It is a medical journal just like the BMJ and many thousand other medical journals (which cannot all be as prominent as the BMJ).

Dr. Clemetson has done something which we cannot see in the references thrown out as indisputable proof of shaken baby syndrome. He had actually done RESEARCH on his theory.

Is there any real harm in carrying out his suggestions even if you don't believe them? I have consumed 34,000 mg of Vitamin C (as ascorbic acid) in the past week. I have had no poor side effects. Am I addicted to Vitamin C? No, I will stop eating them when the bottle is empty, but the point is that Vitamin C is not a harmful substance and your body will rid itself of overkill Vitamin C consumption.

So why not give a dose of Vitamin C before vaccination? It won't hurt anything. Why not do the few extra tests? Doctors run "unneccessary" tests all the time. The only thing that seems to make sense here is that by doing these tests and giving some C, maybe Clemetson's theory will in fact turn out to be a reality. Maybe children will be saved. And that wouldn't be a good thing for the "classic shaken baby."

It's the same old, same old. Every time a report is published which contradicts the "classic shaken baby" it is tossed out without consideration and certainly without testing it. I say do away with all the medical journals because apparently all that we "know" is all we will ever know or need to know.

I do believe children are abused and have never said otherwise. I am not antivaccine. I do find it curious as to the number of acute events which occur around vaccinations which are labeled child abuse. I am also curious about all the accidents which occur and are labeled as child abuse. My personal nightmare has nothing to do with either. But none the less, I feel it negligent not to entertain these theories when the "classic shaken baby" is supported by far less physical and medical evidence and a ton of circumstantial nonsense.

Competing interests: I love vitamin C
Re: Re: Clemetson's work 7 July 2004
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C. Alan B. Clemetson, M.D.,
Professor Emeritus
New Orleans, LA 70125

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Re: Re: Re: Clemetson's work

Theo H. Fenton, M.D.

With reference to your rapid response to Geddes and Plunkett dated July 6, it would be useful if you would read and try to understand my work before associating it with a list of “anti-vaccination liars.” Neither I, nor any of my friends, have ever been opposed to vaccines. I have simply suggested giving fewer vaccines at one time, and I have suggested giving vitamin C with vaccines -- to reduce the risk of harmful reactions -- but never have I opposed vaccinations.

Since you are an experienced research worker, I would like to suggest that you study plasma ascorbic acid and whole blood histamine levels, before and at various intervals after vaccinations, first in adults and then in children.

May I also suggest that it is not wise to refer your readers to scurrilous literature suggesting that your medical colleagues are wanting to kill or maim children.

C. Alan B. Clemetson, M.D., Professor Emeritus, Tulane University School of Medicine, New Orleans, Louisiana

Competing interests: None declared
Re: Re: Clemetson's work 7 July 2004
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Michael D Innis,
Director Medisets International
Home 4575

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Re: Re: Re: Clemetson's work

Editor,

Permit me to record a couple of extracts from the web site Dr Fenton recommends as evidence that “even in Australia Clemetson and Kalokerinos are viewed with considerable scepticism.”

1. “The diocese is opening a new school next year and, in accordance with the instructions of Jesus to care for children's bodies as well as their souls, the school has an explicit policy that all children attending must be fully vaccinated. Predictably, the anti-vaccination liars (or "morons", as the Dean called them) have erupted like a plague of boils. “

2. "DEATH BY LETHAL INJECTION Today on my daughter's birthday, I will grieve not only for the loss of my own child but for all the innocent children for which the benefits of vaccines do not outweigh the risks and are unnecessarily sentenced to death by lethal injection, under the guise of "the greater good." The true war is not against disease; we have somehow become our own worst enemy by putting our faith in science instead of nature. Today, I call on all mothers across the world to join me in putting an end to this senseless slaughter of our most precious resource, our children.”

I am sure your enlightened readers will agree that the “considerable scepticism” Dr Fenton refers to is not with the work of Drs Clemetson and Kalokerinos whatever the SBS aficionados may say. He should be looking much closer to home.

Michael Innis

Competing interests: I am totally in agreement with Drs Clemetson and Kalokerinos and totally opposed to Dr Fenton's view.
Please tell me that was a joke 7 July 2004
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L. Travis Haws,
Dentist
Lakewood CO 80228

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Re: Please tell me that was a joke

Editor: Dr. Fenton has to be joking in his response to Clemetson's work! There is no other explanation as the website he referenced is nothing more than a mockery of science. "The Millenium Project" has to be on the top ten list of biased polar extremism. Maybe # 1. The link provided by Dr. Fenton goes to a list of websites that the author of "The Millenium Project" despises and, thus, sets out to defame. If this website is what some are relying on as a source for "science" and "education", then I greatly fear Armageddon is near.

However and ironically, caught up in the mix of sites Dr. Fenton claims hurts the cases by Clemetson and Kalokerinos, is citing of an article written by Pamela Rowse RN. The website cites this article as support for the shaky SBS hypothesis and states that the article should be dispersed wide and far to, I guess, inform us ignorants.

Ms. Rowse's article starts off blatantly incorrect as she states SBS was first postulated by a Dr. McCaffey (Hmmm...I thought it was Caffey). Then she states it was in 1975 (Hmmm...most cites to Caffey are 1972 and 1974). Then is a discussion that basically adverse vaccine reactions don't occur and are rare as she cites VAERS. Interesting as it is well known that only 1 - 10% of adverse vaccine reactions are reported to VAERS. This abundance of under-reporting really means we have no idea of the extent of adverse vaccine reactions. For the most part, that is the jist of the "scientific" article that "needs" widespread dissemination, and in my mind, deserves no more discussion.

Maybe Dr. Fenton can explain this ironic situation, the discrepancies and how it seems Dr. Fentons website cite actually hurt his case in his haphazard process of "informing" us. You'd think writing a three volume text book series about Vitamin C...would take scientific rigor. Then again, maybe not, if "The Millenium Project" is our source of determining scientific rigor and reliability? Yikes! Maybe Dr. Fenton can explain why Kalokerinos' administration of Vitamin C peri-innoculation stopped the "coincidental" deaths peri-vaccination? And how that lacks scientific rigor. Quite contrarily, these men seem to define scientific rigor.

Since Caffey (not McCaffey) comes up as the foundation for SBS, once again, I would like to copy and paste some questions I am awaiting answers for. These questions were posted in another BMJ rapid response thread. Maybe Dr. Fenton can help answer them? Maybe the scientifically rigorous and reliable millenium project can help? Either way, lets get down to the heart of the issue. Something that people like Clemetson, Kalokerinos, Plunkett, Geddes, Innis...are only interested in. Unlike their counter parts, they aren't dancing around the issues, they are actually considering the relevant factors...the physiology, biochemistry, microbiology, pathology, biomechanics, the basics....

Some questions, awaiting some answers, from the other response:

Let's take a journey back some 30 years to some of the original SBS research by Caffey. (1) This article is quoted frequently by SBS proponents as the ground-breaking "proof" of what we now know as SBS, non- accidental injury, inflicted trauma... In the paper, Caffey is describing what he calls injury evidence of whiplash shaking deaths. It appears Caffey's suspicions were confirmed when an infant nurse confessed to shaking, heavy handed burping...

Caffey spends some time describing necropsies of two babies--babies H and K.

To quote from the 1974 article:

"Baby H, 12 days of age, premature girl was well until tonight, when she awakened crying as if in pain. There were no external signs of trauma. Nutrition good, respirations deep and gasping, anterior fontanel bulged slightly, diffuse hemorrhages in the ocular fundi...no history of trauma, no fracture of calvaria. Necropsy findings: 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. Brain and head: bulging anterior fontanel, bilateral subdural hematomas, bilateral subarachnoid bleedings, subpial bleeding, lacerations of the cerebral parenchyma, pyknosis and death of ganglion cells and large perivascular bleedings...”

"Baby K, girl 11 weeks of age. Chief complaint: bulging of anterior fontanel. Fell asleep well but awakened crying and lethargic; semicomatose on arrival, tachypneic, fontanel bulging, reflexes hyperactive, ocular fundi invisible (bleeding?), moderate generalized cyanosis. Cerebrospinal fluid was bloody, gross fresh blood. Infant turned greyish and died 2 hours after admission. No external signs of trauma on the face or head...No evidence of fractures. Several small foci of atelectasis in the lungs. Brain: no external signs of trauma to the head; bilateral subdural hematomas with subarachnoid hemorrhages...extensive bleedings at the sites of attachment of the bridging cerebral veins to the superior sagittal sinus...eyes not examined."

It is important to note that Caffey, in his prior paper, discusses at length, traumatic "involucra" at the ends of long bones as eluded to by Dr. Davies. (2)

Caffey concludes from these necropsies that "the findings in these two necropsies demonstrate that the manual whiplash shaking by an adult assailant was pathogenic, especially to the brains and eyes."

A few more "supportive" examples discussed by Caffey:

1)--"An infant 2 months of age was treated for "sunken fontanelle" by his Mexican grandmother. Two days before admission to the hospital, she had attempted to raise the sunken fontanel by...holding the infant topsy- turvy by its ankles, and then shaking the infant up and down while an assistant slapped and pounded on the soles of its feet. The sunken fontanel did rise and had become bulgy...subhyaloid hemorrhages were found in the ocular fundi...clonic seizures developed and the cerebrospinal fluid from the cranial subdural space and the lumbar subarachnoidal space contained fresh blood."

2)--"the father at first attempted to "strangle the infant with a blanket," but when the infant convulsed during this assault and became stuporous, the father apparently repented, and then with the mother spent the rest of the night manually shaking the comatose infant in a belated effort to revive it...the infant was admitted to the hospital with extensive bruising of the skin and bilateral intraocular bleedings...necropsy findings included bilateral large subdural hematomas and widely scattered intraocular hemorrhages in the retinas."

Caffey concludes at the end of the article that "the essential elements in the infantile whiplash shaking syndrome present an extraordinary diagnostic contradiction. They include intracranial and intraocular hemorrhages, in the absence of signs of external trauma to the head or fractures of the calvaria, and are associated with traction lesions of the periosteums of the long bones in the absence of fractures and traumatic changes in the overlying skin of the extremities."

Questions:

1) In the description of Baby H, are "the hemorrhages in the myocardium: pinkish cellular exudates in the pulmonary alveoli: small subcapsular laceration of the liver filled with fresh blood" of significance? And how do they relate to whiplash shaking? What would be your list of differentials considering the above? What additional testing should have been done to eliminate or confirm differential diagnosis?

2) What of Baby H's going to bed well, but awakening as if in pain...and then proceeding to her demise? Did the nurse sneak in and shake the baby while it was sleeping/not crying? Don't the SBS "experts" tell us, depending on the day and case, that the "trauma" immediately precedes the ill infant?

3) In the description of Baby K: semi-comatose with hyperactive reflexes, several areas of atelectasis, no fractures, eyes not visible and/or not examined (?). Again, how does baby K relate to Caffey's whiplash shaking conclusions and the trio of proposed signs? I only see one of the signs. What of the atelectasis? What is your list of differentials? What further testing...could have been done according to the list of differentials? What of Baby K falling asleep well, but awakening crying and lethargic? Again, did the nurse sneak in and violently shake the well sleeping infant? Don't the SBS "experts" tell us, depending on the day and case, that the "trauma" immediately supercedes the ill infant?

4) Does the example of the Mexican grandmother support whiplash shaking? Or does it sound more like cervical compression/extension? Do you agree or disagree that increased intracranial blood pressure from topsy- turvy up and down shaking...may have played a significant role in the hemorrhages and edema as compared to acceleration/deceleration? Where are the accompanying long bone traumatic involucra? One certainly would think this case would show periosteal traction?

5) Does the strangling example support SBS or whiplash? Did the subsequent shaking/revival attempts have anything to do with the hemorrhages? Or does this case more adequately support hypoxic induced hemorrhages from the strangle attempt? Or, along the same lines, does this case also support increased intracranial blood pressure (strangling blocking cerebral venous return...) induced hemorrhages? In this case, how would one go about differentiating between these etiologies?

6) In general, what happened to the long bone lesions? The traumatic involucra? I thought that was part of the triad? Would you agree, or disagree, that bones grow at the epiphysis? Would you agree, or disagree, that such newly forming bone tissues/periosteum may stretch rather easily as compared to mature developed tissue? Perhaps during play, swinging a baby, picking one up by the legs or arms? Or does it require violent abusive forces? Would bone fractures from inflicted abuse/trauma commonly result in changes in the overlying skin...i.e. bruising, edema...?

7) This is a little off of Caffey's discussions, but do you agree or disagree that rib fractures, caused from inflicted non-accidental trauma/abuse, would result in significant pain upon respiration/expiration, physical palpation from a pediatric office visit, laughing, crying...? Or would the infant generally not have pain from the trauma? Would spontaneous fractures from poor nutrition, TBBD be more or less likely to exhibit pain than traumatic fractures?

8) Considering all the above, what do you think the internal validity of Caffey's paper is? Are the conclusions made from the available data valid or invalid?

9) Considering all the above, what is the external validity of Caffey's paper? Is the external validity high or low? Can the conclusions be generalized to all infants with subdural hematoma and intraocular hemorrhage as pathognomonic of SBS or does thorough testing or history taking need to be carried out to eliminate other causes? Without thorough testing, what is the confidence of diagnosing SBS from Caffey's paper?

10) Do you think much more research should have been done, especially regarding tissue properties, tissue injurability thresholds, biomechanics, differential etiologies...before drawing such bold conclusions? Especially in regards to the few, more recent biomechanical studies that conflict with Caffey's conclusions? (3,4)

11) What are your feelings on the reliability of confessions? How might such confessions effect internal or external validity? How would coercion, threats, promises of leniency, the "immunity or right to keep your kids if you name your partner game"...effect the reliability of a confession, and thus, the reliability of such data?

Believe me, there are many more similar questions regarding the rest of the "supportive" SBS literature.

L. Travis Haws

1) 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.

2) Caffey J. On the Theory and Practice of Shaking Infants. American Journal of Diseases in Childhood 1972; 124:161-9.

3) Duhaime A. et al., The Shaken baby syndrome. A clinical, pathological, and biomechanical study. J Neurosurg 1987; 66:409-415.

4) Prange M. et al. Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants. Journal of Neurosurgery 2003 99: 143-150.

Competing interests: Know the falsely accused and the utter devastation heaped upon them with dogmatic hands
Re: Re: Re: Clemetson's work 8 July 2004
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Ed Cooper,
Locum Cons. Pediatrician
London

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Re: Re: Re: Re: Clemetson's work

Like thousands of others around the world, I skip down the list of every day's Rapid Responses to the eBMJ. Recently I have been skipping more rapidly, as the tone and rationality of many has degenerated. But I am glad to see that Professor C. A. Clemetson keeps an eye on them too, as his response of 7th July gets right to something I was wondering about: "... I would like to suggest that you study plasma ascorbic acid and whole blood histamine levels, before and at various intervals after vaccinations, first in adults and then in children". I think this implies that there have been no reported measurements of these things. A Medline search for Clemetson's own papers does not seem to reveal any reports of experiments - only hypothetical discussion. Is this the work of which he speaks? There has been some mention in the Rapid Responses of a report in a journal of "orthomolecular medicine" - this one does not seem to be listed in Medline. Actually, there are no journals with the word "orthomolecular" in the PubMed database anyway.

If there is no actual evidence, I do not think there is justification for the suggestion of "... giving fewer vaccines at one time, and ... giving vitamin C with vaccines -- to reduce the risk of harmful reactions."

That said, if anyone does make these measurements and report them in a peer-reviewed journal, I shall be glad to know the results.

Competing interests: None declared
Re:Re:Re:Re: Clemetson's Work 9 July 2004
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C. Alan B. Clemetson, M.D.,
Professor Emeritus
New Orleans, LA 70125

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Re: Re:Re:Re:Re: Clemetson's Work

Dr. Cooper:

You are correct in noting that a study of plasma ascorbic acid and whole blood histamine levels before and at intervals after vaccinations has not yet been done on human subjects.

My own work suggests that ascorbate-depleted subjects will show a greater than normal histamine elevation following vaccinations -- because ascorbic acid is essential for the conversion of histamine to hydantoin-5- acetic acid and on to aspartic acid in vivo, for elimination of histamine from the blood.

Besides several of my articles listed in PubMed, please see Histamine and ascorbic acid in human blood. J. Nutrition 110 (1980) 662-668, by C. Alan B. Clemetson.

Also: Vitamin C. Three volumes by C.A.B. Clemetson. Published by CRC Press in 1998. Now out of print, but held by some major medical libraries.

C. Alan B. Clemetson, M.D., Professor Emeritus, Tulane University School of Medicine, New Orleans, Louisiana

Competing interests: None declared
Clemetson's work is not at the end of a mouse. 9 July 2004
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Hilary Butler,
freelance journalist
Home 1892, NZ

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Re: Clemetson's work is not at the end of a mouse.

Dear Sir,

Dr Cooper talks about the tone and rationality of many responses degenerating. His reply drives me to frustration, but I will try to remain rational. He says:

>>>There has been some mention in the Rapid Responses of a report in a journal of "orthomolecular medicine" - this one does not seem to be listed in Medline. Actually, there are no journals with the word "orthomolecular" in the PubMed database anyway.

If there is no actual evidence, I do not think there is justification for the suggestion of "... giving fewer vaccines at one time, and ... giving vitamin C with vaccines -- to reduce the risk of harmful reactions."

That said, if anyone does make these measurements and report them in a peer-reviewed journal, I shall be glad to know the results.<<<

The work done, is quoted in the large three volume text book, Called Vitamin C, published by CRC Press, which Professor Clemetson wrote in 1989. Which should be standard issue in every medical library, but I don't know one which has it.

In the absense of information at the end of a mouse, Dr Cooper's comments remind me of those reportedly made by the naysayers who told Marconi that his theory of sending radio waves out into the sky was bollocks, because they would just keep on going right out there ad infinitum. Or perhaps a story Ed Cooper might remember? That of Barnes Wallace's detractors. Or maybe he remembers Louise Pillemer, and what the "icons" of the day did to him. Drove him to suicide, they did. After all, properdin was just a figment of his imagination. Oh yes. Same result for Semmelweis too, wasn't it? Who, after all, needed to wash their hands. Much too simple an idea.

Professor Clemetson has already provided all the answers.

They just don't happen to be at the end of a mouse.

Besides which, wouldn't it be wonderful, if instead of saying "When someone else has done it, I'd like to know" Ed Cooper took the issue face on and replicated it himself? It would be such a pleasure to witness Ed Cooper tell us the results of personal initiative, rather than offer excuses to dismiss what he couldn't read on his computer screen.

Dr Clemetson is right at the end of the phone, and could easily tell him exactly what he has already done, and how to do it himself.

Hilary Butler.

Competing interests: None declared
Re: Re: Re: Re: Clemetson's work 9 July 2004
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Michael D Innis,
Director Medisets International
Home 4575

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Re: Re: Re: Re: Re: Clemetson's work

Editor,

Ed Cooper says, ”There has been some mention in the Rapid Responses of a report in a journal of "orthomolecular medicine" - this one does not seem to be listed in Medline.”

I suggest he try ‘Google’. Search – orthomolecular medicine – Journal Orthomolecular Med – Table of Contents.

I’m sure he will have no trouble locating the excellently researched reports of Professor Clemetson and he will see ample evidence for the advice of "... giving fewer vaccines at one time, and ... giving vitamin C with vaccines -- to reduce the risk of harmful reactions."

Hopefully he and his colleagues will take that advice and muster ‘all the King’s horses and all the King’s men’, as John Stone suggests, to put sense back into immunization of children.

Michael Innis

Competing interests: I agree with Professor Clemetson and have quoted his work.
Re: Re:Re:Re:Re: Clemetson's Work 14 July 2004
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Ed Cooper,
Locum Cons, Pediatrician
London (in Bangkok at present)

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Re: Re: Re:Re:Re:Re: Clemetson's Work

I would just like to note Professor Clemetson's helpful response below, with specific information, delivered in the measured tone of a corresponding scientist, and to thank him for this.

Competing interests: None declared
Ed Cooper's response 16 July 2004
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John Stone,
none
London N22

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Re: Ed Cooper's response

I wonder if Ed Cooper feels that there are no grounds to be emotional or distressed about these issues? I do not think the fact that people feel passionately - and in many cases may have endured terrible injustice - should be held against them.

Competing interests: None declared
Subdural Haemorrhage/Effusion – are low velocity falls or other minor impacts to the head a factor in the aetiology? 7 August 2004
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Chris J Hobbs,
Consultant Paediatrician
St James's University Hospital, Leeds LS9 7TF,
Anne-Marie Childs

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Re: Subdural Haemorrhage/Effusion – are low velocity falls or other minor impacts to the head a factor in the aetiology?

Geddes and Plunkett (BMJ 328 27th March 2004, 719-720) question whether minor trauma is responsible for the clinical features which are usually categorized as “shaken baby syndrome”. It is generally accepted that the most usual cause of subdural haemorrhage/effusion (SDH/E) is trauma. Debate continues however on the nature and severity of the trauma required to produce SDH/E.

We decided to review data from a UK and Republic of Ireland dataset. The series consisted of 164 infants aged 0-2 years with subdural haematoma or effusion reported via the British Paediatric Surveillance Unit from 1st May 1998 – 31st March 1999. Cases with SDH/E diagnosed in the perinatal period, associated with infection, coagulation disorder or other medical aetiology were excluded. This left 109 infants in whom trauma was presumed responsible for the SDH/E. Paediatricians/ Pathologists/ Neurosurgeons were asked whether the carer provided at any time a history of injury to their infant.

In 46 infants a history of injury was given. In only 2 children was a history of major trauma given. This involved a single case of twins involved in a high speed car accident where one died. These infants were excluded. There were 5 cases with a history of minor abusive behaviour toward the infant (2 gently shaken, 2 hit and 1 forcibly pushed into a seat) and these were included in the data. In the remainder (44) a history of relatively minor accidental trauma was given.

The details of these histories were as follows: fell off bed or settee (4), fell from kitchen work surface (3), dropped from parents arms (7 - all fathers), small object fell on child’s head (1), banged head whilst lying prone - arm gave way whilst crawling (1), banged head on door whilst parent carrying baby (2 ), adult tripped/fell +- whiplashed the child (5), fall downstairs (1),dropped onto pavement from car seat (1), baby chair or buggy tipped over (5) injury by implication e.g. slept with dog, unsteady on feet (2), somehow injured self (1), fell over while walking (1), hit with small toy by 2 year old sibling (1), child/adult fell or rolled onto child (2), laid on rattle (1), bumped head on father’s collarbone (1), shook baby but only gently (2), child caught up in parental fight (1), hit by parent (1), lost temper pushing baby into chair hard (1). Where there was more than one history given the first has been reported. In 65 infants there was no history of injury. The data on certain key parameters is presented in Table below.

As can be seen the outcomes for these 2 groups are similar. It is likely that if there had been any significant minor accidental trauma in the “no history group” then parents would have recalled this and informed medical staff. It would appear that a history of minor trauma is unlikely to be a significant factor in the aetiology of SDH/E in this age group. The alternative hypothesis i.e. that more severe trauma is responsible, seems to us the more obvious explanation. We can imagine only one reason why carers were unwilling to share such important information with those to whom they entrust the survival of their offspring.

Reference:

Hobbs C.J Childs A, Wynne J, Livingston J, Seal A. 2000 Subdural Haematoma and Effusion in Infancy - An epidemiological study. Presented at RCPCH annual meeting, York.

History of
minor injury No history of minor
injury

Total infants 44 65
Average age at diagnosis (w) 20 15.3
Moderately or severely ill 28 32
Well 16 30
Required resuscitation 22 27
Required ventilation 20 21
No of infants with a bruise 25 28
Average no of bruises/infant
with a bruise 3.3 5.6
Retinal haemorrhages 20 27
No of infants with fracture 23 22
Average no of fractures/infant
with a fracture 3.0 4.1
Died 5 11

Competing interests: This data is from a larger study currently submitted to Archives of Disease in Childhood. It is not included in that paper in the way presented here.
Re: Subdural Haemorrhage/Effusion - misdignosed 9 August 2004
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Michael D Innis,
Director Medisets International
Home 4575

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Re: Re: Subdural Haemorrhage/Effusion - misdignosed

Editor,

“It is generally accepted that the most usual cause of subdural haemorrhage/effusion (SDH/E) is trauma,” says Chris J Hobbs, Consultant Paediatrician. He should have added “by those that have been advised to “think dirty” and ignore the history given by the carer.”

Further he says “Debate continues however on the nature and severity of the trauma required to produce SDH/E” That is not the current debate surrounding the diagnosis of Shaken Baby Syndrome.

Surely after all that has appeared in the BMJ, and after the recent retrials of three mothers and one father, he should know that the debate is whether or not the diagnosis is fabricated (= invented) by those who have inadequately investigated the condition of a child with SDH/E or have incorrectly interpreted the Laboratory evidence.

Instead of the history of Injury or Non Injury he provides us with could he tell us:

1.How many were vaccinated within 21 days of the onset of SDH/E?

2.In how many was the ‘Protein Induced by Vitamin K Absence/Abnormality (PIVKA) test done to exclude a disorder of haemostasis?

3.In how many was Vitamin C deficiency excluded by appropriate tests?

4.In how many of the children with supposed fractures was the Serum Albumin found to be low and Malnutrition or Malabsorption investigated?

5.How was Temporary Brittle Bone Disease/Osteopenia of Prematurity/Rickets excluded as a cause of the alleged fractures

From cases sent to me on the subject of SDH/E I believe that virtually all 164 infants reported by Hobbs will have been misdiagnosed because of inadequate investigation and will fall into one or other of the groups listed above.

If he denies misdiagnoses perhaps he will be good enough to provide answers to questions listed.

I am firmly of the opinion that the diagnosis of Shaken Baby Syndrome was conceived in error and is perpetuated in ignorance of the conditions Adverse Reactions to a Vaccine, Haemostasis, Vitamins C deficiency and Temporary Brittle Bone Disease/Osteopenia of Prematurity/Rickets.

It is time the General Medical Council made a thorough investigation of the cause of SDH/E and demanded proper investigation, both clinical and Laboratory, before allowing its members to cause innocent carers to be incarcerated.

Michael D Innis MBBS; DTM&H; FRCPA; FRCPath.

Competing interests: I have children and grandchildren who are at a vulnerable stage in their lives and could easily fall victims to medical ignorance.
“Shaken baby” conviction overturned. The case of Alan Yurko 7 September 2004
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Mark Struthers,
GP
Bedfordshire, UK

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Re: “Shaken baby” conviction overturned. The case of Alan Yurko

The following is an account of the evidentiary hearing that took place August 23-26 in Orlando, Florida. The judge overturned Alan Yurko’s conviction for murdering his baby son. This account is published on the website of the Association of American Physicians and Surgeons (http://www.aapsonline.org/) and is a very significant indictment of the role played by members of the medical profession in an outrageous injustice.

Why?

September 9 2004

On August 27, Judge Alan Lawson overturned the conviction of Alan Yurko, who had been sentenced to life imprisonment without possibility of parole, for allegedly shaking his 10-week-old son to death. Yurko had been imprisoned for six years, 125 days.

At a week-long hearing, defense witnesses argued that the infant’s death resulted from natural causes and medical error.

“Mr. Yurko was convicted of doing the impossible,” stated Jane Orient, M.D., Executive Director of AAPS. While subdural hemorrhage can be caused by acceleration-deceleration injury (whiplash) alone, recent experimental evidence shows that an adult male cannot generate the needed force by shaking alone, without impact. Autopsy showed no head trauma, and also no neck injury.

Unquestionably, the baby suffered a respiratory arrest, followed by cardiac arrest, and had anoxic encephalopathy as a result. These facts could explain all of the autopsy findings, Dr. Orient argued, especially since the baby was started on intravenous heparin soon after admission, and some five hours before a CT scan showed a small subdural hematoma.

Several witnesses stated that the apneic episode as well as other findings resulted from a vaccine reaction. The infant, who was born after 35 weeks gestation, received six vaccines at once, while ill, 13 days prior to the fatal event. Dr. Orient stated that vomiting with aspiration was another possible explanation.

Horace Gardner, M.D., of Colorado, an ophthalmologist, observed that alleged shaken baby syndrome occurs at much younger ages in the U.S., peaking at age 3 months, than in Japan, where it peaks at 9 months. There is less than a one in a million chance that the age distribution is different on the basis of chance alone. Dr. Gardner notes that the age of vaccination is later in Japan, with the timing consistent with a causal connection.

Dr. Gardner also testified that shaking could not produce unilateral retinal hemorrhage, as observed in Baby Yurko, for biomechanical reasons.

The DtaP, Hib, OPV, and hepatitis b vaccines were contraindicated at the time that they were given, testified pediatrician F.E. Yazbak, M.D., of Massachusetts. The pediatrician did not even record the baby’s temperature on that day.

Dr. Yazbak also raised the possibility of late hemorrhagic disease of the newborn in addition to other reasons for a bleeding tendency.

A key element in Yurko’s conviction was the presence of four “probable” healing rib fractures of various ages. This sustained the charge of aggravated child abuse. Dr. Yazbak stated that the probability of inflicted injury was very low in the absence of any bruising or damage to the lung. Each traumatic fracture has a 75% probability of damaging the lung, he stated. (Thus, the probability that four independent traumatic fractures will not damage the lung is [0.25]4 or 0.4%). Dr. Orient also noted the improbability of breaking just one rib in each of four presumed episodes of violent squeezing.

Nontraumatic explanations for rib fractures include temporary brittle bone disease, for which the baby was at risk because of oligohydramnios. Barlow’s disease or vitamin C deficiency is another possible explanation. Dr. Archie Kalokerinos had flown in from Australia to testify to this, but early in the hearing was disqualified as an expert because he had stated that his views were not “generally accepted” by the medical community. He had reduced infant mortality in his district from one of the highest levels in the world to near zero by giving vitamin C at the time of vaccination; however, the court chose to exclude these results from consideration.

The prosecution’s case depended on the autopsy report by Sashi Gore, M.D., the first chief medical examiner in the history of Florida to be disciplined so harshly for errors on an autopsy. He had reported a gross and macroscopic examination of the heart, which had previously been removed for transplantation. As Dr. Yazbak pointed out, Dr. Gore had testified at trial to the presence of “diffuse” axonal injury on the basis of examining only one section. Dr. Orient noted that the window of time for the supposed injury, which happened to coincide with the time when Yurko was alone with the child, was dated back from the time of certification of brain death. The senior manager from the medical examiner’s office testified that the corpse had been received on Nov. 27, 1997. However, at 3:45 a.m., Nov. 29, 1997, the child was on an operating table undergoing an organ harvest.

Dr. Orient raised questions about the timing of brain death, based on failure to follow the accepted protocol. The report of the EEG that purportedly showed electrocerebral silence gave the child’s temperature as 90 degrees Fahrenheit. An EEG is uninterpretable in a patient so severely hypothermic. Moreover, drug levels were never done to rule out oversedation. The child had been treated with an anesthetic agent Versed and a paralyzing agent Norcuron, which could mimic all the signs of brain death.

Judge Lawson found that “the credible cause and manner of death cannot be gleaned from Mr. Gore's autopsy because of the very serious deficiencies that were found by the medical board and brought to light in this hearing and of course in other places.”

“Because of that I think it does cast doubt on the entire trial,” Lawson held. “I don't know how you can maintain public trust in a system of justice if you let stand a conviction obtained through reliance on an autopsy that is later so thoroughly discredited.”

Mr. Yurko then entered a plea of no contest to manslaughter, and the Judge sentenced him to time served. The Orlando Sentinel reported that “Mr. Yurko stated that he was accepting responsibility for permitting the vaccination of his son at a time when he was ill, without adequately investigating indications and adverse effects. He was then released from prison.”

Competing interests: None declared
Re: “Shaken baby” conviction overturned. The case of Alan Yurko 8 September 2004
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Andrew L. Schlafly,
General Counsel for Assoc. of Am. Physicians & Surgeons
Far Hills, NJ 10175

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Re: Re: “Shaken baby” conviction overturned. The case of Alan Yurko

Attorneys know that Shaken Baby Syndrome (SBS) is a fiction of the prosecution to rule out accidental injury as the cause. The absence of external trauma makes it easier to convict a hapless defendant of murder or manslaughter, as so-called medical experts simply declare to the jury that the defendant must have shaken the baby to death.

Hospitals like SBS allegations as a way to avoid a $10M malpractice case. Also, hospitals can terminate life support more quickly if the parents are charged with SBS. This recent case from Ohio (U.S.) illustrates how this game is played:

Medicine & Law Weekly September 3, 2004, Pg. 181

Judge upholds do-not-resuscitate order for comatose baby

A judge has upheld a do-not-resuscitate order for a comatose 9-month- old baby whose father is suspected of child abuse.

Aiden Stein, of Mansfield, was assigned a guardian because authorities said his 21-year-old parents have a conflict of interest for wanting to keep him alive.

... Aiden has been diagnosed with shaken baby syndrome, and his death could lead to a possible murder charge.

Summit County Probate Court Judge Bill Spicer had allowed Aiden's medical guardian, Ellen Kaforey, to have the baby's life-support turned off, but the Ohio Supreme Court in June halted Spicer's order and is reviewing the case. ...

Copyright 2004, Medicine & Law Weekly via LawRx.com.

Andy Schlafly, Esq. General Counsel Association of American Physicians & Surgeons

Competing interests: None declared
Re: Re: “Shaken baby” conviction overturned. The case of Alan Yurko 9 September 2004
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Heather Lohr,
parent
Huntingdon, PA 16652

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Re: Re: Re: “Shaken baby” conviction overturned. The case of Alan Yurko

The story of Aiden Stein breaks my heart. I have seen reports of this child taking breaths above the vent and I can fully understand where his parents are coming from when they say they can see some reaction from him.

I am against the removal of life support so the state can bring charges of murder when Aiden dies. I don't believe to date any charges have been brought yet. They seem to be waiting ... for Aiden to die? It is wrong to commit this child to death to convenience the prosecutors in this case.

Competing interests: None declared
Re: Subdural Haemorrhage/Effusion – are low velocity falls or other minor impacts to the head a factor in the aetiology? 14 September 2004
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L. Travis Haws,
Dentist
Lakewood CO 80228

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Re: Re: Subdural Haemorrhage/Effusion – are low velocity falls or other minor impacts to the head a factor in the aetiology?

Editor: It greatly appears we have another misinterpretation/representation of the data from the child protection "experts".

First of all, Hobbs' data actually supports that minor trauma can cause SDH/E. Hobbs makes quite a leap in concluding that their epidemiologic chart review actually supported major trauma as a more likely cause of SDH/E. The only way to make such a leap is to believe that the minor injury reports are fabrications. And how does one do this from a chart review? Or without even seeing these "injured" children or families? Hobbs tries to tell us, in a sideways fashion, that all of the caretakers reports are lies. That all the data is actually representative of the major trauma (vehicle accident) that was excluded. That's not what the data is saying. The debate over "trivial" falls being able to cause fatality, SDH, RH etc. is over as the literature is repleat with examples.

I'm at a complete loss as to how the conclusions were drawn, from shown data--that major trauma is more likely the cause. It appears that prior held dogmatic beliefs influenced such conclusions.

So, I only have a few questions. I don't expect any answers, however. We've all waited a long time, but have yet to see any reliable answers from the so called experts. You'd think we could have come to better research when families and childrens lives are at stake.

Questions:

1) What is the exact nature of these SDH/E? How were they dated? Where were they located? Were they acute, chronic, maybe subacute? A combination of the above?

2) When were the RH's diagnosed? Prior to, simultaneous to, or following signs/symptoms of increased intracranial pressure or hypoxia?

3) Were the infants full term, pre-mature, or induced? Mother's prenatal health?

4) What of the child's health history itself? Prior illnesses, odd behaviors? Any concerns for abuse from the families every-day pediatrician? Family/social history?Timing of jabs? Prior responses to jabs...? History of medications?

5) Would you consider birth to be a source of major trauma? Is Hobbs et al aware that SDH during birth may not appear until 6 weeks of life and present with vomiting, lethargy, seizures...? (1) How does birthing forces, and how they commonly cause SDH/E or RH, relate to major trauma, acceleration/deceleration as etiologies of SDH/E?

6) How much force is required to deform the shape of the infant cranial vault and underlying gray/white matter and vasculature? What is the threshold of deformation?

7) Are Hobbs et al aware of a recent case presented by Adams et al. where an infant undergoing screening for ROP had widespread RH's, within varying retinal layers, which resulted from very mild pressure or spontaneously? (2) How does this relate to being pathognomonic of severe trauma or acceleration/deceleration THEORIES/ALLEGATIONS? Maybe this infant should have been immediately removed from the health carers until it was found who the shaker was?

8) Maybe Hobbs et al. can explain how children with brain edema, SDH or EDH following minor trauma can be walking around ASYMPTOMATIC with a glascow coma scale of 13-15 if it requires "major" trauma to cause SDH/E? (3,4,5,6,7) Should these kids be ripped from their homes on a "preponderance" of "evidence" that is usually only required in child "protection" legal arenas? Should these parents be immediately black- listed on the abuse registry before

9) Was there any history of hydrocephalus, benign extra-axial fluid spaces within the epidemiological records Hobbs et al reviewed?

10) Where were the locations of these "fractures" and what type, or what was the appearance of the "fractures"? What types of fractures should be seen following major trauma? Can a minor impact fracture a thin/friable skull? Could play cause stretching of proliferating periosteum or epiphysis? What about poor nutrition or vitamin deficiencies?

11) Probably most importantly, how were the differential diagnoses tested for or ruled out? What tests were performed? Should any others have been done?

12) Would you expect to see cervical cord or neck trauma prior to brain injury with such violent shaking/whiplashing of the head about the neck?

13) All the same questions Dr. Innis has been asking for quite some time?

Hobbs states that 109 cases were PRESUMED to be from trauma. Here we go again--confession based medicine and presumptive familial dismantling-- CBM and PFD. Were these preemptive presumptions, or were all PROPER screening/testing results weighed prior to such presumptions?

The conclusions are made from beliefs that it is likely all parents would know of all minor accidents (recall, that infants/children with SDH can be asymptomatic)...and since they did not recall, then they must be hiding a major incident. I don't know many toddlers without bruises, and are parents now suppossed to witness every accident or fall a child has?

Perhaps some have something to hide, as abuse does happen, but to generalize from unproven theories, assumptions, presumptions and conjecture, summons frightening implications for all of society. Implications we are now becoming all too familiar with.

References:

1) Neonatology—Perinatal Medicine Diseases of the Fetus and Infant 5th Edition 1992. Edited by Fanaroff A., Martin R. Mosby-year book.

2) Adams GGW, Clark BJ, Fang S, Hill M. Retinal Hemorrhages in an infant following RetCam screening for retinopathy of prematurity. Eye 2004 18; 652-53.

3) Simon B, Letourneau P, Vitorino E, McCall J. Pediatric minor head trauma:indications for computed tomographic scanning revisited. J Trauma. 2001 Aug;51(2):231-7; discussion 237-8.

4) Mandera M, Wencel T, Bazowski P, Krauze J. How should we manage children after mild head injury? Childs Nerv Syst. 2000 Mar;16(3):156-60.

5) Stein SC, Young GS, Talucci RC, Greenbaum BH, Ross SE. Delayed brain injury after head trauma: significance of coagulopathy. Neurosurgery. 1992 Feb;30(2):16.

6) Ros SP, Cetta. Are skull radiographs useful in the evaluation of asymptomatic infants following minor head injury? Pediatr Emerg Care. 1992 Dec;8(6):328-30.

7) Hahn YS, McLone DG. Risk factors in the outcome of children with minor head injury. Pediatr Neurosurg. 1993 May-Jun;19(3):135-42.

Competing interests: Know the falsely accused and the severe iatrogenic life impairments
Re: Re: Re: Clemetson's work 14 September 2004
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Michael D Innis,
Director Medisets International
Home 4575

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Re: Re: Re: Re: Clemetson's work

Editor,

The controversy generated by Dr Fenton and his ill considered and unjustified comment “Clemetson and Kalokerinos are viewed with considerable scepticism” may have a positive result if he and his like minded colleagues follow the advice of Heather Lohr as under.

“So why not give a dose of Vitamin C before vaccination? It won't hurt … maybe Clemetson's theory will in fact turn out to be a reality. Maybe children will be saved."

Heather Lohr’s advice is much more sensible than that given to Paediatricians in their discredited publication “The Fabricated and Induced Illness Report”

It is time parents were given the choice. A time to let ‘Shaken Baby Syndrome’ fade into another ‘Witches of Salem’ blight on history and the Justice Systems of England, Australia and the USA.

Michael Innis.

Competing interests: I am in favour of giving Vitamin C prior to vaccination.
The case of Alan Yurko - A clarification 16 September 2004
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Anthony R Cox,
Pharmacist
City Hospital, Birmingham. B18 7QH.

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Re: The case of Alan Yurko - A clarification

Struthers cites the recent overturning of a murder conviction against Alan Yurko as "a very significant indictment of the role played by members of the medical profession in an outrageous injustice."

Alan Yurko was convicted of the murder of his 10-week-old son, Alan Ream. Alan Yurko and his supporters have claimed that the death was caused by vaccines. His case becoming a cause celebre of anti-vaccinationists.

Yurko was given the opportunity of a new trial, not because evidence suggested a vaccine was the cause of death, but because of a botched autopsy by a discredited Medical Examiner. In fact, the judge explicitly stated that "I also find that there is no reliable medical evidence that links the death directly to a vaccine,".

Yurko plea bargained for manslaughter, and was sentenced to to the time he had already served - just over six years.

Attorney Robin Wilkinson from the prosecution stated that Alan Yurko had still left the court with a conviction:

"For, I believe a week, we've heard that this child died of a vaccine reaction," Wilkinson said. "In the judge's ruling in court, he found that there was not credible evidence, that it's not been accepted by medical science, which leads to one explanation left ... this child was shaken to death."

... "That is not that we don't believe that Alan Yurko killed his child," she said. "At this point in time we would have to put Dr. Gore back on the witness stand, and there's an issue as to errors that he made ... What this is, is it's a compromise between both sides."(1)

The report posted by Struthers, originated from the vaccine skeptical Association of American Physicians and Surgeons. The final paragraph of the report, quoting the Orlando Sentinel , is highly misleading. It states that "Mr. Yurko stated that he was accepting responsibility for permitting the vaccination of his son at a time when he was ill, without adequately investigating indications and adverse effects. He was then released from prison."

It is important to note that at no point was the case proved that a vaccine was responsible for the death of Alan Ream. Alan Yurko was convicted of manslaughter.

The case of Alan Yurko tells us little about the safety of vaccines, and little about shaken baby syndrome. It tells us a lot about the importance of correct autopsy procedures in criminal cases.

Despite serving his sentence Alan Yurko is in Orange County Jail. He is awaiting extradition to Ohio, where he had violated his parole - a few weeks before his son's death - for a 1989 burglary conviction.[2]

1. The Kansas City Star. 10th September 2004.
2. http://tinyurl.com/5a7s2 Orlando Sentinel 10 September 2004.

Competing interests: None declared
Re: The case of Alan Yurko - A clarification 17 September 2004
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Mark Struthers,
GP
Bedfordshire, UK

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Re: Re: The case of Alan Yurko - A clarification

This was a shameful, mean spirited posting by Cox.

In November 1997, baby Alan Yurko sadly died. It was alleged that he had died from shaken baby syndrome (SBS) and been murdered by his father. Alan Yurko Snr, was subject to an oppressive judicial system, was tried, convicted and jailed for life without possibility of release.

The baby had died but his father hadn’t killed him. If his father hadn’t killed him then why had he died? There had to be a reason. Babies don’t die without a reason. The doctors were not helpful. It was simple for them. They were certain that the baby had been shaken. They hadn’t looked for any other reason. The evidence they provided was a sham. The chief medical examiner “reported a gross and macroscopic examination of a heart which had been removed for transplantation.” A conviction was obtained through reliance on an autopsy that was thoroughly discredited. Guilt was not proven by the prosecution. Alan Yurko was left to prove his innocence. After six years in prison, he was freed.

Vaccines were contraindicated. A sickly baby was vaccinated anyway. The vulnerability to vaccines could have been detected. Baby Alan might have been saved. He wasn’t tested and he wasn’t treated. He died. His organs were taken for transplantation. Blame was diverted. The father was brutally punished.

Why is Cox so defensive about vaccines? What are his conflicts and interests? Why is he so sensitive about vaccination and yet so insensitive to the plight of a fellow human being suffering injustice? Why?

There can be no doubt that the trial and punishment of Alan Yurko was obscene, a loathsome travesty of justice. What happened to Alan Yurko could have happened to you. What would you have done Mr Cox?

Competing interests: None declared
Toxic histaminaemia 28 September 2004
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C. Alan B. Clemetson, M.D.,
Professor Emeritus
5844 Fontainebleau Drive, New Orleans, Louisiana 70125

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Re: Toxic histaminaemia

I wish to thank Dr. Michael D. Innis for his kind remarks on July 9 re “Clemetson’s work.”

There seem to be few paediatricians who consider a capillary fragility state as being responsible for retinal petechiae, and for bleeding from the venules of the bridging veins, between the brain and the dura mater, which could lead to a major subdural haemorrhage. All-or- nothing phenomena are rare in physiology and in pathology, so we need to consider degrees of weakness in these blood vessels. We see detailed reports of blood coagulation studies in accusations of “shaken-baby- syndrome”, but no reports of capillary fragility studies.

Plasma ascorbic acid and whole blood histamine analyses are absolutely essential for anyone wishing to study capillary fragility in these compromised infants. There is a big difference between blood histamine levels, which can be toxic when dangerously high, and tissue histamine sensitivities, which may be only local. No accusations of child- abuse should ever be made without these simple blood tests to exclude capillary fragility.

The blood histamine concentration increases in an exponential manner as the plasma ascorbic acid level falls. There is a ten-fold increase in the blood histamine concentration -- rising from 18 to 180 micrograms/L - - when the plasma ascorbic acid level falls from 1.0 to 0.1 mg/100 mL, even in apparently healthy, ambulant people. This elevated blood histamine level, or histaminaemia, can rise to a toxic level during infection and/or following the injection of foreign proteins.

No physician can accurately diagnose or treat infants suspected of having been shaken, unless he or she understands the basic physiology of capillary fragility and toxic histaminaemia.

C. Alan B. Clemetson, Professor Emeritus, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A.

References

1) Clemetson, C.A.B. Histamine and ascorbic acid in human blood. J Nutr 1980;110:662-668.

2) Chatterjee, I.B., Majumder, A.K., Nandi, B.K., Subramanian, N. Synthesis and some major functions of vitamin C in animals. Ann NY Acad Sci 1975;258:24-47.

3) Kalokerinos, A. Every Second Child. Thomas Nelson (Australia) Ltd.: Sydney, 1974. Also in Pivot Health Books: Every Second Child. Keats Publishing, Inc.: New Canaan, CT, 1981.

4) King, C., Menten, M.L. The influence of vitamin C level upon resistance to diphtheria toxin. J Nutr 1935;10:129-140.

5) Parrot, J.L., Richet, G. Accroissement de la sensibilité a histamine chez le cobaye soumis a un régime scorbutogène. CR Soc Biol 1945;139:1072-1075.

6) Clemetson, C.A.B. Vaccinations, inoculations and ascorbic acid. J Orthomol Med 1999;14:137-142.

7) Clemetson, C.A.B. Is it “Shaken Baby,” or a Barlow’s disease variant? J Amer Phys Surg 2004; 9:78-80.

8) Clemetson, C.A.B. Elevated blood histamine caused by vaccinations and vitamin C deficiency may mimic the shaken baby syndrome. Medical Hypotheses 2004;62:533-536.

Competing interests: None declared
the current evidence base - make believe? 12 October 2004
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Heather Lohr,
parent
Huntingdon, PA 16652

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Re: the current evidence base - make believe?

Last Thursday, ABC hosted a segment on Shaken Baby Syndrome on it's show "Primetime." The show was a look at some of the questions surrounding this diagnoses. It was questioning the evidence base of SBS much like Geddes and Plunkett have done in this article. In response to this show, I have seen several media articles posted on the Web from one hospital or another proclaiming the sound foundation of the diagnoses. The following is a quote which was found on Cincinatti.com, as reported by 9news:

--But Dr. Robert Shapiro, with Childrens Hospital Medical Center, says just because science hasn't proven why it happens -- doesn't mean it doesn't happen.

"I have absolutely no question that SBS exists," said Dr. Shapiro.

"Whether the injury is caused by shaking alone or whether the child's head is impacted against a surface, I can't be sure -- but I know because of the children I see and the stories I hear," Shapiro said, "children are injured this way."--

And there it folks, in a nutshell. "just because science hasn't proven why it happens --doesn't mean it doesn't happen."

Yep, Dr. Shapiro and many others like him have the same logic as my son. He can't see it, he can't feel it, he can't prove it scientifically, but sure enough every time he loses a tooth there's money under his pillow ... therefore the Tooth Fairy does exist.

It is time to emerge from the land of Make Believe.

Competing interests: previously stated
Re: the current evidence base - make believe? 13 October 2004
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L. Travis Haws,
Dentist
Lakewood CO 80228

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Re: Re: the current evidence base - make believe?

Editor: As follow up from Heather Lohr's response, I notice Dr. Shapiro spends some time discussing the lack of scientific proof, but is still certain that SBS is 100% related to inflicted, intentional and violent trauma.

So what we have on one hand is acceptance by many in the medical community of an injury mechanism that is not supported by solid science. It is called CBM (confession based medicine). Just because someone says they shook their child, that doesn't mean no underlying pathologies existed which were predisposing, or played a major role in the injury. We are told babies cry uncontrollably due to "colic". Did anyone ever stop to think that perhaps they suffered a birth SDH or had some encephalitis post-vaccine for example and were "colicy" from a migraine headache. The gun has been primed.

Then on the other hand we have a grand denial of solid science that demonstrates that short falls, for one example, can and do cause fatal injury, SDH or RH's. For another example, science has shown that extra- axial fluid spaces or chronic SDH can bleed or re-bleed with minimal or no trauma. Yet, parents stories of a fall from a high-chair or off the sofa onto a fireplace hearth (i.e. Ken Marsh--www.freekenmarsh.com--he is now free after 21 years of innocent imprisonment)are discounted and the heavy hand of the law is relentlessly pursued.

Does this reasoning make any sense to you? How do they weed out the grey fuzzy areas? From the cases I've seen, the grey areas certainly aren't cleared up via differential diagnosis testing. Presumption prevails and the investigation begins. Investigator threats etc. will certainly clear up the grey. If not, the thump of a judges gavel surely will. Problem is, they are not the ones to decipher the meaning of such hotly contested science.

I hope none of these docs are surgeons, as how do you operate when your hands oppose each other? How do your hands function when your cortex is sending out mixed messages?

Competing interests: Know the falsely accused and the severe iatrogenic life impairments
A sacrificial lamb on the vaccination altar? 13 October 2004
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Jenny L Robertson,
Journalist and writer
London SW15 5DP

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Re: A sacrificial lamb on the vaccination altar?

Just how far will a state be prepared to go to ignore the adverse effects of vaccinations and thus justify a mandatory vaccination policy? Just how far will some people go to cover up negligence? As far as falsely accusing a parent of murdering his sick baby, incarcerating him into prison for a life sentence without parole? Well, it can't be the vaccinations’ fault because they are safe – so, it must be the parent’s fault!

Parents can't win, can they? If you don't vaccinate your child, you are irresponsible as you are putting your child and others at risk of catching 'deadly diseases'. If you do vaccinate, and your child is left damaged or dies, you are STILL to blame, as vaccines are safe (or, you should not have been so stupid as to believe that vaccines are completely safe...) Kafkaesque nightmare? You bet!

Woe betide the rebel parent who elects against vaccinations - you become the local pariah, as you alone are held responsible for the ‘threat’ of a sweeping epidemic that will supposedly bring devastation to thousands of children in its wake. (Really - even in the UK or USA in 2004 – what happened to progress or are we are still living in 1850 conditions?)

So what happens if you are a good, sensible, ‘responsible’ parent with a ‘herd’ instinct and your offspring is dutifully vaccinated against all these terrible infectious diseases AND is unfortunate enough to suffer from an ‘adverse reaction’, which you, quite rightly, as a responsible citizen, attempt to bring to the attention of the health authorities?’ Well, sadly, you are still a pariah – because you must be a ‘trouble maker’ or, far worse in the eyes of the health service, ‘compensation seeker’. The official line is that anything adverse that happens after vaccinations is a coincidence. A similar line is taken in cases of negligent medical treatment – adverse effects are nearly always stated to be: just a coincidence. This is flawed logic - it is also not a sensible way to protect the public or improve the health service. It probably also costs more money in the long run (tax payers' money, don't forget - your money.)

It’s rather ironic to label those who are left damaged by medical treatment, negligent or otherwise, as ‘ambulance chasers’, when everyone else – pharmaceutical companies, health workers and the whole gravy train - have been laughing all the way to the bank, yet you or your child are left - possibly without a job, or your health or both - to pick up the pieces of your shattered lives. But that’s how it works in our caring, sharing health services. In whose interests is the system working, the public should ask themselves?

It’s fascinating how zealously determined the state is for your baby to be immunized to the extent that contraindications to vaccinations are scarcely deemed to exist. According to the American Centre for Disease Control and Prevention recommendations on vaccinations there are no more than a handful of true contraindications, the main one being previous severe allergic reaction to a vaccine. The astonishingly few other contraindications listed, mostly in relation to the DTP or MMR, are encephalopathy within 7 days of previous DTP or DTaP; progressive neurologic disorder; immunodeficiency and pregnancy (for live vaccines.)

Practically every single other ‘event’ or condition that you care to think of, including collapse following previous vaccine, or prematurity, or family history of adverse event to vaccines, falls into the category of either ‘precaution’ or ‘perfectly safe to vaccinate.’ Severe illness, collapse or shock-like state, or seizure up to three days after a previous dose of DTP or DtaP, are NOT listed as contraindications but ‘precautions’. Just precautions? This CAN’T be right. Surely these extreme reactions in any otherwise healthy baby following an intervention would have responsible parents (and doctors as well maybe?) screaming from the rooftops before a further vaccination was made? Isn’t it incredible how cavalier people/’health professionals’ can be when their own health/their families' health is not at stake?

What does a precaution mean, anyway? We are told that it is a condition in a recipient that ‘might increase the risk for a serious adverse reaction’, or that might ‘compromise the ability of the vaccine to produce immunity’. The guidelines tell us that: “Under normal circumstances, vaccinations should be deferred when a precaution is present.” Nevertheless: “Benefits and risks of administering a specific vaccine to a person under these circumstances should be considered. If the risk from the vaccine is believed to outweigh the benefit, the vaccine should not be administered. If the benefit of vaccination is believed to outweigh the risk, vaccine should be administered.” So, in the space of a few minutes, the nurse administering the vaccinations is expected to make a comprehensive risk analysis? Yet the manufacturers of the vaccines and the public health authorities responsible for the safety of these vaccinations are unable to carry out this risk assessment? Nice work if you can get it. Sorry - I must rush off and sort out my pharmaceutical share portfolio.

Competing interests: None declared
Re: A sacrificial lamb on the vaccination altar? 14 October 2004
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Michael D Innis,
Director Medisets International
Home 4575

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Re: Re: A sacrificial lamb on the vaccination altar?

Editor,

“Just how far will a state be prepared to go to ignore the adverse effects of vaccinations and thus justify a mandatory vaccination policy? Just how far will some people go to cover up negligence? As far as falsely accusing a parent of murdering his sick baby, incarcerating him into prison for a life sentence without parole? Well, it can't be the vaccinations’ fault because they are safe – so, it must be the parent’s fault!”

Jenny Robertson says it all. The deception - Iatrogenic Manslaughter masquerading as Shaken Baby Syndrome - cannot go on for much longer.

This is the shame of the Medical Profession – not only are children dying but some carers are facing the death penalty. We should no longer tolerate this conspiracy.

Our Silence kills.

Michael Innis

Competing interests: As previously declared
Subdural haematomas in infants 22 October 2004
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C. Alan B. Clemetson, M.D.,
Professor Emeritus
Tulane University School of Medicine, c/o 5844 Fontainebleau Drive, New Orleans, Louisiana 70125

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Re: Subdural haematomas in infants

Re: Geddes & Plunkett

When a declaration of ”shaken-baby-syndrome” is based solely upon the findings of retinal petechiae and subdural haemorrhage, the assessment is an unfounded accusation and not a diagnosis. Cervical spine injuries, on the other hand, may well be due to shaking.

The subdural haemorrhages and retinal petechiae occurring without trauma, or with only minor trauma, are most likely due to capillary fragility. This vascular weakness is due to a toxic histaminaemia generated by a concatenation of vitamin C depletion, infection, injury, or the injection of foreign proteins, etc.

I am not opposed to vaccinations, but we know that mild, severe, or even fatal vaccine reactions do occur, and it is unjustifiable then to accuse one of the parents or a caregiver of murder. The proper diagnosis is most likely a virulent variant of Barlow’s disease, or infantile scurvy, which was a well-recognized condition in the first 75 years of the 20th century .

The change of diagnosis from Barlow’s disease to “shaken-baby- syndrome” came about following the writings of Caffey [1] (1946) and Kempe [2] (1962), but even they recognized and discussed the possibility of scurvy as the cause of the sub-periosteal haemorrhages, long-bone fractures, epiphyseal separations, and rib fractures in the cases that they reported as battered children.

It would seem that the paediatricians and other physicians who still teach that subdural haemorrhage and retinal petechiae invariably indicate child abuse, are unaware of the need to obtain plasma vitamin C or whole blood histamine analyses.

Fortunately, there is a solution to this catastrophic problem. If only physicians would 1) avoid giving too many vaccines all at once, 2) delay vaccinations for infants who are unwell, even with the common cold, and 3) adopt the simple policy of giving 500 mg of vitamin C to drink in orange juice before all vaccinations [3,4], the great majority of vaccine reactions could be prevented (see Kalokerinos [5]).

I am not a paediatrician, but I have written a three-volume monograph, Vitamin C, and am aware of the various presentations of vitamin C depletion [6].

C. Alan B. Clemetson, M.D., Professor Emeritus, Tulane University School of Medicine, megcc2000@yahoo.com

References

1 Caffey J. Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. American Journal of Roentgenology 1946;56:163-173.

2 Kempe CH, Silverman FN, Steele BF, Droegemueller W, Silver HK. The battered-child syndrome. JAMA 1962;181:105-112.

3 Clemetson, C.A.B. Vaccinations, inoculations and ascorbic acid. Journal of Orthomolecular Medicine 1999;14:137-142.

4 Clemetson, C.A.B. Is it “Shaken Baby,” or Barlow's Disease Variant? Journal of American Physicians and Surgeons 2004;9:78-80.

5 Kalokerinos A. Every Second Child. Thomas Nelson (Australia) Ltd: Sydney, 1974. Also in Pivot Health Books. Every Second Child. Keats Publishing, Inc: New Canaan, CT, 1981.

6 Clemetson, CAB. Vitamin C. Volumes I, II, & III. CRC Press, Boca Raton, FL, 1989.

Competing interests: None declared
Re: Errors in the diagnosis of child abuse 10 December 2004
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Michael D Innis,
Director Medisets International
Home 4575

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Re: Re: Errors in the diagnosis of child abuse

Editor,

In the thirty or so well documented cases of alleged child abuse sent to me for my opinion there are several in which the diagnosis of ‘shaken baby syndrome’ was made within 3 weeks of the infant being immunized.

Professor Clemetson suggests that high levels blood Histamine are found in subjects with low Vitamin C levels and Histaminaemia may follow “the injection of foreign proteins or vaccines” thereby adding to Vitamin C depletion if it already exists.

Barlow’s disease, or Infantile Scurvy, is the result of reduced levels of Vitamin C in the blood and, with regard to this, Professor Clemetson’s findings, and my (unpublished) reports confirm the views of Dr Kalokerinos[1,2].

Dr Kalokerinos, working with Aborigine communities in Australia, was the first to point out, in his book ‘Every Second Child’, the devastating effect of vaccines in poorly nourished children. Needless to say the Establishment was sceptical but he proved his point by halving the Infant mortality simply by premedicating the infants with Vitamin C. No longer did “every second child ” succumb to vaccination.

Professor Clemetson has made the same suggestion and it is time for those responsible for the health of children to embrace this preventive measure.

The presence of “broken bones” fanciful “cigarette burns”, Subdural and Retinal haemorrhages hitherto stated to be evidence of “Shaken Baby Syndrome” should, in this century be rightly called the “Kalokerinos- Clemetson Syndrome” after the two authors who identified the association with vaccines.

Child Protection Services especially need to take note, as should Judges and Juries, and enquire the dates of vaccination before condemning an innocent parent.

If the Royal Colleges object let them produce a single case of “Shaken Baby Syndrome” not immunized in the previous 3 weeks and in whom malnutrition was excluded.

The Kalokerinos-Clemetson Syndrome is here to stay.

Michael D Innis FRCPA; FRCPath

Reference:

1) Kalokerinos A. Every Second Child: Thomas Nelson Australia Ltd, 1974. Also in Pivot Health Books. Every Second Child:Keats Publishing, Inc., New Canaan, CT, 1981.

2) Clemetson, CAB. Is it “shaken baby”, or Barlow’s disease variant? J Amer Phys Surg 2004; 9:78-80.

Competing interests: As previously declared
Errors in the diagnosis of child abuse 21 December 2004
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C. Alan B. Clemetson, M.D.,
Professor Emeritus, Tulane University School of Medicine
c/o 5844 Fontainebleau Drive, New Orleans, Louisiana 70125, U.S.A.

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Re: Errors in the diagnosis of child abuse

Reply to Geddes and Plunkett, The evidence base for shaken baby syndrome. bmj.com 2004:328(7442):719-720, March 27, 2004.

Reading legal depositions and a medical conference summary on “shaken baby syndrome” has led me to believe that many physicians are under the impression that a haematologist’s report showing no abnormality in the blood coagulation mechanism, can be used to rule out a diagnosis of Barlow’s disease, or infantile scurvy.

If this misguided belief prevails, it explains why so many detailed hospital reports of deaths from “shaken baby syndrome” omit the necessary plasma ascorbic acid and whole-blood histamine analyses to diagnose or discount the presence of infantile scurvy.

FIGURE 1: HISTAMINE & ASCORBIC ACID

Legend for Figure 1. Results of plasma ascorbic acid (reduced form) and whole blood histamine concentrations in the same blood samples from 437 human volunteers in Brooklyn, NY, 1980. A highly significant increase in the blood histamine level was evident when the plasma ascorbic acid level fell below 0.7 mg/100 mL. This comprised 150 of the 437 (34%) men and women. From Clemetson CAB, Volume III, Vitamin C (1989), page 6. Reproduced with permission from CRC Press.

There is no abnormality in the blood coagulation system in scurvy. The bleeding of scurvy results from capillary fragility due to a toxic histaminaemia, which opens the tight junctions between the vascular endothelial cells (1, 2). There is, as we know, a collagen deficiency in scurvy. This deficiency cannot be the cause of the bleeding, for there is very little fibrous tissue surrounding the capillaries and venules from which the bleeding occurs.

The swollen, spongy, bleeding gums of classical scurvy are never seen before the eruption of the teeth, so infantile scurvy is not obvious on initial physical examination. Subdural haemorrhages and retinal petechiae may appear alone, or may be accompanied by fractures of the ribs at the costo-chondral junctions, subperiosteal haemorrhages in the long bones, epiphyseal separations, skin bruises, and sores that will not heal. One is bound to consider physical abuse. However, all of these signs are also characteristic of Barlow’s disease, so blood chemistry analyses are essential in order to make a proper diagnosis.

In adults, vitamin C depletion alone can cause a four- or five-fold increase in the blood histamine levels of apparently healthy, ambulant men and women (3), as shown in Figure 1. Complete deficiency of this vitamin leads to even greater histaminaemia, which causes capillary fragility and bleeding. The presence of ascorbic acid is necessary for the removal of histamine from the blood. Vitamin C acts like a catalyst or a co-enzyme and is essential for the conversion of histamine to hydantoin-5-acetic acid, and on to aspartic acid in vivo.

Histaminaemia from other causes, such as the bacterial and viral toxins accompanying infection or following the injection of the foreign proteins of vaccines, add to the histaminaemia of vitamin C depletion. This hyper-histaminaemic state can cause retinal petechiae and bleeding from the capillaries and in the walls of the bridging veins between the brain and the dura mater, leading to subdural haemorrhage.

Barlow’s disease, or infantile scurvy, was a well-recognized disease in bottle-fed infants in the first 75 years of the 20th century, but that diagnosis is falling into disuse and shaken-baby accusations have largely replaced it. Today we are seeing a Barlow’s disease variant -- a form of infantile scurvy which occurs earlier and may be due to a concatenation of factors, including the increased number of vaccines given all at once to infants at eight weeks of age.

Child-abuse laws require immediate reporting to the proper authorities by anyone who even suspects the mishandling of a child. Such cases soon involve the police and the members of the news media, who, to be dramatic, sometimes refer to sores that will not heal as “cigarette burns.”

The laws should be changed, so that none of these accusatory people would be called until plasma ascorbic acid and blood histamine analyses have been determined, and the details assessed by a physician. We cannot allow an alarmist, public hysteria to precede and even supplant the full evaluation of the appropriate data by unbiased physicians.

There is every reason to believe that infant deaths following vaccinations could be prevented or markedly reduced by the administration of vitamin C before inoculations, instead of the more usual paracetamol (4, 5). Not only will there be a decrease in the infant death rate; but also an important reduction in the incidence of cerebral palsy, epilepsy, cognitive and behavioural problems, and intellectual impairment, can be expected.

Suggestions

A. Vaccinations should be deferred when an infant has an infection or other illness, even the common cold.

B. Centers for Disease Control and Prevention should consider reducing the number of vaccinations administered all at one time.

C. Five hundred milligrams of vitamin C powder (or crystals) should be dissolved in fruit juice and given to the infant to drink within a day or two before any vaccination.

D. A study of plasma vitamin C and blood histamine levels, at various intervals following single and multiple inoculations, could be carried out on adults. Such a study would ascertain which vaccines cause the greatest histaminaemia, and when the histaminaemia peaks.

References

1) Clemetson, CAB. Is it “shaken baby”, or Barlow’s disease variant? J Amer Phys Surg 2004; 9:78-80.

2) Clemetson CAB. Elevated blood histamine caused by vaccinations and vitamin C deficiency may mimic the shaken baby syndrome. Medical Hypotheses 2004; 62:533-536.

3) Clemetson CAB. Histamine and ascorbic acid in human blood. J Nutr 1980; 110:662-668.

4) Kalokerinos A. Every Second Child: Thomas Nelson Australia Ltd, 1974. Also in Pivot Health Books. Every Second Child: Keats Publishing, Inc., New Canaan, CT, 1981.

5) Clemetson CAB. Vaccinations, inoculations and ascorbic acid. J Orthomolecular Med 1999; 14:137-142.

C. Alan B. Clemetson, M.D., Professor Emeritus, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A. Email: megcc2000@yahoo.com. Tele: 504-866-1525

CABC/mgc

Competing interests: None declared
Has any progress been made? 31 March 2005
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Heather Lohr,
parent
Huntingdon, PA 16652

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Re: Has any progress been made?

Just tonight I took the time to reread all the articles in the March 27, 2004, issue of the BMJ, and all subsequent articles pertaining to the diagnosis of shaken baby syndrome.

I'm wondering ... in the past year ... has there been an independently witnessed case of shaken baby syndrome to report yet?

Is the medical community still running on conjecture and dogma?

How many babies have died since? Has the massive amount of funding given to SBS advocates stemmed the tide of increasing cases yet? Is the SBS educational plan working?

Has anyone used that money to do research? Did any pediatricians give an infant vitamin C prior to immunization just to see? Did any child fall from a short distance and die? Did we do a CT scan or MRI on every child born to ensure no birth-related injuries? Fundoscopic examinations prior to discharge on all infants before discharge and follow-up exams until any findings resolved?

Have PICU physicians started a complete diagnostic series to rule out any and all etiologies of intercranial and retinal hemorrhage?

Here's a little food for thought I just came across on the Internet yesterday: No one is sure what the total cost is for treating, caring and educating children who survive being shaken. That's because no one is quite sure how many children have been injured from being shaken, experts said.

"There is nobody keeping track," said Robert Reece, clinical professor of pediatrics at Tufts-New England Medical Center's Floating Hospital for Children, an expert on shaken baby syndrome.

The injuries — except in the more severe cases — can be difficult to diagnose and the symptoms, such as vomiting and lethargy, can mimic other problems, Reece and others said.

Experts in the field estimate there are between 750 and 3,750 shaken baby cases each year in the country. But there may be dozens, hundreds or thousands of other children in the state who were shaken and not taken to the hospital, who suffered injuries that were misdiagnosed or weren't obvious.

Those children may have behavioral difficulties, be a bit slow grasping schoolwork or have problems talking.

"At least 15 percent of children's deaths are caused by shaken baby syndrome. There are probably many that go undetected or undiagnosed," said Allison Scobie-Lloyd, a social worker at the child protection program at Children's Hospital in Boston. "There could be serious cognitive ramifications that are not identified as such."

School officials also say they're not sure how many children in their classrooms might have been shaken as infants.

Special needs-children are classified based on their disability, not its cause, they noted.

"It is a difficult one to track," said Robert N. Murray, director of special education in Taunton. "You may have shaken babies in the school that we may not know about. Unless a child goes into a hospital setting because of a trauma, there may not be any outward signs and we would have no way of knowing."

Joanne Malonson, director of special education in Brockton, agreed. "You just don't know."

I see a very frightening future coming. Parents of special needs kids need to pay attention and reread this excert. It now seems that instead of doing the research necessary to defend the SBS diagnosis, they are just stretching the diagnosis even further to include those with learning disabilities.

What has happened in the past year?

April is National Child Abuse Prevention Month in the United States. I expect shaken baby syndrome will top the list again. I still have not seen any report to support the weak foundation of the diagnosis of shaken baby syndrome.

Take the time to reread all the articles pertaining to shaken baby syndrome.

Heather Lohr attaboof@yahoo.com

Competing interests: Previously stated
Re: Has any progress been made? 1 April 2005
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Michael D Innis,
Director Medisets International
Home 4575

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Re: Re: Has any progress been made?

Editor,

With regard to the diagnosis of Shaken Baby Syndrome (SBS) Heather Lohr asks, “Is the medical community still running on conjecture and dogma? “

Sadly the answer is ‘Yes’.

I regret to say the “conjecture and dogma” is now not only in the United Kingdom, Australia and the United States of America but has manifested itself in India.

In one report, “the history of shaking, presence of intracranial and retinal bleed and no coagulopathy allowed a firm diagnosis of shaken baby syndrome to be made”

“The parents were directly and tactfully questioned regarding the possibility of the child having been vigorously shaken, They admitted that an elder sibling aged 5 years used to play frequently with his infant brother and at times had been observed to have shaken him violently and vigorously. The history of shaking, presence of intracranial and retinal bleed and no coagulopathy allowed a firm diagnosis of shaken baby syndrome to be made.”[1]

So now, to the “conjecture and dogma ” of SBS in the medical community can added the activities of 5 year old children!

In another report, “among the wide spectrum of disorders presenting as ALTE, child abuse occurs quite frequently. Presence of strong gender bias in India highlights the necessity of suspecting abuse particularly in all female infants who present with ALTE to the emergency.”[2]

Hopefully in the UK, USA and Australia the medical community will not include “gender bias” as one of the “emerging concerns” they should be aware of when called to see a child with Subdural and Retinal haemorrhages [3]. But stranger things have happened in the UK, USA and Australia.

In neither report from India is mention made of the immunization or nutritional status of the three infants involved. I have requested further information from the principal authors and I am awaiting replies.

Michael Innis.

References:

1.Jayakumar I, Rangit S, Gandhi D. Shaken Baby Syndrome . Case Report. Indian Pediatrics 2004; 41:280-282

2.Ray M, Ghosh D, Malhi P, Khandelwal N, Singhi PD. Shaken baby syndrome masquerading as apparent life threatening event. Indian J Pediatr 2005;72:85-85

3.Report of the Working Party of the Royal College of Paediatrics and Child Health November 2001

Competing interests: Worried Grandfather