With the Twelfth International Conference on Shaken Baby Syndrome/Abusive Head Trauma coming up this weekend, I’ve been reviewing the literature and sorting my thoughts. What I see is an odd mix of new thinking and old stances.
In the June 2012 issue of Pediatric Radiology, for example, Dr. Thomas Slovis and his colleagues open their editorial, “The creation of a non-disease: an assault on the diagnosis of child abuse,” with a triad I’m not familiar with, but it’s got a classic ring to it:
The triad of subdural hematoma, retinal hemorrhage and multiple fractures in a child has been extensively documented to strongly suggest non-accidental trauma. Based on confessional evidence, a medical workup excluding diseases that can present with some of these abnormalities, and almost 50 years of scientific medical supportive literature, the diagnosis of abuse is being made with increasing medical certainty [1–7].*
With that diagnostic guideline in place, the authors object to “a small group of individuals” who have “created controversy where there should be none” and “perverted cases by using incomplete statements of the facts and unproven hypotheses to obscure the straightforward historical and physical findings utilized to make the diagnosis of child abuse.”
The paper describes a recent training that included these presentations:
- Pediatrician and geneticist Dr. Ingrid Holm explaining that vitamin D levels have not been scientifically connected with fractures in the fetus or neonate, presumably a counter to the rickets work of Drs. Pat Barnes, Kathy Keller, David Ayoub and others; and
- Pediatric radiologist Dr. Gary Hedlund noting that “intracranial venous thrombosis alone” is not known to be associated with subdural hematoma, possibly a response to many of Dr. John Plunkett’s diagnoses, with the additional observation “that one of the commonest causes of intracranial venous thrombosis is trauma, and that trauma does cause subdural hemorrhage.”
The key point about the non-disease commentary, though, is near the introduction, in an off-hand reference to new understandings in the field:
[The seminar] presented the scientifically accepted methodology for the diagnosis of nonaccidental trauma with emphasis on the pathophysiology of various injuries, and covered areas where new data have changed our understanding (e.g., subdural hematoma can occur from bleeding dural veins and not only bridging veins) [20–22].
20. Mack J, Squier W, Eastman JT (2009) “Anatomy and development of the meninges: implications for subdural collections and CSF circulation.” Pediatr Radiol 39:200–210
21. Nelson MD Jr (2009) “Unraveling the puzzle.” Pediatr Radiol 39:199
22. Slovis TL, Chapman S (2009) “The pathophysiology does not denote the mechanism.” Pediatr Radiol 39:197–19
What we have here is an editorial criticizing and dismissing the defense experts in the shaken baby syndrome debate, but with the concession that Drs. Mack, Squier and Eastman were correct in their 2009 proposition, which they also published in a different paper, “The neuropathology of infant subdural hemorrhage,” Forensic Sci Int 2009, soi:10.1016 j.forscicnt.2009.02.005. At the time it was published, that paper received a scathing review in The Quarterly Update, a guide to the child-abuse literature published four times a year by Dr. Robert Reece at Tufts University School of Medicine. Dr. Lucy Rorke-Adams objected in the Quarterly (Winter 2010, Vol. XVII, No. 1, p. 14) that the authors “reject the mountains of evidence that tears of bridging veins consequent to trauma are the primary cause of SDH,” adding in the Reviewer’s Notes:
This concept, initially proposing a non-traumatic pathogenesis of SDH in infants, namely hypoxia, advanced by Geddes et al. in a severely flawed paper with no credibility whatsoever and later repudiated by her, is not being allowed to rest in the dustbin of junk science [10-11]. The disciples of Geddes cannot allow this to happen, else they will be unable to introduce “reasonable doubt” when tetifying on behalf of perpetrators of abusive head injury to infants. Hence, they are flooding the literature with pie-in-the-sky claims that totally lack any evidence base.
10. Geddes JF, Tasker Rc, Hackshaw AK et al. “Dural haemorrhage in non-tramatic infant deaths: Does it explain bleeding in ‘shaken baby syndrome’?” Neuropathol Appl Neurobiol 2009;29:14-22
11. Jenny C. The timtimidation of British pediatricians. Pediatrics 2007;119:797-799
This transition, from “pie-in-the-sky” to “new data have changed our understanding,” strikes me as a change in the recognized model of abusive head trauma. It reminds me of comments made by a number of presenters at the 2010 NCSBS conference, when the take-home message was that the “triad” (the AHT triad, that is: subdural hematoma, retinal hemorrhages and brain swelling) was a straw man invented by defense experts to discredit shaken baby syndrome theory.
2016 Update: Denial of the triad has been formalized in a commentary by Dr. Christopher S. Greeley, “‘Shaken Baby Syndrome’ and Forensic Pathology” (Forensic Sci Med Pathol 16 Feb 2014 DOI 10.1007/s12024-014-9540-0), where he wrote:
“The complex features of AHT are often disparagingly distilled simply to ‘‘The Triad’’; a term devoid of any real clinical meaning and not used at all in practice.”
But I also have notebooks from prior conferences, when the triad was, indeed, considered enough. I will close this posting with a quote from a letter published in Pediatrics in 1998, signed by 70 child-abuse physicians, including a few of those 2010 presenters, objecting to the defense testimony in the Louise Woodward trial:
The shaken baby syndrome (with or without evidence of impact) is now a well characterized clinical and pathological entity with diagnostic features in severe cases virtually unique to this type of injury – swelling of the brain (cerebral edema) secondary to severe brain injury, bleeding within the head (subdural hemorrhage), and bleeding in the interior linings of the eyes (retinal hemorrhages). Let those who would challenge the specificity of these diagnostic features first do so in the peer-reviewed literature, before speculating on other causes in court.
My point is that the model is evolving in the face of new evidence. What I don’t understand is the reluctance of the child-abuse community to look back at possible mistakes in the past.
I’m off to the conference now and not likely to be blogging on the road, but you never know.
* Citations from the opening quote of the Slovis et al. article:
- Caffey J (1946) “Multiple fractures in the long bones of infants suffering from chronic subdural hematoma.” AJR 56:163–173
- Silverman FN (1953) “The roentgen manifestations of unrecognized skeletal trauma in infants.” AJR 69:413–427
- Woolley PV Jr, Evans WA Jr (1955) “Significance of skeletal lesions in infants resembling those of traumatic origin.” JAMA 158:539–543
- Kempe CH, Silverman FN, Steele BF et al (1962) “The battered-child syndrome.” JAMA 181:105–112
- Silverman FN (1972) “Unrecognized trauma in infants, the battered child syndrome, and the syndrome of Ambroise Tardieu.” Rigler lecture. Radiology 104:337–353
- Faure C, Kalifa G, Sellier N (1994) “Les responses de l’imagerie medicale chez l’enfant battu. Syndrome de Silverman-Ambroise Tardieu.” J Radiol 75:619–627
- Kleinman PK (ed) (1998) “Diagnostic imaging of child abuse,” 2nd edn. Mosby, St. Louis