A recent decision from Sweden’s Supreme Court is changing the landscape for Swedish citizens fighting misguided accusations of infant shaking.
An English translation of the decision has been posted by Riksförbundet För Familjers Rättigheter (RFFR, translated as the National Association for Families’ Rights), a union of families and their supporters created in 2013 so its members could approach the government as a coalition rather than as individuals. The ruling, from October of 2014, sets aside the June 2012 conviction of a father for presumably shaking one of his twin sons in 2009, with the explanation:
It can be concluded that, in general terms, the scientific evidence for the diagnosis of violent shaking has turned out to be uncertain.
As in so many of these cases, the infant collapsed at home and was found at the hospital to have both fresh and aging subdural bleeding, as well as retinal hemorrhages and brain swelling. The doctors concluded that the boy was the victim of abusive head trauma, and the prosecution seems to have offered a range of possibilities for how the injuries were actually inflicted. From the court’s summary of the prosecution’s position:
On 14 May 2009 in his home in Kungsbacka, MM did assault his son OM by shaking him vigorously or directing blows at his head, banging his head against something or using other violence against his head… In the alternate, MM did by shaking O vigorously or directing blows at his head, banging his head against something or using other violence against his head cause O’s injuries through carelessness.
In reviewing the father’s appeal, the Supreme Court listened to testimony from two physicians, Prof. Anders Eriksson, a forensics expert and an advisor to the National Board of Health and Welfare, and Prof. Peter Aspelin, a radiologist and a former chair of the Scientific Advisory Council of the Swedish Council on Health Technology Assessment (SBU). Both physicians told the court that the SBU, concerned about the reliability of a shaking diagnosis, has now launched a syste
matic study of the literature regarding infant shaking, an effort that is expected to take at least two years.
In October of 2013, Dr. Eriksson had told the Legal Advisory Council that “the probability that O’s symptoms had arisen in some other way than through the intentional actions of an adult person is very small.” When he later testified in front of the Supreme Court, however, Dr. Eriksson had changed his position. In the words of the translated decision:
[Dr. Eriksson] based the conclusion in the opinion to the Legal Advisory Council on the fact that O presented three symptoms (a triad) that, if they occur at the same time, have been held, according to the traditional view, to strongly indicate that there has been violent shaking if it is not the case that the child has been subjected to some other form of “high-energy violence” such as a traffic accident or a fall from a high height. The symptoms included in the triad are haemorrhaging under the dura mater, haemorrhaging in the fundus of the eyes and swelling of the brain. However, this diagnosed model has been criticized. The point of the criticism is that the symptoms given can have other causes . . . So it is not possible to say today that the occurrence of the triad means that violent shaking has been proved. Instead, it must be concluded that we do not know; we are in a quagmire.
And Dr. Aspelin told the court:
The controversy is not about whether it is harmful to shake a child violently. The issue under discussion is with what scientific certainty it can be established how various injuries found in a child have arisen. The claim that the occurrence of the triad is strong evidence that violent shaking has occurred goes back to the late 1960s; however, the medical evidence for it was relatively thin. But the claim became generally accepted and grew into medical truth over several decades, even though the situation in terms of evidence did not change. It is known that a very large share of fundus haemorrhages are not linked to violence and arise in another way. Nor has it been shown that nerve fibers are torn, and that the brain therefore begins to swell, in connection with violent shaking. It can also be asked whether violent shaking can occur without neck injuries arising… To sum up, it can be said that the scientific support for the diagnosis of violent shaking is uncertain.
The twins had been born by scheduled Caesarean section, apparently without complications. When less than a month old, however, both boys were hospitalized for two weeks with respiratory infections. At that time, medical workers noted that O had a a couple of bruises on one cheek and bruising on the front of his lower legs.
Six weeks later, the parents brought O to the child healthcare center with a report that he had been “vomiting torrents” for two straight days. Apparently he was treated and release
d, but that afternoon the boy began screaming during a diaper change, and then suddenly fell silent. The child’s mother heard both the screaming and the sudden silence, but did not see what happened. The father reported that when the child fell quiet, he became unconscious and “loose-limbed” and started to “roll the whites of his eyes.” The father said he was “gripped with panic” and that he shook the boy gently in an attempt to resuscitate. The Supreme Court reviewed a video recording of the father’s statement and noted, “The shakes appear fairly cautious and by no means match the description of shaking violence.” Looking at the bigger picture, the court concluded:
It has not emerged that the facts in this particular case are such that it can be established… that O’s injuries were caused by violent shaking or other violence on the part of MM. On the contrary, certain facts, including the facts that O had previously had RS virus and that there were signs of older haemorrhaging under the dura mater, indicate that there is another explanation for the symptoms that O had.
The RFFR web site, which posted both the original decision and the English translation, also offers links to Swedish news coverage of the topic as well as an English-language commentary by pediatric neuropathologist Dr. Waney Squier in Britain and television news coverage out of Dallas, Texas, of a family accused of assault when their daughter’s genetic disorder was misdiagnosed as abuse.
A doctor in Sweden reports that since the Supreme Court’s decision, two convicted fathers have been freed on appeal after years in prison and a third has won in court and is now home with his family.
Fall 2016 update: The SBU has published its review of the shaken baby literature, as reported in this blog posting.
Summer 2017 update: The journal Acta Paediatrica has devoted an issue to the debate that following the SBU’s report, as reported in this blog posting.
If you are not familiar with the debate surrounding shaken baby syndrome, please see the home page of this site.
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Charles J Hyman, MD, FAAP
Retired Clinical Professor of Pediatrics
Redlands, California, USA
Abusive head injury does exist, and it is primarily caused by maliciously inflicted head impact. The signs and symptoms of abusive head injury can, in many instances, be the same as those of accidental head impact. As stated in Mrs. Luttner’s January 19, 2015 commentary, the combination of retinal hemorrhages (regardless of the number, types, and locations thereof), subdural hemorrhages, and encephalopathy (changes in the infant’s level of consciousness) is not specific for abusive head trauma. Without impact, shaking an infant with sufficient force to cause this triad – including the child abuse concept that tearing of the bridging veins causes the subdural hemorrhage – cannot occur without at least soft tissue swelling of the neck and most probably also cervical vertebrae and/or spinal cord pathology. Soft tissue swelling of the neck is seen in even mild neck strain.
The child abuse community has a long and checkered history of declaring some medical findings considered diagnostic of abusive injuries that have had to be retracted or revised. Shaken baby syndrome – more recently termed abusive head trauma (AHT) – has recently endured diagnostic revisions of its own.
While the imprimaturs of pediatric and pediatric radiology societies have supported the diagnostic specificity of the triad – or parts of the triad – for abuse, these do not create science, nor does the repetition of untested concepts in decades of child abuse literature. The triad can be seen in medical as well as in accidental or nonaccidental traumatic conditions. There is now evidence that the child abuse community is backing away from their decades old pronouncements regarding the specificity of the triad for abuse.
The finding of unexplained fractures in different stages of healing or the presence of “child abuse specific fractures” cannot be used to support the abusive etiology of triad” cases, because these features can be seen in both abusive and non-abusive situations. The concept of child abuse specific fractures is an erroneous since there is virtually no fracture that cannot be seen with accidental trauma.
The child abuse literature uses unscientific expressions such as “highly probable,” “highly suspicious,” and “most likely” which are subjective, speculative terms that are without statistical meaning. The new catchphrase is that a certain “constellation of injuries” proves child abuse. This suggests that virtually any combination of injuries, regardless of exculpatory explanations is proof of abuse. This term, also, remains undefined and is used, in my opinion, to suggest a presumption of validity that cannot be scientifically substantiated.
Since the child abuse community has admitted that there is no rigorous scientific proof that the triad can occur from shaking without neck trauma, they often rely upon alleged perpetrator confessions to diagnose AHT. While a number of these confessions may be valid, the articles documenting them are not transparent. These confessions should be videotaped for the purpose of external review. Non-reviewable confessions cannot be used to definitively diagnose child abuse given that confessions may be made in order to protect a spouse, satisfy a plea bargain, or may be coerced after hours of stressful police interrogation. They may also pertain to benign or otherwise non-abusive activities, such as tossing a baby into the air, bouncing an infant on a knee, or post-collapse resuscitation.
When it is not possible to reach a definitive diagnosis in an alleged abuse case, the etiology should be recorded as undetermined; a default diagnosis of child abuse must not be used. Child abuse certainly exists and physicians must utilize science, not clinical impressions or assumptions, to identify its perpetrators. Just as it is egregious for a physician to not consider abuse in the differential diagnosis in a potential AHT case, it is equally egregious to use invalid and/or untested diagnostic criteria to damage innocent families.
The Baroness Helena Kennedy’s statement before the Royal College of Pathologists and the Royal College of Paediatrics has much merit in this debate: “A doctor can be convinced, based on his or her experience, that a defendant is guilty – but unless there is compelling evidence supported scientifically, he or she should not express that view in criminal proceedings,” which sets the standard for an expert opinion in the British courts.
Few topics in medicine invite as much emotion as the topic of child abuse diagnoses and misdiagnoses. There must be a scientific evaluation of both sides of this debate by an unbiased, esteemed scientific body, such as the National Academy of Science in the United States or a similar body in Sweden.
Thank you, Dr. Hyman, for your valuable and well-considered explanation of the situation.
Michael D Innis FRCPA;FRCPath
Retired Haematologist
Princess Alexandra Hospital Brisbane
Title
Liver Dysfunction not Shaken Baby
Key words
Shaken Baby Syndrome Liver disease. Haemostasis Carboxylation
Osteogenesis
Manuscript
Liver Dysfunction not Shaken Baby
“As is your pathology, so is your Medicine” said Sir William Osler
Haemostasis (Blood clotting) and of Osteogenesis (Bone formation) require the Carboxylation of certain proteins, Factors II.VII, IX and X in Haemostasis and Osteocalcin and matrix Gla Protein in Osteogenesis, to function effectively. Carboxylation takes place in the Liver and is disrupted by Liver dysfunction. The “Triad”, retinal and subdural haemorrhages with encephalopathy and fractures in children, hitherto regarded as a form of child abuse caused by vigorous shaking , is in fact the result of Liver disease as demonstrated in the following cases.
Case 1.
Date of Birth 12th February 2012
Birth Record
The child was born after a gestation period of 31 weeks via vaginal delivery due to pre-term labour. She was placed in the Neonatal Intensive Care Unit and required Continuous Positive Airway Pressure. Her birth weight was 1300 grams.
Progress
Immunizations were “up to date” on 18th May 2012. She had some twitching of legs for a couple of seconds for the last 2 or 3 weeks and had a bruise on her left arm, a diaper rash and scratches on her legs.
Her progress was satisfactory until at the age of 3 months, when on 5th June 2012, her mother noticed her mouth was bleeding and on looking into the infant’s mouth saw a lesion under the tongue which she thought was due to Thrush. The mother gave the child a dose of Tylenol but she continued to be “fussy ”, had difficulty in breathing, and was taken to the hospital Emergency Room. On examination she had an Oxygen saturation of 100% on room air, mild retractions, shallow breathing and tachypnoea. A 6mm tear distal to the frenulum without active bleeding was found and petechiae were seen on the left arm and right thigh.
Investigations
1. A pediagram showed multiple rib fractures, left tibial and left femur fractures.
2. Blood Chemistry
a. Creatinine 0.1 mg/dL Normal Range o.4 – 1.2
b. Glucose 113 mg/dL 70 – 99
c. Total Protein 5.7 g/dL 6.4 – 8.4
d. Albumin 3.4 g/dL 3.8 – 5.4?
e. ALT 140 unit/L 0 – 65
f. AST 46 unit/L 0 – 37
Comment.
The increased level of Glucose in the Blood is an indication that the level of Insulin in the Blood is reduced and a reduction of Insulin means Vitamin C is not entering the cells in the Liver[1] causing cellular dysfunction as shown by the increase in the AST and ALT and reduction of Albumin.
The cause of the increase in Blood Glucose is and autoimmune destruction of the βcells of the Pancreas [2]
As a result of disruption of Liver Function (about 17 days following the administration of vaccines} there was a failure of Carboxylation of some clotting factors, Factors II,VII,IX,X, and also of Osteocalcin and matrix Gla protein. The result is haemorrhages and fractures in the child.
There is clear evidence that this child had an Autoimmune reaction as a result of an Adverse Vaccine Reaction which affected the Liver and resulted in the failure of Haemostasis and Osteogenesis.
Case 2
Date of Birth 3/03/2013
Pregnancy History.
The pregnancy was normal but it should be noted that there was a pet cat in the house during this time. Cats are known to carry the parasite Toxoplasma Gondii which can infect a mother and subsequently the unborn foetus causing Liver damage in the child.
Birth History.
Delivery was an uncomplicated vaginal delivery and the infant weighed 2960 gm and was breast fed initially but later was Formula fed.
Progress
Progress was satisfactory and she was given the routine mandated vaccines on 13/04/2013. Five days later the parents noted her leg was swollen and they took her to the local Hospital.
HOSPITAL Record dated 18/04/2013.
Swollen right lower leg, ankle and foot observed by the parents on 17/04/2013
No history of trauma.
Bruise on right jaw angle.
Two bruises on the fold of the neck (left side)
Moderately extensive subcutaneous soft tissue swelling is present in the lower leg and ankle region. There is slightly displaced right tibial metaphyseal bucket-handle fracture. No other fracture is identified in the right leg. Further evaluation.
Blood Tests.
1. APTT 30 sec Normal Range 25 – 37
2. Fibrinogen 4.4 g/L 1.5 – 4.0
3. PR 0.9 0.8 – 1.2
4. CRP 13 mg/L 0.0 – 10
5. Bilirubin 95 umol/L 0.0 – 24
Comment.
The elevated Fibrinogen is an Acute Phase Reactant which means it is a response to an Acute Inflammation. The elevated level of Bilirubin indicates Liver dysfunction is the site of the inflammatory reaction.
Other evidence of an Inflammatory Response is the elevated CRP level.
Conclusion
The child shows all the signs and symptoms of an Infection of the liver and this is a known cause of fractures and bruising as indicated above. One cause of a liver infection is Toxoplasmosis and this should be investigated with appropriate tests.
Case 3.
Date of Birth 28.12.12
The child was born by emergency caesarean section at term and because of maternal infection and foetal stress was placed in the special care baby unit till 11th January 2013. He was given regular small doses of antibiotics as he had a problem with one of his kidneys.
On June 1st 2013 he was admitted to the Royal Hospital for Sick Children because his head growth had suddenly accelerated which on investigation was shown to be the result of a cerebral haemorrhage.
A hospital report states “In the absence of a medical explanation the most likely explanation of the bleeding is trauma. Given that there is no explanation of accidental trauma which would account for the bleeding the most likely explanation is that of non-accidental trauma”.
Significant Laboratory Investigations 22nd February 2013 showed abnormal Liver function
1. ALT 70 U/L Normal Range 50 – 60 U/L
2. AST 105 U/L 15 – 45 U/L
Comment.
These two investigations are proof that the Liver is severely dysfunctional and the clotting factors II, VII, IX and X, along with osteocalcin and matrix Gla protein are not being carboxylated and bleeding and fractures are inevitable.
It cannot be stressed too strongly that the Liver is the site of chemical processes which ensure blood coagulation is normal and where the bone mineralization is maintained.
Conclusion
Doctors making accusations of Non-accidental Injuries ignore the fact that Liver dysfunction, as shown by the abnormal Liver Function Tests, means that bone formation and haemostasis are impaired and fractures and haemorrhages are bound to occur.
The Shaken Baby Syndrome is a fabrication with no scientific basis.
References
1. Cunningham JJ. “The Glucose/Insulin System and Vitamin C: Implications in Insulin-dependent Diabetes Mellitus.” J Am CollNutr; 1998:vol 17 p105-108
2. Innis MD Autoimmune Tissue Scurvy Misdiagnosed as Child Abuse. Clinical Medicine Research. Vol. 2, No. 6, 2013,pp.154-157.
Thank you, Dr. Innis. I am glad professionals like you are continuing to look carefully at these cases.
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You may have been convinced, as many like you are, but that does not make it real. It isn’t.
Steven Gabaeff MD.
Boo! shame on you! I’m a survivor of Shaken Baby Syndrome!!! and it ‘does’ exist!!!!!
Patti Mackenzie patti.mackenzie@aol.com
Phone: (262) 441-8969
It’s not about whether it exists or not. It does. It’s about how many times it is being falsely accused and convicted! More times then you know. Doctors aren’t getting it right and as a result lives are being destroyed.