Category Archives: American Academy of Pediatrics

Shaking Theorists Repel Criticism

PBSNewsHourSBSWhile ripples persist in the wake of last month’s news stories questioning shaken baby syndrome in the courtroom, innocent parents and babysitters are still going to prison and most press coverage still treats shaking theory as established fact. Now the news magazine of the American Academy of Pediatrics, AAP News, has published a  commentary that dismisses the controversy as a “false debate” and criticizes The Washington Post coverage in March as “unbalanced, sowing doubt on scientific issues that actually are well-established.”

The commentary’s authors, Drs. Howard Dubowitz and Errol R. Alden, argue that both the Post article and the PBS NewsHour segment that ran the same week make too much fuss over the views of only a few doctors:

What are the facts? Similar to the so-called debate over climate change, it involves a tiny cadre of physicians. These few physicians testify regularly for the defense in criminal trials — even when the medical evidence indicating abuse is overwhelming. They deny what science in this field has well-established. They are well beyond the bounds where professionals may disagree reasonably. Instead, they concoct different and changing theories, ones not based on medical evidence and scientific principles. All they need to do in the courtroom is to obfuscate the science and sow doubt.

globalWarmingI’m not sure which side is supposed to be which in the climate change reference. In the fall of 2014, at the conference of the National Center on Shaken Baby Syndrome, law professor Joëlle Anne Moreno closed her talk with a clip from comedian John Oliver that I think was intended to equate the critics of shaken baby theory with the 4% of scientists who still deny that human activities affect climate change. But I remember the era, a few decades ago, when a handful of researchers was raising the alarm about climate change while mainstream scientists and public opinion dismissed them as fringe thinkers, and I just reviewed my notes from a pointed talk by forensic pathologist William R. Oliver at a 2013 pediatric head-injury conference organized by the publishing arm of the National Association of Medical Examiners, in which Dr. Oliver criticized the tactics and intellectual rigor of both sides in the climate debate, while drawing parallels with the struggle over shaken baby.

The AAP commentary joins the statement from the National Center on Shaken Baby Syndrome criticizing The Washington Post and PBS NewsHour coverage, as well as a posting to the National Association of Counsel for Children (NACC) listserve from law professor Frank Vandervort, who called the Post coverage “slanted and misleading” and criticized the American Bar Association for publishing a piece on its web site about shaken baby by Innocence Network attorney Katherine Judson. Attorneys Diane Redleaf and Melissa Staas at the Family Defense Center in Chicago have now published, on the NACC blog, their rebuttal to that posting.

A “Classic” Case

Debates aside, shaken baby theory is still winning in court. In mid-April, after a trial covered in the national press, a New Jersey jury found child care provider Michelle Heale innocent of murder but guilty of first-degree manslaughter in the presumed shaking death of a 14-month-old boy she was watching. Heale told emergency responders that the boy had seemed to choke on some applesauce. The Asbury Park Press web page offers complementary text and video treatments, including this moving anecdote from reporter Kathleen Hopkins:

Before Heale was led out of the courtroom in handcuffs, she turned to her husband, Michael, and asked him to take care of their children, a set of 5-year-old twins.

“Don’t let them forget me,” she said to him, sobbing.

According to coverage during the trial, pediatric ophthalmologist Alex Levin told the jury that the retinal hemorrhages found in the toddler’s eyes were a “classic” example of shaking injury—he said, in fact, that the image he was showing in court was scheduled to appear on the cover of a professional ophthalmology journal.

Dr. John Plunkett

Dr. John Plunkett

Another day’s coverage, however, quoted pathologist John Plunkett, who testified that “shaking had nothing to do” with the boy’s collapse. He rejected the specificity of retinal hemorrhages and said that choking was a possible trigger for the child’s brain swelling and ultimate death.

Like so many other children diagnosed as shaken, the boy had been sick in the days before his crisis, in his case with coughing and congestion, to the point of “vomiting mucous.” He was diagnosed with an ear infection and started on amoxicillin the day before his collapse. His only visible injury was an old bruise on the right side of his forehead, suffered in a fall the week before in his own home.

Other Disturbing Cases

rosenwinkel2

Cindy Rosenwinkel with her son

In Illinois, wife and mother Cindy Rosenwinkel was sentenced in April to six years in prison for the presumed shaking and slamming of an infant she was watching in 2011. According to press coverage, the judge imposed the minimum possible sentence. Ms. Rosenwinkel reported that she had slipped on the steps and fallen onto the conrete floor of the garage while carrying the infant in his car seat. The boy survived and is now described as “an active four-year-old.” Her supporters have created this web site protesting her innocence.

In a slightly encouraging update from Boston, the trial of Irish nanny Aisling Brady McCarthy has been postponed again, this time for a review of the case by the county medical examiner. Last week’s report was that a judge had denied a defense motion to drop the charges, so a delay for a review of the evidence is progress.

May 5 update: After two-and-a-half years in jail, Aisling Brady McCarthy has been released on $15,000 bail.  http://www.bostonglobe.com/metro/2015/05/05/bail-hearing-murder-case-for-nanny/g6z1mGNt6XeJuCpHw91IgL/story.html

burnsPhilIn the media, meanwhile, Dr. Phil ran a segment this week, “Was It Abuse, or Was It an Accident?,” sympathetic to Joshua and Brenda Burns in Michigan, where supporters have rallied behind the family even after Joshua’s child abuse conviction this winter. The page about the program on Dr. Phil’s web site offers a video clip in which Dr. Phil himself runs through the commonalities between the signs of shaken baby syndrome and the side effects of vacuum extraction—during the delivery of the Burns’s daughter, doctors had applied the vacuum device four times without success before eventually performing a C-section.

Joshua reported that when the girl was 11 weeks old, he had nearly dropped her while setting down his cell phone—he said he caught her by the face and head in one hand. She seemed fine that afternoon, but over the next several days, the couple took their daughter to the emergency room twice and to the walk-in clinic once because she was vomiting and appeared ill—on one visit they described her as “pale, cold, and clammy,” for example. Each time she was examined and released. Finally, when the girl developed breathing problems and the parents called 911, doctors looked more closely and found retinal hemorrhages and subdural hematomas, but no encephalopathy.

Dr. Phil’s show featured Dr. Robert Block, former president of the American Academy of Pediatrics, who had not reviewed the Burns case but said that critics of shaken baby “are absolutely wrong.” The program included no doctors who doubt the theory, but Dr. Phil was clear in his support of both Brenda and Joshua Burns. While Joshua serves his sentence, supporters maintain a web site at http://tornfamily.com/. The little girl seems to have recovered fully.

Fox news reported a different story this month, about doctors in Atlanta, Georgia, who accepted a father’s report that his 10-month-old son had fallen backwards while pulling himself up on a chair the day before his collapse. Surgeons removed a blot clot from his brain, and the boy has apparently recovered with no long-term effects and no child abuse accusations against the family. It’s hard to know from the news report what made the difference.

Meanwhile, the publicity for Child Abuse Prevention Month, April, has inspired news stories referencing children diagnosed as shaken in the past, such as this piece about a fund-raising race in South Dakota, this touching moment with a mother whose infant son was presumed shaken to death by his babysitter, and this feature about a loving family who adopted a child believed to be shaken by his maternal grandfather. With no details, it’s hard to know how accurate these stories are. I do believe that shaking a baby is dangerous and unacceptable, but I’ve seen so many dubious convictions that I find myself skeptical, of either the diagnosis or the correct identification of the perpetrator.

I feel like I’m back where I started in 1997, when a child care provider I knew was convicted of child abuse because a baby collapsed in her care, even though the child had been dropped off that morning with “a touch of the flu” and brain imaging showed old bleeding as well as new. In the Burns case, the prosecutors seemed to be arguing that Joshua abused his daughter the day he was alone with her and reported the near fall, but the breathing problems didn’t emerge until three days later. In a letter reproduced on the home page of my blog, a pathologist reported the case of a toddler hospitalized with vomiting for some 18 hours before the symptoms of an ultimately fatal head injury emerged. So why are the experts still saying that the symptoms are always immediate? In his appearance on Dr. Phil’s show, Dr. Block made the point, “In almost every one of these cases, the baby changes from being well to being in trouble when alone with a caregiver,” the same guideline that informed my 1997 case and that seems to be behind the accusations against another child care provider now on trial in Michigan. According to the press report of that case, the babysitter says the infant seemed to have a seizure, and she denies hurting the child in any way. Based on the brain injury, though, she is accused of “inflicting abusive head trauma, possibly by shaking the child.”

When is someone from the justice system going to stop and notice that the symptoms can evolve slowly over time? Or that there are other causes than abuse for subdural hematoma, retinal hemorrhages, and encephalopathy?

copyright 2015, Sue Luttner

If you are not familiar with the debate surrounding shaken baby syndrome, please see the home page of this blog site.

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Filed under abusive head trauma, AHT, American Academy of Pediatrics, parents accused, SBS, shaken baby syndrome

Separating the Sheep From the Wolves

Gray fox at a wildlife rescue center in Lafayette, CA

I have returned sobered from the Twelfth International Conference on Shaken Baby Syndrome/Abusive Head Trauma, Sept 29–Oct 1 in Boston.

Dr. Robert Block, President of the American Academy of Pediatrics (AAP), opened the conference with an address titled “While We Argue, Children Die:  The Consequences of Misinformation,” arguing that the press has been getting it wrong by reporting that shaken baby syndrome is now in doubt.

If the number of shaking diagnoses is not decreasing, Block said, then “the assertion that there has been a significant shift in medical opinion and medical thinking is false and it is not supported in basis of fact.”

Block protested that an upcoming law-journal article misrepresents the intent of the 2009 AAP position statement recommending that doctors drop the term “Shaken Baby Syndrome” in favor of “Abusive Head Trauma.” The goal of the new name, Block said, was “not to detract from shaking as a mechanism of abusive head trauma as much as to broaden the terminology to account for the multitude of primary and secondary injuries that result from abusive head trauma.”

The article Block cited—“Shaken Baby Syndrome, Abusive Head Trauma, and Actual Innocence:  Getting It Right”—was written by law professors Keith Findley and David Moran, with pediatric radiologist Patrick Barnes and pediatric neuropathologist Waney Squier, in response to an earlier article in the same journal —“A Daubert Analysis of Abusive Head Trauma/Shaken Baby Syndrome“—by pediatrician, attorney, and pediatrics professor Sandeep Narang. Dr. Narang had proposed in that piece, as he did again at the Boston conference, that the diagnosis of child abuse is best left to the experts who have devoted their careers to studying it.*

Like Dr. Narang, Block emphasized the importance of clinical experience. The experts have seen “thousands and thousands of children, of all ages, in all stages of health, from perfectly healthy to perfectly dead,” Block said, “Without that experience one cannot understand, get involved in, begin or end that science that we so desperately need.”

Arguing that child-protection doctors are forced to spend their time fighting baseless attacks, Block asked, “Can the media, and the folks who feed the media, be held responsible for injuries to, and deaths of, children?”

Block encouraged the building of multi-disciplinary bridges, where physicians from different specialties can share experiences and learn from each other. Conversation is difficult “with people who are emotionally invested,” he said, and he would welcome the entry of the Institute of Medicine and the National Academy of Sciences into the arena.

Monday morning’s keynote address—”A Wolf in Sheep’s Clothing:  Denialism in Child Abuse Pediatrics” by Dr. Christopher Greeley, professor of pediatrics at the University of Texas Health Science Center—reaffirmed that there is no disagreement within the medical community about abusive head trauma.

“I believe this not to be a medical debate,” Dr. Greeley opened, but “a legal debate with a white coat on.”

Greeley proposed that critics of the known science behind shaken baby syndrome have fallen for the allure of their own personal narratives. “They think, ‘This is Galileo trying to prove his case to the people,'” he explained. “They think, ‘I have this knowledge and it’s being squashed by misguided authority.'”

Alluring at it is, that narrative is false, he said. “Are we the overbearing establishment? Is Dr. Block our pope?”

Dr. Greeley characterized those who question SBS theory as denialists, and he outlined their tactics:

  • Manufacture of doubt—emphasizing small areas of disagreement to give the impression of fundamental flaws
  • Identification of conspiracies
  • Creation of impossible expectations—demanding that the child abuse literature  provide the same kind of evidence produced by drug trials, for example
  • Use of fake experts
  • Misrepresentation and logical fallacies—the “straw man,” for example
  • Selectivity of citation

Dr. Greeley’s slide show of media denialism included offerings from major news outlets (the 2008 Discover magazine piece by Mark Anderson, Prof. Deborah Tuerkheimer’s 2010 New York Times op ed, Emily Bazelon’s New York Times Magazine cover story, and the Frontline/ProPublica/NPR critique of child death investigations) as well as small internet voices (the Medill Innocence Project, MedicalMisdiagnosisResesarch, Medical Veritas [which seems to be an anti-vaccine organization], this blog, and the EBMSI conferences), plus a radio commentary by Phyllis Schlafly.

In the professional arena, Dr. Greeley lambasted the 2003  literature review by Dr. Mark Donohoe, “Evidence-Based Medicine and Shaken Baby Syndrome,” which had concluded that “the commonly held opinion that the finding of subdural hematoma and retinal hemorrhage in an infant was strong evidence of SBS was unsustainable, at least from the medical literature.”

Donohoe had searched the Biomednet Medline database using only the phrase “Shaken Baby Syndrome,” Greeley pointed out, four years before the phrase was officially adopted into the Medical Subject Headings maintained by the National Library of Medicine. Donohoe did not search for terms like “abusive head trauma,” “child abuse,” “subdural hematoma,” or any of the other phrases that might have captured additional relevant articles, Greeley charged, and then he didn’t even read all of the articles he found. Although Donohoe’s search was conducted in 1998, the article wasn’t published until 2003. Greeley said that his own search using Donohoe’s described strategy, even limiting the time range to 1966-1998, produced far more citations than the 54 Donohoe reported. (Greeley did not, however, offer any examples of papers that would have provided stronger scientific support for shaking theory than those Donohoe evaluated).

“Donohoe is a horrible paper and you should never cite it,” Greeley summarized. Noting that Supreme Court Justice Ruth Bader Ginsburg had in fact referenced Donohoe in her minority opinion in the Shirley Ree Smith decision, he speculated, “Surely Justice Ginsburg didn’t read this paper…  or she wouldn’t have cited it.”

He also criticized medical-journal articles by Drs. Pat Barnes, Waney Squier, Jennian Geddes, and Steven Gabaeff and the “Getting It Right” law-journal article by Findley et al.

In other sessions I heard speakers explain that Vitamin D levels in a newborn are unrelated to bone fragility, hypoxia does not cause subdural hematoma, and physicians always do a complete work-up for other conditions that might cause the symptoms before diagnosing abuse. While I’m still puzzling over the medical possibilities, I know from personal experience that the third point is an unattained ideal.

I had hoped the conversation was opening up, but it’s hard to feel encouraged after being dismissed as a denialist. More to come.

* Dr. Narang’s article posits that there is no real medical debate about AHT and concludes:

“It is understandable that lawyers will look for opportunities to create doubt in the minds of jurors. However, the only way to appropriately improve the chances for justice in the courts with respect to AHT is to assure that an unbiased, financially-unmotivated, medical expert testifies to the current state of medical evidence.”

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Filed under abusive head trauma, AHT, American Academy of Pediatrics, National Center on Shaken Baby Syndrome, SBS, shaken baby syndrome