A case study illustrating a liver dysfunction misdiagnosed as shaken baby syndrome, refuting the reliability of current diagnostic criteria
by Michael D Innis FRCPA; FRCPath
Retired Haematologist
Princess Alexandra Hospital Brisbane Australia
email micinnis@bigpond.com
Abstract
The authenticity of the diagnosis “Shaken Baby Syndrome” is investigated by examining the reports of doctors who failed to appreciate the consequences of severe liver damage as shown by alteration of the coagulation profile, made a diagnosis of Shaken Baby Syndrome, and caused an innocent man to be charged with murder and sentenced to life imprisonment (1).
Key Words
Shaken Baby Syndrome, Liver Dysfunction, Hyperglycaemia, Fractures
Introduction
The term “Shaken Baby Syndrome” is attributed to Neuro-surgeon, Dr Guthkelch, to explain intracranial haemorrhages in children.
He wrote ”I am disappointed that Helen Carty and Jane Ratcliffe wrongly give priority to the late John Caffey for recognizing the potentially serious effects of shaking babies. Caffey was the first to implicate parental violence in the aetiology of subdural haematoma associated with fractures of the skull and long bones, and for that his fame is secure. But the first mention of shaking of infants as a cause of subdural haematoma appeared in the BMJ as a paper that I wrote almost a year before Caffey’s paper was published.
Unlike Caffey, I never believed that such shaking was playful; rather, I suggested it was thought of as a socially more acceptable form of correction than a beating, and I referred to a paper by Court in which she told of a mother confessing to shaking her baby “in an insane rage”. I also noted how infants’ big heads and relatively weak neck muscles, to which the editorial refers, made them particularly liable to sustain brain injury under these circumstances. ” (Letters. BMJ Vol 310 17th June 1995).
Dr Guthkelch’s opinion spread among a population of doctors who ignored the pathophysiology of haemostasis and ontogenesis outlined below.
The blood coagulation proteins Factors II, VII, IX and X and the bone forming proteins osteocalcin and matrix Gla protein, to be functionally active and prevent spontaneous bleeding and spontaneous fractures, must be carboxylated by the Vitamin K dependent enzyme γ glutamyl carboxylase(2) a process which takes place in the Liver and either Liver dysfunction or Vitamin K deficiency will result in spontaneous bleeding and fractures(3) which Dr Guthkelch and his followers have interpreted as the Shaken Baby Syndrome.
Main-stream Medical opinion has imbibed this concept whole-heartedly causing considerable distress and anxiety in the general population while the true explanation, antigen induced Autoimmune reaction, is ignored.
Case Report.
Mr Darryl Elliot was convicted for the murder of Amelia Bowmar and sentenced to life imprisonment on the evidence of doctors who alleged Amelia was shaken to death. The basis of this allegation was the presence of a subdural haematoma, swelling of the brain with ischaemic changes and haemorrhagic contusions in the cortex of the right and left superior frontal gyri of the brain. The brain and spinal cord showed evidence of old and recent injury which was attributed to “Non-accidental Injury”. (Nottingham Post 22/08/2013. Baby murder trial update: She was thought to have been “vigorously shaken”. Darryl Elliott denies murder. Amelia Bowmar had bleeding on her brain a doctor thought was caused by her being “vigorously shaken”, a murder trial heard. The 14-month-old’s injuries were typical of a child being shaken, explained Patrick Cartlidge, a senior lecturer in Child Health and Consultant paediatrician.
The condition in which the carers of the child could offer no explanation for fractures, bruises, retinal and cerebral haemorrhages with ischaemic encephalopathy was given the inane diagnosis “Shaken Baby Syndrome” in 1971 by the neurosurgeon Dr Guthkelch who could offer no other explanation for the lesions. .
Method
Amelia had a disorder of the coagulation system as shown by a raised INR of 1.3,(NR <1.2) an APTT of 39.6.(NR <39.0) which would explain the brain and other haemorrhages but the evidence was ignored by the doctors alleging murder who were obviously ill-informed in relation to the interpretation of these and other Laboratory results.
Their preoccupation with the Shaken Baby Syndrome hypothesis also ignored the elevation of the level of Glucose in the blood and the presence of Glucose in the urine of Amelia. Both these features are manifestations of an Autoimmune response to antigenic stimulation which destroyed the β cells of the Pancreas resulting in a reduction of Insulin and hence the Hyperglycaemia.[1]. In this case it was most probably the vaccines given to Amelia a few days prior to her falling ill which initiated the process. A simple skin “scratch test” may help to identify individuals sensitive to a particular vaccine and may help to avoid similar disasters.
Until the Medical Profession realizes that the Shaken Baby Syndrome is a slanderous, ignorant, fabricated diagnosis without a shred of scientific evidence they are going to continue to falsely accuse and destroy the lives of innocent people
Mr Justice MacDuff sentencing Darryl Elliott for the alleged murder of his partner’s baby Amelia Bowmar said, “You have been convicted, on overwhelming evidence, of the murder of Amelia Bowmar, a little girl of 14 months whose care had been entrusted to you by your partner; her mother. Your job was to look after and protect her but, instead, she died at your hands.
It is clear to me that because you perceived her to be misbehaving, or perhaps because you had to deal with her when she was sick, or just because you lost your temper at something wholly unconnected with her behaviour, you so violently and deliberately shook her causing the catastrophic injuries from which she died. Only you know exactly what went on inside that house on July 28 last year.
I accept that this was a spur of the moment loss of temper and also that you did not intend to kill. I also accept that you were immediately full of remorse – although that remorse has to be seen alongside an attempt to distance yourself from what you did and a failure to acknowledge your responsibility. Your failure to tell the truth in those early hours meant that the medical teams spent time investigating other possible causes. I am satisfied that Amelia was so seriously compromised that she would have died anyway. But you were not to know that.” (Nottingham Post 22/08/2013).
The Judge believed the evidence of the doctors and the “overwhelming evidence” he refers to is analysed and is demonstrably “overwhelmingly incorrect” as demonstrated here.
r P H T Cartlidge, Specialist in Paediatrics said “in my opinion the head injury was not caused by a fall from the seat of the settee and I struggle to conceive how Amelia could have climbed higher”. He goes on to say “the mechanism of non-accidental head injury causing an acute encephalopathic illness, acute subdural bleeding and retinal haemorrhages is thought to be shaking, an impact or a combination of both. In shaking a child is often grasped around the chest and shaken.
Squeezing the chest impairs the return of blood to the heart and thereby causes an increase in venous blood pressure. This in turn causes engorgement of the veins that traverse the subdural space on the surface of the brain. Shaking the child and/or hitting the child’s head on a firm object leads to marked accellaration-decellaration forces that rupture these engorged veins, resulting in subdural haemorrhage The same shearing forces generated by shaking-impact can damage the parenchyma of the brain and also the spinal cord and cord roots”.
Dr Cartlidge gives an account of the “mainstream” opinion of the Shaken Baby Syndrome which ignores crucial biochemical evidence such as Increased Glucose in the Blood (Hyperglycaemia), Abnormal Liver Function Test, Abnormal Coagulation Tests and Glycosuria proving an Autoimmune Disease [1,2]. The Shaken Baby Syndrome is unscientific speculation.
Dr S J Hamilton, Forensic Pathology Unit Leeds who, with his colleague Dr Malcomson, performed the Post mortem examination on Amelia also gave evidence for the prosecution in which he stated “having considered all the findings with respect to the death of Amelia, it is my opinion that she died of a head and spinal injuries. Neuropathology has revealed recent injuries including subdural bleeding, axonal injury in the medulla and spinal nerve roots, and fresh bleeding within older contusions within the brain itself. There is also evidence of older injury including older subdural bleeding and cerebral contusions. These are indicative of at least one, but possibly more than one, episode of significant head trauma. These neuropathological appearances are entirely consistent with non-accidental injury also referred to as paediatric head injury or sometimes “Adult Induced Injury”. Although some authors have proposed theoretical models that would indicate a natural single underlying cause leading to the finding of subdural haematoma brain swelling and retinal haemorrhage to my knowledge these theoretical models have not been accepted by the Courts. The presence of this combination of findings is entirely consistent with a traumatic aetiology. The lack of external injury means that it is not possible to state that there has been an impact to the head, although the possibility of an impact that has not left an external injury must exist”.
I am one of the authors that “have proposed theoretical models that would indicate a natural single underlying cause leading to the finding of subdural haematoma brain swelling and retinal haemorrhage”. Amelia had an elevated Blood Glucose and Glucose in her Urine features which confirm Insulin deficiency initiated the onset of Tissue Scurvy [2].
Dr Jayamohan Jayaratnam. Consultant Paediatric Neurosurgeon discussed all the available evidence including the fact that Initial blood clotting tests show some raised clotting times with an INR of 1.3, an APTT of 39.6 and an APTT ratio of 1.3. With support from the evidence of Dr AL SARRAG concluded “in my view this sufficient support for my already formed view that there is likely to have been a traumatic explanation for Amelia’s collapse. In view the globalized findings of ischemia, it was hard to place exactly what may have occurred. However with the focal injuries described by Dr AL SARRAG, in view of the absence of external signs of injury and in view of the bilateral severe ophthalmology findings, I believe it is highly indicative that a non-impact traumatic injury otherwise known as a shaking type injury has occurred to Amelia”.
Dr Jayamohan clearly identifies an abnormality of the clotting mechanism and then, for no apparent reason, chooses to ignore it as a cause of the bleeding in the skull and elsewhere. His illogical conclusion needs to be further investigated as others may suffer the same fate as Darryl Elliot if he continues to hold this view.
Dr Neil Gordon Stoodley Consultant Neuroradiologist concluded his assessment of the situation with the remark “I cannot think of a biologically plausible mechanism that would potentially directly link any event occurring toward the end of May 2012 and Amelia’s presentation with a severe (indeed fatal) encephalopathic illness at the end of July.
The scan abnormalities are all explicable on the basis of being due to an episode of non-accidental head injury. The mechanism of the injury is likely to have involved shaking. Majority medical opinion is of the view that what is likely to be required to produce such injuries is the backwards and forward movement of the unsupported infant head pivoting on the neck. It is believed that this leads to a degree of acceleration/deceleration and rotational forces and that the consequent differential rotation of the brain and skull leads to stretching of the subdural veins which cross the subdural space and it is this which leads to bleeding in the subdural space”.
Dr Stoodley could not “think of a biologically plausible mechanism that would potentially directly link any event occurring toward the end of May 2012 and Amelia’s presentation with a severe (indeed fatal) encephalopathic illness at the end of July”.
The biologically plausible mechanism Dr Stoodley has difficulty in thinking that would potentially directly link an event occurring toward the end of May 2012 and Amelia’s presentation with severe (indeed fatal) encephalopathic illness at the end of July is the MMR vaccine administered on 25th May 2012 isTISSUE SCURVY [2] which doctors including Dr Stoodley are obviously unaware. When doctors understand Tissue Scurvy can be induced by vaccines and causes the signs and symptoms found in Amelia they will stop diagnosing Shaken Baby Syndrome.
Dr AL-SARRAJ provides a detailed account of the findings and concludes “the clinical history indicates presence of extensive bilateral retinal haemorrhages. These injuries, in addition to the presence of subdural haematoma and generalized ischemia (ischaemic encephalopathy) form the triad frequently seen in patients with non-accidental head injury. This is further supported by presence of subdural haematoma in the spinal cord, axonal injury in the pyramids of the medulla and axonal injury in the spinal nerve roots.
The presence of axonal injury in the pyramids and spinal nerve roots suggest head and spinal cord injury resulting from violent hyper-extension and hyper-flexion of the head and neck similar to those seen in shaking. The presence of extensive retinal haemorrhages supports this suggestion.
The pathological findings in the brain have to be considered closely with other findings of autopsy examination, radiological examination, eye examination and other investigations, before final conclusion. I will review the pathological findings in the brain and my interpretation if further information becomes available.
Conclusion
Head and spinal cord injury consistent with non-accidental injury.”
There is no conflict with Dr AL-SARRAJ’S findings but it is the interpretation of those findings which I dispute. He is evidently prepared to review his interpretation if further information becomes available and I draw his attention to the fact that Amelia had Biochemical as well as Anatomical lesions. The Biochemical lesions of Hyperglycaemia, Glycosuria, Coagulation Abnormality (INR 1,3, APTT 39.6) all suggest an Autoimmune Disorder –TISSUE SCURVY [2] which I am sure Dr AL-SARRAJ is willing to consider.
Dr Bonshak gives a detailed account of the pathological changes seen in the eye when exposed to infection and injury and concludes “non-traumatic injuries which might possibly cause this form and extent of pathology include severe coagulopathy (bleeding disorder) leukaemia (with coagulopathy) septicaemia(with coagulopathy) meningitis(with coagulopathy)and catastrophic intracranial bleeding. I am not aware that these conditions have been identified”.
The Hospital Records and Pathology Report of Amelia clearly did show a severe coagulopathy which Dr Bonshak did not recognize:
1. INR (International Normalized Ratio) 1.3 (Normal Range 2 – 4.5)
2. APTT (Accelerated Partial Thromboplastin Time) 39.6 sec (Normal 27-35 sec)
Having been a Haematologist in a Teaching Hospital I HAVE REPORTED ON MANY THOUSANDS OF HAEMATOLOGICAL RESULTS. These results indicate that a Coagulopathy is present due to the reduction in the Clotting factors XII, XI, IX, and VIII and spontaneous bleeding is inevitable. It also indicates that the Liver is damaged because these factors are formed in the Liver.
Dr Bonshak has the evidence of a coagulopathy he requires to conclude “non-traumatic injuries which might possibly cause this form and extent of pathology ”.
Conclusion
Darryl Elliot has been found guilty of murder on the evidence of doctors not competent in interpreting the Haematological evidence which clearly indicated a Coagulopathy caused the death of Amelia Bowmar. Unless these doctors are made to apologize and recompense the accused this atrocity will continue.
Acknowledgements:
I wish to thank Mr Darryl Elliot and his mother Ms Liz Peel for providing me with all the details of the prosecution and for permission to publish my findings.
Prior to migrating to Australia I I was one of the Pathologists working for the Coroner in The West Riding of Yorkshire UK.
I declare that I have not made any statement that I know to be untrue.
Michael D Innis MBBS; DTM&H; FRCPA; FRCPath
References
1. Nottingham Post 22/08/2013. Baby murder trial update: She was thought to have been “vigorously shaken”
2. Vermeer C. Knapen MHJ, Schurgers LJ Vitamin K and metabolic bone disease. J Clin Path 1998;51;424-426.
3. Innis MD. Vitamin K Deficiency Disease. J Ortho Mol Med 2008:23;15-20
4. Guthkelch N Letters. BMJ Vol 310 17th June 1995
5. Innis MD Autoimmunity and Non-Accidental Injury in Children, Clinical Medicine Research. Vol. 2, No. 3, 2013, pp. 40-44. doi: 10.11648/j.cmr.20130203.15
6. Innis M D. Autoimmune Tissue Scurvy Misdiagnosed as Child Abuse, Clinical Medicine Research. Vol. 2, No. 6, 2013, pp. 154-157. doi: 10.11648/j.cmr.20130206.17
On Shaken Baby 