Tag Archives: shaken baby research

From the heart, from the brain: A top-notch TEDx talk on shaken baby

Pediatric neuropathologist Dr. Waney Squier has hit one out of the park in her TEDx talk, “I believed in Shaken Baby Syndrome until science showed I was wrong,” published Friday on Progress Video TV.

While telling her own story with calm, compelling intensity, she also describes the pain inflicted on innocent families by misguided accusations of abuse and documents the refusal of the legal and medical communities to accept the unwelcome truth about their flawed theory.

“By ignoring the science and adopting an unproven hypothesis, doctors have done great harm,” she concludes, “and have led the courts astray.”

The talk opens with the story of Linda, a mother convicted of shaking her third child to death based on the presence of the triad: bleeding in the retinas, bleeding beneath the lining of the brain, and brain swelling. “At her trial, Linda was described as a woman of good character, a caring and careful mother,” Dr. Squier recounts, “But doctors—medical experts—said that those three findings meant that [the boy] must have been violently shaken” when alone with his mother.

Three years later, Linda’s conviction was overturned on appeal. “Her name was cleared, but her life was ruined,” Squier says. Her parents had died and her husband had left her. Her fourth child, a little girl born in prison, had been taken from her at birth and placed for adoption, and even after her exoneration, Linda was prohibited from attempting contact.

When Linda was first accused, the police had called in Dr. Squier, an expert on infant brain pathology. After examining the brain, she had endorsed the opinion of the other doctors, that it was a case of shaken baby syndrome. “They believed in it, and I believed in it,” she grimaces, “and so my report was part of the evidence that cost Linda so much.”

Dr. Squier says her own doubts about shaking theory started when another neuropathologist, Dr. Jennian Geddes, published research suggesting that the damage in presumed shaking cases resulted from lack of oxygen, not from direct violence. Dr. Squier recalls:

“Back in 2001, the Geddes research stopped me in my tracks. It wasn’t what I had expected. So I read everything I could about shaken baby syndrome, and as a scientist, I’m embarrassed to admit to you I hadn’t done so before. I’d been making this diagnosis on the basis of my uncritical acceptance of what was in the textbooks and what I’d been taught. I was startled to learn that there was no scientific foundation for the hypothesis.”

No one has ever witnessed a shaking assault that resulted in the triad, she reports. Laboratory research and biomechanical calculations have only cast doubt on the theory, and past experience with front-facing car seats tells us that whiplash forces cause fractures and dislocations in the neck, not intracranial bleeding and swelling.

After her realization that the theory was not only unproven but likely wrong, Dr. Squier started conducting her own research, and she started testifying for the defense. But her willingness to speak out against the common knowledge resulted in criticism from colleagues, scoldings from judges, and complaints to the authorities. In the spring of 2016, after hearings triggered by a police complaint to the General Medical Council, she temporarily lost the right to practice medicine, until a higher court reinstated her, declaring most of the first findings “unsustainable.” She is still prohibited from testifying in British courts for another year and a half.

The actions against her have successfully stifled the voices of dissent, Dr. Squier argues, leaving innocent families “defenseless” against their accusers. “Back in 2005, Linda had seven medical experts to support her. Today she would be likely to have none.”

Some other key points from Dr. Squier’s talk:

“So today, as I stand here, I am sure that shaking can harm babies, and we certainly shouldn’t shake babies. But nearly 50 years of research has failed to provide us with the justification to make the assumption that a baby who has the triad or any of its components must have been shaken.”

“If we do nothing, then ordinary people, people who have already suffered the tragedy of the death of a baby, will continue to have their families torn apart by incorrect and unscientific opinions…

“If we do nothing, this travesty will continue… this willful refusal of the courts and the doctors advising them to recognize the science that shows they are wrong.”

But you might have other favorite quotes. I suggest you watch the entire talk.

Copyright 2018, Sue Luttner

If you are not familiar with the debate about shaken baby theory, please see the home page of this blog.

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Filed under parents accused, SBS, shaken baby

Shaken Baby Theory: Poking the Hornet’s Nest

The July issue of Acta Paediatrica offers a collection of free, live links to a volley of rebuttals published over the past four months to an article in March submitted by medical ethicist Dr. Niels Lynøe and most of the other experts who informed the 2016 Swedish report critical of shaking theory, commissioned by a government agency whose name is abbreviated SBU.

In an email exchange last week, Dr. Lynøe wrote that his team knew the topic was controversial, but they were “rather surprised” at the vehemence of the criticisms. “I also think that there was something positive with the critical comments,” he added, “because we got the opportunity to explain and explore some aspects more.”

Dr. Niels Lynøe

The March paper reported on the same research as the SBU study, an exhaustive evaluation of the shaken baby literature that ultimately declared the scientific evidence behind shaking theory “weak.” The analysis noted fundamental problems with the bulk of the published research—in a typical study design, the report noted, researchers had applied the criteria they were attempting to prove when identifying and sorting their subjects, so the results necessarily supported their theory.

Weeks after the Lynøe et al. paper appeared, Acta Paediatrica published an editorial  by epidemiology professor Jonas F. Ludvigsson criticizing  the SBU’s methods and warning of an “imminent risk” that the paper will discourage the reporting of child abuse and leave abused children undiagnosed. Dr. Ludvigsson conceded quality problems with past SBS research, but rejected the SBU’s conclusions and endorsed reliance on the triad:

“[The study’s] publication in Acta Paediatrica does not spell the end of the discussion. Instead, it is a clear signal that more research is needed. But for now, paediatricians should continue to alert social services when they observe a child with the triad, once other explanations for subdural haematomas, retinal haemorrhages and brain ischaemia and oedema have been ruled out.”

The next critique of Lynøe et al., in mid April, added irony to the collection by denying the triad itself. An editorial by violence and abuse specialist Dr. Steven Lucas and others charged that the SBU’s methods had become “untethered from the agency’s published methodology” and argued that the study was fundamentally flawed, because it had examined the question of whether the presence of the triad proves infant shaking. Lucas et al. wrote:

“The construct of the ‘triad’ represents a rhetorical fallacy known as a straw man, which gives the impression of refuting an opponent’s argument – the ‘triad’ is pathognomonic for AHT – when, in fact, that argument was never advanced by that opponent. We maintain that the term ‘triad’ carries no value for clinicians experienced in evaluating suspected AHT.”

In refutation of the straw man argument, I point out that both Joshua Burns and Michelle Heale were convicted based only on the opinion of child abuse experts that the triad proves abusive head trauma—these cases are not unique, only easy to reference here. I myself have researched dozens of convictions based on the triad, sometimes on only one or two elements of the triad.

Lynøe et al. addressed the straw man argument in a response to a different criticism (the response to Narang et al.), by quoting these physician guidelines, which clearly endorse the triad:

“If there is no history of traffic accident or fall from a considerable height, the combination of subdural hematoma and encephalopathy with edema or hemorrhage strongly suggest that the infant has been abused. If there are also retinal hemorrhages then from the medical point of view the diagnosis of abuse is quite clear.”

Also in April, Acta Paediatrica published an editorial by pediatric ophthalmologist Dr. Alex Levin, who declared, “There is a plethora of scientific evidence that retinal hemorrhages are a cardinal feature of abusive head trauma.” Among other objections to the study, he criticized the SBU’s failure to consider the various possible sizes and locations of retinal hemorrhages. “To ignore these descriptors,” he wrote, “is like saying that a rose is no different than any other ‘flower.'”

Dr. Levin also objected that the SBU team had ignored the “wealth of clinical experience” available from the community of child abuse experts.  He argued that certain retinal findings, even in the absence of any other evidence, should shift the assumption to one of abuse:

“A diagnosis of abuse should not be made solely based on retinal haemorrhages, but certain retinal findings make that likelihood dramatically high, so high that one must actively seek (or rule out) supportive evidence that the child has been abused and is in need of protection.”

Another commentary in the April issue, by eye and vision specialist Dr. Kerstin Hellgren and others, called the SBU report “misleading.” In an apparent endorsement of both the triad and the literature that supports it, the authors wrote:

“The SBU report concludes that there is only limited evidence that shaking of an infant can cause the triad signs, in contrast with the numerous reports describing such lesions in victims of verified shaking. It is unfortunate that the SBU panel neither included a paediatrician nor a paediatric ophthalmologist with experience of child abuse to facilitate a correct interpretation of the cited papers.”

In a response to both Levin and Hellgren et al., the Lynøe authors reiterated their commitment to objectivity:

“If physicians involved in child protection teams embraced the research question as if it was a generally accepted scientific fact when classifying cases and controls, this would have resulted in circular reasoning when estimating the diagnostic accuracy of the triad. For that reason, and in order to avoid conflicts of interest and circular reasoning, the expert panel did not include any experts associated with child protection teams. The panel comprised two paediatricians and one expert each from the fields of forensic medicine, radiology, epidemiology and medical ethics. All the included had long experience of assessing scientific work and were scrutinised for potential conflicts of interest and cleared by the Agency. The expert panel followed the guidance in handbooks for assessing health technology and any other panel reproducing the study would have probably arrived at the same conclusions.”

In May, Dr. Sandeep Narang and Dr. Christopher Greeley, both renowned child abuse specialists, published a column in the Acta Paeditrica series “A Different View” that lambasted the methodology, objectivity, and transparency of the SBU study. Like Lucas et al., Narang and Greeley declared the triad a “strawman,” with the statement:

“Physicians experienced in the clinical evaluation of paediatric traumatic brain injury and AHT do not diagnose SBS by a ‘triad’.”

Narang and Greeley also found it “troubling” that the SBU panel “was offered and refused external peer review by no fewer than seven international professional medical societies” before the publication of their report, and charged that the panel was biased in two ways:

  • One of the SBU panelists had testified before the highest court in Sweden, prior to the study, that “the diagnostic model of the ‘triad’ for diagnosing SBS ‘has been criticised’, and that ‘there is currently no clarity about the extent to which the components of the triad are specific to violent shaking’.”
  • A former chair of the SBU had also testified in the same case, and “has openly expressed scepticism of the diagnosis of AHT because of his personal experiences with a family member being criminally charged in a suspected shaken baby case.”

Another “Different View” column published in May, by Dr. Robert A.C. Bilo and others, focused specifically on the papers used to support the study’s conclusion that the triad had many “alternative explanations.” Bilo et al. rejected the cases and papers cited in support of these explanations, with three main arguments:

  • many of the cases would never have been diagnosed as abuse, because the children clearly suffered other medical conditions
  • some of the cases did not fully conform to the triad
  • some of the cases were in fact abuse misrepresented as organic causes

Like other critics, including Lucas et al., the Bilo authors accused the SBU of applying a double standard, because the reviewers accepted individual case reports as evidence for other causes, while they rejected studies with fewer than 10 cases from their main literature review.

Lynøe et al. clarified in their response that the papers cited as evidence for other causes had simply emerged during their literature review, and had been rejected from the main study for the same reasons as many others. They explained:

“From an epidemiological point of view, and due to random fluctuations, studies with less than 10 study cases are of very limited value. But when looking for differential diagnoses, one single case is sufficient to question the general assumption that when the triad is present the infant must have been violently shaken.”

The original study had addressed the question:

With what certainty can it be claimed that the triad, subdural hematoma, retinal hemorrhages and encephalopathy, is attributable to isolated traumatic shaking (i.e. when no external signs of trauma are present)?

The Acta Paediatrica treatment articulated the answer in two, subtly different conclusions. First:

“[T]here is insufficient scientific evidence on which to assess the diagnostic accuracy of the triad in identifying traumatic shaking (very low-quality evidence).”

That is, the literature supporting the opinion that the presence of the triad proves a child was shaken is “insufficient,” because none of the papers supporting that opinion ranked above “very low-quality.” Second:

“[T]here is limited scientific evidence that the triad and therefore its components can be associated with traumatic shaking (low-quality evidence).”

That is, the researchers found some low-quality papers supporting the opinion that traumatic shaking causes the triad—two French papers based on confessions—but no medium- or high-quality papers. Before reaching their conclusions, the authors had read and evaluated 1,000 academic papers, only 30 of which met their inclusion criteria. They ranked 28 of those 30 papers as having a “high risk of bias,” 2 of them as having a “moderate risk,” and none of them as having a “low risk” of bias (a flow chart illustrating the literature search).

In an over-reaching answer to their many critics, the Lynøe team called for a more scientific approach to research in the arena:

“We acknowledge the concerns expressed by all of the authors who responded with regard to child welfare and the possibility that the diagnoses may be delayed in individual cases of child abuse. However, we are very troubled by the disregard displayed by those authors to the significant methodological problems inherent in published research on shaken baby syndrome. With the exception of Ludvigsson, none of these authors expressed concern about the problems of circular reasoning, lack of comparison groups or the other methodological problems we identified in the systematic review. Where has all the critical thinking in research gone?…

“The purpose of a systematic review is to examine the quality of published research. With that in mind, please accept the substantial difficulties and limitations of previous research carried out by the ‘shaken baby syndrome’ and ‘abusive head trauma’ and help to add true knowledge by performing better research that overcomes the methodological problems.”

copyright 2017, Sue Luttner

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

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Filed under AHT, shaken baby syndrome, Uncategorized

Swedish Review Declares Shaken Baby Theory Unproven

sbuheaderSwedish agency charged with assessing health technology and social services has published a review of the shaken baby literature declaring the scientific evidence for shaking theory “weak” and noting that a number of other medical conditions can cause the findings typically used to diagnose shaking injury.

The posted report from the SBU (Statens Feredning för Medicinsk Och Social Utvärdering) is in Swedish, so I am relying on a Google translation and private email exchanges with native Swedish speakers for this summary.

Feb. 2017 update: The report is now available in English

babySilhouetteThe SBU team looked only at cases of pure shaking, without evidence of impact, in children younger than 12 months, and they set standards regarding sample size, study design, and more.  Their literature search strategies yielded 3,773 abstracts, and they screened 1,065 of the articles in full text. Only 30 of the papers met their reliability guidelines. The authors ranked two of those papers as medium quality, designating 28 of them low quality and none of them high quality.

The report identifies the recurring problems with the published research, especially the circular reasoning introduced when shaken infants are identified by the criteria being studied. The two papers that passed the quality review are both from France, Vinchon 2010 and Adamsbaum 2010:

  • Vinchon M, de Foort­Dhellemmes S, Desurmont M, Delestret I. “Confessed abuse versus witnessed accidents in infants: comparison of clinical, radiological, and ophthalmological data in corroborated cases.” Childs Nerv Syst 2010;26:637­45
  • Adamsbaum C, Grabar S, Mejean N, Rey­Salmon C. “Abusive head trauma: judicial admissions highlight violent and repetitive shaking.” Pediatrics 2010;126:546­55

Both papers used confessions to identify abused children—the report noted that neither paper provided details of the circumstances in which the confessions were obtained.

The SBU report follows a Swedish Supreme Court decision last year that overturned the conviction of a father with the observation (from the English translation of the decision):

It can be concluded that, in general terms, the scientific evidence for the diagnosis of violent shaking has turned out to be uncertain.

This week’s report, which confirms the court’s conclusion, has made a splash in the Swedish press, with headlines like “Shaky support [skakig bevisning] för shaken-baby-syndrome.” Google translates the introductory paragraph of that piece as:

The diagnosis of “shaken baby syndrome” has previously been questioned both medically and legally. Now comes the SBU and Smers investigative report argues that the evidence of [shaking violence] not measure up.

Mats Hellberg, a board member of the Swedish group RFFR (Riksförbundet För Famijers Råttigheter, or National Association for the Rights of Families), reports that the Swedish child protection teams are objecting that the SBU’s conclusions will make it harder for them to protect children in the future. “Positions are extremely polarized and group thinking is strong,” he wrote.

In addition to criticizing the existing literature, the report suggests the kinds of research that would help resolve the ongoing debate about shaking theory. I hope the SBU analysis, which I’m told is now being translated into English, will trigger more reflection, more rigorous research, and more clear thinking about shaken baby theory.

Oct. 29 update:  With thanks to readers who alerted me:  The American Academy of Pediatrics (AAP), the Society for Pediatric Radiology, and a number of other professional organizations approached the SBU earlier this month, asking for input on the final report before it was published. These letters were published in the Swedish periodical Expressen, which presented them as an attempt to interfere with the independent Swedish review. There is a translation tool at the top of their on-line treatment, which includes close-ups on the letters in the photo collection. An excerpt from the AAP letter:

“Medical and biomechanical research, clinical and pathologic experience, and radiologic evidence have confirmed the understanding of the range of mechanism that contribute to brain injury from these forms of abuse.

“Because a report from the SBU could have global medical, public health, and legal ramifications, we respectfully request that you allow international peer review by AAP experts on child abuse, pediatric radiology, neurological surgery, and that you consider their feedback in the final report. In addition, we request that you promptly provide us with the draft report so that we can evaluate your  methods, sources, conclusions, and review processes and prepare a timely response if appropriate.”

I think it’s fair to assume the AAP is now working on a rebuttal.

If you are unfamiliar with the debate about shaken baby syndrome, please see the home page of this blog.

copyright 2016, Sue Luttner

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Filed under abusive head trauma, AHT, SBS, shaken baby, shaken baby syndrome