BMJ -Shaken Baby - Subdural and retinal haemorrhages are not necessarily signs of abuse

March 26, 2004

http://bmj.bmjjournals.com/cgi/content/full/328/7442/767

BMJ 2004;328:767 (27 March), doi:10.1136/bmj.328.7442.767

Letter

Patterns of presentation of the shaken baby syndrome

Subdural and retinal haemorrhages are not necessarily signs of abuse

EDITOR—The " serious data gaps, flaws of logic, and inconsistency of case

definition " shown up by the evidence based case report of the shaken baby

syndrome (p 754) and highlighted in the accompanying editorials (pp 719 and

720) will be of interest to the many parents who over the past 10 years

have maintained that they have been wrongly accused and convicted of

causing their children's injuries.1-3

Furthermore, the recent evidence emphasised by Geddes and Plunkett that

trivial falls and other minor injuries can give rise to the allegedly

characteristic signs of subdural and retinal haemorrhages is consistent

with a triad of possible alternative explanations for shaken baby syndrome.

This triad has emerged from an analysis of 98 parental accounts reported to

the support group the Five Percenters, each of the three being compatible

with a distinct type of neuropathology.

The first is minor trauma (37% of cases). This group gives a history of

minor trauma (such as a fall from a bed or sofa) with either immediate loss

of consciousness or delayed presentation of an acute subdural bleed and

retinal haemorrhages. This is in line with the recently reported series

from the United States of independently witnessed minor falls resulting in

an acute intracranial bleed, the retinal haemorrhages being caused by a

sudden rise in retinal venous pressure as in Terson's syndrome.4

The second is birth injury (29% of cases). The clinical presentation in the

second group is quite different. There is a general period of variable

length of non-specific symptoms such as vomiting and lethargy warranting

repeated medical consultations until computed tomography shows the presence

of a chronic subdural haemorrhage. The most likely aetiology is a subdural

bleed at birth, which, though usually associated with prematurity or a

difficult labour, can follow a normal delivery.5

The third is respiratory arrest (22% of cases). In this group the

precipitating event is suggestive of respiratory arrest—often followed by

attempts at resuscitation—that could result in the subdural and retinal

haemorrhages characteristic of hypoxic encephalopathy. The findings that

severe traumatic brain damage is not, as previously thought, present in

these cases contradicts the assumption that such injuries could only have

been induced by violent shaking.6

A fourth type of presentation, epileptiform seizures (12%) is presumably

secondary to underlying intracranial disease—and is thus uninformative

about possible aetiology.

These three patterns of clinical events—in the absence of other

circumstantial evidence for non-accidental injury—offer a more credible

explanation than shaken baby syndrome for the presence of subdural and

retinal haemorrhages. It should be noted that shaking has never been

directly observed or proved to cause such injuries but is rather an

inference based on (contested) theories of biomechanics.7 By contrast,

consistent parental testimony tallies with descriptions from independent

witnesses. Furthermore, each pattern of clinical events is consistent with

a distinctive type of neuropathology of acute subdural, chronic subdural,

or the thin subdurals of hypoxic encephalopathy.

While we recognise the limitations of the volunteered parental testimony on

which this analysis is based, the same triad of presentations—designated as

acute encephalopathic, idiopathic subdural, and hyperacute presentation—has

also been independently identified from an extended database of cases of

suspected non-accidental injury (see previous letter).8 These findings

necessarily raise disturbing questions about the validity of the opinions

expressed by medical experts in the courts. They warrant further, urgent,

and appropriate scientific investigation.

LeFanu, general practitioner

Mawbey Brough Health Centre, London SW8 2UD

Rioch -Brown, director

The Five Percenters, PO Box 23212, London SE14 5WB sbs5@...

----------------------------------------------------------------------------

----

Competing interests: JLeF—none declared. RE-B is director of a voluntary

organisation providing advice, information, and support to parents who

state that they have been wrongly accused of shaken baby syndrome. Neither

she nor any individual in the organisation has any financial competing

interests.

References

Lantz PE, Sinal SH, Stanton CA, Weaver RG Jr. Perimacular retinal folds

from childhood head trauma. BMJ 2004;328: 754-6. (27 March.)[Free Full Text]

Geddes JF, Plunkett J. The evidence base for the shaken baby syndrome. BMJ

2004;328: 719-20. (27 March.)[Free Full Text]

Harding B, Risdon RA, Krous HF. Shaken baby syndrome. BMJ 2004;328: 720-1.

(27 March.)[Free Full Text]

Plunkett J. Fatal pediatric head injuries caused by short-distance falls.

Am J Forensic Med Pathol 2001;22: 1-12.[CrossRef][iSI][Medline]

Towner D, Castro M, Eby-Wilkins E, Gilbert W. Effect of mode of delivery in

nulliparous women on neonatal intracranial injury. N Engl J Med 1999;341:

1709-14.[Abstract/Free Full Text]

Geddes J, Tasker R, Hackshaw A, Nickols C, G, Whitwell H, Schenberg

J. Dural haemorrhage in non-traumatic infant deaths. Does it explain the

bleeding in " shaken baby syndrome? " Neuropathol Appl Neurobiol 2003;29:

14-22.[CrossRef][iSI][Medline]

Ommaya AK, Goldsmith W, Thibault L. Biomechanics and neuropathology of

adult and paediatric head injury. Br J Neurosurg 2002;16:

220-42.[CrossRef][iSI][Medline]

Minns RA, Busuttil A. Patterns of presentation of shaken baby syndrome.

Electronic response to: Brain haemorrhage in babies may not indicate

violent abuse. bmj.com 2003. bmj.com/cgi/eletters/326/7390/616a (accessed

17 July 2003).

--------------------------------------------------------

Sheri Nakken, R.N., MA, Classical Homeopath

Vaccination Information & Choice Network, Nevada City CA & Wales UK

$$ Donations to help in the work - accepted by Paypal account

vaccineinfo@... voicemail US 530-740-0561

(go to http://www.paypal.com) or by mail

Vaccines - http://www.nccn.net/~wwithin/vaccine.htm

Vaccine Dangers On-Line course - http://www.nccn.net/~wwithin/vaccineclass.htm

Homeopathy On-Line course - http://www.nccn.net/~wwithin/homeo.htm

ANY INFO OBTAINED HERE NOT TO BE CONSTRUED AS MEDICAL

OR LEGAL ADVICE. THE DECISION TO VACCINATE IS YOURS AND YOURS ALONE.

******

" Just look at us. Everything is backwards; everything is upside down.

Doctors destroy health, lawyers destroy justice, universities destroy

knowledge, governments destroy freedom, the major media destroy information

and religions destroy spirituality " .... Ellner

April 6, 2007

>

> From: Sheri Nakken <vaccineinfo@...>

> Date: 2005/01/19 Wed PM 07:34:37 GMT

> carflo54@...

> Subject: BMJ -Shaken Baby - Subdural and retinal haemorrhages are not

> necessarily signs of abuse

>

> http://bmj.bmjjournals.com/cgi/content/full/328/7442/767

>

> BMJ 2004;328:767 (27 March), doi:10.1136/bmj.328.7442.767

>

> Letter

>

> Patterns of presentation of the shaken baby syndrome

> Subdural and retinal haemorrhages are not necessarily signs of abuse

>

> EDITOR—The " serious data gaps, flaws of logic, and inconsistency of case

> definition " shown up by the evidence based case report of the shaken baby

> syndrome (p 754) and highlighted in the accompanying editorials (pp 719 and

> 720) will be of interest to the many parents who over the past 10 years

> have maintained that they have been wrongly accused and convicted of

> causing their children's injuries.1-3

>

> Furthermore, the recent evidence emphasised by Geddes and Plunkett that

> trivial falls and other minor injuries can give rise to the allegedly

> characteristic signs of subdural and retinal haemorrhages is consistent

> with a triad of possible alternative explanations for shaken baby syndrome.

> This triad has emerged from an analysis of 98 parental accounts reported to

> the support group the Five Percenters, each of the three being compatible

> with a distinct type of neuropathology.

>

> The first is minor trauma (37% of cases). This group gives a history of

> minor trauma (such as a fall from a bed or sofa) with either immediate loss

> of consciousness or delayed presentation of an acute subdural bleed and

> retinal haemorrhages. This is in line with the recently reported series

> from the United States of independently witnessed minor falls resulting in

> an acute intracranial bleed, the retinal haemorrhages being caused by a

> sudden rise in retinal venous pressure as in Terson's syndrome.4

>

> The second is birth injury (29% of cases). The clinical presentation in the

> second group is quite different. There is a general period of variable

> length of non-specific symptoms such as vomiting and lethargy warranting

> repeated medical consultations until computed tomography shows the presence

> of a chronic subdural haemorrhage. The most likely aetiology is a subdural

> bleed at birth, which, though usually associated with prematurity or a

> difficult labour, can follow a normal delivery.5

>

> The third is respiratory arrest (22% of cases). In this group the

> precipitating event is suggestive of respiratory arrest—often followed by

> attempts at resuscitation—that could result in the subdural and retinal

> haemorrhages characteristic of hypoxic encephalopathy. The findings that

> severe traumatic brain damage is not, as previously thought, present in

> these cases contradicts the assumption that such injuries could only have

> been induced by violent shaking.6

>

> A fourth type of presentation, epileptiform seizures (12%) is presumably

> secondary to underlying intracranial disease—and is thus uninformative

> about possible aetiology.

>

> These three patterns of clinical events—in the absence of other

> circumstantial evidence for non-accidental injury—offer a more credible

> explanation than shaken baby syndrome for the presence of subdural and

> retinal haemorrhages. It should be noted that shaking has never been

> directly observed or proved to cause such injuries but is rather an

> inference based on (contested) theories of biomechanics.7 By contrast,

> consistent parental testimony tallies with descriptions from independent

> witnesses. Furthermore, each pattern of clinical events is consistent with

> a distinctive type of neuropathology of acute subdural, chronic subdural,

> or the thin subdurals of hypoxic encephalopathy.

>

> While we recognise the limitations of the volunteered parental testimony on

> which this analysis is based, the same triad of presentations—designated as

> acute encephalopathic, idiopathic subdural, and hyperacute presentation—has

> also been independently identified from an extended database of cases of

> suspected non-accidental injury (see previous letter).8 These findings

> necessarily raise disturbing questions about the validity of the opinions

> expressed by medical experts in the courts. They warrant further, urgent,

> and appropriate scientific investigation.

>

> LeFanu, general practitioner

>

> Mawbey Brough Health Centre, London SW8 2UD

>

> Rioch -Brown, director

>

> The Five Percenters, PO Box 23212, London SE14 5WB sbs5@...

>

> ----------------------------------------------------------------------------

> ----

> Competing interests: JLeF—none declared. RE-B is director of a voluntary

> organisation providing advice, information, and support to parents who

> state that they have been wrongly accused of shaken baby syndrome. Neither

> she nor any individual in the organisation has any financial competing

> interests.

> References

>

> Lantz PE, Sinal SH, Stanton CA, Weaver RG Jr. Perimacular retinal folds

> from childhood head trauma. BMJ 2004;328: 754-6. (27 March.)[Free Full

Text]

> Geddes JF, Plunkett J. The evidence base for the shaken baby syndrome. BMJ

> 2004;328: 719-20. (27 March.)[Free Full Text]

> Harding B, Risdon RA, Krous HF. Shaken baby syndrome. BMJ 2004;328: 720-1.

> (27 March.)[Free Full Text]

> Plunkett J. Fatal pediatric head injuries caused by short-distance falls.

> Am J Forensic Med Pathol 2001;22: 1-12.[CrossRef][iSI][Medline]

> Towner D, Castro M, Eby-Wilkins E, Gilbert W. Effect of mode of delivery in

> nulliparous women on neonatal intracranial injury. N Engl J Med 1999;341:

> 1709-14.[Abstract/Free Full Text]

> Geddes J, Tasker R, Hackshaw A, Nickols C, G, Whitwell H, Schenberg

> J. Dural haemorrhage in non-traumatic infant deaths. Does it explain the

> bleeding in " shaken baby syndrome? " Neuropathol Appl Neurobiol 2003;29:

> 14-22.[CrossRef][iSI][Medline]

> Ommaya AK, Goldsmith W, Thibault L. Biomechanics and neuropathology of

> adult and paediatric head injury. Br J Neurosurg 2002;16:

> 220-42.[CrossRef][iSI][Medline]

> Minns RA, Busuttil A. Patterns of presentation of shaken baby syndrome.

> Electronic response to: Brain haemorrhage in babies may not indicate

> violent abuse. bmj.com 2003. bmj.com/cgi/eletters/326/7390/616a (accessed

> 17 July 2003).

>

> --------------------------------------------------------

> Sheri Nakken, R.N., MA, Classical Homeopath

> Vaccination Information & Choice Network, Nevada City CA & Wales UK

> $$ Donations to help in the work - accepted by Paypal account

> vaccineinfo@... voicemail US 530-740-0561

> (go to http://www.paypal.com) or by mail

> Vaccines - http://www.nccn.net/~wwithin/vaccine.htm

> Vaccine Dangers On-Line course -

http://www.nccn.net/~wwithin/vaccineclass.htm

> Homeopathy On-Line course - http://www.nccn.net/~wwithin/homeo.htm

> ANY INFO OBTAINED HERE NOT TO BE CONSTRUED AS MEDICAL

> OR LEGAL ADVICE. THE DECISION TO VACCINATE IS YOURS AND YOURS ALONE.

>

> ******

> " Just look at us. Everything is backwards; everything is upside down.

> Doctors destroy health, lawyers destroy justice, universities destroy

> knowledge, governments destroy freedom, the major media destroy information

> and religions destroy spirituality " .... Ellner

>

> --------------------------------------------------------

> Sheri Nakken, R.N., MA, Classical Homeopath

> Vaccination Information & Choice Network, Nevada City CA & Wales UK

> $$ Donations to help in the work - accepted by Paypal account

> vaccineinfo@... voicemail US 530-740-0561

> (go to http://www.paypal.com) or by mail

> Vaccines - http://www.nccn.net/~wwithin/vaccine.htm

> Vaccine Dangers On-Line course -

http://www.nccn.net/~wwithin/vaccineclass.htm

> Homeopathy On-Line course - http://www.nccn.net/~wwithin/homeo.htm

> ANY INFO OBTAINED HERE NOT TO BE CONSTRUED AS MEDICAL

> OR LEGAL ADVICE. THE DECISION TO VACCINATE IS YOURS AND YOURS ALONE.

> ******

> " Just look at us. Everything is backwards; everything is upside down.

> Doctors destroy health, lawyers destroy justice, universities destroy

> knowledge, governments destroy freedom, the major media destroy information

> and religions destroy spirituality " .... Ellner

>

--------------------------------------------------------

Sheri Nakken, R.N., MA, Hahnemannian Homeopath

Vaccination Information & Choice Network, Nevada City CA & Wales UK

$$ Donations to help in the work - accepted by Paypal account

earthmysteriestours@... voicemail US 530-740-0561

(go to http://www.paypal.com) or by mail

Vaccines - http://www.nccn.net/~wwithin/vaccine.htm

Vaccine Dangers On-Line course - http://www.nccn.net/~wwithin/vaccineclass.htm

Reality of the Diseases & Treatment -

http://www.nccn.net/~wwithin/vaccineclass.htm

Homeopathy On-Line course - http://www.nccn.net/~wwithin/homeo.htm

November 27, 2008