Pseudo-controversies in Pseudo-controversies in Abusive Head TraumaAbusive Head Trauma

John E. Wright, MD, FAAPJohn E. Wright, MD, FAAP

Medical Director, Medical Director,

Broward County Child Protection Broward County Child Protection teamteam

EpidemiologyEpidemiology

The incidence of inflicted head The incidence of inflicted head trauma during the first or second trauma during the first or second years of life has been estimated in years of life has been estimated in various studies to range from 16.1 to various studies to range from 16.1 to 33.8 cases/100,000 infants/y33.8 cases/100,000 infants/y

Abusive head trauma appears to be Abusive head trauma appears to be the leading cause of infant homicide the leading cause of infant homicide in the United States. in the United States.

Epidemiology, (cont.)Epidemiology, (cont.)

The incidence of traumatic brain The incidence of traumatic brain injury and/or fracture due to abuse injury and/or fracture due to abuse was 21.9/100,000 in children less was 21.9/100,000 in children less than 36m and 50.0/100,000 in than 36m and 50.0/100,000 in children less than 12m. children less than 12m.

Broward County, FLBroward County, FL

109,060 total population under age 4109,060 total population under age 4 452,754 total population under 19.452,754 total population under 19. State Child Protection System, Local State Child Protection System, Local

system administered by Sheriff’s system administered by Sheriff’s Office with expert consultation by Office with expert consultation by CPT for mandatory referrals. CPT for mandatory referrals.

Personal intro

Practicing pediatrics in Fort Lauderdale since 1987.

First saw child abuse in training at U of M

Serves as medical director of Broward CPT from 1989 to 1991 and 1999 to present

Described “abusive head crushing”

Commonality Factors In Safety and Risk Assessments for Commonality Factors In Safety and Risk Assessments for

Reports with FindingsReports with Findings

Safety Factors Safety Factors in Verified and in Verified and

indicated indicated reportsreports

AGE <= 4AGE <= 4Increased Increased VulnerabilitVulnerabilit

yy

Dom. Dom. Violence Violence

Hist.Hist.

Criminal Criminal HistoryHistory

Mental Mental Health / Health / Drugs Drugs

Prior Prior ReportReport

ss

Pattern Pattern of of

IncidentIncidentss

Unrelated Unrelated visitor / or visitor / or

biologically biologically unrelated unrelated person in person in householdhousehold

Percentage:Percentage: 3131 1515 4848 5050 1313 7373 4949 2525

Economic drivers of junk Economic drivers of junk sciencescience

Individual cases are unique, but not Individual cases are unique, but not generally without precedentgenerally without precedent

Data collection is time sensitiveData collection is time sensitive Input from multiple sources some with Input from multiple sources some with

agendaeagendae System reacts to case: System reacts to case:

Civil system of child protectionCivil system of child protection Criminal system of prosecution of perpCriminal system of prosecution of perp

Information is filtered and re-presented in an Information is filtered and re-presented in an illogical fashionillogical fashion

Economic drivers of junk Economic drivers of junk science in the courtroomscience in the courtroom

Systemic response is cumbersom and Systemic response is cumbersom and susceptible to sabotage at multiple stepssusceptible to sabotage at multiple steps

Alternative hypothesis are not subjected to Alternative hypothesis are not subjected to any testing or reasonable filters of medical any testing or reasonable filters of medical knowledge. Their intention is to raise knowledge. Their intention is to raise confusion and doubt. confusion and doubt.

Courtroom diagnoses are profferedCourtroom diagnoses are proffered A variety of logical errors are exploited in A variety of logical errors are exploited in

the theatrical conflagration that ensuesthe theatrical conflagration that ensues The media loves it: free entertainment. The media loves it: free entertainment.

Alternative hypothesis themes Alternative hypothesis themes (in no particular order)(in no particular order)

BiomechanicalBiomechanical Same “expert” will state that there’s not Same “expert” will state that there’s not

enough force and that the findings could be enough force and that the findings could be cause by minimum trauma. cause by minimum trauma.

Blame the victim: it’s not traumaBlame the victim: it’s not trauma Coagulopathy, connective tissue defect, Coagulopathy, connective tissue defect,

temporary brittle baby, temporary brittle baby,

Blame the environmentBlame the environment vitamin/nutrient deficiency, environmental vitamin/nutrient deficiency, environmental

toxintoxin

Alternative hypothesis (cont.)Alternative hypothesis (cont.)

Any test not ordered in the acute phase.Any test not ordered in the acute phase. CPR/resuscitation effortsCPR/resuscitation efforts SeizureSeizure InfectionInfection Older injuryOlder injury Birth traumaBirth trauma Spontaneous xSpontaneous x Arteriovenous malformationArteriovenous malformation

Irresponsible expert tricksIrresponsible expert tricks

Divide and conquerDivide and conquer Tease out a few abnormalities and pretend Tease out a few abnormalities and pretend

that they were causative rather than the that they were causative rather than the result of the head injuryresult of the head injury

You forgot to check…serum porcelain You forgot to check…serum porcelain levellevel

Find some obscure ill-defined case Find some obscure ill-defined case report from the medical literature that report from the medical literature that was probably in itself missed child was probably in itself missed child abuse. abuse.

Dealing with Irresponsible Dealing with Irresponsible Expert TestimonyExpert Testimony

Question to the visiting expert: What Information Question to the visiting expert: What Information regarding this case have you brought with you regarding this case have you brought with you from wherever?from wherever?

Examine writings/written opinions/previous Examine writings/written opinions/previous testimony.testimony. John Plunkett, MD John Plunkett, MD Sudden Death in an Infant Caused by Rupture of a Basilar Artery Sudden Death in an Infant Caused by Rupture of a Basilar Artery

Aneurysm, Am J. Forensic Medicine and Pathology, 20(2):211-214, 1999.Aneurysm, Am J. Forensic Medicine and Pathology, 20(2):211-214, 1999.

Cites in abstract that morphologic findings of ruptured Cites in abstract that morphologic findings of ruptured aneurysm include retinal hemorrhage.aneurysm include retinal hemorrhage.

In case report notes: The eyes were not examined.In case report notes: The eyes were not examined.

Carl Sagan’s Baloney Detection Carl Sagan’s Baloney Detection KitKit

Ad nominem attackAd nominem attack Argument from authorityArgument from authority Argument from adverse Argument from adverse

consequencesconsequences Appeal to ignoranceAppeal to ignorance Special pleadingSpecial pleading Begging the questionBegging the question Observational selectionObservational selection Suppressed evidenceSuppressed evidence Weasel wordsWeasel words

Statistics of small numbersStatistics of small numbers InconsistencyInconsistency Non sequiturNon sequitur Post hoc, ergo propter hocPost hoc, ergo propter hoc Meaningless questionMeaningless question Excluded middle or false Excluded middle or false

dicotomydicotomy Slippery slopeSlippery slope Confusion of correlation Confusion of correlation

and causationand causation Straw manStraw man

7 warning signs of bogus 7 warning signs of bogus sciencescience

1. discoverer pitches 1. discoverer pitches the claim directly to the the claim directly to the mediamedia

2. discoverer says that 2. discoverer says that a powerful a powerful establishment is trying establishment is trying to suppress his/her to suppress his/her work.work.

3. The scientific effect 3. The scientific effect involved is always at the involved is always at the very limit of detectionvery limit of detection

4. evidence for a 4. evidence for a discovery is anecdotaldiscovery is anecdotal

5. discoverer says a 5. discoverer says a belief is credible belief is credible because it has because it has endured for endured for centuriescenturies

6. discoverer has 6. discoverer has worked in isolation.worked in isolation.

7. discoverer must 7. discoverer must propose new laws of propose new laws of nature to explain an nature to explain an observation observation

Mathematician, Mark KacMathematician, Mark Kac

““Proof: That which convinces a Proof: That which convinces a reasonable person.reasonable person.

Rigorous Proof: That which convinces Rigorous Proof: That which convinces an unreasonable person.”an unreasonable person.”

Legal standard of Proof: ?Legal standard of Proof: ?

Consilience: Scientific evidence Consilience: Scientific evidence is accretionaryis accretionary

““Interesting”Interesting” ““Suggestive”Suggestive” ““Persuasive”Persuasive” ““Compelling”Compelling” ““Obvious”Obvious”

““Interesting”Interesting”

Catherine Welch : April 10Catherine Welch : April 10thth 1828. 1828.

“ “ I am a surgeon and live at Fulham…theI am a surgeon and live at Fulham…the

Eyes were a good deal suffused withEyes were a good deal suffused with

blood…I opened the body after theblood…I opened the body after the

inquisition, the internal parts were perfectlyinquisition, the internal parts were perfectly

healthy, except the vessels of the brain andhealthy, except the vessels of the brain and

lungs, being overloaded with blood.”lungs, being overloaded with blood.”

Interesting/suggestiveInteresting/suggestive

“ “ I asked my husband what he had I asked my husband what he had done and he said he had taken the done and he said he had taken the baby by the shoulders and must have baby by the shoulders and must have shaken it too much…”shaken it too much…”

Ethel Muckle, a neighbour said when Ethel Muckle, a neighbour said when sheshe

asked Strand what he had done he said asked Strand what he had done he said “… “… I only shook the baby…”I only shook the baby…”

““Suggestive/compelling”Suggestive/compelling”

NYT 1937NYT 1937

Joseph MOLINARIJoseph MOLINARI

ProsecutorProsecutor

Boyfriend confessesBoyfriend confesses

he shook to death a he shook to death a 1515

month old babymonth old baby

because “it bit me”because “it bit me”

SuggestiveSuggestive

Dr. John Caffey, Multiple Fractures in the long bones Dr. John Caffey, Multiple Fractures in the long bones of infants suffering from chronic subdural of infants suffering from chronic subdural hematoma, American Journal of Roentgenology, hematoma, American Journal of Roentgenology, 1946.1946. Dr. Caffey described 6 cases of his own and 6 cases that Dr. Caffey described 6 cases of his own and 6 cases that

had been reported to him by other physicians. had been reported to him by other physicians. ““In each case the unexplained fresh fracture appeared In each case the unexplained fresh fracture appeared

shortly after the patient had arrived home from the shortly after the patient had arrived home from the hospital. In one case the infant was clearly unwanted by hospital. In one case the infant was clearly unwanted by both parents and this raised the question on intentional both parents and this raised the question on intentional ill-treatment.” ill-treatment.”

Virginia JaspersVirginia Jaspers August 23August 23rdrd 1956 1956

shook 11 day old shook 11 day old Abbey Kasparov to Abbey Kasparov to death.death.

Killed three children in Killed three children in her care in New her care in New Haven, USA.Haven, USA.

Said that she had to Said that she had to shake the children, shake the children, to‘bring the bubble to‘bring the bubble upup’.’.

Compelling/persuasiveCompelling/persuasive

Guthkelch, Infantile Subdural Haematoma and its Guthkelch, Infantile Subdural Haematoma and its Relationship to Whiplash Injuries, BMJ 1971Relationship to Whiplash Injuries, BMJ 1971

““One must keep in mind the possibility One must keep in mind the possibility of assault in considering any case of of assault in considering any case of infantile subdural haematoma, even infantile subdural haematoma, even when there are only trivial bruises or when there are only trivial bruises or indeed no marks of injury at all, and indeed no marks of injury at all, and inquire, however guardedly or inquire, however guardedly or tactfully, whether perhaps the baby’s tactfully, whether perhaps the baby’s head could have been shaken.”head could have been shaken.”

On the Theory and Practice of On the Theory and Practice of Shaking Infants: AJDC, 1972Shaking Infants: AJDC, 1972

““During the last 25 years substantial During the last 25 years substantial evidence both manifest and evidence both manifest and circumstantial, has gradually circumstantial, has gradually accumulated which suggests that the accumulated which suggests that the whiplash-shaking and jerking of abused whiplash-shaking and jerking of abused infants are common causes of the infants are common causes of the skeletal as well as the cerebrovascular skeletal as well as the cerebrovascular lesions; the latter is the most serious lesions; the latter is the most serious acute complication and by far the most acute complication and by far the most common cause of early death.”common cause of early death.”

Abusive Head InjuriesAbusive Head Injuries

Subdural hemorrhageSubdural hemorrhage Retinal hemorrhageRetinal hemorrhage Brain injury (diffuse axonal injury)Brain injury (diffuse axonal injury) Secondary effects (include):Secondary effects (include):

seizures, seizures, hypoxic-ischemic, hypoxic-ischemic, toxic metabolytes, toxic metabolytes, SwellingSwelling CoagulopathyCoagulopathy Loss of autoregulationLoss of autoregulation

Duhaime, et alDuhaime, et al

Described 48 cases at CHOP between Described 48 cases at CHOP between 1978 and 1985. Autopsy findings of 1978 and 1985. Autopsy findings of 13 fatalities: all fatal cases had signs 13 fatalities: all fatal cases had signs of blunt impact to the head. In half of blunt impact to the head. In half of these impact site found only on of these impact site found only on autopsy.autopsy.

All deaths assoc. with uncontrolled All deaths assoc. with uncontrolled increased intracranial pressure. increased intracranial pressure. Small subdural collections.Small subdural collections.

Duhaime et al.Duhaime et al.

Part 2 of her NEJM article used a Part 2 of her NEJM article used a model with a single velocity model with a single velocity transducer and measured peak transducer and measured peak change in velocity in shaking vs. change in velocity in shaking vs. impact (g force). Suggesting that impact (g force). Suggesting that shaking alone was not sufficient to shaking alone was not sufficient to cause brain injury. She cited:cause brain injury. She cited:

Thibault and Gennarelli: Thibault and Gennarelli: Biomechanics of diffuse brain Biomechanics of diffuse brain injuries, Proceedings of the injuries, Proceedings of the Fourth Experimental Safety Vehicle Fourth Experimental Safety Vehicle Conference. New York: Am Assoc. of Conference. New York: Am Assoc. of Automotive Engineers, 1985.Automotive Engineers, 1985. Cited by Duhaime et al as basis for Cited by Duhaime et al as basis for

biomechanical thresholds.biomechanical thresholds. Used adult monkeys (rhesus, Used adult monkeys (rhesus,

More recent biomed studies.

More recent biomedical More recent biomedical analysesanalyses

Computer model (2 dimentional model of an Computer model (2 dimentional model of an axial skull and brain slice subjected to two axial skull and brain slice subjected to two seconds of four cycles/sec shaking):seconds of four cycles/sec shaking):

produced brain strains sufficient to produce produced brain strains sufficient to produce traumatic axonal injury in the corpus calosum traumatic axonal injury in the corpus calosum and cerebral pedicles, cingulate gyrus, and cerebral pedicles, cingulate gyrus, inferior frontal lobe, and inferior occipital lobe inferior frontal lobe, and inferior occipital lobe and most bridging veins developed sufficient and most bridging veins developed sufficient skull/brain displacement to predict vein skull/brain displacement to predict vein rupture.rupture.

pp

AHT: Shaking and/or Impact?AHT: Shaking and/or Impact?

Shaking can causeShaking can cause Retinal hemorrhageRetinal hemorrhage Hemorrhage outside of Hemorrhage outside of

optic nerve sheathoptic nerve sheath Subdural hemorrhageSubdural hemorrhage DAIDAI Cerebral edemaCerebral edema deathdeath

Impact can causeImpact can cause Skull fracturesSkull fractures Subgaleal hemorrhageSubgaleal hemorrhage Visible bruises, Visible bruises,

abrasions, skin fxsabrasions, skin fxs Epidural hem.Epidural hem. Focal findingsFocal findings Coup/contracoupCoup/contracoup Cerebral edemaCerebral edema deathdeath

Shaken Adult SyndromeShaken Adult Syndrome Derrick J. Pounder, MB, MRC Path, American Derrick J. Pounder, MB, MRC Path, American

Journal of Forensic Medicine and Pathology, Journal of Forensic Medicine and Pathology, 18(4):321-24, 1997.18(4):321-24, 1997.

30 year old Palestinian collapsed under 30 year old Palestinian collapsed under interrogation by Israeli General Security Service, interrogation by Israeli General Security Service, declared brain dead 3 days later.declared brain dead 3 days later. Extensive anterior chest and shoulder bruises, acute Extensive anterior chest and shoulder bruises, acute

subdural hemorrhage, DAI, RH. Wt. 44.3kg, Ht151cmsubdural hemorrhage, DAI, RH. Wt. 44.3kg, Ht151cm All 3 pathologists agreed that the death was unnatural All 3 pathologists agreed that the death was unnatural

and the result of brain damage due to rotational and the result of brain damage due to rotational acceleration of the head without direct impact.acceleration of the head without direct impact.

Shaken Adult SyndromeShaken Adult Syndrome

Disclosed in court proceedings that Disclosed in court proceedings that interrogation began at 4:45 am and interrogation began at 4:45 am and continued until 4:10 pm. continued until 4:10 pm.

Shaken 12 times, 10x grabbed by Shaken 12 times, 10x grabbed by clothing 2x grabbed by shoulders.clothing 2x grabbed by shoulders.

““Collapsed with clouded Collapsed with clouded consciousness, mucous fluid came consciousness, mucous fluid came out of his nostrils and fluid came out of his nostrils and fluid came bubbling out of his mouth.”bubbling out of his mouth.”

MayaMaya

61/2 week old61/2 week old Last seen frisky and Last seen frisky and

healthy the night beforehealthy the night before Couldn’t lift head, 2 legs Couldn’t lift head, 2 legs

rigid, 3rigid, 3rdrd leg weak, leg weak, Couldn’t swallow or move Couldn’t swallow or move

tonguetongue Had been isolated in a Had been isolated in a

special pen with her 3 special pen with her 3 year old mother and year old mother and another mother and cubanother mother and cub

Maya, cont.Maya, cont.

MRI scan: Cerebral MRI scan: Cerebral edema, loss of gray/white edema, loss of gray/white matter differentiation, matter differentiation, increased signal on T2 increased signal on T2 weighted sequence. No weighted sequence. No significant mass effect. significant mass effect. Prognosis good.Prognosis good.

Clinical improvement; Clinical improvement; growling and batting at IV growling and batting at IV tubing by day #5.tubing by day #5.

Animal Models: Observations Animal Models: Observations of Natureof Nature

Nature films showing young male Nature films showing young male lions shaking lion cubs (mother’s new lions shaking lion cubs (mother’s new boyfriend)boyfriend)

The Functional Anatomy of the The Functional Anatomy of the WoodpeckerWoodpecker

Predator hunting behaviors involving Predator hunting behaviors involving shaking of smaller prey; canine, shaking of smaller prey; canine, feline. feline.

IRRESPONSIBLE MEDICAL IRRESPONSIBLE MEDICAL TESTIMONYTESTIMONY

Krous and Chadwick (1997) Krous and Chadwick (1997) described several features including:described several features including: Physicians without adequate background Physicians without adequate background

(e.g. training, don’t do research or see (e.g. training, don’t do research or see patients with regard to issue)patients with regard to issue)

Contrived or far-fetched theories of Contrived or far-fetched theories of causationcausation

Not reproducibleNot reproducible Selective use of the literatureSelective use of the literature

SHAKEN BABY SYNDROMESHAKEN BABY SYNDROME

Probably the diagnosis that brings Probably the diagnosis that brings out the most “junk science” in the out the most “junk science” in the courtcourt

Media:Media: Newspapers - usually do a pretty good Newspapers - usually do a pretty good

jobjob National television networks - awful to National television networks - awful to

mediocre to excellent (thanks CNN!)mediocre to excellent (thanks CNN!)

CPRCPR

Claim: causes rib fractures and Claim: causes rib fractures and retinal hemorrhagesretinal hemorrhages

Truth: Truth: Rib fractures do not occur in infants and Rib fractures do not occur in infants and

young children (they bend)young children (they bend) A few petechiae or spots in very rare A few petechiae or spots in very rare

cases of children with existing bleeding cases of children with existing bleeding tendencies (e.g. sepsis, DIC)tendencies (e.g. sepsis, DIC)

RESCUE SHAKINGRESCUE SHAKING

Claim: Shook to revive. Amateurs, Claim: Shook to revive. Amateurs, panicky.panicky.

Truth: Truth: Doesn’t happen in cases where reason Doesn’t happen in cases where reason

for revival is knownfor revival is known Not enough force, unless they are Not enough force, unless they are

claiming abuseclaiming abuse

SUBDURAL HEMORRHAGESSUBDURAL HEMORRHAGES

Claim: caused by trivial trauma or Claim: caused by trivial trauma or CPRCPR

Truth:Truth: Subdurals rarely seen with short falls - Subdurals rarely seen with short falls -

especially if no fractureespecially if no fracture CPR does not cause subduralsCPR does not cause subdurals

SBS IS NOT REALSBS IS NOT REAL

Claim: SBS is not real, it is all impact Claim: SBS is not real, it is all impact or something else.or something else.

SBS IS REALSBS IS REAL

Truth:Truth: Hundreds of articles in medical literatureHundreds of articles in medical literature 2 position papers by AAP2 position papers by AAP Statements by National Association of Statements by National Association of

Medical Examiners, Canadian Pediatric Medical Examiners, Canadian Pediatric SocietySociety

Statements by US Advisory Board on Child Statements by US Advisory Board on Child Abuse and NeglectAbuse and Neglect

NO statement to the contrary by any NO statement to the contrary by any major medical associationmajor medical association

SBS IS REALSBS IS REAL

Truth:Truth: ICD - 9 code for “shaken infant ICD - 9 code for “shaken infant

syndrome”syndrome” Over 600 participants at four USA SBS Over 600 participants at four USA SBS

conferencesconferences International conferences in Sydney, International conferences in Sydney,

Edinburgh – Montreal in Sept. 2004Edinburgh – Montreal in Sept. 2004

SBS IS REALSBS IS REAL

Starling S, et al. Analysis of Starling S, et al. Analysis of perpetrator admissions to inflicted perpetrator admissions to inflicted traumatic brain injury in children. traumatic brain injury in children. Archives of Pediatrics and Adolescent Archives of Pediatrics and Adolescent MedicineMedicine 158:454-458, 2004. 158:454-458, 2004.

SBS IS REALSBS IS REAL

Retrospective look at 81 cases of admitted Retrospective look at 81 cases of admitted brain injury to 90 cases of in which no brain injury to 90 cases of in which no abuse admission was madeabuse admission was made

68% of the confessed perpetrators said no 68% of the confessed perpetrators said no impact – only shakingimpact – only shaking

91% of the cases in which timing was 91% of the cases in which timing was described – symptoms were immediate. In described – symptoms were immediate. In 9% the timing was unclear. 9% the timing was unclear.

NONE were normal after the eventNONE were normal after the event

SBS IS REALSBS IS REAL

Conclusions:Conclusions:1.1. Symptoms are immediateSymptoms are immediate

2.2. Most perpetrators admit shaking Most perpetrators admit shaking without impactwithout impact

3.3. Relative lack of skull/scalp findings (vs. Relative lack of skull/scalp findings (vs. impact admitted cases) = shaking impact admitted cases) = shaking alone can produce the findings of SBSalone can produce the findings of SBS

CONTRARIANSCONTRARIANS

Statement in a highly publicized case – Statement in a highly publicized case – “more recently it has been shown that “more recently it has been shown that short falls can some times cause short falls can some times cause serious or fatal injuries”serious or fatal injuries”

Talk about the “new science”Talk about the “new science” YET – no data that really supports thisYET – no data that really supports this Example that some just do not want to Example that some just do not want to

see child abuse, especially with “nice” see child abuse, especially with “nice” peoplepeople

Dr. Ronald UzcinskiDr. Ronald Uzcinski

SBS not realSBS not real Can’t generate severe enough forcesCan’t generate severe enough forces F=ma “It’s all about physics”F=ma “It’s all about physics”

[View shared in part by Vincent [View shared in part by Vincent DeMaio, John Plunkett]DeMaio, John Plunkett]

Dr. Ronald UzcinskiDr. Ronald Uzcinski

In a recent Naples FL case he said In a recent Naples FL case he said that burping an infant can cause that burping an infant can cause bleeding in the headbleeding in the head

Also the infant straining with a bowel Also the infant straining with a bowel movementmovement

LANTZ ET AL. 2004LANTZ ET AL. 2004

Reported that a 40 pound TV falling Reported that a 40 pound TV falling on a month old caused perimacular on a month old caused perimacular foldsfolds

Prior to this, such folds seen only Prior to this, such folds seen only with shaken baby syndromewith shaken baby syndrome

Lantz PE, Sinal SH, Stanton CA, Weaver RG. Perimacular retinal folds Lantz PE, Sinal SH, Stanton CA, Weaver RG. Perimacular retinal folds from childhood head trauma. from childhood head trauma. BMJBMJ (2004) 328:754-756. (2004) 328:754-756.

LANTZ ET AL. 2004LANTZ ET AL. 2004

In an editorial in the BMJ, Geddes and In an editorial in the BMJ, Geddes and Plunkett extrapolated this to retinal Plunkett extrapolated this to retinal hemorrhages and said whole concept hemorrhages and said whole concept of SBS is untrueof SBS is untrue

Comment: Based on one Comment: Based on one controversial case of a TV crush controversial case of a TV crush injury?injury?

GEDDESGEDDES

Has published several articles showing Has published several articles showing deep brain damage with shakingdeep brain damage with shaking

Thinks secondary to hypoxiaThinks secondary to hypoxia Has Has speculatedspeculated that mild shaking that mild shaking

might cause more SBS than we thinkmight cause more SBS than we think Has claimed microscopic intradural Has claimed microscopic intradural

hemorrhages present in many hemorrhages present in many situations (most think of this as an situations (most think of this as an artifact – not the larger SDH of SBS)artifact – not the larger SDH of SBS)

GEDDESGEDDES

Why not same findings in drownings Why not same findings in drownings if hypoxia is the mechanism? What if hypoxia is the mechanism? What about retinal hemorrhages?about retinal hemorrhages?

While her speculation is seemingly While her speculation is seemingly opposite of others saying shaking not opposite of others saying shaking not enough to cause serious brain enough to cause serious brain damage, they seem to have no damage, they seem to have no problem disputing mainstream SBS problem disputing mainstream SBS wisdomwisdom

GEDDESGEDDES

Retracted her “hypothesis” in British Retracted her “hypothesis” in British courtcourt

But others still use itBut others still use it

Dr. Tom NakagowaDr. Tom Nakagowa

If f = ma, and a = gravity (a If f = ma, and a = gravity (a constant)constant)

Then f ~ mThen f ~ m Then bigger m leads to bigger fThen bigger m leads to bigger f The bigger you are, the harder you The bigger you are, the harder you

fallfall When adults fall off couches, they hit When adults fall off couches, they hit

the floor much harder.the floor much harder.

Dr. Tom NakagowaDr. Tom Nakagowa

Why do adults commit suicide by Why do adults commit suicide by jumping off of bridges/buildings – jumping off of bridges/buildings – when the couch or bed would do?when the couch or bed would do?

Geddes notion

Single shake models

Time (# of shakes)

Force

Human range

BIOMECHANICS OF SHAKING

KEY DAMAGE ISSUESKEY DAMAGE ISSUES

• It is the brain damage that causes It is the brain damage that causes serious injury or death. Not the serious injury or death. Not the secondary injuries of bleeding in the secondary injuries of bleeding in the retina or intracranial spacesretina or intracranial spaces

• Not a mass effect issueNot a mass effect issue• SBS brain injury is not superficial, but SBS brain injury is not superficial, but

involves deeper structures. (Pattern of involves deeper structures. (Pattern of atrophy in survivors is different than atrophy in survivors is different than seen with isolated contact injuries.)seen with isolated contact injuries.)

KEY DAMAGE ISSUESKEY DAMAGE ISSUES

Arguments against Arguments against mainstream opinion tend to mainstream opinion tend to focus on the secondary focus on the secondary injuries (especially SDH) and injuries (especially SDH) and lightly dismiss the brain lightly dismiss the brain injury and retinal injury and retinal hemorrhageshemorrhages

SHORT FALLS CAN KILLSHORT FALLS CAN KILL

Van EE and others (engineers, Van EE and others (engineers, physicists) do models and claim short physicists) do models and claim short falls can killfalls can kill

Truth:Truth: They do not apparently know or care They do not apparently know or care

about real world dataabout real world data

ACCIDENTAL FALLSACCIDENTAL FALLS

Claim: Short falls cause serious or Claim: Short falls cause serious or fatal injuries. SBS injuries look like fatal injuries. SBS injuries look like short fall injuries.short fall injuries.

Truth: Truth: Frequently the excuse Frequently the excuse Extensive review of fall studies does not Extensive review of fall studies does not

support serious injuries (e.g. Helfer et al, support serious injuries (e.g. Helfer et al, 1977; Chadwick et al, 1991; see 1977; Chadwick et al, 1991; see Alexander, Levitt, and Smith’s upcoming Alexander, Levitt, and Smith’s upcoming chapter).chapter).

ACCIDENTAL FALLS (CONT)ACCIDENTAL FALLS (CONT)

Experience shows that children are Experience shows that children are constantly having short falls without constantly having short falls without serious injuryserious injury

Like a single shakeLike a single shake Retinal hemorrhages almost never seen Retinal hemorrhages almost never seen

and should not be extensiveand should not be extensive Strong evidence of impactStrong evidence of impact

ACCIDENTAL FALLS (CONT)ACCIDENTAL FALLS (CONT)

About 1% of children falling 3 feet to a About 1% of children falling 3 feet to a hard surface will have a short fracture to hard surface will have a short fracture to the side of the headthe side of the head

They do not have significant brain injuryThey do not have significant brain injury

ACCIDENTAL FALLSACCIDENTAL FALLS

““Killer beds”, “killer couches”Killer beds”, “killer couches” Patterns of injury with accidental Patterns of injury with accidental

impacts do not look like SBSimpacts do not look like SBS

DUHAIME ET AL, 1987DUHAIME ET AL, 1987

Study found 13 dead SBS victims - all Study found 13 dead SBS victims - all had signs of head impacthad signs of head impact

Models and testing suggested that Models and testing suggested that shaking alone not sufficient to cause shaking alone not sufficient to cause serious injury or death serious injury or death

Forces are immenseForces are immense SBS cases should be called shaken-SBS cases should be called shaken-

impact syndromeimpact syndrome

DUHAIME ET AL, (CONT.)DUHAIME ET AL, (CONT.)

At least a dozen data-based studies At least a dozen data-based studies since then all have found shaking is since then all have found shaking is sufficient. No other study shows sufficient. No other study shows impact is necessary.impact is necessary.

Thus there is no controversy Thus there is no controversy It does not matter in court anyway - It does not matter in court anyway -

it is all violent abusive head traumait is all violent abusive head trauma

DUHAIME ET AL, (CONT.)DUHAIME ET AL, (CONT.)

Note: Duhaime says the forces are worse Note: Duhaime says the forces are worse than the most violent shakingthan the most violent shaking

Those who think shaking is sufficient also Those who think shaking is sufficient also believe in extreme forces being necessarybelieve in extreme forces being necessary

Thus the perpetrator was violently abusiveThus the perpetrator was violently abusive

Duhaime AC, Gennarelli TA, Thibault LE, Bruce BA, Margulies SS, Wiser Duhaime AC, Gennarelli TA, Thibault LE, Bruce BA, Margulies SS, Wiser R. The shaken baby syndrome. A clinical, pathological, R. The shaken baby syndrome. A clinical, pathological, biomechanical study. biomechanical study. J NeurosurgJ Neurosurg (1987) 66:309-15. (1987) 66:309-15.

RE-BLEEDSRE-BLEEDS

Claim: These cases have an old Claim: These cases have an old injury (timing is too uncertain to injury (timing is too uncertain to establish perpetrator) and a re-bleed establish perpetrator) and a re-bleed of the subdural causes new of the subdural causes new subdurals, retinal hemorrhages, and subdurals, retinal hemorrhages, and can be fatalcan be fatal

[Dr. Jan Leetsma often claims this, [Dr. Jan Leetsma often claims this, Plunkett and Uzcinski sometimes Plunkett and Uzcinski sometimes also]also]

RE-BLEEDSRE-BLEEDS

Truth:Truth: Any scab will ooze blood with small Any scab will ooze blood with small

trauma prior to complete healingtrauma prior to complete healing After several weeks of healing, a After several weeks of healing, a

subdural hematoma will form delicate subdural hematoma will form delicate new blood vesselsnew blood vessels

Minor head trauma can cause re-bleedMinor head trauma can cause re-bleed No associated retinal hemorrhages or No associated retinal hemorrhages or

cerebral edemacerebral edema

RE-BLEEDSRE-BLEEDS

Slow processSlow process Possibly expanding head sizePossibly expanding head size Increasing lethargyIncreasing lethargy Diminished appetite Diminished appetite

RE-BLEEDS VS. SBSRE-BLEEDS VS. SBS

Re-bleeds should not be sudden or fatalRe-bleeds should not be sudden or fatal SBS is primarily a brain injury, re-SBS is primarily a brain injury, re-

bleeds are notbleeds are not The presence of old injuries, new The presence of old injuries, new

intracranial bleeding, retinal intracranial bleeding, retinal hemorrhages,and clinical signs of brain hemorrhages,and clinical signs of brain injury = old and new SBSinjury = old and new SBS

Second shaking needs to be violent as Second shaking needs to be violent as wellwell

VACINNATIONSVACINNATIONS

Claim: DPT shot causes SBSClaim: DPT shot causes SBS [Vera Schribner – paleoarcheologist [Vera Schribner – paleoarcheologist

from Australia is active on the from Australia is active on the internet]internet]

Truth: No Truth: No No mechanism for thisNo mechanism for this No evidence for thisNo evidence for this

METABOLIC DISEASEMETABOLIC DISEASE

Claim: metabolic diseases mimic Claim: metabolic diseases mimic SBSSBS e.g. Glutaric aciduriae.g. Glutaric aciduria unspecified othersunspecified others

METABOLIC DISEASESMETABOLIC DISEASES

Truth: Truth: Name the metabolic conditionName the metabolic condition Bleeding diseases usually cause fatty Bleeding diseases usually cause fatty

liverslivers SBS is not a bleeding diseaseSBS is not a bleeding disease Metabolic diseases do not suddenly Metabolic diseases do not suddenly

appear and disappearappear and disappear

CHILD IS TOO OLD FOR SBSCHILD IS TOO OLD FOR SBS

Claim: SBS happens only to children Claim: SBS happens only to children under 1 or 2 years of ageunder 1 or 2 years of age

Truth:Truth: Most under 1 year, some between 1-2 Most under 1 year, some between 1-2

years, less 2 year olds, rare 3 or 4 year years, less 2 year olds, rare 3 or 4 year oldsolds

Physiologically can happen at any agePhysiologically can happen at any age SIZE SIZE is the issueis the issue

CHILDREN ARE UNIQUELY CHILDREN ARE UNIQUELY VULNERABLEVULNERABLE

Claim: children are easily damaged Claim: children are easily damaged because of weak neck muscles, large because of weak neck muscles, large heads, etc.heads, etc.

Truth:Truth: No literature to support assertion of No literature to support assertion of

“weak” neck muscles“weak” neck muscles No data to show that child’s physiology No data to show that child’s physiology

puts them at extra riskputs them at extra risk

CHILDREN ARE UNIQUELY CHILDREN ARE UNIQUELY VULNERABLEVULNERABLE

Brain fits inside skull - no room to bang Brain fits inside skull - no room to bang around in itaround in it

Adults could not resist a 2000 pound Adults could not resist a 2000 pound gorilla, and their physiology would not gorilla, and their physiology would not helphelp

Note: this claim blames the victim!Note: this claim blames the victim!

RETINAL HEMORRHAGES RETINAL HEMORRHAGES ALWAYS MEAN SBSALWAYS MEAN SBS

Claim: Child “savers” always say Claim: Child “savers” always say retinal hemorrhages = SBSretinal hemorrhages = SBS

Truth:Truth: Not true (MVC may cause retinal Not true (MVC may cause retinal

hemorrhages)hemorrhages) It is the type and pattern of retinal It is the type and pattern of retinal

hemorrhages (extensive, to the hemorrhages (extensive, to the periphery, different layers) that is even periphery, different layers) that is even stronger evidencestronger evidence

RETINAL HEMORRHAGES RETINAL HEMORRHAGES ALWAYS MEAN SBSALWAYS MEAN SBS

BUT: BUT: We too often list differential diagnoses We too often list differential diagnoses

that make no sense for children in that make no sense for children in general, or for the clinical circumstances general, or for the clinical circumstances of the caseof the case

Such mindless differentials can cause Such mindless differentials can cause court confusioncourt confusion

LUCID INTERVALLUCID INTERVAL

Claim: Can not time when the injury Claim: Can not time when the injury occurred clinically. May act fairly occurred clinically. May act fairly normal for awhile before sudden normal for awhile before sudden collapse.collapse.

Truth:Truth: NONO Not the finding in known accidental injuriesNot the finding in known accidental injuries Assumes bleeding, not brain injury is the Assumes bleeding, not brain injury is the

issue.issue.

MODELSMODELS

CONSUMER PRODUCT SAFETY COMMISSIONCONSUMER PRODUCT SAFETY COMMISSION

When studying playground fallsWhen studying playground falls They did They did calculationscalculations Decided that falls as little as 2 inches Decided that falls as little as 2 inches

onto a hard surface might cause onto a hard surface might cause serious or fatal injuries!serious or fatal injuries!

Quoted by Iowa State Quoted by Iowa State UniversityUniversity

MODELSMODELS

Models attempt to describe reality – Models attempt to describe reality – but they are NOT realitybut they are NOT reality

They are always an approximationThey are always an approximation They may be helpfulThey may be helpful They are often too simpleThey are often too simple They may be wrong or insufficientThey may be wrong or insufficient

MODELS THAT ARE TOO SIMPLEMODELS THAT ARE TOO SIMPLE

F = ma. SBS is like a fallF = ma. SBS is like a fall Clinical injury pattern is not that of a Clinical injury pattern is not that of a

fallfall Are the histories by perpetrators of Are the histories by perpetrators of

shaking really wrong? (Maybe those shaking really wrong? (Maybe those “killer” couches really did it.)“killer” couches really did it.)

MODELS THAT ARE TOO SIMPLEMODELS THAT ARE TOO SIMPLE

The amount of force reduces to a The amount of force reduces to a single unit (often a “g” force)single unit (often a “g” force)

42?42? Which of 100 billion neurons is being Which of 100 billion neurons is being

described?described? Which of 1000’s of forces is being Which of 1000’s of forces is being

selected?selected? Complex motions: how much force Complex motions: how much force

does it take to walk?does it take to walk?

MODELS THAT ARE TOO SIMPLEMODELS THAT ARE TOO SIMPLE

F = ma. SBS is like a fallF = ma. SBS is like a fall As Chadwick (1991) showed, third As Chadwick (1991) showed, third

story falls have a <1% death rate story falls have a <1% death rate (without RH), yet SBS has a 25% (without RH), yet SBS has a 25% death rate (with RHs in about 90% of death rate (with RHs in about 90% of cases). SBS is a different entity.cases). SBS is a different entity.

The simple fall notion ignores The simple fall notion ignores individual brain cells/layers. Usually individual brain cells/layers. Usually this “model” focuses on SDH only.this “model” focuses on SDH only.

MODELS THAT ARE TOO SIMPLEMODELS THAT ARE TOO SIMPLE

F = ma. SBS is like a fallF = ma. SBS is like a fall Corresponds to a single shakeCorresponds to a single shake No one really thinks that a single shake No one really thinks that a single shake

causes SBS – the argument sets up a causes SBS – the argument sets up a strawmanstrawman

Example: Duhaime et al (1987) used a doll Example: Duhaime et al (1987) used a doll model and showed that stopping suddenly model and showed that stopping suddenly (impact) creates more G forces than stopping (impact) creates more G forces than stopping slower (end of shake in air). Obvious finding. slower (end of shake in air). Obvious finding. Does not speak to repetitive injuries at all (for Does not speak to repetitive injuries at all (for which no animal data is shown).which no animal data is shown).

MODELS THAT ARE TOO SIMPLEMODELS THAT ARE TOO SIMPLE

F = ma. SBS is like a fallF = ma. SBS is like a fall Sets up idea that shaking is not Sets up idea that shaking is not

enough – the perpetrator must have enough – the perpetrator must have been exceptionally violent! been exceptionally violent!

(Not what is argued by defense (Not what is argued by defense witnesses who want it both ways – witnesses who want it both ways – violent shaking is not enough force, violent shaking is not enough force, but mild impacts can cause but mild impacts can cause everything.)everything.)

MODELS THAT ARE TOO SIMPLEMODELS THAT ARE TOO SIMPLE

APNEA MODELAPNEA MODEL Key brain cells are damaged and Key brain cells are damaged and

apnea resultsapnea results May need only minimal forces – May need only minimal forces –

Geddes argument in several of her Geddes argument in several of her paperspapers

This is stated as a conclusion This is stated as a conclusion without data.without data.

MODELS THAT ARE TOO SIMPLEMODELS THAT ARE TOO SIMPLE

APNEA MODELAPNEA MODEL Apnea is a common clinical entity in the Apnea is a common clinical entity in the

NICU – not common outside of itNICU – not common outside of it The pattern of brain injury and bleeding The pattern of brain injury and bleeding

in SBS does not correspond to injuries in SBS does not correspond to injuries seen by other apnea causesseen by other apnea causes

However: hypoxic/ischemic injuries are However: hypoxic/ischemic injuries are part of the evolution of most SBS injuries part of the evolution of most SBS injuries to the brain (but a small number of to the brain (but a small number of children die very quickly before much children die very quickly before much bleeding or cerebral edema)bleeding or cerebral edema)

MODELS THAT ARE TOO SIMPLEMODELS THAT ARE TOO SIMPLE

APNEA MODELAPNEA MODEL Missing in such histories: why the Missing in such histories: why the

apnea in the first place?apnea in the first place? AAP is against apnea monitors – AAP is against apnea monitors –

they don’t really workthey don’t really work

A MORE REALISTIC MODELA MORE REALISTIC MODEL

MotionsMotions Arc in the AP direction (raises angular Arc in the AP direction (raises angular

acceleration to the 4acceleration to the 4thth power – not power – not terminal impact)terminal impact)

Head pivots on the neckHead pivots on the neck Neck can bend to the left and/or right sideNeck can bend to the left and/or right side All this happens on a body that is moving All this happens on a body that is moving

back and forthback and forth Motions are repetitiveMotions are repetitive

A MORE REALISTIC MODELA MORE REALISTIC MODEL

Result: a repetitive, 3-dimensional series of Result: a repetitive, 3-dimensional series of complex motions with features of complex motions with features of reinforcement, resonance, and consecutive reinforcement, resonance, and consecutive damagedamage

The complex of motions explains why one The complex of motions explains why one side of the brain (or one eye) is exposed to side of the brain (or one eye) is exposed to somewhat different forces and asymmetry somewhat different forces and asymmetry may be seenmay be seen

Explains direct brain injury, intracranial Explains direct brain injury, intracranial bleeding, and retinal hemorrhages bleeding, and retinal hemorrhages (presumably vitreous traction/mechanical (presumably vitreous traction/mechanical rotational flow stresses)rotational flow stresses)

DIFFICULT DIAGNOSIS?DIFFICULT DIAGNOSIS?

Claim: SBS is a difficult diagnosisClaim: SBS is a difficult diagnosis Truth: Truth:

Often made by local physicians without Often made by local physicians without undue difficultyundue difficulty

Paramedics and residents often make Paramedics and residents often make the diagnosisthe diagnosis

No medical condition truly mimics SBSNo medical condition truly mimics SBS

NEW DIAGNOSIS?NEW DIAGNOSIS?

Claim: SBS is a new diagnosis to Claim: SBS is a new diagnosis to medicinemedicine

Truth: Truth: Tardieu (1860) described casesTardieu (1860) described cases Caffey (1946) clearly described casesCaffey (1946) clearly described cases Guthkelch (1971) first linked shaking to Guthkelch (1971) first linked shaking to

the injuriesthe injuries

NEW DIAGNOSIS?NEW DIAGNOSIS?

SBS has been recognized longer than:SBS has been recognized longer than: AIDSAIDS Lyme diseaseLyme disease Gulf War syndromeGulf War syndrome Ebola virus Ebola virus Infectious cause for ulcersInfectious cause for ulcers