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Shaken Baby Syndrome

A Theory Under Attack


Science is beginning to question the fundamental assumptions of Shaken Baby Syndrome. Recent research indicates that the forces generated by shaking are not sufficient to cause the injuries claimed. Non abusive factors may be the cause of the findings thought to result from shaking. Zachary M. Bravos focuses on issues involving science and the law, have offices in Wheaton, Illinois, and consult throughout the United States.

Approximately 1,400 infants and young children are reported to suffer brain injury as a result of abuse each year in the U.S.[1] Violent shaking is considered to be a leading cause of those injuries.[2]  The theory that violent shaking causes brain injuries in infants and young children is referred to as Shaken Baby Syndrome. Is the theory valid?

The validity of the theory is critically important to those accused of shaking a child.  Each year, many parents and child caregivers are accused of child abuse as a result of Shaken Baby Syndrome. Two specific findings: subdural hematoma and bilateral retinal hemorrhaging, with no other evidence of external injury, are considered classic signs of Shaken Baby Syndrome.

What is particularly troubling about such accusations is that the allegation of shaking can be made and sustained based solely on the presence of these two findings in the absence of any other indicia of abuse such as long-bone injuries, spiral fractures, skull fractures, evidence of impact or blunt trauma, bruising, or other indications or evidence that abuse has occurred.  Criminal convictions and lengthy prison sentences often result from such Shaken Baby Syndrome prosecutions.  Neglect and abuse proceedings and the split-up of families commonly follow Shaken Baby Syndrome accusations.  These serious and frequently permanent outcomes demand that the theory of Shaken Baby Syndrome be scrutinized and its validity tested.

This scrutiny and testing is now occurring.  Shaken Baby Syndrome has become so popularized over the years that to question it has been tantamount to questioning the very existence of child abuse.  Nevertheless, forensic scientists are now sharply criticizing the foundation of the theory as rooted in anecdote, bad study, and speculation.  Biomechanical experts, pathophysiologists, physicians, medical specialists, and medical researchers have tested elements of the theory and have established a growing body of evidence disproving many of its assumptions.

Courts too are now examining the foundations of the theory of Shaken Baby Syndrome.  Recent challenges to the Shaken Baby Syndrome theory have been successful at the trial court level in Frye and Daubert hearings. [3]  In April 2006, a Kentucky Circuit Court ruled that, in the absence of other evidence of abuse the theory of Shaken Baby Syndrome could not be introduced.[4]  The Wisconsin Appellate Court recently acknowledged the current controversy regarding the Shaken Baby Syndrome theory in granting a new trial to a convicted babysitter who had been imprisoned for over 10 years.[5]

Foreign courts have also ruled against the admissibility of the theory.  In 2005, the Court of Appeals in the United Kingdom overturned two convictions for murder, and reduced the charges on a third, all which were based upon the theory of Shaken Baby Syndrome. [6]  In each case, there was no other evidence about what happened and no evidence of earlier ill treatment.  The court rejected the claim that subdural hematoma and retinal hemorrhaging automatically lead to a conclusion of unlawfully killing or injury.

Similarly, in late 2001, the Supreme Court of the Australian Capital Territory reviewed the science behind an accusation of shaking based upon subdural hemorrhages and bilateral retinal bleeding in the absence of other injuries.[7]  The Crown’s theory was that the “constellation” of injuries was caused by shaking.  Seven Crown experts testified, over objection, in support of the theory.  Nevertheless, the court found “The evidence revealed a paucity of empirical research on potentially critical issues.” The high court ruled:

“I find the evidence was not admissible that to the effect that the injuries were caused in that manner [shaking], whether by the accused or otherwise, or that they could only have been caused in that manner.  The evidence suggests that such opinions would not be based wholly or even substantially on the expert’s specialized knowledge as a paediatrician but [ ] on a combination of speculation, inference, and reasoning beyond the relevant field of expertise.”

Empirical research is now being conducted which examines the basic hypothesis behind the theory that shaking can and does cause the injuries observed.


History

In 1971, Dr. A. Norman Guthkelch suggested that repeated shaking could cause of subdural hematoma even in the absence of evidence of external injury to the head.[8]  To support his suggestion, Guthkelch referenced a series of twenty-three children of “proved or strongly suspected parental assault.”  He did not disclose how these assault determinations were made.  Of this group, five children had subdural hematoma with no evidence of direct trauma to the head. Guthkelch theorized that repeated shaking rather than direct impact was the cause of these hematomas.  He compared such shaking to two cases of adults suffering subdural hematoma as a result of automobile whiplash injury in rear-end collisions published by Ayub Ommaya in 1968.[9] Guthkelch conducted no scientific study to support his theory.

The Shaken Baby Syndrome theory was brought to further widespread attention by Dr. John Caffey in his 1972 article “On the Theory and Practice of Shaking Infants”[10] and his 1974 paper “The Whiplash Shaken Infant Syndrome”[11] He drew upon the Guthkelch article, a Newsweek magazine article, and the work of Dr. Ommaya.  Like Guthkelch, Dr. Caffey conducted no research or scientific investigation to support his theory.  Moreover, his reliance upon Dr. Ommaya’s study of whiplash injury in rear-end automobile collisions, the only scientific study referenced in support of his theory, was misapplied.  Dr. Ommaya, commented:

. . .  our experimental results were referenced as providing the experimental basis of the 'shaken baby syndrome' (SBS) by Caffey, Gulthkelch and others by analogy not realizing that the energy level of acceleration in our work related to speeds at motor vehicle crashes at 30 mph. [12]

Nonetheless, Caffey suggested that findings of subdural hematoma and retinal hemorrhages could be diagnostic criteria sufficient to determine abuse. In offering his suggestion, Caffey acknowledged that the evidence supporting his theory was not only incomplete and circumstantial, but also contradictory to medical expectations.

The most characteristic pattern of physical findings in the whiplashed infant is the absence of external signs of trauma to the head and the soft tissues of the face and neck, and of the facial bones and calvaria, in the presence of massive traumatic intracranial and intraocular bleedings. This is an extraordinary diagnostic contradiction. (Caffey 1974 p.403)

This “extraordinary diagnostic contradiction” has never been resolved.  Indeed, the lack of external evidence of trauma is the most troubling aspect of the Shaken Baby Syndrome theory because it raises the obvious question: Can an infant be shaken with sufficient force to cause brain injury and leave no external evidence of trauma?

Subsequent articles and papers advanced in support of the Shaken Baby Syndrome theory are commonly based on anecdote, and the quality of such papers and articles have been sharply criticized in peer reviews and subsequent articles. [13]  Indeed, some research appears to refute basic principles behind the theory.  As a result, some scientists and medical practitioners now question the very existence of Shaken Baby Syndrome.


Biomechanics

A demonstration of the force claimed to cause Shaken Baby Syndrome has a powerful effect.Imagine a full-grown man shaking in infant back and forth with all of his might and as rapidly as he can. The head flops back and forth violently as the arms, legs, and torso are shaken like a rag doll. The force involved is such that any reasonable person would expect injury. It is extremely violent and clearly abusive. A defendant’s claim of innocence often fails in the face of the expert testimony that the only way subdural hematoma and retinal hemorrhages can be caused (other than some extremely rare genetic conditions) is through violent shaking.

However, obvious questions arise. Why is there no evidence of external trauma?  Why are there no grab marks on the body?  Why are there no injuries to the infant neck, a structure that seems so weak and vulnerable?  This is Caffey’s “extraordinary diagnostic contradiction.”  Can an infant be shaken so violently as to cause the shaken baby markers without any sign of external injury?  The science of biomechanics, the application of mechanical principals to living organisms, has studied this question.  To date the experiments conducted not only fail to corroborate the Shaken Baby Syndrome theory, they call into question its most basic premise.

In 1987 by Ann-Christine Duhaime, et. al.[14] sought to quantify the forces involved in manual shaking of an infant. Model dolls were constructed, fitted with accelerometers, and then shaken.  The results demonstrated that shaking alone could only generate about 25% of the angular acceleration needed to cause brain concussion and only about 7% of the angular acceleration required to cause subdural hematoma.  The authors concluded:

. . .  it can be seen that the angular acceleration and velocity associated with shaking occurs well below the injury range . . . (Duhaime 1987 p.414)

This result has since been replicated.  In 2003 Prange et. al. utilized more realistic baby models and obtained similar results.  Shaking, even with impact on foam, could not produce enough force to cause brain injury, including subdural hematoma. [15]   Even Dr. Ommaya, whose primate studies were utilized by Caffey and Guthkelch, confirms that shaking alone produces maximum angular acceleration “. . . well below thresholds for cerebral concussion, SDH (subdural hematoma), subarachnoid haemorrhage, deep brain haemorrhages and cortical contusions.” [16]

Scientific studies demonstrating that shaking alone can produce sufficient force or acceleration to cause brain injury are lacking.  Therefore a necessary principle of Shaken Baby Syndrome theory – that manual shaking causes subdural hematoma – has never been scientifically established.  To the contrary, all available research provides evidence that falsifies this assumption.  This research should end the discussion.  A theory may be disproved by a single competent, reliable, journal article or research paper, no matter how many other articles have been published that agree with the theory.


Other Competent Causes of Subdural Hematoma

A variety of conditions, known and unknown, can cause subdural hematomas.  For example, subdural hematomas are a known complication of childbirth.[17]  They can occur with no history of birth trauma and have even been described prenataly.[18]  Hemorrhages have been found in 70% of infants who died from non-traumatic causes, some with bleeding identical to cases presented as classic “Shaken Baby Syndrome.”[19]  In a recent survey of asymptomatic newborns 16% had subdural hematomas.  Fully 26% had some form of intracranial bleed.[20]  There is no suggestion that these children were abused.

Older infants with external hydrocephalus commonly suffer subdural hemorrhages.[21]  Children with external hydrocephalus are subject to spontaneous subdural hematoma at a rate of up to 11%.[22] 


Other Competent Causes of Retinal Hemorrhages

Proponents of Shaken Baby Syndrome theory, argue that retinal hemorrhages are caused by mechanical traction on the optic nerve and retina during shaking.[23]  However, the exact cause of retinal hemorrhages remains unknown.[24]   There appears to be a relationship to increased intracranial pressure.  This relationship has been known for decades.[25]  Extensive, bilateral retinal hemorrhages, that in other contexts could lead proponents to diagnose Shaken Baby Syndrome, has been described in cases of external hydrocephalus.[26]

Retinal hemorrhages are common.  Approximately 30% of children are born with them.[27]  Since children are not routinely screened for retinal hemorrhage there is no good data regarding their rate of occurrence for older infants.  However, the fact that they are common and related to many other conditions, known and unknown is well documented. [28]


Other Competent Causes of Subdural Hematoma and Retinal Hemorrhage

Retinal hemorrhage and subdural hematoma are found together, at reported rates of 65–95%.[29]  However, the relation, if any, between these two conditions remains unproven.  Proponents of Shaken Baby Syndrome theory assert that presumed manual shaking causes these conditions.  However, the cause(s) of retinal hemorrhages, as already noted, is unknown with several theories postulated but none proven.  Both subdural hematoma and retinal hemorrhage can appear at birth or from multiple non-traumatic causes.  To argue that they are causally related to manual shaking goes beyond the evidence.  They may be related as a result of a third or even multiple different causes as yet undetermined.  For example, there is a body of research that asserts that retinal hemorrhages are caused by increased intracranial pressure.  There is support for that position.[30]  Further, subdural hematoma is a competent medical cause for increased intracranial pressure.[31] Therefore it follows that subdural hematoma, from whatever cause, may also be associated with retinal hemorrhage.  In other words, subdural hematoma and retinal hemorrhages may be correlated by a third factor – increased intracranial pressure – not presumed shaking.

To conclude that manual shaking causes both subdural hematoma and retinal hemorrhage because they occur together in instances where it is theorized that manual shaking has occurred is to construct a circular argument – a false argument that fails in its proof because the truth of what it seeks to prove is assumed.  This is not science.  This is not sound logic.


Biomechanics And The Neck

If an act of manual shaking is sufficiently violent to cause subdural hematoma and retinal hemorrhaging, how then does the violently shaken infant escape serious neck injury?  Proponents of the theory of Shaken Baby Syndrome offer no satisfactory answer.  The mechanical limitations of the infant neck can determined.   In 2005 Dr. Faris Bandak performed biomechanical research on infant shaking and its consequences on the head-neck to determine if it is possible for the infant neck to withstand Shaken Baby Syndrome defined levels of head accelerations without injury.[32]   The study concluded that cervical spine or brain stem injuries, perhaps even lethal injuries, would occur “at levels well below those reported for the Shaking Baby Syndrome.”[33]  Peer review of this work is supportive.


Conclusion

No one would disagree that the protection of innocent children is a laudable goal.  However, this protection must be grounded in reproducible scientific concepts.  Should the science be erroneous or ill-founded, we have an obligation to call it into account lest the innocent become victims themselves.

The history of medicine is filled with unwise and unfortunate diagnostic approaches and failed theories of causation, healing, and disease.  Until we learn all that there is no know about all aspects of medical science such failures are to be expected and represent a normal course of learning.  As attorneys we are not only advocates, we are an integral part of the legal system, a system engaged in the truth seeking process.  We need to question the very existence of Shaken Baby Syndrome. 



[1]               Center for Disease Control: Facts for Physicians     http://www.cdc.gov/ncipc/tbi/Facts_for_Physicians_booklet.pdf - p.10. Retrieved on 2008-03-13

[2]               Center For Disease Control: Preventing Injuries in America: Public Health in Action                http://www.cdc.gov/ncipc/fact_book/Preventing%20Injuries%20in%20America%20Public%20Health%20in%20Action-2006.pdf, p.42. Retrieved on 2008-03-13.

[3]               Florida (Johnson v. Florida, 933 So.2d 568 (Fla. 2006) and Florida v. Sanidad, 00-524 CFFA (Cir.Ct., Flager Cty. 2006)), Oklahoma (Oklahoma v. Watts, CF-2001-43 (Dist.Ct., Woods Cty., Okla.2002)), Missouri (Missouri v. Hyatt, 06 M7-CR00016-02, Cir.Ct. Shelby Cty.,   MO, Order dated November 6, 2007) Tennessee (People v. Maze, M2000-02249-CCA-R3-CD   (Tenn.Ct.App., Davidson Cty. Tenn.2002), and Ohio (Ohio v. Mills, 2006 CR 100315  Ct.Com.Pleas, Tuscarawas Cty. Ohio 2006)).

[4]               Commonwealth Of Kentucky VS. Christopher A. Davis. 04 CR 205. Trial Court Opinion April 17, 2006  Greenup Circuit Court.  http://www.aapsonline.org/sbs/daubert.pdf.                     Retrieved on 2008-03-13.

[5]               Edmonds v. Wisconsin

[6]               “Shaken baby convictions overturned.” http://www.guardian.co.uk/society/2005/jul/21/childrensservices.childprotection

[7]               The Queen v. Stuart Lee, SCC 69 of 2000 (Sup.Ct. Australia Capital Territory, Canberra)

[8]               Guthkelch A. N., Infantile Subdural Haematoma and its Relationship to Whiplash Injuries, British Medical Journal, 2,430-431 (1971)

[9]               Ommaya A, Faas F, Yarnell P, Whiplash. Injury and Brain Damage, JAMA, 204(4) 285 – 289 (1968)

[10] Caffey J, On the Theory and Practice of Shaking Infants, American Journal of the Disease of Children 124, 161 – 169, (1972)

[11] Caffey J., The Whiplash Shaken Baby Syndrome: Manual Shaking by the Extremities With Whiplash-Induced Intracranial and Intraocular Bleedings, Linked With Residual Permanent Brain Damage and Mental Retardation, Pediatrics, 54, 396 – 403 (1974)

[12] Ommaya A, Goldsmith W, Thibault L.  Biomechanics And Neuropathology Of Adult And Pediatric Head Injury.  British Journal of Neurosurgery, 16(3):220-242 (2002)

[13] Donohoe M, Evidence-Based Medicine and Shaken Baby Syndrome Part I: Literature Review, 1966 –1998, The American Journal of Forensic Medicine and Pathology, 24(3), 239 – 242 (2003)

[14] Duhaime A.C., Gennarelli T, Thibault L, Bruce D, Margulies S, Wiser R, The Shaken Baby Syndrome, A clinical, pathological, and biomechanical study, Journal of Neurosurgery  66: 409 – 415 (1987)

 

[15] Prange M, Coats B, Duhaime AC, Margulies S, Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants, Journal of Neurosurgery, 99, 143-150 (2003):

   

[16] Ommaya A, Goldsmith W, Thibault L.  Biomechanics and neuropathology of adult and pediatric head injury.  British Journal of Neurosurgery, 16(3):220-242 (2002)

[17] Chamnanvanakij s, Rollins N, Perlman J, Subdural Hematoma in Term Infants, Pediatric Neurology, 26(4), 301 – 304 (2002)

[18] Chamnanvanakij s, Rollins N, Perlman J, Subdural Hematoma in Term Infants, Pediatric  Neurology, 26(4), 301 – 304 (2002)

[19] Geddes J, Taskert R, Hackshaw A, Nickols C, AdamsG, Whitwell H, Scheimberg I, Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in 'shaken baby syndrome'? Neuropathology and Applied Neurobiology 29, 14-22 (2003)

[20] Looney, C, et. al, Intracranial Hemorrhage in Asymptomatic Neonates: Prevalence on MR     Images and Relationship to Obstetric and Neonatal Risk Factors, Radiology, 242(2) 535 – 541 (2007)

[21] McNeely P, Atkinson J, Saigal G, O'Gorman A, Farmer J, Subdural Hematomas in Infants with Benign Enlargement of the Subarachnoid Spaces Are Not Pathognomonic for Child Abuse, American Journal of Neuroradiology, 27:1725-1728 (2006)

[22] Piatt J, A pitfall in the diagnosis of child abuse: external hydrocephalus, subdural  hematoma, and retinal hemorrhages, Neurosurgical Focus, 7 (4): Article 4, (1999)

[23] Ommaya A, Goldsmith W, Thibault L.  Biomechanics and neuropathology of adult and pediatric head injury.  British Journal of Neurosurgery, 16(3):220-242 (2002)

[24] Duhaime A.C., Christian C, Rorke L, Zimmerman R, Nonaccldental Head Injury In Infants - The "'Shaken-Baby Syndrome," The New England Journal of Medicine, 338(25): 1822 – 1829 (1998)

                Geddes J, Talbertt G, Paroxysmal coughing, subdural and retinal bleeding: a computer modeling approach, Neuropathology and Applied Neurobiology, 32,625-634 (2006)

[25] Muller P, Deck J, Intraocular and optic nerve sheath hemorrhage in cases of sudden intracranial hypertension, Journal of Neurosurgery, 41, 160 – 166 (1974)

                Ommaya A, Goldsmith W, Thibault L.  Biomechanics and neuropathology of adult and pediatric head injury.  British Journal of Neurosurgery, 16(3):220-242 (2002)

                Uscinski R, Shaken Baby Syndrome: fundamental questions, British Journal of Neurosurgery, 16(3): 217 – 219 (2002)         

[26] Piatt J, A pitfall in the diagnosis of child abuse: external hydrocephalus, subdural hematoma, and retinal hemorrhages, Neurosurgical Focus, 7 (4): Article 4, (1999)        

[27]             Baum J, Bulpitt C, Retinal and Conjunctival Haemorrhage in the Newborn, Archives of Disease In Childhood, 45, 344 – 349 (1970)

[28]          Barnes P, Ethical Issues in Imaging Nonaccidental Injury: Child Abuse

                Topics in Magnetic Resonance Imaging, 13(2), 86-93 (2002)    

                Gardner H, A Witnessed Short Fall Mimicking Presumed Shaken Baby Syndrome    (Inflicted Childhood Neurotrauma), Pediatric Neurosurgery, 43,433-435 (2007)

                Geddes J, Talbertt G, Paroxysmal coughing, subdural and retinal bleeding: a computer modeling approach, Neuropathology and Applied Neurobiology, 32,625-634 (2006)

                Goetting M, Sowa B, Retinal Hemorrhage After Cardiopulmonary Resuscitation in Children: An Etiologic Reevaluation, Pediatrics, 85(4), 585 – 588 (1990)

                Lantz P, Researchers Say Criterion For Diagnosing Child Abuse Not Always Accurate, Science Daily, 02-26-2006

Lantz P, Sinal S, Stanton C, Weaver R, Evidence based case report Perimacular retinal folds from childhood head trauma, British Medical Journal, 328, 754 – 756 (2004))

               

[29] Duhaime A.C., Christian C, Rorke L, Zimmerman R, Nonaccldental Head Injury In Infants - The "'Shaken-Baby Syndrome," The New England Journal of Medicine, 338(25): 1822 – 1829 (1998)

[30] Muller P, Deck J, Intraocular and optic nerve sheath hemorrhage in cases of sudden intracranial hypertension, Journal of Neurosurgery, 41, 160 – 166 (1974)

[31] Uscinski R, Shaken Baby Syndrome: fundamental questions, British Journal of Neurosurgery, 16(3): 217 – 219 (2002)

[32] Bandak F, Shaken baby syndrome: a biomechanics analysis of injury mechanisms.  Forensic Science International 151(1): 71-79 (2005)

[33] Bandak F, Shaken baby syndrome: a biomechanics analysis of injury mechanisms.  Forensic Science International 151(1): 71-79 (2005)“

[34] Geddes J, Talbertt G, Paroxysmal coughing, subdural and retinal bleeding: a computer modeling approach, Neuropathology and Applied Neurobiology, 32,625-634 (2006)

                     Uscinski R, Shaken Baby Syndrome: An Odyssey, Neural Med Chir (Tokyo) 46, 57 –61 (2006)

 



Zachary M. Bravos
Law Offices Of Zachary M. Bravos
600 W. Roosevelt Rd., Ste. B1
Wheaton, IL 60187
ZackB@aol.com




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