October 4, 2010 | 2:53 PM | By

Pediatrics Academy President-Elect On ‘Shaken Baby Syndrome’

FILED UNDER: Medicine/Science, Personal Health, forensics, pediatrics, shaken baby syndrome

American Academy of Pediatrics President-Elect Robert Block

This CommonHealth post – The Real Consensus On Shaken Baby Syndrome — has brought such a cornucopia of powerful comments that one media-watcher even called it an interesting exploration of Internet journalism. The Knight Science Journalism Tracker, which critiques science media, writes here:

It’s an interesting way of doing journalism in the blog era. Instead of calling sources for comment, open it up to anyone who cares to respond. I’m guessing that even reporters as good as Goldberg and Zimmerman would not have found some of these fascinating responses using the old-fashioned tricks of our trade.

Too true! And we thank you all for allowing us to host your discussion. Our own contributions for today: Rachel Zimmerman heard again from Deborah Tuerkheimer, the law professor whose New York Times op-ed piece triggered this outpouring of response (see below). She also gained some helpful insights from a Children’s Hospital Boston specialist.

And I spoke with Dr. Robert W. Block in his official capacity as the president-elect of the American Academy of Pediatrics, which has 60,000 members. If anyone knows what the consensus really is, I figured, he must.

The debate will surely continue, I said, but if you could post the final word on this, what would it be?

“I think that stated most simply, there are decades now of accumulating reports, clinical observations, and evaluations of both individual cases and other data relating to the ways babies are injured through shaking, shaking with impact or perhaps impact alone.” Dr. Block said.

“The debate has been fueled by a few people who ignore the known science and excuse the confessional literature, the clinical experience that many of us have working with babies who are injured or killed and the people who hurt them, and choose instead to come up with alternative hypotheses, none of which are substantiated by reasonable science.

And unfortunately, then this becomes a courtroom and media display rather than a sound discussion of the science in medical and other scientific forums where it ought to occur.”

“Is this a doctors vs. lawyers fight?” I asked.

“I don’t think so,” Dr. Block said. Prof. Tuerkheimer “has been heavily influenced by only one side of the discussion, and she has written a piece that ignores the overwhelming majority of science in favor of expressing the unsupported statements of a few people who occupy their days testifying for defenses in cases across the country.”

As Prof. Turkheimer presents it, Dr. Block said, “Doctors are looking at some key findings that do have a variety of causes, and are only looking at one diagnosis, the shaken baby sydnrome. And that is actually a gross misrepresentation of the process of considering what we call a differential diagnosis, where we look at not only the medical aspects of the case but also coordinate the medical findings with investigatory findings from law enforcement, human services and other folks putting together the entire case before it goes into a courtroom.

So I think that creating reasonable doubt in the minds of the jury by presenting evidence that has no science to support it can be very confusing, and also puts in the hands of the jury the responsibility to understand medicine, which doesn’t make much sense.”

Prof. Tuerkheimer wrote in her op-ed piece that “experts are questioning the scientific basis for shaken baby syndrome.” What sentence, I asked, would Dr. Block substitute for that one?

He replied: “I’d say the real experts are the physicians who work every day with these cases and have both authored and read voluminous literature that substantiates the existence of abusive head trauma, and those are the folks who are the most capable of informing the public about what the issue really is, rather than creating these sham media blasts that casue great confusion.”

Now this from Rachel:

CommonHealth once again asked Prof. Tuerkheimer to comment on the torrent of responses to her op-ed piece. Again, she declined but wrote in an email:

“I would make two observations. First, as to the scientific debate surrounding SBS, my claims are more modest than the tenor of many comments might lead one to believe. Second, the evolution of forensic understandings and diagnostic protocols – highlighted even by those medical professionals who take issue with the op-ed – has important implications for the criminal justice system.”

Hmm, her claims are more modest? But isn’t she saying the science underlying shaken baby syndrome is, well, shaky? That doesn’t seem terribly modest.

But, as Allison Scobie-Carroll, program director for the child protection program at Children’s Hospital Boston, said in an interview: “For those us who actually see these children, there is no debate.”

Ms. Scobie-Caroll commented on-line: “Each year our team consults on approximately 1800 cases of child maltreatment. And each year we are directly involved in the care of dozens of cases of abusive head trauma. It has been my experience that despite our wishes to the contrary, some caregivers, (even those with no known documented history of violence toward others, and even those who closely resemble the very lawyers and physicians enlisted to defend them) do, in fact, inflict devastating and irrevocable harm on children.

Like many serious acts of maltreatment of children, the severe shaking of an infant is rarely witnessed. This may be, in part, due to the “guardian” effect that was noted in an earlier post. That is, that people, when in the presence of others, may exercise restraint in their response to the frustrations of care giving. It may also be due to the fact that individuals who lack the internal or external resources (maturity, stability, judgment, sobriety, social supports etc) necessary to manage the stresses of a crying infant are sometimes left alone to do so.

In just a few frustrated seconds of rigorous shaking, whether intended to stop a child’s crying or simply to relieve the caregiver’s frustration, the child’s life, and the lives of those that love that child, are forever changed. Denying that this occurs does little to prevent future incidents of such abuse, and it is a profound invalidation of the maltreatment that these children have endured.”

  • Stephen Boosmd

    I would invite any interested party to examine the history of testimony provided by all who have opined on this matter in court. You will find demagogues, on both sides of the issue, but principally among the most vocal, active, and highly compensated perennial “experts.” You will find nuanced thoughtful and balanced analysis countered by demagoguery. You will find opinions that pop up regardless of the actual facts of the case. You will also find what Ms. Tuerkheimer seemed most concerned with in her original legal review article, simplistic analysis unchallenged by capable opposing experts; something that should concern us all. While you will find overly simplistic analysis based on the presence of a “triad”, more commonly you will see careful analysis dismissed using the trojan horse of fealty to a “triad.” Only by looking at the real experience, and history of those that opine, will you be able to judge their opinions. Alternatively you will need to check all your presumptions and your personal vested interests at the door, and start from square one with first hand data. This is a remarkably arduous task, and has been the life’s work of many of the doctors who posted on the original blog strain.

    The post by Illum starts, “Doctors are not God and they do not have all the answers; they are not infallible. An expert in any field is only as good as their experience, their education, and their knowledge and understanding of on-going non-bias studies and information.” This is certainly true and I welcome this sort of analysis! Doctors are not asked to testify as God, however. They are asked to testify “to a reasonable medical certainty.” This is not a standard taught in medical school. It is a term of art of the legal profession, yet one that lawyers, and commonly judges, decline to define for the doctors who must adhere to it. Only once has a judge defined it for me. I was shocked to hear him say it was simply “more likely than not.” I would suggest that your anger should not be with doctors, but with the legal system that consumes, constrains and attempts to influence, bias, dismiss, distort and otherwise use their opinions in the pursuit of legal victory.

    As to the comments of Innis. I have never seen a case of abusive head trauma proceed without looking carefully at clotting. The few cases where OI has presented with retinal hemorrhage or symptomatic subdural hemorrhage hardly justify universal OI testing, but most cases are carefully assessed for clinical evidence of OI and many are assessed for laboratory evidence. I would challenge him to document clear evidence that trace mineral and vitamin deficiencies are anything more than a red herring or very rare contributor to this issue. This post magnifies fascinating, unfortunate, and truly rare cases to the status of major diagnostic pitfall.

    Unfortunately, we are in a stage similar to global warming science research years ago. Though the great bulk of science may agree, a band of vociferous opponents who manufacture disagreement and magnify the natural disagreements in a developing scientific field, trumpeted by a news hungry press, and capitalized upon by lawyers and politicians hungry for victory, can mislead the public into seeing controversy where little exists. Hopefully our science is still growing. Hopefully opinions of tomorrow will have differences from opinions of today. But please don’t dismiss what you do not want to hear because a century ago someone with my same degree bled his patient. The case for shaking only starts with John Caffey, and has faced, and adapted to valid scientific challenges in the subsequent forty years.

    It would be nice if as much care was shown in the public discourse, defense, and prosecution related to this topic as professionals like Dr Block show in their clinical work. I fight to take that degree of care in my work as well, as do all of the professionals I know who have made this the focus of their clinical life. Shaking injury appears to be a real issue. it is not present every time the “triad” is present, nor is it invoked every time a baby is injured. There are many other ways, both abusive and otherwise to injure a baby. The careful clinician understands the odds, the alternatives, the uncertainties, and testifies to them, no matter how disturbing or inconvenient the answer.

  • Michael Innis

    ,
    Nutritional deficiencies of essential Vitamins and minerals can cause all the signs and symptoms currently attributed to Non-accidental Injury, Shaken Baby Syndrome, Inflicted Brain Injury or Abusive Head Trauma. The appropriate tests for Haemostasis and Osteogenesis must be done and correctly interpreted before any accusations of child abuse are made.
    Google – http://www.Shaken Baby Syndrome/Innis

    The Shaken Baby Syndrome and its synonyms are, as I have said many times before, a fabrication of doctors and others ignorant of the pathophysiology of Haemostasis and Osteogenesis.

    I declare a conflict of interest. My children and grandchildren could be victims of these misdirected professionals

    Michael Innis

  • illum

    Doctors are not God and they do not have all the answers; they are not infallible. An expert in any field is only as good as their experience, their education, and their knowledge and understanding of on-going non-bias studies and information. There are discoveries and new information every day as methods and treatments evolve. From antiquity to the late 19th century, patients were bled to health; it was the most common medical practice of that time. It was finally established that it was not effective, but most harmful patients.
    What of the lobotomy? It has been controversial since its inception in 1935; it was a mainstream procedure for more than two decades. Egas Moniz was actually awarded “The Nobel Prize for Physiology or Medicine” of 1949 for his discovery of the therapeutic value, this despite general recognition of frequent and serious side-effects.
    As noted above, there are numerous obsolete medical theories and procedures in our history. I am not saying that child abuse does not occur, on the contrary it does and it needs to be addressed and stopped. However, there are many underlying medical conditions that can cause the so called triad of Shaken Baby Syndrome. Advocates, such as me, are pleading that the medical community educate themselves and render an unbiased theory of those possible conditions instead of swiftly and wrongly accusing the care givers of a child. The concept of SBS was initially described in the early 1970s, based on a theory by Dr. John Caffey. It is 2010 and it is time to take a real medical/scientific look at this 36 year old theory and bury it along with bleeding patients to health and the lobotomy! One man’s obsolete THEORY based on the medicine of 1970 is not the word of God and does not make medical sense in our 21st Century. It only demonstrates unrealistic assumptions.

    • Eifsman Steve Stowe

      Either you are not as educated as you sound, or you have a close friend or family member that has shaken a baby. My wife and I cared for our grandson for almost three years. That is 24 hours a day my friend. He was shaken by his father. He had more love and silent wisdom than most people can fathom. We had to tell him it was ok to let go, that WE would be ok. His heart stopped beating while sitting on my wifes lap watching the Christmas tree last December. Make a true sacrafice one day, live it unconditionally, and then share with people your journey. Being negative to get attention has no spiritual value. I wonder what you know about the word of God since you use the phrase so often. Maybe you need forgivness for something yourself.

  • Geolith

    As an aside, I wonder if the Knight Science Journalism Tracker comment intentionally used the correct verb form – “doing journalism” – to describe the exchange of dialogue on this topic. Like a naval battle of yore, it’s not “done” until the smoke of battle clears, the facts are assessed and analysis begets perspective. Even then, perspectives may vary. It’s a great forum for having at it, but providing the forum is merely one step in telling the stor(ies)y.

    Otherwise, this simply proves the point made by Mark McKinnon, director of advertising for the Bush campaign, that “the nature of the news business is that conflict is news,”