A Sojourn in the Abyss: Hypothesis, Theory, and Established Truth in Infant Head Injury
Marvin Miller, MD
Jan Leestma, MD
Patrick Barnes, MD
Thomas Carlstrom, MD
Horace Gardner, MD
John Plunkett, MD
John Stephenson, BM, DM
Kirk Thibault, PhD
Ron Uscinski, MD
Julie Niedermier, MD
John Galaznik, MD
Department of Pediatrics
Wright State University School of Medicine
Dayton, OH 45404
Chicago, IL 60622
Department of Pediatric Neuroradiology
Stanford University Medical Center
Palo Alto, CA 94305
Department of Neurosurgery
Iowa Methodist Medical Center
Des Moines, IA 50309
Department of Pathology
Regina Medical Center
Manitou Springs, CO 80829
Department of Pathology
Regina Medical Center
Hastings, MN 55033
Department of Paediatric Neurology
Royal Hospital for Sick Children
G3 8SJ Glasgow, Scotland
Philadelphia, PA 19112
Department of Neurosurgery
George Washington University School of Medicine
Olney, MD 20832
Columbus, OH 43214
Northport, AL 35476
To the Editor. —
Dr Block’s criticism1 of the work by Geddes is disturbing. The response by Pediatrics Editor Lucey2 is equally disturbing, because Pediatrics typically gives a balanced perspective of controversial issues. Geddes, a neuropathologist with many years’ experience examining infant brains, observed that she was not finding traumatic brain injury in infants thought to be victims of inflicted trauma/shaken-baby syndrome. She was not alone in her observations, as the co-authors of her articles attest.3,4 She found anoxic axonal damage rather than traumatic brain injury, except for a small number of cases in which there were significant impact injuries such as skull fractures. A number of the infants in her study also had evidence for axonal injury in the brainstem but no other structural damage, suggesting that primary brainstem damage may lead to an anoxic event. Interestingly, her group of infants with morphologic evidence for brainstem damage included a number of children who apparently died suddenly and unexpectedly and were not resuscitated, suggesting that the observed brainstem damage significantly preceded the collapse of the infant and death. Thus far, there is no problem from the child abuse professional’s perspective except that Geddes et al were suggesting that “violent” shaking may not be necessary to cause the observed pathology. In fact, her studies were widely cited in the presentations at the 4th National Shaken Baby Syndrome Conference in Salt Lake City, Utah, in 2002 and at the Shaken Baby Syndrome Conference, Edinburgh, Scotland, in 2003. Geddes had found the holy grail: the evidence that “shaking” caused direct neck damage.
The problem (and Block’s ire) arose when Geddes et al published a subsequent article suggesting that hypoxia, not “violence,” was the common denominator in the pathology of many cases of both assumed inflicted injury and deaths due to natural causes. The article was published as a “hypothesis paper,” as reference to the actual print title of the work will confirm.5 The authors’ conclusions are supported by the observations. (We urge those interested to look at the actual publication photographs rather than a photocopy and decide for themselves.) Her hypothesis is testable and, if repeated and confirmed, will be a significant advance in understanding cascade or secondary phenomena that may lead to symptoms and death hours and perhaps days after the primary event.
Physicians should be troubled by Geddes’ work and the other studies that question the causes of traumatic brain injury in children. However, it is not the scientific bases for these studies that should concern us but rather the implications of these findings to the public. If shaking is not the cause of traumatic brain injuries/shaken-baby syndrome, then many thousands of parents/caretakers have been unjustly accused and convicted for the past 30 years. Families, finances, and reputations have been destroyed. If the mechanism(s) that cause(s) subdural hematoma and retinal hematoma may be other than inflicted trauma, then the floodgates would open for these prior cases to be revisited in our legal system. Perhaps Block’s criticism and Lucey’s acquiescence of Geddes’ “unfashionable” work has a political rather than a scientific basis.
Drs Block and Lucey may find that the Geddes’ hypothesis paper is “junk science” and that Neuropathology and Applied Neurobiology and the British Medical Journal are lax in their publication standards. However, these are well established, peer-review journals, and many neuropathologists, forensic pathologists, neurosurgeons, and biomechanical engineers have found her observations and conclusions reasonable and provocative. To accuse the editors of these journals of sloppy standards is disingenuous. We urge the pediatrics and general medical communities to read the relevant literature, including studies that may have conclusions different from the perceived truth, and decide for themselves what is and what is not junk science.6–8
1. Block RW. Fillers [letter]. Pediatrics. 2004;113 :432[Free Full Text]
3. Geddes JF, Hackshaw AK, Vowles GH, Nickols CD, Whitwell HL. Neuropathology of inflicted head injury in children. I. Patterns of brain damage. Brain. 2001;124 :1290 –1298[Abstract/Free Full Text]
4. Geddes JF, Vowles GH, Hackshaw AK, Nickols CD, Scott IS, Whitwell HL. Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants. Brain. 2001;124 :1299 –1306[Abstract/Free Full Text]
5. Geddes JF, Tasker RC, Hackshaw AK, et al. Dural haemmorhage in non-traumatic infant deaths: does it explain the bleeding in ‘shaken baby syndrome?’ Neuropathol Appl Neurobiol. 2003;29 :14 –22[CrossRef][Web of Science][Medline]
6. American Academy of Pediatrics, Committee on Child Abuse and Neglect. Shaken baby syndrome: rotational cranial injuries—technical report. Pediatrics. 2001;108 :206 –210[Abstract/Free Full Text]
8. Lantz PE, Sinai SH, Stanton CA, Weaver RG Jr. Perimacular retinal folds from childhood head trauma. BMJ. 2004;328 :754 –756[Free Full Text]
PEDIATRICS Vol. 114 No. 1 July 2004, pp. 326
Capillary Fragility As A Cause Of Subural
Hemorraghe In Infants
By C Alan B Clemetson
Department Of Obstetrics And Gynecology, Tulane University School Of Medicine, New Orleans Louisiana 70112
Malnutrition, excessive vomiting, surgery or infection can cause a pregnant woman to develop a profound vitamin C deficiency and an excessive blood histamine level, leading to capillary and venular fragility. Sleep lack and other stresses in the mother can elevate her blood histamine level and affect the unborn child, thus weakening the retinal capillaries and the bridging veins between the brain and the dura mater. Subdural hemorraghes in the infant have now been identified by ultrasound examination before birth and even before labor. Vaccines and toxoids have been shown to increase the blood histamine level of guinea pigs. We need to establish the blood histamine and ascorbic acid levels of human subjects before and after single and multiple inoculations. Undoubtedly the histamine level will increase more in those having low ascorbic acid levels and especially in those receiving multiple inoculations. Research is needed to determine which inoculations cause the highest blood histamine level or histaminemia and when it peaks.
FROM: Injury Biomechanics Researcher: Chris Van Ee, PhD
TO: The Honorable Court
SUBJECT: Dynamic Biomechanical Findings on SBS-LMF
DATE: March 3, 2008
1. Accepted Findings Will Assist Court:
The purpose of this document is to assist the Court with its understanding of two injury causation mechanisms that have caused significant disputes within the medico- legal communities.
These injury mechanisms are SBS (Shaken Baby Syndrome) and LMF (lethal [-6’] minor falls with severe head impact). Impact and injury biomechanics is the study of the mechanics of how injury occurs. In that respect, biomechanics is in a unique position to aid in the understanding of how falls or shaking can result in serious or fatal head injury.
While many in the medico- legal communities have debated these injury causation mechanisms, the Court is advised that most medical doctors are not trained in our scientific discipline and do not access our databases nor study our peer-reviewed research.
Indeed, as our findings show, there is no credible debate in our discipline over certain Inconvenient Truths”, truths that some have ignored or distorted.
This is not to say that all the answers are in, for they most assuredly are not. There is a great deal of study ongoing regarding the understanding of infant and adolescent head injury. However, the studies to date have allowed for great advances in the understanding of head injury and the development of state of the art safety devices and interventions. Indeed their success is predicated on an accurate understanding of head injury. Some of the applications of the work of injury biomechanics include automotive child safety seats, helmets, advanced airbags, playground surface materials, and crib design. In the development of products or safety interventions it is important to understand how injury takes place and identify the governing factors. The intervention can then be designed to affect the governing factors as to eliminate or mitigate the resulting injury. Based on the reliable scientific data that is currently available and used for the understanding of pediatric head injury in other applications the following statements can be made.
Dynamic Biomechanical Findings March 7, 2008 Page 2 of 4
2. SBS/LMF Findings From Biomechanical Tests and Studies:
(A) Scientific testing has shown that head acceleration levels from anterior/posterior human shaking of a normal 0- to 2-year-old child in the sagittal plane results in head acceleration and force levels that are much lower than those which are associated with traumatic head injury. Repeated testing of this hypothetical has shown that the head accelerations associated with shaking are far below the level associated with injury and there is no quality data to support the SBS brain injury mechanism. Thus shaking, even if done in a fit of anger, is not expected to result in head dynamics sufficient to cause direct intracerebral trauma.
(B) Human shaking (id.) may cause lethal brain stem and cervical spine injuries in a 0-to 2-year-old child, as the forces necessary for these injuries are well below the level needed for fatal brain injuries and are consistent with the forces that can be produced in shaking. Put another way, these neck injuries would be expected in any hypothetical-superhuman-strength case of SBS where superhuman dynamics resulted in head accelerations leading to intercerebral trauma (if SBS were valid, which it is not).
(C) If a 0- to 2-year-old child accidentally falls from a height of six feet and impacts head- first on a hard sur face such as carpeted cement, the sudden impact has the potential to generate sufficient head accelerations to cause fatal intracerebral injuries. Whether any given fall is fatal depends on a host of variables and the fall mechanics which are different in each accident, but the potential head dynamics that result from a 6 foot high fall could far exceed the tolerance associated with fatal head injury.
(D) Intentionally impacting a 0- to 2-year-old child’s head against a hard surface could easily cause fatal brain injuries that would mimic those of a fall and today’s science cannot distinguish accidental from non-accidental impacts of falls of similar magnitude, barring extraordinary signs, e.g., grip marks or eye-witness accounts.
(E) The foregoing findings are based on principles universally accepted within my field and concern scientific subject matters that I am willing to testify on in this case. The findings are overwhelmingly supported by the following reference list of biomechanical tests and studies.
3. References of Scientific Validation:
(A) Duncan M. Laboratory note: On the tensile strength of the fresh adult foetus. BMJ 1874;2:763–764.
(B) Ommaya AK, Faas F, Yarnell P. Whiplash injury brain damage. JAMA 204 1968;285-289.
(C) Ommaya AK, Yarnell P. Subdural hematoma after whiplash injury. Lancet 1969;257.
Dynamic Biomechanical Findings March 7, 2008 Page 3 of 4
(D) Mertz HJ, Patrick LM. Strength and response of the human neck. In: Proc of the 15th Stapp Car Crash Conference; Warrendale, PA; Society of Automotive Engineers 1971; SAE paper #710855:2903–28.
(E) Mohan D, Bowman BM, Snyder RG, et al. A biomechanical analysis of head impact injuries to children. J Biom Engng 1979;101:250-260.
(F) Stürtz G. Biomechanical data of children. In: Proc. 24th Stapp Car Crash Conference; Warrendale, PA; Society of Automotive Engineers 1980; SAE paper #801313:525-59.
(G) Stürtz G. Correlation of dummy- loadings with real injuries of children by repetition tests. In: Proc. Vth International IRCOBI Conference; Bron, France; IRCOBI 1986:121-131.
(H) Weber W. Experimental studies of skull fractures in infants. Z Rechtsmed 1984; 92:87–94.
(I) Weber W. Biomechanical fragility of the infant skull. Z Rechtsmed 1985;94:93– 101.
(J) Duhaime A-C, Gennarelli TA, Thibault LE, Bruce DA, Margulies SS, Wiser R. The shaken baby syndrome: a clinical, pathological and biomechanical study. J Neurosurg 1987;66:409-15.
(K) Melvin JW, Injury Assessment Reference Values for the CRABI 6-Month Infant Dummy in a Rear-Facing Infant Restraint with Airbag Deployment. SAE Paper # 950872, 1995.
(L) Irwin AL, Mertz HJ. Biomechanical Bases for the Crabi and Hybrid III Child Dummies, SAE Paper # 973317.
(M) Tylko S, D Dalmotas. Assessment if Injury Risk to Children from Side Airbags, 44th Stapp Car Crash Conference, 2000-01-SC02.
(N) Margulies SS, Thibault KL. Infant skull and suture properties: measurements and implications for mechanisms of pediatric head injury. J Biom Eng 2000;122: 364-371.
(O) Accidental Injury, Alan M. Nahum (Editor), John Melvin (Editor), Springer Verlag; 2nd edition, ISBN: 0387988203, 2001.
(P) Hagedorn AV, Rhule DA Daniel A. Rhule, Child injury tolerance through case reconstruction, International Technical Conference on the Enhanced Safety of Vehicles, 2001-06-0026.
(Q) Prange MT, Coats B, Raghupathi R, et al. Rotational loads during inflicted and accidental infant head injury. J Neurotr 2001; Abst. D8;18:1142. Dynamic Biomechanical Findings March 7, 2008 Page 4 of 4
(R) Plunkett J. Fatal pediatric head injuries caused by short distance falls. Am J Forens Med Pathol. 2001;22:1-12. (included due biom. Reconstruction of videotape accident).
(S) Ommaya AK, Goldsmith W, Thibault LE. Biomechanics and neuropathology of adult and paediatric head injury. Br J Neurosurg 2002;16-220-42.
(T) Klinich, K. D.; Hulbert, G. M.; Schneider, L. W. 2002. Estimating infant head injury criteria and impact response using crash reconstruction and finite element modeling. Stapp Car Crash Journal, Vol. 46, SAE Paper #2002-22-0009.
(U) Prange MT, Coats B, Duhaime A-C, Margulies SS. Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants. J Neurosurg 2003; 99:143-50
(V) Prange MT, Luck JF, Dibb A, Van Ee CA, Nightingale RW, Myers BS. 2004. Mechanical properties and anthropometry of the human infant head.. Stapp car crash journal. Vol. 48
(W) Goldsmith W, Plunkett J. A biomechanical analysis of the causes of traumatic brain injury in infants and children. Am J Forens Med Pathol 2004;25:89-100. (X) 2005, NPSC, Fall surfaces tests.
(Y) Bandak FA. Shaken baby syndrome: a biomechanics analysis of injury mechanisms. Forens Sci Int 2005;151:71-79, including comments in 2006:164,278–279.
(Z) Prange M, Newberry W, Moore T, Peterson D, Smyth B, Corrigan C. Inertial neck injuries in children involved in frontal collisions. SAE 2007 World Congress; Warrendale, PA; Society of Automotive Engineers; SAE paper #2007011170.
(AA) Monson K, Sparrey C, Cheng L, Van Ee C, Manley G. Head exposure levels in pediatric falls. NNS 2007; abstract.
By: ___________________Chris Van Ee, PhD