Shaken Baby Syndrome or Scurvy?

C. Alan B. Clemetson, M.D.

There has undoubtedly been a grave miscarriage of justice in the conviction of Alan Yurko of Orlando, Florida, who was accused of “shaken baby syndrome” and was sentenced to life imprisonment for murder. The error seems to have arisen because of fashionable adherence to a diagnosis now in vogue, and to a desire to blame one single preventable occurrence for an infant death. Everything is supposed to be preventable nowadays.
Surely Alan held his 10-week-old son by the heels and slapped him on the bottom after he began wheezing, spat up and stopped breathing, but he did not cause his son’s death; he was trying to resuscitate him.
Actually the infant died from a concatenation of circumstances, having been born prematurely, weighing 5 lbs. 8 oz., of a malnourished mother with several medical problems. After becoming pregnant, she became sick and remained so during her pregnancy, often to the point of dehydration, going from her original weight of 130 lbs. down to 120 lbs. at one point and finally coming back to her original weight of 130 lbs. at the time of delivery. She said she was too sick to take her pre-natal vitamins.
When one considers that the currently recommended weight gain for pregnancy is 25 to 30 lbs., it is clear that she was malnourished and so was her unborn child. The infant had several medical problems including respiratory distress syndrome, pneumonitis and also jaundice which was still evident four weeks after leaving hospital; his health was further impaired when he received six inoculations (for diphtheria, whooping cough, tetanus, influenza B, oral polio vaccine and hepatitis B) at eight weeks of age.
Actually, the autopsy findings of subdural hemorrhage, four broken ribs, severe anemia and a few bruises, are characteristic of Barlow’s disease or infantile scurvy, but that diagnosis went out of fashion many years ago, so no blood analysis for vitamin C or for histamine was conducted. The prosecutors suspected both parents, but Francine Yurko refused to implicate her husband and Alan Yurko refused to plead guilty to a lesser charge, because he knew he was innocent.
Undoubtedly many others have also been wrongly convicted on equally flimsy evidence, sometimes just because there were petechial hemorrhages in the retina at the back of the eye, or because the fatal event occurred more the usual 3 to 7 days after the inoculations.
Undoubtedly child abuse does occur and we are all alarmed when we hear about an infant with bruises and broken bones, but we must appreciate that there are ge-netic disorders such as osteogenesis imper-fecta, fragilitas osseum (brittle bone dis-ease) other metabolic disorders and also nutritional states like Barlow’s disease, which can be mistaken for child abuse.
It is said that ignorance is bliss; this may be true for those who give evidence in our law courts with such conviction, fol-lowing the standard teaching of the day. We should all keep an open mind and consider the possibility that the standard teaching may be wrong.

Barlow’s Disease

In the first half of the twentieth century many infants with bruises, broken bones and sores that would not heal, were correctly diagnosed as having infantile scurvy or Barlow’s disease, and recovered quickly when treated with orange juice, but now people don’t want to believe that malnutrition still occurs in the Western World, so one or other of the parents or a care giver has to be accused and possibly convicted of child abuse, without any blood analysis for vitamin C. Sores that will not heal are seen as cigarette burns and reported in newspapers. Barlow’s disease used to occur even in the homes of the wealthy, some-times due to the custom of boiling cow’s milk to kill the germs of tuberculosis, some-times due to feeding of a commercial “malt soup”, whose alkalinity destroyed vitamin C and sometimes due to ignorance of the need to provide an orange juice supplement for bottle-fed infants.
There are even records of such an infant suffering a complete fracture across both femoral bones of the thigh in hospital, when a nurse lifted the heels in the gentle act of diapering a scorbutic infant. Luckily it did not occur at home, for even then someone would have been suspected of child abuse. Part of the problem now arises from the child abuse laws which require immediate reporting of any suspicion of child abuse, so that even the natural pigmentation of the “Mongol Spot,” just above the natal cleft, was suspected as child abuse when a young mother brought her baby to our hospital for advice because it was not thriving. One of the nurses rushed to the phone to call the child abuse authorities. Before long the nurses were presenting the infant to each other, to social workers and to the doctors, as “this is the child abuse case”. The physician who first sees the infant can have his or her opinion prejudiced by such hysteria, before making an examination.
What has happened to the practice of medicine? Our duty as physicians is to make a well-considered diagnosis and to provide advice with compassion, not accusation and vilification. Soon parents will be afraid to take their children to the emergency room of a hospital after a fall for fear that some “expert” will find petechial hemorrhages in the eyes and label the parents as child abusers. The social workers are in an unenviable position, for they can be dammed if they do and dammed if they don’t remove a child from parental custody. Even more perilous is the job of infant care providers and preschool teachers, who have so often been embroiled in totally unreasonable litigation, like the McMartin preschool family, who endured a new version of the Salem Witchcraft Trials.

Popeye, A Case of Classical Adult Scurvy

Ignorance is bliss. Not many people are aware that “Popeye the Sailor Man” was a well recognized character to be seen around any English seaport in the days of sail. The protrusion of one eye was due to a hemorrhage behind the eye ball (a retrobul-bar hemorrhage) due to scurvy; this was only one of many hemorrhages beneath his skin and elsewhere; he should be recognized as a symbol of suffering who deserves our compassion and not a comic cartoon character for people to laugh at. He is a young man, who looks old beyond his years due to scurvy. He would have had foul breath due to his infected bleeding gums. His pipe juts up in front of his face because he has lost all his teeth to scurvy and he is holding his pipe between his upper and lower gums.
Clearly he has returned from a long sea voyage where he lived on food held in storage and maybe as many as half of his ship-mates died of scurvy. We are told that his arch enemy “Bluto” has gone off with his woman “Olive Oil” and his child “Sweet Pea,” but he does not have the strength to fight Bluto until he has been fortified with spinach. Of course it is vitamin C-rich fresh greens or fruit that he needs, not canned spinach that has lost its vitality, but his misery has been exploited and transformed into an advertising cartoon. In fact, we may conjecture that these poor men received little respect at the time, for the phrase “scurvy knave” persists in our literature.
It will be about a week before his bleeding gums are healed when he gets oranges, lemons, limes, tomatoes or lettuce, but it will be several weeks before his strength is restored. The bleeding gums, which are so characteristic of adult scurvy, are not seen in toothless infants, so the diagnosis is easily missed. Infection causes local vita-min C deficiency and vitamin C deficiency predisposes to infection, so a vicious cycle develops. Clearly it is the bacteria in the crevice between the tooth and the gum that cause a local infection leading to the foul mouth and the swollen bleeding gums of adult scurvy. This does not occur in edentulous infants.

Borderline Vitamin C Deficiency

There is a wide separation between frank scurvy and perfect health, and this is becoming more and more apparent as we learn about the underlying defects in vita-min C deficiency.
Bleeding from the smallest blood vessels, the capillaries and small venules is the prin-cipal manifestation of the disease; this is due to a weakness of the blood vessel wall and not the result of any defect in the blood co-agulation system. Several tests have been used to measure capillary fragility, the strength or weakness of the small blood vessels, by count-ing the number of small pinpoint hemorrhages or petechiae produced by suc-tion on the skin of the arm or by venous oc-clusion, but these tests for vitamin C deple-tion are rendered unreliable by the fact that so many other conditions such as thrombo-cytopenic purpura, measles and scarlet fever also cause capillary fragility and petechial hemorrhages. Only by chemical analysis can we tell for sure whether petechial hemorrhages are due to vitamin C deficiency or to something else. The word scurvy is used only for the almost complete absence of vita-min C from the blood and tissues, when fibroblasts and the related osteoblasts, chondroblasts and odontoblast cells can no longer manufacture collagen, the foundation matrix for connective tissue, bone, cartilage and tooth dentin respectively. But we now know that lesser degrees of vitamin C deple-tion cause the accumulation of histamine in the blood, and this causes weakness of the capillary blood vessels by separating the cells of the vascular intima from one another.

Histamine accumulation dissolves the inter cellular cement; this increase in the blood histamine level begins as soon as the blood plasma vitamin C level begins to fall below the normal level of 1.0 mg/100 ml; frank scurvy does not occur until the vita-min C level falls to one tenth of that value.
The plasma vitamin C status of the general population is much poorer than is generally appreciated, being below 0.7 mg/100 ml in 34 per cent of ambulant people in Brooklyn, New York;1 below 0.5 mg/100 ml in 30 per cent and below 0.2 mg/100 ml in 6 percent of people attending a Health Maintenance Organization (HMO) clinic in Tempe, Arizona.2 Likewise the National Health and Nutrition Examination Survey3 for the years 1988-94 revealed plasma vitamin C (or ascorbic acid) deficiency (<0.2 mg/100 ml) in 12 percent of Caucasians, 15 per cent of African Americans and 9 per cent of Mexican Americans. So we must not assume that small capillary hemorrhages in the retina are due to child abuse; they could be due to vitamin C depletion or to many other factors which in-crease the blood histamine level.

Vaccinations and Inoculations

We now know that vaccinations and inoculations cause increased blood histamine levels, as can many systemic infections and other illnesses, so an infant already low in vitamin C will have its blood histamine level further increased by any such insult. Undoubtedly this accounts for the fact that vitamin C supplementation markedly reduces the risk of death following immunization or vaccination in rats, mice, guinea pigs and human infants; vita-min C reduces the blood histamine level.

Medical Prejudice

Physicians are just like other people: they believe only what they want to believe and they are spoon-fed by the major medical journals. It would seem that the editors of most medical journals do not want to publish any article discussing the risks of inoculations. They would like to see a higher percentage of children being immunized and they are afraid that any talk of risks could frighten parents away. I submitted a review of the literature proving quite conclusively that vitamin C can be used to reduce the risk of death or brain damage following inoculations, both in animals and in human infants, but nine of the major English language medical journals refused to publish it. The reviewers must be unaware that vitamin C deficiency still occurs in the modem world. My article was eventually published the open-minded editors of The Journal of Orthomolecular Medicine, (Volume 14, no 3, pages 137-142) in 1999. Unfortunately this excellent journal has, as yet, a relatively small circulation, so the truth is not yet well known.

Infant Nutrition

Bottle-fed infants need a vitamin C supplement with their milk diet and this can be readily provided by giving them a bottle of orange juice every day, as one hundred grams of fresh orange juice con-tains about 49 mg of vitamin C. Nowadays the fashion is to give them apple juice, in-stead of orange juice, but apple juice con-tains only I mg of vitamin C in the same volume of juice. So unless the parent knows to buy apple juice with added vitamin C, there can be a risk of vitamin C deficiency.
Another problem to be considered is that the white blood cell or leukocyte C level is halved within 24 hours after the development of a head cold, and even more during the healing of an injury. Moreover, heavy metals like mercury and even ex-cesses of copper or iron can deplete vita-min C stores, so one has to wonder about the effect of the mercury-based, additive thimerosol used as an antiseptic in some pediatric inoculants. Suffice it to say that it is probably wise to postpone vaccinations and inoculations for any premature or sickly infant; moreover, a 500 mg vitamin C supplement should be given in orange juice before or at the time of an inoculationto any healthy infant. Extensive studies have been conducted to ascertain the presence or absence of toxicity for each individual inoculant, but now that we recognize the toxic effects of elevated blood histamine lev-els resulting from inoculations, we must consider the additive toxic effect of all the inoculants taken together. So many inoculants are given together nowadays.
Moreover, the parents should not be held responsible for “Shaken Baby Syndrome” just because an infant convulses or dies with petechial hemorrhages in the retina within a week or two after receiving the usual inoculations. Even some American soldiers going to the Gulf War suffered grievous consequences following the battery of inoculations they received. Elevated tissue histamine levels cause asthma, hay fever, nettle rash or angioneurotic edema, but elevated blood histamine levels cause endothelial damage and capillary fragility throughout the body.

Laboratory Analysis

Very few hospital laboratories routinely do blood plasma analysis for vitamin C and any spot analysis done by special order can be very unreliable. One of the reasons for their unreliability is that vitamin C (ascorbic acid) crystals or powder, is hygroscopic and can double its weight with moisture.
So when comparing test results with internal or external standards, it is essential that the ascorbic acid standard powder be dried over calcium chloride in a desiccator, for a week or so, without heating. Otherwise the results of analysis can give falsely high values.

References

1.
Clemetson, C. Alan, Vitamin C, CRC Press, Boca Raton, Florida, 1989.
2.
Johnston, Thomson: Vitamin C Status of an Out-patient population. J Am Coll Nutr, 1998; 17(4): 366-70.
3.
The Third National Health and Nutrition Exami-nation Survey 1988-94 (NHANES III) http:// www.cehn.org/cehn/resourceguide/ nhanes.html

Source:

http://www.orthomolecular.org/library/jom/2002/pdf/2002-v17n04-p193.pdf

The Evidence Base For Shaken Baby Syndrome – Authors Reply

J F Geddes, retired (formerly reader in clinical neuropathology, Queen Mary, University of London)

London ; Email: j.f.geddes@doctors.org.uk

J Plunkett, forensic pathologist

Regina Medical Center, 1175 Nininger Road, Hastings, MN 55033, USA

___________________________________________________________________________________________

It is difficult to understand how Reece et al could interpret our editorial as displaying “a worrisome and persistent bias against the diagnosis of child abuse in general.” Child abuse exists, and we know and attest that it exists. In fact, one of us (JP) has testified before the Minnesota State House and Senate on the need for “mandated reporting” laws. The editorial does not discuss “child abuse in general.”

Child abuse exists in many forms: our editorial addresses the diagnostic criteria for a specific type of abuse, the so-called shaken baby syndrome. We emphasise, as have Donohoe and Lantz et al, that the literature to support a diagnosis of shaken baby syndrome/inflicted head injury is based on imprecise and ill-defined criteria, biased selection, circular reasoning, inappropriate controls, and conclusions that overstep the data. If it is the questioning of the criteria that is worrisome, we will continue to do so and to cause worry.

We omit “the most important element in this condition: brain injury itself” because there is little scientifically acceptable evidence that “shaking” causes primary traumatic brain injury except under laboratory conditions. Detailed neuropathological studies have shown that apart from the craniocervical junction, the brain is seldom damaged even in those deaths thought to be due to “shaking.” Furthermore, the “research” referenced by the authors is misstated, misused, and remarkably selective. The diagnosis of non-accidental trauma in the authors’ cited studies is based on “assessment of the child protection committee,” “multidisciplinary child protective team…or the forensic pathologist of the state medical examiner,” or “multidisciplinary team consensus.” We would no longer even use “the inclusion criteria of Geddes et al” for the reasons stated below. None of the above studies provides objective, reproducible criteria for case selection needed to evaluate methods of case selection, arrive at meaningful conclusions, or allow cross-study comparisons. These are exactly the concerns of Donohoe and Lantz et al., and the focus of our comments. Furthermore, two of the studies stated by the authors to show that “30% to 40% of newly diagnosed shaken baby cases had medical evidence of previously diagnosed head injury” do not even discuss this issue: Alexander et al describe impact trauma in association with shaken baby syndrome, while Kemp et al relate outcome to initial presentation.

We have ourselves previously used confession and criminal conviction as criteria to support a diagnosis of abuse, including “shaking.” However, we would no longer do so. A person may confess for a variety of reasons, and even when properly assessed, a confession must be interpreted cautiously if it is used as “evidence” to prove a medical hypothesis. In the field of child abuse, the carer being told that the only way in which injury was possible was by shaking, or that the charge will be reduced if the carer confesses, may influence a confession. In the family courts a confession may prevent children being sent into care. Unless we have full details of the type of legal proceedings involved, the stage at which confession was made, whether a lighter sentence was passed, or whether it was a plea to get parole¾ all of which are highly relevant¾ the use of a confession to support a scientific argument is unsound. How does one reconcile “confession to shaking” with the fact that more than 50% of the infants in the study by Kemp et al had overt evidence for impact head injury?

If, as the authors state, in “crushing head injuries, as in Lantz et al’s report… child abuse is not a consideration” why was this injury initially considered “highly suspicious” for child abuse on the bais of the ocular findings, and why was the older sibling removed from the home because the eye findings were considered pathognomonic of shaken baby syndrome? The current American Academy of Ophthalmology website on ocular involvement in shaken baby syndrome, as in Lantz et al’s report contains the following statement: “When extensive retinal hemorrhage accompanied by perimacular folds and schisis cavities is found in association with intracranial hemorrhage or other evidence of trauma to the brain in an infant, shaking injury can be diagnosed with confidence regardless of other circumstances” (our italics). If shaken baby syndrome is “old news” why does a child abuse specialist believe that a diagnosis of an accidental injury is valid only if the incident is witnessed by a non-family member, and then create a scenario to fit a formulated belief system of infant head injury, shaken baby syndrome?

The primary objective of our editorial was to bring readers’ attention to one new and one recent study relating to infant head trauma, a specific subcategory of child abuse and to voice concerns about the quality of the scientific information available in the literature. We encouraged the readers to evaluate critically the evidentiary basis for a diagnosis of shaken baby syndrome in the light of the questions raised by the two papers. Of course Donohoe’s study was limited and would only retrieve papers that included the words “shaken baby syndrome” in the title, key words, or abstract. Nevertheless, his search did produce a number of articles that are commonly cited as authoritative in the pre-1999 literature. The important thing is that the lack of scientific rigour that he identified is not restricted to infant head injury papers that specifically mention shaken baby syndrome. If Reece et al perform a critical review of the “number of qualified studies” that they assert would have been included by a wider search they will encounter the same “data gaps, flaws of logic, and inconsistency of case definition” that were present in the literature studied Donohoe. We would urge them to look again, for example, at the paper they cite by Alexander et al, where they will find all the above shortcomings.

Evidence-based medicine (EBM) is a tool, not a panacea, to be sure. However, it is a method that encourages rigorous evaluation of what has been published, and what we believe to be true. Does this mean that anecdote cannot be valued? That small non-controlled studies cannot be one basis for evaluating or treating a patient? That “consensus statements” by “experts” cannot guide us? No. It does, however, mean that we must recognise when a diagnosis and treatment recommendation are a belief system, not a scientific truth. It does mean that we must be ever vigilant to recognise and to attest when “the Emperor is wearing no clothes.” The authors implied difficulty in performing valid studies on diagnostic specificity or casual mechanisms does not excuse poorly designed observational studies or conclusions that overstep the data. Association does not equal causation.

Finally, we are at a loss to explain or accept the authors’ statement in their penultimate sentence: “Unfortunately, there remains considerable difficulty for some doctors to accept that children are abused.” If the authors are suggesting that we are among those doctors, or are encouraging others to do so, their argument is a willful misinterpretation of what we have written. When there is new evidence that challenges an established conviction, medicine has the responsibility to critically evaluate the data, and if verifiable, reflect that change. We must have no vested interest in yesterday’s belief. We are encouraging doctors to think clearly and critically, even in an area as emotive as child abuse. No more. And no less.

1. Donohoe M. Evidence-based medicine and shaken baby syndrome. Part I: literature review, 1966-1998. Am J Forensic Med Pathol 2003;24:239-42.
2. Lantz PE, Sinal SH, Stanton CA, Weaver RG, Jr. Perimacular retinal folds from childhood head trauma. BMJ 2004;328:754-6. (27 March.)
3. 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;124:1299-306
4. Ewing-Cobbs L, Kramer L, Prasad M, et al. Neuroimaging, physical and developmental findings after inflicted and non-inflicted traumatic brain injury in young children. Pediatrics 1998;102:300-7.
5. Alexander R, Sato Y, Smith W, Bennett T. Incidence of impact trauma with cranial injuries ascribed to shaking. Am J Dis Child 1990;144:724-6.
6. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. JAMA 1999;282:621-6.
7. Kemp AM, Stoodley N, Cobley C, Coles L, Kemp KW. Apnoea and brain swelling in non-accidental head injury. Arch Dis Child 2003;88:472-6.
8. Esernio-Jenssen DD. Killer televisions. Electronic response to: Perimacular retinal folds from childhood head trauma. http://bmj.bmjjournals.com/cgi/eletters/328/7442/754#55167 (accessed 20 May).
9. Lantz PE. Re: Killer televisions. Electronic response to: Perimacular retinal folds from childhood head trauma. http://bmj.bmjjournals.com/cgi/eletters/328/7442/754#55418 (accessed 20 May 2004).

Source:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC420182/bin/bmj_328_7451_1317__.html

Persecuted Parents Or Protected Children?

Allegations cost their reputations, their money and nearly their kids

Wednesday, August 7, 2002

By CAROL SMITH
SEATTLE POST-INTELLIGENCER REPORTER

The pounding on the door late that August night set Chris Brooker’s heart hammering.

He and his wife were just getting ready for bed. His stepdaughter and grandson, who lived with them, had gone to Disneyland and the older couple were enjoying the unaccustomed peace of an evening alone.

Now four police cars were blockading the street in front of his house, their flashing lights creating an eerie strobe against the Renton neighborhood’s modest split-levels.

Brooker opened the door and stared into the face of a beefy detective, one hand on his holster, the other thrusting out a warrant. He was flanked by three more officers.

	Christopher Bateman and his mom, Michelle, cut out a paper airplane. Bateman was accused by Dr. Kenneth Feldman of intentionally poisoning her son. Bateman lost custody of her son until a CPS inquiry cleared her. Grant M. Haller / Seattle Post-Intelligencer Click for larger photo

They came to take Brooker’s 4-year-old grandson into protective custody.

And to gather evidence against the person accused of poisoning him — the boy’s mother.

With that, the Brookers plunged down a rabbit hole of accusations into the bizarre world of Munchausen syndrome by proxy. It would take nearly three years and $100,000 in legal fees to find their way out and clear their daughter’s name.

They blame their odyssey on a Seattle pediatrician named Kenneth Feldman.

So do at least five other families who claim they, too, were victimized by a misdiagnosis that ripped apart their lives.

Feldman, one of Washington’s top child-abuse experts, considers himself an authority on Munchausen by proxy — a controversial mental illness that drives mothers to deliberately make their children sick, or falsify symptoms, in order to get attention for themselves. Fathers are almost never diagnosed with the disorder.

Many experts believe the syndrome to be rare, but Feldman is convinced otherwise. During the last 25 years, he’s been involved in more than 100 Munchausen cases — far more than any other doctor in the state.

Because Feldman works for Children’s Hospital and Medical Center in Seattle and consults for the state’s Child Protective Services agency, those allegations invariably trigger strong emergency responses, often resulting in the removal of young children, at least temporarily, from their homes.

It’s that power that is now being publicly questioned. At least five families have sued Feldman over the past six years, claiming he was negligent or reckless in misdiagnosing Munchausen by proxy. In each case, CPS investigators found no evidence of Munchausen, poisoning or any other abuse. Children were returned, cases closed. Never were any criminal charges filed.

P-I Special Report Read more

But the consequences were severe: One family lost a child they were in the process of adopting. Others spent their life savings getting their kids back, undergoing intense psychiatric testing.

“It was like the Salem witch hunts,” Brooker said. “You are guilty until proven innocent.”Once a mother is labeled a Munchausen by proxy suspect the stigma is severe. The suspicions follow families, often from state to state. They become pariahs in their communities. They fear taking sick children to the doctor. Some children are traumatized from forced separations.

Feldman has so far escaped legal penalties or sanctions because he’s required to report suspected abuse, and he’s protected even if he’s wrong.

On the advice of his attorney, Feldman won’t say whether he has ever been wrong or changed his mind regarding a Munchausen case.

“It’s always a balancing act when you’re dealing with the safety of the child versus the family’s integrity and the family’s well-being,” he said in a recent interview. “We do our best to narrow the level of uncertainty.”

But other experts who have reviewed the cases are convinced Feldman’s conclusions distorted the evidence, unfairly implicating parents.

“It looks to me like there is a big epidemic of Munchausen surrounding Dr. Feldman,” said Dr. Gil Kliman, a San Francisco psychiatrist who testified against Feldman in several of the lawsuits.

“Even if he were seeing a million patients a year, he couldn’t diagnose that many,” said Tom Ryan, an Arizona attorney who has handled dozens of cases in which mothers have been falsely accused of having Munchausen by proxy.

While Feldman believes most pediatricians have undetected Munchausen-by-proxy parents in their caseloads, he’s claimed in depositions to have seen an equal number of cases in which he’s ruled out the syndrome. Because there’s no central place where documented cases are reported, it’s impossible to tell how common Munchausen by proxy is. Estimates by experts range from 1 in a million to 2.5 in 100,000.

Prosecutions of Munchausen cases are rare as well. King County authorities could only recall one or two criminal prosecutions in the past 20 years.

The rate of Feldman’s allegations so alarmed Kliman that he filed a complaint with CPS, citing the “error rate Dr. Feldman has in making this diagnosis, and the frequency with which the children have other causes for their conditions.”

All of the children involved in the cases that triggered lawsuits had been or were eventually diagnosed with verifiable diseases or disorders that explained their symptoms. One child, for example, was later diagnosed with cerebral palsy, after her mother was first suspected of Munchausen.

When the lawsuits came, Feldman claimed immunity under child-protection reporting laws and won. The cases were dismissed before trial.

As a physician, Feldman is a “mandated reporter,” which means he’s legally required to report abuse if he has “reasonable cause to believe” that a child is being harmed. He doesn’t need proof, and if he makes a mistake, unlike a treating physician, he can’t be held accountable for a wrong diagnosis and its aftermath. In the most recently appealed case, however, Washington Court of Appeals Judge Kenneth Kato wrote a stinging dissent.

	Ida Brooker, left, and her husband, Chris, second from right, spent $100,000 clearing their daughter, Michelle Bateman, of accusations that she abused her son, Christopher. Grant M. Haller / Seattle Post-Intelligencer Click for larger photo

“Dr. Feldman apparently has a penchant for diagnosing (or misdiagnosing) MSBP, notwithstanding its rarity and his questioned qualifications to make that diagnosis,” Kato wrote in May. “Whether the doctor acted in good faith cannot be determined as a matter of law in these circumstances. It is a question for the jury to decide, not the court.”

Lawyers for the family that filed the appeal are now asking the state Supreme Court to review the case. A decision is expected within a few weeks.

The families who have dealt with the Munchausen allegations say they’ve suffered emotionally and financially. They want Feldman, CPS and Children’s Hospital to be held accountable.

Doug and Melissa de Jong lost their daughter for six months in 1997 when she was still breast-feeding. They spent $17,000, maxing out their credit cards in the process, to handle legal fees.The experience was so distressing they moved to Birch Bay, Wash., to be away from the Seattle doctors. Their daughter was eventually diagnosed with cerebral palsy.”We’re still to this day paying for it, emotionally and financially,” said Doug de Jong. “They put the burden of proof on the parents to prove our innocence.”

Dena Royal can no longer find a local pediatrician willing to treat her three school-age children, two of whom have chronic medical problems, because of the stigma of suspected Munchausen.CPS closed its investigation of her family in April after preliminary tests showed many of one son’s unusual symptoms may be the result of a rare genetic disorder. Even though the case was closed as unfounded, Feldman has refused to remove the red child abuse alert on her children’s medical charts at Children’s, where her kids see specialists. Royal feels the alert is affecting their medical care by making specialists fearful to pursue tests as questions arise.”It’s like being branded with a big scarlet letter,” she said.

Kevin and Nancy Grennan traveled from Illinois to see specialists at Children’s in 1995 in hopes of curing their daughter’s epilepsy. Previous treatments hadn’t alleviated the seizures, which were affecting her ability to speak.Instead, Feldman reported the case to Illinois child-protection authorities and they lost their daughter for three months. They spent about $30,000 before the child-abuse case was closed.

Robert and Kristi Yuille were planning to raise a family on their ranch in Republic, Wash., when Munchausen allegations derailed the dream. A baby they were in the process of adopting was taken away in 1996 after living with them for nearly a year.Although CPS closed the case, the Yuilles had to sell their ranch to fund their legal battle to get the baby back. They never did.In each case, the families got swept into the child protection system with no independent evaluation of whether Feldman had made the right call.Indeed, Feldman himself admits in court documents that as a pediatrician, he is not qualified to assess the mental health of the mother, which would require a psychiatric evaluation.Yet when a parent suspected of Munchausen is reported to CPS, the agency calls on a list of medical specialists to evaluate the case. Because of his reputation, Feldman is the specialist most frequently called.CPS said the lawsuits haven’t affected Feldman’s standing as a consultant. “You are innocent until proven guilty,” said Bernie Friedman, a risk-management official with the agency.

Feldman reviews the child’s medical history looking for “inconsistency and elaborations” or outright falsifications. He admits he doesn’t always have access to all the child’s medical records.

He usually doesn’t interview the mother because he says the mothers, by definition, will misrepresent the situation. But he will sometimes try to interview another family member about her. Sometimes, he also recommends covert video surveillance during hospitalization to catch the mother in the act of harming her child.

If Feldman decides the mother likely has Munchausen by proxy, the agency mounts a full child-abuse response, typically removing the child from the home pending a dependency hearing. In most cases, parents have to find and pay for their own second opinions to get their children back.

Feldman is paid for his consultations with CPS through a consulting contract funded by the state and managed by the University of Washington. He is also one of the main medical advisers to the Child Protection Team at Children’s.

Typically, the team meets to discuss the case before making a referral. Outsiders, such as the child’s regular doctors, may be invited to that meeting. Feldman reports his findings to the team.

“He’s viewed as someone with an awful lot of expertise and because of his report, his expertise needs to be listened to carefully,” said Dr. Richard Molteni, medical director at Children’s.

Angry accused parents and lawsuits come with the territory of child-abuse consulting, Molteni said. So does the risk of being wrong.

“I know what it must feel like to be accused unjustly,” Molteni said. “I also understand the consequence of not doing that. … It’s a lot harder to look a relative in the face and have to say I’m sorry we didn’t report (suspected abuse) when we had the chance and now a child is dead.”

Critics say there aren’t enough safeguards built into the system.

“The destructive force it unleashes on these families is tremendous,” Ryan said. “It’s like being sucked into a black hole. … The state can expend millions and the poor family is absolutely overwhelmed.”

Poisoned perceptions

That was true for Michelle Bateman and her parents, the Brookers.

As police meticulously searched their house, even rifling through their spice drawers, the stunned grandparents tried to piece together what was happening.

Police eventually found what would become a key piece of evidence against their daughter: a small bottle of syrup of ipecac.

Ipecac is a common first-aid supply used to induce vomiting in accidental poisonings and found in most households with young children. The bottle, still sealed and past its expiration date, was on the top shelf of the family’s hall medicine cabinet.

Bateman was 20 when her son, Christopher, was born. Unmarried, she and her baby lived with the Brookers so she could go to nursing school.But the baby was fussy and uncomfortable nearly from birth, said Ida Brooker, who recalls walking the inconsolable baby for hours before dawn. The family grew increasingly frustrated as doctors couldn’t help them.

Finally, they were referred to Dr. Ross Kendall, a pediatric gastroenterologist at Mary Bridge Children’s Hospital and Health Center in Tacoma. Although he diagnosed Christopher with cyclic vomiting stemming from abdominal migraines and started him on medication, he admitted in depositions that he suspected Bateman of Munchausen from the start.

	Doctors say their suspicions that Michelle Bateman suffered from Munchausen syndrome by proxy were triggered by Christopher’s many trips to the hospital. Grant M. Haller / Seattle Post-Intelligencer Click for larger photo

Her “hostility” to people who suggested other diagnoses, persistent doctor visits and Christopher’s lack of response to treatment reinforced this belief, he said later in court documents, noting: “Mother fits the profile.” Over the next two years, without telling the family, he began testing Christopher’s urine for ipecac to see if Bateman was intentionally dosing him to make him vomit.

After three times, a test came back positive. Kendall reported Bateman to state authorities. And CPS went to Feldman.

Without seeing Christopher or talking to Bateman, and based on his own reading of certain records and discussions with Kendall, Feldman told CPS, “Christopher clearly fits the primary criteria for Munchausen syndrome by proxy.” He based part of his assessment on her repeated trips to the emergency room to treat Christopher’s vomiting. Yet Kendall’s orders were that she was to take him to the ER after each episode for IV infusions of an experimental drug called Kytril.

The ipecac test also figured prominently in Feldman’s analysis, even though toxicologists say it cannot distinguish ipecac from pseudoephedrine, a common cold medicine ingredient Christopher was taking on Kendall’s advice.

Based on Feldman’s recommendation, the state removed Christopher from his home.

Bateman was devastated. So was Chris Brooker, who recalls breaking down on his front porch that day.

“I just sat out there and cried for two hours,” he said.

To mount a legal defense, Ida cashed in her Boeing retirement fund. He sold stock and other assets, including a cherished collection of rare military helmet plates.

They petitioned the court to become Christopher’s legal guardians and won, but only on the condition that Bateman move out and her visits be restricted to two hours a week. For the next 2 1/2 years, she was supervised and tested by CPS until authorities were finally satisfied she didn’t have Munchausen and closed the case in 1999.

Christopher, now 10, is still in counseling to deal with the experience.

According to the family, Kendall contacted them years later through their attorney and apologized for “the inconvenience” he had caused them.

“I lost my child, my home, my job, my parents. My son lost his mother, his home and his security,” Bateman said. “That’s an inconvenience?”

Kendall could not be reached for comment. Feldman, who declined to discuss specific cases, has never contacted the family.

Many parents fit ‘profile’

Bateman’s case illustrates the dangers of “profiling” parents, experts said. Parents of very sick children, young or anxious parents, or those who advocate aggressively for their children all “fit” the profile of people suffering from Munchausen by proxy.Those who seek multiple opinions, who have worked in the medical field, or who go to the doctor frequently also fit, as do those whose children have multiple illnesses that don’t match known syndromes.

Some specialists point out that many of their patients’ mothers have been accused of Munchausen before their children were eventually diagnosed with unusual disorders.A parent who is calm in the face of serious difficulties, or one who gets extremely angry and demanding both fit the profile. Also fitting the profile are parents of sick children who frequently acquire detailed knowledge about diseases, leading them to appear “obsessed” with their children’s disorders.

And in a particularly Kafkaesque twist, denial that you have Munchausen is a sign you have it.

“There are individuals who see Munchausen by proxy around every corner,” said Dr. Marc Feldman (no relation), an Alabama psychiatrist who has testified on both sides of those cases.

“Some people became intrigued with the novelty and drama of it and have sought to establish themselves rapidly as experts in the field,” he said. “One way to do that is to say you’ve seen a whole lot of cases.”

But that doesn’t mean all those reported cases were truly Munchausen.

“It can lead to pinhole vision, where only those features that matched Munchausen by proxy were commented on and all information contrary to the diagnosis was disregarded,” he said.

Being sued five times for alleged misdiagnoses, he said, should raise red flags.

“That’s pretty high,” he said. “If I’d been sued five times for anything, I would probably ask for supervision for my work before I proceeded.”

Molteni, of Children’s Hospital, stands behind Kenneth Feldman’s work, saying that despite the lawsuits and complaints there’s no need for any additional review or auditing of the Munchausen diagnoses.

But in recent years, a half-dozen families have complained about Feldman to the state licensing board alleging unprofessional conduct related to misdiagnosing the disorder. In five of those cases, the Washington State Medical Quality Commission closed the complaints after reviewing Feldman’s explanations for his actions, asking for no further review. One case is still under investigation.

A strong advocate

None of this fazes Feldman, who lectures around the region on the threat of Munchausen by proxy.

Bespectacled and soft-spoken, Feldman, 58, betrays little of the passion that has given him a reputation as a tireless advocate for children’s welfare. He doesn’t flinch at criticism, but admits to being wearied by the relentless legal challenges. “It’s stressful to be involved in any way, let’s just leave it at that,” he said. “But someone has to do it.”

Feldman, who went to medical school in his home state of Wisconsin, came to Seattle in 1970 as an intern in pediatrics at Children’s. Over the years, the father of two increasingly focused on childhood-injury prevention. He claims to have seen his first case of Munchausen by proxy in the ’70s before the phrase was even coined.

Today, he divides his time between his work in general pediatrics at Children’s, research and child-abuse consulting and work with low-income families.

He operates out of a cramped, windowless office at Children’s, lined with case files. The Munchausen database he keeps is one of the only ones like it in the country.

“He’s a pioneer in Munchausen,” said his former teacher, Dr. Abe Bergman, a pediatrician at Harborview Medical Center and head of the child abuse medical consulting network run by the University of Washington, through which Feldman consults.

Feldman, whom Bergman said was a conscientious objector during the Vietnam War, is accustomed to fighting for causes he believes in.

His research on the effect of water heater settings on scalding injuries has been credited with reducing the national incidence of tap-water burns. In the mid-’80s, he fought to get legislation passed that reduced settings on water heaters.

Admirers say Feldman is a brilliant diagnostician.

“He knows every rare disease,” said Bergman. “His mind is like a computer.”

Feldman said he deals aggressively with suspected Munchausen cases because children are in grave danger. “About 1,200 kids will sustain new events of suffocation and poisoning in the United States this year,” he said. “And that’s probably an underestimate.”

Children should not be reunited with mothers who’ve been diagnosed with Munchausen, he said. And he faults the courts for returning them.

“It’s hard for the court system to get a handle on this,” he said. “Juries tend to believe a parent wouldn’t do it. Judges tend to believe they wouldn’t do it.

“Children are usually returned. But that doesn’t obviate the diagnosis.”

Families call for oversight

Given the murky nature of most Munchausen cases, some experts are calling for more oversight before a child is removed from his parent.

One solution is to get rid of the label altogether. If a parent is suspected of harming a child, investigate it as a criminal assault case, not a vague psychiatric condition, some experts say.

Others say the state should not let a pediatrician alone make what is essentially a mental health assessment. And before a child is removed from a home, the family should have the opportunity to get an independent assessment.

Experts also recommend that all records be scrutinized in determining whether a mother has lied or mischaracterized her child’s medical history, not just some of them.

“Munchausen by proxy should be diagnosed based on objective signs and symptoms, not based on one’s impression of the parent,” said Marc Feldman, the psychiatrist.

The families that have sued Kenneth Feldman argue that there needs to be some way to hold him accountable. “I understand the need to protect our children, but the way the system is set up there are severe penalties if you don’t report, but nothing on the other side,” said Doug deJong, who nearly lost his daughter to a Munchausen allegation.

“If you falsely accuse or make a mistake, there is no penalty. There’s no incentive to be careful.”

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P-I reporter Carol Smith can be reached at 206-448-8070 or carolsmith@seattlepi.com

Source:

http://www.seattlepi.com/local/81574_munchausen07.shtml

More Than Half of Pediatricians Make Diagnostic Errors, Study Says

by Honey Berk Jun 22nd 2010 4:00PM

Maybe it’s time to rethink that age-old “doctor-is-god” stereotype.

Fifty-four percent of pediatricians say they make diagnostic errors at least once or twice per month, according to a new survey of more than 700 pediatricians and pediatric trainees.

The data for trainees was even more striking, with 77 percent admitting they make errors at least once or twice per month. And nearly half of the pediatricians surveyed say their errors harm patients at least once or twice per year.

However, according to Business Week, researchers did not ask the extent of the harm and said they didn’t have enough information to gauge the seriousness of it. But the authors say previous research points to the existence of diagnostic errors in 32 percent of pediatric malpractice claims.

“These are perceptions and much more research has to be done to really delineate how often this happens,” senior study author Dr. Geeta Singhal, of Baylor College of Medicine, tells Business Week.

Diagnostic errors typically include those that are delayed, wrong or missed, Business Week reports. Those detailed in the study involve a range of activities, from prescribing, dispensing and administering medications to surgery- and anesthesia-related activities that occur in the operating room.

The most frequent diagnostic error reported was viral illnesses being misidentified as bacterial illnesses, according to the study — so stop feeling guilty for thinking your child’s last bout with strep throat was just a cold. Other diagnostic errors frequently reported were the misdiagnosis of medication side effects, psychiatric disorders and appendicitis.

Pediatricians surveyed most often cited a failure to gather information through medical history, exam or chart review as the cause of errors. Other causes of misdiagnoses included failure of parents to seek care for their child in a timely manner, failure to follow up on abnormal lab tests and parents ignoring follow-up recommendations, Business Week reports.

Physicians say closer follow up of patients and improved teamwork between practitioners would decrease the likelihood of errors, as would improving access to information through electronic health records and diagnostic decision-support tools, according to the authors.

Singhal tells BusinessWeek that parents who are unsure of a diagnosis should be encouraged to ask for more information or seek a second opinion, since physicians are not always right.

“It’s important to me as a pediatrician and as a mom to empower our patients and our families to ask good questions of their physicians,” Singhal tells the magazine. “If they are not comfortable with the diagnosis, it’s OK to ask the doctor to elaborate more or help them understand better.”

Source:

http://www.parentdish.com/2010/06/22/more-than-half-of-pediatricians-make-diagnostic-errors-study-sa/

Cutaneous Mimickers Of Child Abuse: A Primer For Pediatricians

Mohammed AlJasser¹ and Sultan Al-Khenaizan¹

(1)	Division of Dermatology, Department of Medicine, King Saud Bin Abdulaziz University for Health Sciences and King Fahad National Guard Hospital, King Abdulaziz Medical City, P.O. Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia

Sultan Al-Khenaizan Email: khenaizans@ngha.med.sa

Received: 1 April 2008  Accepted: 26 June 2008  Published online: 26 July 2008

Abstract

The annual incidence of child abuse was estimated to be 2.8 million by the national incidence study conducted in the USA in 1993, which is a two-fold increase compared to 1986. Awareness of child abuse has been increasing since the 1960s. Although most victims of child abuse present with cutaneous lesions, many genuine skin diseases may appear as non-accidental injuries which, if not recognized, may lead to misdiagnosis of child abuse. Here, we review the most common cutaneous mimickers of child abuse in order to increase awareness of these disorders and reduce erroneous diagnosis of child abuse.

Introduction

Child abuse is defined by the Child Abuse Prevention and Treatment Act as a recent act or failure to act that results in death, serious physical, or emotional harm, sexual abuse or exploitation, or imminent risk of serious harm; involves a child; and is carried out by a parent or caregiver who is responsible for the child’s welfare [2]. Child sexual abuse is defined as the employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or the rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children [2]. Awareness of child abuse has been increasing since the 1960s [39]. The annual incidence of child abuse was estimated to be 2.8 million by the national incidence study conducted in the USA in 1993, which is twofold increase compared to 1986 [1]. In 2006, an estimated 3.6 million children were the subject of an investigation by child protective services agencies [4]. An abused child has approximately a 50% chance of being abused again and has an increased risk of dying if the abuser is not caught and stopped after the first presentation. Such figures indicate that the early diagnosis of child abuse is of great importance [48, 50]. Despite advancements in diagnosing child abuse, mistakes in diagnosis still occur. Because skin lesions are one of the most common presentations of child abuse, the findings of unexplained skin changes are alarming to healthcare workers, and if not correctly identified as cutaneous mimickers of child abuse, a false diagnosis of child abuse may—and do—result [22]. Such misdiagnoses can lead to serious consequences to the child, the family, and the falsely accused [19]. Irrefutable physical findings of sexual abuse occur in less than 10% of all cases [38]. Thus, the medical history, in addition to a thorough medical examination, takes on an importance of enormous proportions in both physical and sexual maltreatment cases [56]. Although skin diseases are the most common mimickers of child abuse, other non-dermatologic conditions (such as osteogenesis imperfecta) may also take on this role. There are many reviews that have tackled the subject of cutaneous manifestation of child abuse, but only few have discussed cutaneous mimickers of child abuse. This review will be limited to the most important cutaneous mimickers of child abuse, which can be classified into mimickers of physical abuse and mimickers of sexual abuse (Table 1). We hope that this review will increase the awareness of healthcare workers of different specialties of these presentations and decrease the incidence of the bitter experience of false accusations of child abuse.

Table 1 Classification of cutaneous mimickers of child abuse

Mimickers of physical abuse	Mimickers of sexual abuse
Linear eruptions	Lichen sclerosus et atrophicus
Inflammatory linear verrucous epidermal nevus	Anogenital warts
Allergic contact dermatitis	Perianal streptococcal cellulitis and streptococcal
Stretch marks	vulvovaginitis
Phytophotodermatitis	Genital herpes zoster
	Vulvitis circumscripta plasmacellularis
Non-linear eruptions	Perianal and vulvar Crohn’s disease
Mongolian spots
Hemangiomas
Henoch-Schönlein Purpura
Urticaria pigmentosa
Dermatitis artefacta
X-linked icthyosis
Bullous impetigo
Congenital blistering diseases
Acquired blistering diseases
Neuroblastoma

Mimickers of physical abuse

Linear eruptions

Because of their linearity, most linear eruptions can raise the suspicion of child abuse as many of them occur particularly in children. Pediatricians should be aware that not all linear skin lesions are externally induced and that genuine skin diseases may present in linear fashion.

Inflammatory linear verrucous epidermal nevus   Inflammatory linear verrucous epidermal nevus (ILVEN) is a relatively rare linear psoriasiform papules and plaques with the majority of cases appearing before the age of 5 years (Fig. 1). This condition is more common in females. It most commonly affects the extremities and occasionally the trunk and is usually unilateral. In addition to its linearity, ILVEN is red and itchy. Misdiagnosis of ILVEN as child abuse has been reported before [53].

Fig. 1 Inflammatory linear verrucous epidermal nevus. Well-defined linear erythematous scaly papules involving the dorsal aspect of the hand

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Allergic contact dermatitis   Allergic contact dermatitis (ACD) is a delayed-type hypersensitivity reaction that is elicited when the skin comes in contact with an allergen to which an individual has previously been sensitized. Acute ACD usually presents with a well-demarcated pruritic eczematous eruption with or without blistering. Lesions are typically limited to the site of contact with the allergen. In children, acute ACD to henna tattoos, commonly applied in festivals and parties, can induce an angry looking linear dermatitis (Fig. 2). The medical history and pattern are usually confirmative. There have been a few reports of ACD misdiagnosed as child abuse [31, 59]. Paraphenylenediamine (PPD) is the culprit allergen, and hair dyes are contraindicated because they contain PPD or cross-reactants.

Fig. 2 Allergic contact dermatitis. Well-defined erythematous angry-looking plaques with vesicles due to henna tattoo

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Stretch marks   Stretch marks are commonly seen in adolescents undergoing rapid linear growth and are seen in many physiological states, including normal puberty and pregnancy; however, they are rarely indicative of endocrine abnormalities [32]. Because of their linearity and appearance, they can be mistaken for physical abuse, particularly whipping marks (Fig. 3) [14, 33]. The atrophic appearance, horizontal orientation, and the classic location on the lower back, abdomen, gluteal region, upper thighs, and breasts differentiate them from non-accidental injuries [33].

Fig. 3 Stretch marks. Reddish, horizontally oriented, atrophic plaques involving the lower back

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Phytophotodermatitis   Phytophotodermatitis refers to sun-induced inflammation and hyperpigmentation due to psoralens, which is commonly found in many plants, including citrus fruits [26]. It is commonly seen in children squeezing oranges and limes in sunny climates during the holidays, and it presents as linear brown burn-like blistering erythema followed by hyperpigmentation (Fig. 4) [26]. The erythema and vesicles, which are commonly linear, can even occur in the shape of hands and thus might be misdiagnosed as inflected burns or hand slaps [12, 26].

Fig. 4 Phytophotodermatitis. Well-demarcated linear dark-brown hyperpigmentation due to psoralens in citrus fruit

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Non-linear eruptions

Mongolian spots   Mongolian spots are ill-defined grey to greenish-bluish patches that are usually present at birth or develop within the first few weeks of life. They commonly involve the lumbosacral area or the inner aspect of buttocks. Because of their color, Mongolian spots can be mistaken for bruises, especially when they are located on atypical sites (Figs. 5 and 6) [47]. Unlike bruises, they are not tender and do not evolve over time [42]. They usually fade in early childhood but can persist indefinitely.

Fig. 5 Mongolian spot. Ill-defined bluish-greenish patch on the upper back

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Fig. 6 Mongolian spot. A bluish-greenish patch involving the right thigh

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Hemangiomas   Hemangiomas are the most common tumors in infancy, with the majority of lesions noticed within the first few weeks of life. They are more common in girls and premature infants and may occur on the skin or mucosal surfaces [46]. They can be superficial, deep, or mixed, with the latter being the most common [23]. Superficial hemangiomas are bright red in color with a finely lobulated surface. Deep hemangiomas are warm blue-purple masses with minimal or no overlying skin changes. Because of their red color and liability to ulcerate, hemangiomas can be mistaken for physical abuse when located on lips (Fig. 7) and for sexual abuse when located on perianal area (Fig. 8). There have been many reports of such occurrences [8, 43, 62].

Fig. 7 Hemangioma. A mixed (superficial and deep) hemangioma on the lower lip

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Fig. 8 Hemangioma. Ill-defined erythematous superficial ulcerating hemangioma involving the perianal area

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Henoch-Schönlein purpura   Henoch–Schönlein purpura (HSP), also know as anaphylactoid purpura or allergic vasculitis, is the most common vasculitic disease in children, with an equal prevalence in boys and girls. It presents as erythematous, urticarial papules that rapidly evolve into palpable purpura. The eruption might be preceded by fever or accompanied by headache, myalgias or arthralgias, and abdominal pain. There is usually a typical symmetrical distribution around the buttocks, extensors of extremities, and distal legs, although any area of the body may be involved, including the face (Fig. 9) [16]. Because HSP presents with edema and erythema, it can be mistaken for child abuse, especially early in its course [10, 16]. Individual lesions usually fade within 5–7 days, but recurrence is possible.

Fig. 9 Henoch–Schönlein purpura. Multiple purpuras symmetrically involving the legs

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Urticaria pigmentosa   Mastocytosis is a spectrum of diseases with tissue mast cell proliferation. It can present at birth or develop any time thereafter. Urticaria pigmentosa (UP), the most common type seen in children, is usually limited to skin involvement. It is characterized by ill-defined tan-brown papules and plaques that urticate on pressure or friction during handling or bathing the child, which is referred to as Darier’s sign (Fig. 10). Lesions may even blister or get bruised and, therefore, can be misdiagnosed as inflected injuries [25, 32]. Urticaria pigmentosa usually resolves or improves spontaneously in late adolescence.

Fig. 10 Urticaria pigmentosa. Multiple ill-defined brown papules and plaques involving the whole back and scalp

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Dermatitis artefacta   Dermatitis artefacta (DA) is a factitious disorder characterized by intentional self-induced skin injury that can take various forms and shapes. Patients usually induce lesions to get emotional and psychological support, escape responsibilities, or collect disability insurance. It is most commonly seen in adolescent girls. The bizarre presentation and unconvincing history may lead to erroneous accusation by the patient or the medical team to family members. A thorough history and examination usually leads to the correct diagnosis. Lesions are usually seen on accessible sites, predominantly on the dominant side of the body, although they may occur anywhere (Fig. 11). Lesions usually have geometric patterns or angulated borders surrounded by completely healthy skin. Histopathology might be useful but is not always revealing. Preventing the patient from inducing lesions, by occlusive dressings or casting, usually leads to healing of the lesions, which is a helpful diagnostic tool to confirm the diagnosis.

Fig. 11 Dermatitis artefacta. Self-induced multiple well-defined, round-to-oval scars on the forearms in an adolescent girl

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X-linked ichthyosis   This is an X-linked recessive disorder (OMIM 308100) caused by steroid sulfatase (STS) deficiency secondary to mutation in the gene encoding STS located on the distal portion of the short arm of the X chromosome. It affects only boys with females being carriers for the disease. Almost 90% of patients present within the first weeks of life with mild erythroderma and generalized peeling with large, translucent scales. Later during infancy, typical large, polygonal, dirty-looking, dark-brown adherent scales develop. The distribution is symmetrical on extremities, trunk, and neck, with a sparing of the palms, soles, and face except for the preauricular area (Fig. 12). Parents of X-linked ichthyosis (XLI) children frequently face blame for uncleanness and negligence by school officials. We had frequent requests for medical reports from parents of children with XLI to prove that their children had a skin disease that gave them the “dirty” appearance. Topical keratolytics can dramatically improve the appearance, and their use should be encouraged.

Fig. 12 X-linked icthyosis. Dirty-looking, dark-brown, polygonal scales on the neck

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Bullous impetigo   Bullous impetigo (BI) is a relatively common, highly contagious, superficial skin infection caused by specific strains of Staphylococcus aureus. It affects young children, most commonly neonates and infants. It usually starts as small vesicles on the face, trunk, buttocks, perineum, or extremities that rapidly enlarge to flaccid bullae which evolve into erosions and crusts that heal without scarring (Fig. 13) [62]. Because of their appearance, BI can be confused with cigarette burns [47, 62]. The variable sizes, the uniphasic appearance, and the typical sites of involvement rule out the latter possibility.

Fig. 13 Bullous impetigo. Crusted erythematous erosions with few flaccid bullae on an erythematous base

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Congenital blistering diseases   Epidermolysis bullosa (EB) is a rare inherited mechanobullous skin disease with a defective loose attachment of the epidermis to the dermis. There are many types and subtypes [63], but all are characterized by easy blistering with minimal friction and trauma [63]. Blisters can be linear and hemorrhagic with a potential for scarring, depending on the type (Fig. 14). Blisters mostly occur on friction-prone areas, mainly on extremities. Because of this appearance, EB can be mistaken for physical abuse [21, 63].

Fig. 14 Epidermolysis bullosa dystrophica. Multiple hemorrhagic bullae and ulcers with hyper- and hypopigmentation

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Acquired blistering diseases   Chronic bullous disease of childhood (CBDC) is a form of linear IgA bullous dermatosis that occurs in children and remits spontaneously around puberty [15]. It is a rare disease, but still considered the most common acquired autoimmune blistering disease in children [15]. It is characterized by annular erythema and blisters forming “clusters of jewels” on genitalia, the lower abdomen, thighs, and periorally (Fig. 15) [15]. Epidermolysis bullosa acquisita (EBA) is a rare, acquired, bullous disease due to autoimmunity to type VII collagen. The disease has been reported mainly in adults but can occur in children. It is characterized by the development of blisters on trauma-prone areas, such as elbows, knees, and dorsa of the hands, which heal with atrophic scarring, milia, and pigmentary changes (Fig. 16). It is usually chronic and refractory to various treatment modalities. Bullous pemphigoid is the most common autoimmune blistering disease in adults, and it may occur rarely in children. The distribution is usually symmetrical and predominates on flexural areas. When any of these diseases occur in children, the blisters can be mistaken for physical and sexual abuse, depending on their location [15]. The latter is more likely when anogenital involvement occurs [44].

Fig. 15 Chronic bullous disease of childhood. Annular bullae forming “clusters of jewels”

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Fig. 16 Epidermolysis bullosa acquisita. Multiple linear erythematous erosions and bullae with hypo- and hyperpigmentation

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Neuroblastoma   Neuroblastoma (NB) is one of the most common solid tumors of early childhood. It arises from precursors of the sympathetic nervous system, most commonly in the adrenal medulla. The tumor metastasizes in about 60% of patients to cortical bone, bone marrow, lymph nodes, and liver [18]. Patients with localized disease are generally asymptomatic, but those with metastasis present with systemic symptoms such as fever and bone pain [61]. Metastasis to periorbital bones results in ecchymotic orbital proptosis known as “raccoon eyes”. Because raccoon eyes is a sign that classically occurs with basal skull fractures, when it happens in a patient with NB, it can be falsely suspected as child abuse [9, 28, 34].

See link for further analysis of child abuse mimickers and references:

http://www.springerlink.com/content/1204527834444356/fulltext.html

Summary

The recognition of child abuse is of great importance, but the avoidance of a false accusation for abuse is even more important. The misdiagnosis of child abuse has serious consequences for the child, the family, and the falsely accused. Therefore, all healthcare providers from different specialties, pediatricians in particular, must be aware of cutaneous child abuse mimickers. Important clues, such as congenital onset and a family history of similar skin diseases, should be carefully searched out. Whenever in doubt, referral to a dermatologist is recommended to rule out any genuine skin disease. Healthcare workers should be encouraged to report conditions mistaken for child abuse to increase awareness and, hopefully, avoidance.

Source:

http://www.springerlink.com/content/1204527834444356/

Caffey Revisited: A Commentary On The Origin Of Shaken Baby Syndrome

C. Alan B. Clemetson, M.D

ABSTRACT

Caffey is often cited as the source of the diagnosis of “shaken
baby syndrome” (SBS). Once the “classic” findings attributed to SBS
are identified, it is rare for a differential diagnosis to be considered.
Caffey focused on radiologic findings, but while he was aware
of the possible diagnosis of scurvy, the radiologic signs of infantile
scurvy may not have had sufficient time to develop. Other findings
in his cases were compatible with scurvy due to toxic histaminemia,
which can cause capillary fragility, retinal petechiae, and subdural
hematoma. Although dietary vitamin C deficiency is very rare today
in our country, both vitamin C deficiency and toxic histaminemia
can accompany systemic infection. Toxic histaminemia may also
occur following immunizations.

Skeletal Findings in Caffey’s Cases

In 1946, John Caffey, a radiologist, described multiple
fractures in the long bones of infants suffering from chronic
subdural hematoma. None of the parents reported any knowledge
of falls or physical injury, but Caffey suspected child abuse to
explain the injuries.
Following this retrospective, radiological study by Caffey, the
diagnosis of “shaken baby syndrome” (SBS—including retinal
petechiae, multiple fractures of the long bones, and subdural
hematomas) evolved and has resulted in many men and women
being convicted of child abuse, all without any meaningful
consideration of a differential diagnosis.
Although Caffey mentioned the word scurvy in the differential
diagnosis of each of the six cases, he stated that none of the infants
showed the typical radiological changes of scurvy: many of the
fractures were in the shafts of the long bones, instead of at the
junctions between the epiphyses and the diaphyses.
The radiologic signs of scurvy, however, are variable. The
most consistent finding used to be elevation and calcification of
the periosteum of the long bones due to subperiosteal hemorrhage,
above and below the fracture sites. In reviewing Caffey’s six
original cases, this finding was present in most of the cases. And,
although osteopenia and contrasting white lines of healing are said
to be characteristic radiological features of classical scurvy,
absence of these findings on radiographs does not rule out a
scorbutic state. The precise time course of increased susceptibility
to fractures and the development of osteopenia and white lines of
healing seen on radiographs is not known. Bones may be
vulnerable to fracture because of proline and lysine hydroxylase
deficiencies affecting chondroblasts and osteoblasts before these
classic radiological signs appear, especially if scurvy develops
rapidly at an early age.

Additional Findings in Caffey’s Case Studies

In addition to the long-bone fractures and subdural hematomas,
other clinical signs consistent with infantile scurvy were evident in
most of Caffey’s six cases:
Case 1. A purulent discharge from the right ear began at age 5
months and persisted for 2 months; a convulsion due to subdural
hemorrhage occurred at 7 months. Spontaneous fracture of the right
radius occurred after nine days in the hospital.
Case 2. Convulsions began at age 1 month. At 7 months, the
infant developed soft, spongy, bleeding gums typical of scurvy, and
retinal petechiae indicative of increased capillary fragility.At age 8
months, he developed signs of subdural hematoma.
Case 3. Multiple fresh hemorrhages were present in both ocular
fundi. Petechiae were also scattered on the abdominal wall, and a
large ecchymosis was seen on the left side of the face.
Case 4. Radiographs showed evidence of epiphyseal separation
at the proximal end of the right humerus, suggestive of scurvy.
Case 5. Subdural hematoma and bone fractures associated with
otitis media were present; black-and-blue spots on the forehead and
face could be interpreted as either traumatic or scorbutic.
Case 6. There was bilateral proptosis due to retrobulbar
hemorrhages consistent with scurvy—akin to the unilateral
proptosis seen in vitamin C-deficient 18 century sailors.
Even with adequate dietary vitamin C intake, infections can
rapidly deplete ascorbic acid stores and increase the blood histamine
level. In cases 1 and 5 above, it is noted that subdural hemorrhages
occurred in the context of ongoing otitis media infections.
Many factors affect vitamin C metabolism, but the most
important is systemic infection. Hess, in his Cutter Lecture at
Harvard Medical School, recognized that infection and vitamin C
deficiency were both related to the development of infantile scurvy.
It was a number of years, however, before he realized that each
affected the other—vitamin C deficiency predisposes to infection,
and infection predisposes to vitamin C deficiency. Blood levels of
vitaminCare also inversely related to blood histamine levels.

Onset of Infantile Scurvy

Infantile scurvy used to occur most commonly after age 7
months, when swollen, bleeding gums were evident, as the lower
incisor teeth had erupted and bacteria could enter the scorbutic
gingival sulcus. In contrast, an earlier onset variant of infantile
scurvy now occurs at 8 to 12 weeks of age. Bleeding gums are rarely
never seen before the eruption of the lower incisor teeth at 7
months, so the diagnosis of scurvy may not be obvious.
The hypothesis that subdural hemorrhages, retinal petechiae,
and spontaneous fractures of the ribs and long bones can occur as an
early variant of scurvy at about 8 to 10 weeks of age has not been
adequately studied, and, therefore, has not been disproven. Unless
and until vitamin C and histamine levels are actually measured in
these infants, who are automatically classified as victims of SBS,

we will not know the truth about causation. Unfortunately, even if
the diagnosis of infantile scurvy is considered, most hospitals do
not have the ability to measure either vitaminCor histamine levels.
Gardner has observed that the age of onset of the diagnosis of
so-called “shaken baby syndrome” is significantly later in Japan
(peaking at 7 to 9 months) than in the United States (peaking at 2 to
4 months). Is this because Japanese infants are abused at a later age
than American infants, or is there another explanation? Gardner
noted that these ages correspond to the standard ages when
vaccinations have been given in the two countries, respectively.

A Multifactorial Cause?

Infants with the findings attributed to SBS may be affected by a
combination of factors causing generalized capillary fragility,
which in turn affects the capillaries of the bridging veins between
the brain and the dura mater—predisposing to subdural
hematoma—due to inadequate ascorbic acid intake and/or
depletion by infections or multiple immunizations.
The defective formation of fibrous tissue, bone, and dentin that
is known to occur in scurvy results from proline and lysine
hydroxylase deficiencies that affect fibroblasts, chondroblasts,
osteoblasts, and ameloblasts. However, the increased capillary
and venular fragility causing the bleeding associated with scurvy
is due to a many-fold increase in the blood histamine level, as
shown by Clemetson.
The total blood histamine increases exponentially as the
plasma ascorbic acid falls. Majno and Palade have shown that
toxic levels of histamine in the blood cause openings in the tight
junctions between the vascular endothelial cells, leading to
extravasation of blood. Leakage of blood into the tissue slowly
leads to local hemolysis, as evidenced by the yellow color
characteristic of the fluid of old subdural hematomas. Hemolysis
also leads to local ascorbate depletion.
Chatterjee et al. reported increased blood histamine levels
following vaccinations in guinea pigs. This effect would likely be
heightened when six vaccinations are given at the same time at 8
weeks of age, such as is now the custom in most English-speaking
countries. If vitamin C levels are low at the time of vaccination, a
resulting toxic histaminemia may cause further clinical problems.
Arelevant finding by Archie Kalokerinos is that the increased
death rate following vaccination of Aboriginal infants in Australia
was arrested by administering vitamin C at the time of
vaccination—because ascorbic acid “detoxifies” histamine.
Indeed, Chatterjee et al. demonstrated that ascorbic acid is
essential for the detoxification of histamine (in guinea pigs), by
converting it to hydantoin-5-acetic acid, and on to aspartic acid in
vivo. Illustrations of the physiology and pathology of ascorbic acid
and blood histamine have been presented previously.
Other factors that are not given sufficient weight in evaluations
for SBS are the presence of chronic subdural hematomas, often
occurring during or shortly after birth, and the fact that chronic
subdurals are susceptible to rebleeding. Subdural hematomas have
been found using fetal ultrasound in utero, before labor, as reported
by Gunn, and also following normal, spontaneous delivery, as
reported by Chamnavanaki et al. The tendency to rebleed could be
exacerbated by toxic histaminemia through the mechanisms
explained above.

More Research Needed

The effects of various vaccinations, given alone or together, on
whole blood histamine levels and plasma ascorbic acid levels,
should be further studied. Concerted research may increase our
understanding of the toxicity of different vaccines and the effects of
giving single versus multiple, simultaneously administered
vaccines. Their impact on vitamin C, histamine, and clinical
manifestations of deficiency/toxemia must be assessed. It should be
helpful to reduce the number of vaccines given simultaneously or in
rapid succession.
A better understanding of these factors may help prevent
adverse reactions following vaccinations. Dr. Kalokerinos has
shown a clear benefit by providing supplemental vitamin C at the
time of vaccination in some children. Vitamin C is an extremely
safe substance—the only ill effects tend to occur in older children
and adults who suffer from hemosiderosis due to sickle cell disease
or Mediterranean anemia. Iron storage depletes ascorbic acid stores
via oxidation and hydrolysis, and the dehydroascorbic acid so
formed can be harmful. Even then, the toxic effect of vitamin C
may only be mild and temporary in young infants.

Conclusions

The so-called “classic” findings of subdural hematoma and
retinal hemorrhages in infants, without any evidence of major
trauma, do not always automatically equate to a diagnosis of
SBS. As in all other areas of medicine, it is prudent to do a
differential diagnosis.
The findings in the cases that initially established SBS as a
diagnosis were compatible with and even suggestive of infantile
scurvy or toxic histaminemia.

C. Alan B. Clemetson, M.D., is Professor Emeritus, Tulane UniversitySchool of Medicine, New Orleans, La. He may be contacted by e-mail atmegcc2000@yahoo.com.

See Source For References and PDF

http://www.jpands.org/vol11no1/clemetson.pdf

Shaking Wrong Beliefs

By: Dr. F. Edward Yazbak

The medical controversies section of the recent issue of the Journal of American Physicians and Surgeons (1) features three outstanding articles on the more and more controversial subject of shaken baby syndrome (SBS).

Together, these papers contribute immensely to the understanding of this obscure syndrome by debunking assumptions that have been accepted for some time as “proof” of abuse of young and innocent infants:

• That subdural and retinal hemorrhages can only be due to severe shaking and, therefore, must be intentional;
• That the presence of a “fracture or fractures” in the ribs and long bones is “evidence” of inflicted trauma.

The papers are:

• “Shaken Baby Syndrome:” Do Confessions by Alleged Perpetrators Validate the Concept? by Jan E. Leestma, MD, MM. (2)
• Vaccines, Apparent Life-Threatening Events, Barlow’s Disease and Questions about “Shaken Baby Syndrome” by Michael D. Innis, MBBS. (3)
• Caffey Revisited: A Commentary on the Origin of “Shaken Baby Syndrome” by C. Alan B. Clemetson, MD. (4)

Jan Leestma is a former professor at the University of Chicago’s division of biological sciences and the Pritzker School of Medicine (pathology and neurology), and neuropathologist and associate medical director for the Chicago Institute of Neurosurgery and Neuroresearch,

Michael Innis is a hematologist and pathologist, former consultant hematologist at Princess Alexandra Hospital in Australia, and the director of Medisets International.

Alan Clemetson is a professor emeritus at Tulane University School of Medicine in New Orleans, Louisiana.

The credentials and qualifications of these distinguished authors are evidently impeccable.

* * * *

The Leestma paper

“The concept that a certain constellation of findings develops immediately after a baby is shaken, with no impact of the head, is based solely on confessions or admissions by alleged perpetrators”¦. A review of the literature reveals very few cases of admissions of “pure” shaking. Methodologic flaws preclude any definitive conclusions about causation from these cases”¦.

“The studies have been regarded by many as strong support for the theory of SBS. Of prime concern in these papers, however, is the basic issue of the value of a supposed confession in determining a mechanism for injury. With any confession or admission, there is the issue of veracity. Accused individuals are well known to fabricate historical information”¦.

“It should be apparent that from virtually every perspective many flaws exist in the theory that shaking is causative. No case studies have ever been undertaken to probe even a partial list of the potential causes”¦.

“The confessions or admissions of a perpetrator are at best tenuous support for the shaking mechanism for infantile head injury. A critical appraisal of any literature that proposes a causal mechanism of shaking for brain injury must include an investigation of case selection methodology, population or sample size, possible case control issues, data analysis methods, and whether the conclusions reached are justified by the data presented”¦.”

The Innis paper

“Apparent Life-Threatening Events (ALTE), as defined by the National Institutes of Health, encompass all the findings hitherto attributed to open “Shaken Baby Syndrome” (SBS), and may follow routine vaccination. Vaccines may also induce vitamin C deficiency (Barlow’s disease), especially in formula-fed infants or infants whose mothers smoke”¦.

“Shaken Baby Syndrome (SBS) is a collection of findings, not all of which may be present in any individual infant diagnosed to have the condition. Findings include intracranial hemorrhage, retinal hemorrhage, and fractures of the ribs and at the ends of long bones”¦.

“The National Institutes of Health, and its 1986 Health Consensus Development Conference on Infantile Apnea and Home Monitoring, defined “Apparent Life-Threatening Event (ALTE) as an episode that is frightening to the observer and is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), and choking and gagging. In some cases, the observer fears that the infant has died. ALTE is not so much a specific diagnosis as a description of an event”¦.

“The current concept of SBS includes intracranial bleeding, usually in the form of a subdural hematoma, which may be acute or chronic; parenchymal injury and/or anoxic changes in the brain; skull fracture (if impact occurred); and retinal hemorrhages. Constant features are subdural and retinal hemorrhages. Various fractures including those of the long bones and ribs are often used to support an impression of child abuse, but it should not be forgotten that Barlow’s disease can resemble “battered baby””¦.

“Animal experiments have demonstrated that administration of vitamin C can counter some of the ill effects of nicotine in newborns. This suggests that mothers who smoke may compromise vitamin C levels in their children”¦.

“One essential function of vitamin C is maintenance of normal connective tissue by the hydroxylation of praline and lysine in procollagen, using the enzyme prolyl hydoxylase with Vitamin C as a cofactor. While vitamin C has numerous other functions, this one maintains the integrity of the blood vessels, bones, and dentine, which is compromised in scurvy, leading to manifestations that might be mistaken for SBS.  Expansion at the ends of the costochondral junctions is highly suspicious for scurvy, and should in itself have raised questions about the diagnosis of SBS.

“Formula feedings are often heated before being given to the infant and heat destroys vitamin C.  Under such circumstances, vitamin C supplements are needed to prevent scurvy”¦.

“As part of the immune response to vaccines, mast cells liberate histamine, causing further widening of the intercellular spaces between the vascular endothelial cells in children who may have subclinical scurvy. Although it has not been established that vaccinations cause vitamin C deficiency, the inverse relationship between histamine and vitamin C levels in the blood would support the hypothesis that vaccinations could lead to vitamin C deficiency, and might explain spontaneous bleeding”¦.

“Post-immunization deaths in aboriginal children in Australia were greatly reduced when Kalokerinos administered vitamin C by IM injection before, and sometimes after, immunizing the child.  Many of these children had the classical signs and symptoms of scurvy.”

The Clemetson paper

“Caffey is often cited as the source of the diagnosis of “shaken baby syndrome” (SBS). Once that “classic” findings attributed to SBS are identified, it is rare for differential diagnosis to be considered”¦

“In 1946, John Caffey, a radiologist, described multiple fractures in the long bones of infants suffering from chronic subdural hematoma. None of the parents reported any knowledge of falls or physical injury, but Caffey suspected child abuse to explain the injuries.

“Following this retrospective, radiologic study by Caffey, the diagnosis of “shaken baby syndrome” (SBS – including retinal petechiae, multiple fractures of the long bones, and subdural hematomas) evolved and has resulted in many men and women being convicted of child abuse, all without any meaningful consideration of a differential diagnosis”¦.

“In addition to the long-bone fractures and subdural hematomas, other clinical signs consistent with infantile scurvy were evident in most of Caffey’s six cases”¦.

“Even with adequate dietary vitamin C intake, infections can rapidly deplete ascorbic acid stores and increase the blood histamine level”¦.

“Many factors affect vitamin C metabolism, but the most important is systemic infection. Hess, in his Cutter Lecture at Harvard Medical School, recognized that infection and vitamin C deficiency were both related to the development of infantile scurvy. It was a number of years, however, before he realized that each affected the other – vitamin C deficiency predisposes to infection, and infection predisposes to vitamin C deficiency. Blood levels of vitamin C are also inversely related to blood histamine levels”¦.

“The hypothesis that subdural hemorrhages, retinal petechiae, and spontaneous fractures of the ribs and long bones can occur as an early variant of scurvy at about 8 to 10 weeks of age has not been adequately studied, and, therefore, has not been disproven. Unless and until vitamin C and histamine levels are actually measured in these infants, who are automatically classified as victims of SBS, we will not know the truth about causation”¦.

The effects of various vaccinations, given alone or together, on whole blood histamine level and plasma ascorbic acid levels, should be further studied.  Concerted research may increase our understanding of the toxicity of different vaccines and the effects of giving single versus multiple, simultaneously administered vaccines. Their impact on vitamin C, histamine, and clinical manifestations of deficiency/toxemia must be assessed. It should be helpful to reduce the number of vaccines given simultaneously or in rapid succession.”

* * * *

In his paper, Leestma summarized the findings of his careful review of the extensive English-language medical literature on child abuse between 1969 and 2001, where he only found 54 cases in which someone had admitted “shaking” the injured infant. (5) In only 11 cases, there was no sign of cranial impact and the infant could have been “free-shaken.” Such a small number of cases obviously did not allow valid statistical analysis.

As mentioned in a previous column (6), a young, scared and disadvantaged parent can literally confess to anything “just to get it over with.” In any other criminal investigation, such “confessions” would not be worth the paper they are written on. In shaken baby trials, they effectively destroy families and put innocent adult caretakers in jail for years.

Innis strongly highlights lessons we should have learned in medical school:

• Take a good history
• Investigate judiciously
• Interpret findings correctly
• Consider all the possibilities in the differential diagnosis
• Reach the diagnosis carefully
• Treat appropriately

Without repeating his now famous challenge, Innis recommended that the diagnosis of SBS not be made until malnutrion, coagulation/hemostatic difficulties, liver dysfunction, gestational, delivery and neonatal factors, and recent vaccinations had been seriously reviewed and found to be non-contributory.

By carefully reviewing every one of Caffey’s original six cases, which had become the bases on which the theory of shaken baby syndrome was built, and by showing that most of them suggested vitamin C deficiency in one way or another, Clementson contributed immensely to the subject. With his very original approach to destroy the cornerstone, he may have brought the whole edifice down.

In a communication to the British Medical Journal on June 27, 2005, Innis said:

“A name change from “˜Shaken Baby Syndrome’ to “˜Kalokerinos-Clemetson Sydrome,’ when haemorrhages, fractures and intracranial lesions follow immunization within 28 days, should be the first step in stopping false allegations against innocent individuals.

“Both [Archie] Kalokerinos and Clemetson have for years been trying to educate the medical profession on the risks of vaccines to some children.

“The witch hunt will be over once the name is changed.”

I can safely add that if this happened, justice would be better served and so would science.

We not only should, we must, recommend that upon detecting retinal and subdural hemorrhages, with or without rib and long bone “fractures”, admitting physicians immediately order blood histamine and serum ascorbate levels, in addition to the usual bleeding and coagulation battery of tests, which should include a PIVKA II test and fibrinogen level, fibrin split products and D Dimer tests. Abnormalities in the liver and kidney function tests should be taken seriously and not discounted as so often happens.

A review of recent vaccinations is also essential. Accessing the VAERS web site is relatively easy and often very informative. Discounting the role of multiple vaccinations without investigating it properly has been evident for years; it should not be permitted any longer.

* * * *

The editor of the Journal of American Physicians and Surgeons should be complimented for publishing these three very important papers in the latest issue.

Reprints of the articles in bundles of 25 to 500 copies are available for those individuals and organizations who wish to distribute them. (7)

Conclusions

Three recent articles in the Journal of American Physicians and Surgeons have helped disperse much of the misinformation about shaken baby syndrome.

Histaminemia and vitamin C deficiency may be responsible for SBS and should be tested in every case in which such diagnosis is suspected.

The role of multiple recent vaccinations in SBS cases should be carefully evaluated before it is discounted.

The Kalokerinos-Clemetson Syndrome is a more appropriate label for cases that present with an apparent life-threatening event soon after vaccinations and where retinal and intracranial hemorrhages and long bones and rib “fractures” are identified.

References

1. The Journal of American Physicians and Surgeons, Vol. 11, No. 1, spring 2006 issue. Also available at http://www.jpands.org/
2. J.E. Leestma. Shaken Baby Syndrome”: Do Confessions by Alleged Perpetrators Validate the Concept? J Am Phys Surg. 2006; 11(1): 14-16.
   Also available at http://www.jpands.org/vol11no1/leestma.pdf
3. M.D. Innis. Vaccines, Apparent Life-Threatening Events, Barlow’s Disease, and Questions about “Shaken Baby Syndrome. J Am Phys Surg. 2006; 11(1): 17-19. Also available at http://www.jpands.org/vol11no1/innis.pdf
4. C.A.B. Clemetson. Caffey Revisited: A Commentary on the Origin of “Shaken Baby Syndrome” J Am Phys Surg. 2006; 11(1): 20-21. Also available at http://www.jpands.org/vol11no1/clemetson.pdf
5. J.E. Leestma. “Case analysis of brain-injured admittedly shaken infants: 54 cases, 1969-2001.” Am J Forensic Med Pathol. September 2005. 26(3): 199-212. Review.
6. F.E. Yazbak. Shaken Baby Syndrome: Pitfalls in Diagnosis and Demographics. Red Flags,February 2006. Available at  http://www.redflagsdaily.com/yazbak/2006_feb17.php
7. http://www.jpands.org/reprints.pdf; A+ Printing Co., 4500 East Speedway, Suite 41, Tucson, AZ 85712.

Source:

http://www.vaccinationnews.com/node/19951

F. Edward Yazbak, MD, FAAP

F. Edward Yazbak, MD, FAAP of Falmouth, Massachusetts, practiced pediatrics and was a school physician in Northern Rhode Island for 34 years. He was formerly the Assistant Clinical Director of the Charles V. Chapin Hospital, a specialized infectious disease hospital and the Director of Pediatrics at the Woonsocket Hospital in Rhode Island. He was also the Pediatric Director of the Child Development Study, the Brown University division of the NINDB Collaborative Study and an assistant member of the Institute of Health Sciences at the University.

Since 1998, Ed has devoted his time to researching vaccine injury and the increased incidence and autoimmune causes of regressive autism focusing on maternal re-vaccination with live viruses.

Ed has been recognized as an expert witness in autism, vaccine injury and Shaken Baby Syndrome litigation and has published extensively on those subjects.

Ed and Maureen, a pediatric nurse practitioner, have four children and twelve grandchildren. Their family like many others has been severely affected by autism.

Source:

http://yazbakarticles.wordpress.com/

The Differential Diagnosis of Child Abuse

Michael Segal MD PhD

2010

Many findings that raise concerns of child abuse or “Munchausen Syndrome by Proxy” (MSBP) also occur in physical diseases.  This article highlights such findings and diseases in order to help child abuse teams broaden the differential diagnosis of child abuse to include physical disease that can mimic child abuse.  By making such diagnoses, the child abuse team can be the heroes who make the correct diagnosis and avoid the pitfall of overlooking potential innocence of the parents.

The material here is organized by findings.  Personal accounts are quoted to give a flavor of the experiences of families.  The lists are not exhaustive, and they are skewed towards neurological and metabolic diseases, reflecting the experience of the author.  All names in quoted materials are replaced by initials.

The lists are meant to evolve, collecting the wisdom of the community.  If you have suggestions of more diseases and findings to add or accounts of erroneous suspicion of parents, please contact us.

These listings are not meant to lower vigilance against child abuse, which clearly occurs often.  Although some have questioned the existence of the MSBP diagnosis, I am not among them, having seen personally a case of a woman fabricating seizure reports about her child.

Lethargy / coma

Lethargy and coma occur in many metabolic diseases, often on an episodic basis, and can appear to be from child abuse.  Examples:

• Glutaric aciduria type 1: this disease causes recurrent episodes of coma, sometimes accompanied by subdural hematomas or retinal hemorrhages, seeming like obvious instances of child abuse.  Parents described what happened in a case of glutaric aciduria type 1 in which the child presented with coma and a subdural hematoma:
  

  The Ss stood by as the medical team tried to revive their son. L overheard a technician exclaim, “What did they do to that baby!?”

  By the time M was taken to LL University Medical Center for surgery to relieve bleeding in his brain, Child Protective Service officials had been called.

  Early reports show doctors’ suspicions that L had shaken M hard enough to cause hemorrhaging behind his eyes. CPS documents show V was suspected of failing to stop the abuse.

  The Ss were kept away from M, questioned, investigated and ordered to appear in court for a custody decision regarding their two older children.

  The children, the Ss’ neighbors and V’s parents were questioned, although L’s two older children and M’s pediatrician were not. The family’s house was searched and photographed, and D and J were put in the custody of V’s parents.

  The Ss were cleared four days after the episode when M was diagnosed with glutaric acidemia.

  Other cases involving glutaric aciduria type 1 are described here and here, the latter noting that the disease “does not predispose patients to fractures; if a subdural haematoma is accompanied by a fracture, exclusion of GA1 is probably unnecessary”.  A similar abuse-like presentation in glutaric aciduria type 2 has been described in an abstract by Krueger et al. 2006 (Neuropediatrics 37:Suppl. 1 S107).

• Methylmalonic acidemia: a child appeared to have died of ethylene glycol poisoning, found by two independent labs.  The mother was sentenced to life in prison, but while in prison, gave birth to a second son, who was found to have methylmalonic acidemia.  Reexamination of serum from the first child also showed methylmalonic acidemia; the labs had misidentified propionic acid as ethylene glycol.  The mother was eventually released from prison.  Note, however, that the opposite error can also occur: intentional poisoning with ethylene glycol can be misinterpreted as an inborn error of metabolism.

Bleeding and bruising

Bleeding and bruising are common in child abuse, but have many medical causes, from coagulation disorders to disorders weakening blood vessels.  Examples:

• Medications:  many cause a bleeding tendency.
• Coagulation disorders: typically cause a bleeding tendency.  An example is Hermansky-Pudlak Syndrome, where according to Donna Appell of the Hermansky-Pudlak syndrome network child abuse is often suspected.  Petechiae and purpura should be looked for as evidence of other coagulation problems.
• Mechanical causes for bleeding: the presence of external hydrocephalus or subarachnoid spaces is associated with subdural bleeding and retinal hemorrhages, apparently with the external hydrocephalus preceding the bleeding.  External hydrocephalus occurs in glutaric aciduria type 1, which is particularly likely to be confused with child abuse because of recurrent episodes of lethargy or coma.
• Menkes disease:  aneurysms develop and predispose to subdural hematomas, mimicking shaken baby syndrome.
• Marfan syndrome: according to some reports there is a bruising tendency in Marfan disease due to blood vessel fragility, though others attribute the bruises to frequent falls.  One mother describes being accused of MSBP due to her two year old’s multiple complaints and bruises.
• Connective tissue disorders: some disorders such as Ehlers-Danlos syndrome can cause weakness of blood vessels, leading to bleeding.
• Structural abnormalities:  congenitally abnormal anal location or size can lead to constipation and resultant rectal bleeding, leading to concerns about abuse.

Failure to thrive

Neglect or abuse is often considered if a child fails to gain weight.  This can also lead to bone fragility, leading to fractures that provide a second finding that resemble a finding in child abuse.  This is more likely to occur in rarer syndromes less likely to be recognized by medical professionals.  Examples:

• Dubowitz syndrome: Sharon Terzian of the Dubowitz Syndrome Support group relates that parents of children with Dubowitz Syndrome are sometimes investigated because of the child’s failure to thrive.  Although the growth retardation is often intrauterine, sometimes this just shifts the time during which abuse is suspected to include gestation.
• GE reflux: Beth Anderson of the Pediatric Adolescent Gastroesophageal Reflux Association reports many mothers being suspected when their child fails to gain weight due Gastroesophageal Reflux.  Some parents are reported only on the basis of poor weight gain, others are reported because of unusual feeding methods they used to try to get their children to gain weight.

Immunodeficiency

A child with multiple illnesses may be assumed to be neglected or purposely infected.  Example:

• Severe Chronic Neutropenia:  A mother of a patient describes what happened after multiple medical visits with several children for severe infections:

When her doctor wasn’t available the next evening, in desperation we went to the Emergency Room. The doctors there were alarmed and we were sent to the USC Medical Center Contagious Disease Ward. Once there, we were accused of abuse and threatened with police action.

High muscle enzymes

High muscle enzymes sometimes are presumed to be from trauma, even though many illnesses have high creatine kinase levels due to non-traumatic causes for muscle breakdown.

Bones breaking, bending or joints dislocating

Many diseases result in bones being susceptible to breaking, leading to allegations of child abuse. Dr. Colin Paterson and others advise checking whether superficial indications of trauma are commensurate with the fractures.  Serial measurement of serum alkaline phosphatase activity is also helpful.  Other bone disease result in bones being undermineralized and likely to bow or bend, leading to accusations of neglect.  Examples particularly likely to lead to errors are:

• Alagille syndrome
• Osteogenesis imperfecta
• X-linked hypophosphatemia:  Joan Reed, President of the XLH Network, relates that the undermineralization and bowing of bones in children with XLH often leads to suspicion of nutritional neglect and delays in diagnosis.  Even after diagnosis of some related disorders such as Autosomal Dominant Hypophosphatemic Rickets, the use of the word rickets causes many non-medical people to assume the problem is nutritional.
• Temporary brittle bone disease
• Bone disease of prematurity<
• Ehlers-Danlos syndrome and other connective tissue disorders
• Rickets due to vitamin D deficiency
• Scurvy (vitamin C deficiency):  particularly suspicious because bruising is also frequent
• Copper deficiency and Menkes disease: particularly suspicious because of frequent subdural hematomas in Menkes disease and seizures.
• Inherited systemic hyalinosis: Shieh et al. relate that “Periosteal reaction or fractures on skeletal radiographs in systemic hyalinosis have been mistaken for nonaccidental trauma. The hyperpigmented skin lesions may mistakenly be considered post-traumatic”.

Some medications can make bones more fragile, most commonly steroids.

Repeated injuries

Many diseases and medications produce insensitivity to pain, with cases of children breaking bones but not reporting the pain at the time of injury and suspicion falling on caretakers.  Parents of children with hereditary sensory and autonomic neuropathies have been investigated for child abuse.

Other diseases such as Ehlers-Danlos syndrome cause connective tissue weakness, leading to bowel perforation, which can lead to accusations of abuse.

Mutism

Diseases such as selective mutism and medications can produce mutism that is interpreted as evidence of child abuse.

Recurring odd complaints

Parents are sometimes accused of MSBP because of repeated medical visits for a variety of odd symptoms.  Such constellations of findings can occur in many inherited diseases and for many rare syndromes doctors will often not recognize the pattern.  A New Yorker article chronicled one such story, though it was clear that something physical was wrong because of various congenital defects.  More difficult are cases in which it is not clear whether any of the findings are actually due to physical disease.  Examples:

• Trifunctional protein deficiency: this fatty-acid oxidation disorder includes a variety of findings that can arouse concern, including muscle breakdown, “failure to thrive”, hypoglycemia and lethargy.  A mother of a patient described her experiences:
  

  On June 4 1999, I got a knock on my door. Unassuming me answers the door to find a representative from the Department of Children and Families standing there. I was being investigated for Abuse. I strongly believe, for various reasons, that a family member, whom had never gone with me to S’s Dr’s visits, had a nurse whom had NEVER seen S before, call in a report because I was taking S to so many doctors. The authorities believed that I had to have Munchausen Syndrome by Proxy.

  The next day I had to appear in court with my son. When I told the Judge that my son had skull surgery and was diagnosed with other ailments, he took my son from me and ordered him to be put in Foster Care.

• Glutaric aciduria type 2: this rare disorder has episodic attacks of hypoglycemia, vomiting and weakness.  A mother of a patient described her experiences:
  

  According to medical records, prior to C’s evaluation, they had already interviewed his former [nurse practitioner] and current pediatrician, both of which helped entertain the diagnosis of Munchausen Syndrome by Proxy! Needless to say, we were very upset and sick to our stomachs that we were being accused of child abuse, for trying to help our sick child! It is the most sickening feeling I have ever had in my life and will never get over the hurt and betray. I had lost faith in the medical system. I knew there were good physicians out there. I just found it hard to believe that we would ever find one.

• Seizure-like episodes: descriptions of movement disorders can sound a lot like seizures, but the EEG is completely normal, sometimes leading to MSBP allegations.  Some allegations have been cleared up after clinicians saw the movement disorders live or on video or after movement disorders were described or shown to the family.  Many diseases have movement disorders, which also occur as a side effect of many medications.  If the medication is also being used to treat a disorder with failure to thrive (e.g. metoclopramide for GE reflux) the two odd problems can lead to a concern about child abuse.

CONCLUSION

Child abuse is a real problem, but many physical illnesses can appear similar to child abuse.  When a common illness mimics child abuse, the diagnosis typically is recognized, but often rare diseases fail to be recognized.  Although such diseases are individually rare, there are so many rare diseases that collectively they are common enough to make it incumbent upon doctors to consider such diseases in the differential diagnosis of findings suggestive of child abuse.

Screening tests are useful in testing for some of these disorders and it may be helpful to develop a battery of tests targeted at situations where abuse is suspected.  However, no set of screening tests will be exhaustive, and a detailed consideration of physical causes for findings is important.  Helpful tools for doing so include simple general tools such as OMIM or, when relevant, more sophisticated tools such as our SimulConsult Neurological Syndromes diagnostic decision support software.

Thanks to Charles Brill MD, Peter Heydemann MD, Imelda Hughes MB, Loren Pankratz PhD and Steven Rothman MD for sharing examples of physical diseases misdiagnosed as child abuse.  If you have comments or suggestions please contact us.

Source:

http://www.simulconsult.com/resources/abuse.html

Dr. Segal is a pediatric neurologist who did research on sodium channels in epilepsy while he was on the faculty of Harvard Medical School. Since 2002 he has been at SimulConsult, a company he founded that produces software to assist in making medical diagnoses. In 2007, together with his colleagues from Harvard, he described a form of attention deficit disorder that resembles hypokalemic periodic paralysis.

Dr. Segal got his PhD and MD degrees in 1982 and 1983 from Columbia University. After a pediatric internship at St. Louis Children’s Hospital he returned to New York to do a pediatric neurology residency at Columbia Presbyterian Hospital from 1984-87. Before joining the faculty at Harvard Medical School he did a fellowship in Harvard’s Neurobiology Department, winning the S. Weir Mitchell young investigator award of the American Academy of Neurology in 1990 for the epilepsy research he did there.

Autistic Girl Uses Laptop To Break Silence

Christina England

vactruth.com
08/10/2010

Last year Cynthia Janak and Leslie Botha made an unusual and very surprising announcement on Leslie Botha’s regular radio show Holy Hormones Honey – The Greatest Story Never Told! www.krfcfm.org It was announced that because the girls who had been adversely affected by the Gardasil vaccine could describe their symptoms, that their words could give the silent world of autism a voice. The ‘Gardasil girls’ as they are now known as, described throbbing head pain , tingling sensations, pains in their limbs, excruciating pain in their abdomen and other symptoms that Janak and Botha both feel, may describe why many autistic children, display strange and often bizarre behaviour, such as head banging, rock and screeching.

Just before this extraordinary show was to be aired, Cynthia wrote on her blog Only the Truth about the fourth coming show and what she had discovered:-

“I have spent hours on the phone with many of Gardasil moms. On one occasion a mom called and asked me to speak to her daughter because she was having a very bad day. This young woman is in pain every day but on this day was experiencing pain that was so intense that she had gotten to the point where she could not stand it anymore. She had told her mom that she wished God would take her already. Of course I told this distraught mother that I would be honored to speak with her daughter.

During the conversation I shared with this young woman how she has been an inspiration to her family, church and the other people on the Gardasil board. I spoke to her about what she will be able to accomplish in the future when she gets better. I also promised her that some day we will visit the White House and maybe even talk to the President. That made her chuckle and she said, “I would like that,” in a quiet voice because her pain magnified all sound.

She then asked me “why did this have to happen?” It was then that I knew the answer and I told her that “the Gardasil Girls have given the silent faces of Autism a Voice for the first time in history. These children have not mastered speech so when they become autistic they cannot tell their moms they have a headache or that their stomach hurts or they cannot feel their legs or tingling in their legs.

It was at this point that all my research into Gardasil took on a new meaning, a new purpose and a new goal. My goal was to prove that autism does not exist. I wanted to prove by using the voices of the Gardasil girls that Autism is only brain damage because of excessive body burden of aluminum in vaccines.

I spent 10 to 14 hours a day over a period of many weeks researching everything I could to see if the information on vaccinations, aluminum and other heavy metals trackbacked to support  this theory. I read personal stories of parents of autistic children and compared them with the stories of the Gardasil girls. I read hundreds of VAERS (Vaccine Adverse Event Reporting System) reports. I read articles about brain damage, reports about aluminum toxicity and all kinds of studies on these topics. I even went so far as to calculate potential toxicity from aluminum prevalent in the environment in combination with the toxic aluminum load found in single and/or multiple vaccines administered at the same time.

After I did all of this I sat back and looked at everything that I had researched with the documents, spreadsheets and graphs that I created during the process.  The connection was there. Looking at the numbers and the side effects side by side, one could notice the direct relationship between the two – the higher the dose of aluminum – the more the severe the side effect.

I presented my findings to my colleague, women’s health advocate and broadcast journalist Leslie Botha.  Intrigued by the data, Botha suggested that I expose my findings on her radio show on KRFC FM , a community radio station in Fort Collins, CO, audio streamed at www.krfcfm.org , 6:00PM Mountain Time. I proposed that the February 16 show be titled “Gardasil Girls Give the Silent Faces of Autism a Voice.” Prior to the show, I alerted the Gardasil and autism communities through various organizations, Internet boards and chat rooms to make them aware of the upcoming radio interview and topic.”

The show was spectacular and a resounding success, sending shock waves through the autistic community, could these ladies have hit on something?

Autism, is sometimes characterised by bizarre behaviour. A sub set of children with autism, often those said to become autistic after an adverse reaction to a vaccine, are prone to sudden screaming fits, arms waving wildly, rocking, head banging and hands covering the ears. Up until now there has been no apparent reason for this strange behaviour, however, had Cynthia Januk and Leslie Botha hit on the reason why these autistic children were acting this way? On the show Cynthia said that these children were displaying symptoms that they were unable to explain, she attributed this to brain damage she said is caused through toxin poisoning. She said that the screaming could be reaction to intense pain, the head banging and rocking could be the throbbing pain in these children’s heads. Janak believes that it is the aluminum in the Gardasil vaccine and other vaccines that many of the autistic children receive shortly before they regressed into their autistic state were to blame for these symptoms and it was in fact brain damage caused by the toxins in the vaccines. Autistic children are unable to describe what they were feeling, so they describe their feelings in the only way they know how.

Since the show, Janak has written much on her theory but it was just a theory, this was until ABC News reported this unusual story.

Mute autistic girl finds a voice – http://www.tvkim.com/watch/357/kims-picks-mute-autistic-girl-finds-a-voice

ABC News showed a film of how a child displaying all of these behaviours of autism, had suddenly, at aged eleven, been able to break out of her autistic state and with the help of a computer, describe exactly what was making her act in this way. Here suddenly was the breakthrough that scientists have been waiting for. Suddenly, a previously wild and mute autistic child, was able to describe in perfect English exactly what she was feeling. What she describes is shocking and heart wrenching:-

“You don’t know what it feels like to be me, when you can’t sit still because your legs feel like they are on fire, or it feels like a hundred ants are crawling up your arms.

What do I want? I want to be like every other kid but I can’t because I am Carly.”

Then she described why she banged her head, she wrote-

“Because if I don’t it feels like my body will explode, it is like when you shake a can of coke. If I could stop it I would but it is not like turning off a switch.”

Suddenly, here was an autistic child, explaining exactly what Cythia Janak and Leslie Botha had suspected all along.

Leslie Botha said:-

“Although tragic, this is a fantastic and exciting breakthrough.  Here is an autistic child, who has suddenly become able, finally, to express the feelings of trauma and pain, that match those of the Gardasil girls, proving that what we suspected was right all along.

Vaccine damage is nothing short than brain damage. The good news is that the brain has the ability to heal itself from the damage it incurs genetically and from environmental toxins if it gets the therapy and nutrients that it needs.

The girls who are damaged from the Gardasil vaccine are experiencing many of the same neurological problems that vaccine-induced autistic children experience and finally we have proof. The Gardasil girls are finally giving voice to these problems that have destroyed the lives of innocent infants for too many years.

Brain damage is brain damage. It can come from many different sources. The emerging field of neuroscience proves this with brain scans and imaging.

Vaccine companies can no longer hide behind their shroud of deceit and deception. The truth will be told and science will back it up.”

Cynthia Janak now feels that this new revelation may offer hope to many families with autistic children and initiate the treatment these children so badly need.

---

• For more on what Janak says on Gardasil go to Only the Truth and Renew America

• For Leslie Botha go to Holy Hormones Honey http://holyhormones.com/ or listen to Leslie’s radio show every second Monday Holy Hormones Honey – The Greatest Story Never Told! on KRFC FM 88.9 in Fort Collins, Colorado

Audio Streamed at www.krfcfm.or

Author:

Christina England

Source:

http://vactruth.com/2010/08/10/autistic-girl-uses-laptop-to-break-silence/

Shaken Baby Case Verdict

Published: Fri, 27 Aug 2010

Description: A Pinellas County jury has reached a verdict in the shaken baby trial of Tenesia Brown.

Automatically Generated Transcript (may not be 100% accurate)

” There is a verdict tonight in the shaken baby trial of Tunisia brown prosecutors charged brown with the murder of the 2008. Death of three year old Luzon — after a four day trial jurors didn’t by the prosecution’s case and found brown. Not guilty news Channel 8 Peter Bernard watched as the verdict came down in a pinellas Scott county courtroom.”

” Standing arm in arm whether attorney former Foster parent Tunisia brown stood here the court clerk announced the verdict. We the — Find his palaces to the defendant’s — back his — counting. Brown faced life in prison for the death of three year old Luzon — prosecutors say brown had shaken — after picking him up from daycare for years ago. The toddler died two years later. — defense brought in a 101000 dollar a day expert witness to debunk the shaken baby syndrome allegation. Brown herself did not take the stand that tactic paid off. After the verdict Brown’s husband told me he and his wife still think about –”

” We don’t want to forget about those. Now we did we. And we took care of him and mom. Who’s gonna continue to pray for him. Defense attorney Ron to appear says he always believed his client was innocent. We knew that if we just had a chance. To defend the case and — our story. That we have a chance for the brown family the case has been draining emotionally and financially. Believing she says she didn’t do it. That’s all — need to know. Ruth Graham had to sell everything they had in Norwich Vermont this offense a crying Tunisia brown didn’t wanna talk to me but her husband tells me this is the toughest thing he’s had to endure. And owned by going to do to protect it was a — Every day trying to shoot — wasn’t going anywhere and try to do the right help she deserved. The browns now have the task of resuming their normal lives any thought of being a Foster parent again this for another day. Peter Bernard news Channel –”

See Source For Video Of Court Ruling

http://video.tbo.com/m/33834828/shaken-baby-case-verdict.htm