Challenging Myths And Assumptions

Challenging An Assumption

A Response

Letters to the Editor

In our August 2009 issue, we published the article “Challenging an Assumption” (p. 29), which was a profile of Dr. John Plunkett, a Minnesota pathologist who questions the validity of the shaken baby syndrome diagnosis. In January, we received and published a letter critical of our article and of Dr. Plunkett’s views (p. 5). That letter was signed by members of the international advisory board of the National Center on Shaken Baby Syndrome. Since then, we have received numerous letters taking issue with their letter and the views of its signers. Clearly, we have touched a nerve in writing about this issue. Our intent for the story about Dr. Plunkett was neither to validate nor to denigrate his work. We merely wanted to highlight the fact that a Minnesota physician is taking part in a highly controversial debate that has ramifications for medicine and the legal system. Below are some of the letters we have received recently on this topic. Others can be viewed online at www.minneotamedicine.com.
—the editors

Growing Body of Contrary Evidence

In your January 2010 issue, nine doctors, a prosecutor, and a police detective—all of whom are associated with the National Center on Shaken Baby Syndrome, an advocacy group devoted to the promotion of “shaken baby” theory—attacked Dr. John Plunkett, who was featured in the August 2009 issue of Minnesota Medicine. Dr. Plunkett has spent his recent career applying basic biomechanical and medical principles to shaken baby syndrome (SBS) and testifying, if needed, when accused parents or caretakers are confronted with unproven or demonstrably incorrect medical claims. Because of his work and research by others, the literature on SBS has changed substantially since 2000, forcing major changes in the SBS position papers of the major medical organizations. In their 2010 letter, the representatives of the National Center on Shaken Baby Syndrome claim that Dr. Plunkett’s findings are based on “belief” rather than “evidence.” In fact, doctors have been diagnosing SBS for nearly 40 years without an adequate scientific basis—and in the face of a growing body of contrary evidence.

In the 1970s, “shaking” was advanced as a theory to explain a triad of findings (subdural hemorrhage, retinal hemorrhage, and/or brain swelling) that is sometimes seen in infants or children who have no signs of trauma. The theory was that shaking caused these findings by rupturing bridging veins and tearing the axons within the brain.

In 1987, Dr. Ann-Christine Duhaime, a neurosurgeon working with biomechanical engineers at the University of Pennsylvania, attempted to prove that shaking could cause these injuries. However, her study showed the opposite: The forces of shaking fell well below established injury thresholds and were 1/50th the force of impact, including impact on soft surfaces.¹

Despite these findings, many doctors continued to testify that shaking was the primary or sole cause for the triad of symptoms and that it would take a fall from a multistory building to cause these findings. In 2001, Dr. Plunkett disproved this premise in an article that included a videotaped fall of a toddler from a 28-inch plastic indoor play structure that resulted in subdural hemorrhage, retinal hemorrhage, and death.² This videotape proved definitively that short falls can cause the triad and are sometimes fatal. Although SBS proponents initially suggested that the videotape had been altered, Dr. Case (one of the signatories to the attack on Dr. Plunkett) has acknowledged the validity of the videotape, which has been shown in courtrooms and at teaching seminars in the United States and England.³ Numerous biomechanical studies have further confirmed that the force from short falls meets the injury thresholds, while shaking does not.^4-6

Short falls are not the only cause of medical findings previously attributed to shaking. Studies by Dr. Jennian Geddes published in Brain, England’s leading neurology journal, from 2001 and 2003 found that the brain injuries of allegedly shaken children were generally hypoxic rather than traumatic in origin, and that subdural hemorrhages are also found in natural deaths.^7,8 In 2002, Drs. Hymel, Jenny, and Block (two of whom signed the attack on Dr. Plunkett) listed the alternative causes for findings previously attributed to shaking or inflicted head trauma as accidental trauma; medical or surgical interventions; prenatal, perinatal, and pregnancy-related conditions; birth trauma; metabolic, genetic, oncologic, or infectious diseases; congenital malformations; autoimmune disorders; clotting disorders; the effects of drugs, poisons, or toxins; and other miscellaneous conditions.⁹ A 2006 text on abusive head trauma in infants and children (co-edited by Dr. Alexander, another signatory to the attack on Dr. Plunkett) and a 2007 review article by Patrick Barnes, professor of radiology at Stanford University and chief of pediatric neuroradiology at Lucile Salter Packard Children’s Hospital, are in accord.¹⁰ Despite this consensus, hundreds to thousands of parents and caretakers have been imprisoned based on testimony by doctors that subdural hemorrhages, retinal hemorrhages, and/or brain swelling are diagnostic of abuse, with little or no regard to the alternatives, including short falls and natural causes. At the same time, many doctors and academics have recognized that the real problem lies in the lack of an evidence base for shaken baby theory.

In 2003, a review article by Dr. Mark Donohoe found that “[T]he evidence for SBS appears analogous to an inverted pyramid, with a small data base (most of it poor-quality original research, retrospective in nature, and without appropriate control groups) spreading to a broad body of somewhat divergent opinions.”¹² In 2006, the National Association of Medical Examiners withdrew its position paper on shaking, and its annual conference included presentations with titles such as “‘Where’s the Shaking?’: Dragons, Elves, the Shaking Baby Syndrome, and Other Mythical Entities” and “Use of the Triad of Scant Subdural Hemorrhage, Brain Swelling, and Retinal Hemorrhages to Diagnose Non-Accidental Injury is Not Scientifically Valid.”

In subsequent publications, Dr. Waney Squier of Oxford University, one of England’s leading neuropathologists, and Dr. Jan Leestma, author of the textbook Forensic Neuropathology, similarly concluded that the evidence base for shaken baby syndrome is lacking.^13,14 None of this material is addressed or cited in the attack on Dr. Plunkett.

The problem, in short, is not that Dr. Plunkett was wrong; the problem is that he was right. Over the past decades, hundreds to thousands of caretakers—many of whom are innocent—have been convicted based on theories that lack a scientific basis. These convictions must now be revisited.

Of course children are abused. But there are many ways to abuse children, one of which is ripping them from their families and imprisoning their parents and caretakers based on misdiagnoses of abuse. We therefore urge the medical profession to join us in developing a calm, rational and evidence-based approach to pediatric head injury and child death.

Heather Kirkwood, J.D.
Seattle, Washington
Barry S. Scheck, J.D.
Co-director, Innocence Project
Benjamin N. Cardozo School of Law
New York City
Keith Findley, J.D.
President, Innocence Network
Co-director, Wisconsin Innocence Project
University of Wisconsin Law School
Madison, Wisconsin
Bridget McCormack, J.D.
Co-director, Michigan Innocence Clinic
University of Michigan Law School
Ann Arbor, Michigan
Julie Jonas, J.D.
University of Minnesota Innocence Clinic
Managing Attorney, Innocence Project of Minnesota
Minneapolis, Minnesota
Jacqueline McMurtrie, J.D.
Director, Innocence Project Northwest Clinic
University of Washington School of Law Seattle, Washington

References

1. Duhaime AC, Gennarelli TA, Thibault LE, Bruce DA, Margulies SS, Wiser R. The shaken baby syndrome. A clinical, pathological, and biomechanical study. J Neurosurg. 1987;66(3):409-15.
2. Plunkett J. Fatal pediatric head injuries caused by short-distance falls. Am J Forensic Med Pathol. 2001;22(1):1-12.
3. Seventh North American Conference on Shaken Baby Syndrome (Abusive Head Trauma), Vancouver, B.C. October 2008.
4. Ommaya AK, Goldsmith W, Thibault L. Biomechanics and neuropathology of adult and paediatric head injury. Br J Neurosurg. 2002;16(3):220-42.
5. Prange MT, Coats B, Duhaime AC, Margulies SS. Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants. J Neurosurg. 2003;99(1):143-50.
6. Goldsmith W, Plunkett J. A biomechanical analysis of the causes of traumatic brain injury in infants and children. Am J Forensic Med Pathology. 2004;25(2):89-100.
7. Geddes JF, Hackshaw AK, Vowles GH, Nickols CD, Whitwell HL. Neuropathology of inflicted head injury in children, I and II. Brain. 2001;124(part 7):1290-8.
8. Geddes J, Tasker RC, Hackshaw AK, et al. Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in ‘shaken baby syndrome’? Neuropathol Appl Neurobiol. 2003;29:114-22.
9. Hymel KP, Jenny C, Block RW. Intracranial hemorrhage and rebleeding in suspected victims of abusive head trauma: addressing the forensic controversies. Child Maltreat. 2002:7(4):329-48.
10. Frasier L, Rauth-Farley K, Alexander R, Parrish R. Abusive Head Trauma in Infants and Children: A Medical, Legal, and Forensic Reference. G.W. Medical Publishing, Inc.; St. Louis, MO: 2006.
11. Barnes PD, Krasnokutsky M. Imaging of the central nervous system in suspected or alleged nonaccidental injury, including the mimics. Top Magn Reson Imaging. 2007;18:53-74
12. Donohoe M. Evidence-based medicine and shaken baby syndrome part I: literature review, 1966-1998. Am J Forensic Med Pathol. 2003;24(3):239-42.
13. Squier W. Shaken baby syndrome: the quest for evidence. Dev Med Child Neurol. 2008;50(1):10-4.
14. Leestma J. Forensic Neuropathology, Second ed. CRC Press; Chicago: 2009.

Circular Reasoning

We read with interest Kate Ledger’s article “Challenging an Assumption: A pathologist questions shaken baby syndrome” (Minnesota Medicine, August 2009) and the response of Drs. Alexander, Barr, Block, et al. (January 2010).

Dr. Block and his cosigners complain that Ms. Ledger ignored the enormous body of international peer-reviewed medical literature about shaken baby syndrome. Much of this literature exhibits circular reasoning, selection bias, or misrepresents the data. Of the 14 references they cite, six are unsystematic reviews or consensus statements that mingle opinion with fact and add no original supporting evidence. Two are based on data described by the authors as “explorative.” Those authors suggest that “further surveillance … and modelling will be required.” Two are invalidated by insufficiently robust criteria to reliably diagnose abuse and one by failure to address the fundamental methods on which the study was based.

Dr. Block and his cosigners suggest that this literature “consistently and repeatedly supports the concept of shaken baby syndrome.” We do not disagree with this but would point out, as Ms. Ledger clearly did, that supporting a concept is far from demonstrating the scientific basis for it.

Just as disturbing as the literature Block and his cosigners cite is the indignation they expressed that someone should challenge their opinions as medical “experts” in a court of law—as if they are somehow exempt from the human tendency for cognitive errors in medical decision making. What scientist is afraid of debate that is crucial to our understanding of evolving ideas?

Fortunately, medicine has never been static. There is much to learn about the pathophysiology of infant brain trauma. We cannot make up for this lack of knowledge by reiterating opinion and poor data: Ignoring new evidence and failing to question and engage in debate is a dereliction of our duties to our patients and their families.

Waney Squier, FRCP FRCPath
Consultant neuropathologist
John Radcliffe Hospital
Oxford, United Kingdom
Julie Mack, M.D.
Assistant professor of radiology
Penn State Hershey Medical Center
Hershey, Pennsylvania
Patrick E. Lantz, M.D.
Professor of pathology
Wake Forest University
Winston-Salem, North Carolina
Patrick D. Barnes, M.D.
Chief of pediatric neuroradiology
Lucile Packard Children’s Hospital
Stanford University Medical Center
Stanford, California
Irene Scheimberg, M.D.
Paediatric and perinatal pathologist
The Royal London Hospital
London, England
James T. Eastman, M.D.
Clinical professor of pathology and laboratory medicine
University of Wisconsin
Madison, Wisconsin
Marta Cohen, M.D.
Sheffield Children’s Hospital NHS Foundation Trust
Sheffield, United Kingdom
Peter J. Stephens, M.D., FCAP
Forensic pathologist
Burnsville, North Carolina
Darinka Mileusnic-Polchan, M.D., Ph.D.
Medical Examiner for Knox and Anderson Counties
Regional Forensic Center
University of Tennessee Medical Center Knoxville, Tennessee

Persuasive Evidence and a Theory

I serve on occasion as an expert witness for the defense in shaken baby syndrome (SBS) cases. That is a matter I disclose as a potential conflict of interest. I wish the writers of the letter in your January 2010 issue had done the same.

When I cast doubt on the validity of SBS, I cite the original literature. In my judgment, SBS is so lacking in evidence, it is hard to understand how the hypothesis ever gained traction.^1,2

I cite a review of seminal SBS literature up to 1998. It concluded the evidence was inadequate.³ I cite Ommaya, et al., who did the original work on whiplash biomechanics that debunks the SBS hypothesis.⁴ I cite experimental work that indicates forces generated by manual shaking are an order of magnitude less than forces of impact, and less than the threshold for injury.⁵ I cite an article that states the neck should be destroyed if manual shaking were capable of producing brain damage.⁶ I have seen no case in which neck injury was observed.

Finally, I cite my own hypothesis. It is untested, just as the SBS hypothesis is untested. If the forces of shaking are sufficient to cause brain damage, the thumbs of the shaker and the places where the thumbs are applied on the victim should be conspicuously injured. They are not.

Edward N. Willey, M.D.
St. Petersburg, Florida

References
1. Guthkelch AN. Infantile subdural haematoma and its relationship to whiplash injuries. Br Med J. 1971;2(5759):430-1.
2. Caffey J. On the theory and practice of shaking infants. Its potential residual effects of permanent brain damage and mental retardation. Am J Dis Child. 1972;124(2):161-9.
3. Donohoe M. Evidence-based medicine and shaken baby syndrome: part I: literature review, 1966-1998. Am J Forensic Med Pathol. 2003;24(3):239-42.
4. Ommaya AK, Goldsmith W, Thibault L. Biomechanics and neuropathology of adult and paediatric head injury. Br J Neurosurg. 2002;16(3): 220-42.
5. Duhaime, AC, Gennarelli TA, Thibault LE, et al. The shaken baby syndrome. A clinical, pathological, and biomechanical study. J Neurosurg. 1987;66(3): 409-15.
6. Bandak FA. Shaken baby syndrome: a biomechanics analysis of injury mechanisms. Forensic Sci Int. 2005;151(1):71-9.

Evolution of the AAP’s Position

I was disappointed that Dr. Block indicated that the goals of the recent American Academy of Pediatrics (AAP) clinical report, “Abusive Head Trauma in Infants and Children,” were to “formally change the name shaken baby syndrome to abusive head trauma and to shift the focus … away from the debate over whether shaking is the key mechanism.”¹ The original title of the report was “Beyond Shaken Baby Syndrome: Mechanisms of Injury in Abusive Head Trauma,”², and it was to have directly addressed the new literature that has been published since 2001. It is the shaking mechanism that Dr. John Plunkett and others have challenged.

We must only assume that the failure of the AAP’s Committee on Child Abuse and Neglect (COCAN) to address “mechanisms” and to “shift the focus” away from mechanisms must mean that the shaking mechanism as a valid and unique cause of the triad (brain injury, subdural hematomas, and retinal hemorrhages) could not be defended in view of the recent literature. Drs. Block, Jenny, and Alexander should be aware of the evolving impact of this new research and the challenges raised by Plunkett and others to the unproven hypothesis that abusive shaking is a valid and the unique cause of the triad. They have been responsible for the wording of the AAP’s official positions over the last decade.

The AAP’s 2001 clinical report “Shaken Baby Syndrome: Rotational Cranial Injuries Technical Report,”, the official position statement from the AAP Committee on Child Abuse and Neglect, asserted that: “Although physical abuse in the past has been a diagnosis of exclusion, data regarding the nature and frequency of head trauma consistently support the need for a presumption of child abuse when a child younger than 1 year has suffered an intracranial injury” and … “The constellation of these injuries [brain injury, SDH, and retinal hemorrhages] does not occur with short falls….”³

I will note that a “presumption of child abuse” is a shift of the burden of proof that is not consistent with the American concept of criminal justice. I would also point out that the statement that the “constellation of these injuries [ie, the triad] does not occur with short falls,” is asserted as an absolute without exception.

This position statement carried the imprimatur of the AAP. Any physician encountering an infant with the triad of findings would be compelled to “presume” that any history of short falls was a lie, that the infant had to have been shaken, and that the person caring for the child at the onset of symptoms was guilty without exception.

Position statements from the AAP have a five-year life-span, unless specifically renewed. The 2001 COCAN position statement was not renewed. It could not be renewed because in the years following this statement, numerous articles appeared that documented the traid in short falls^4-7, crush injuries^8-10, and motor vehicle accidents¹¹ as well as in some medical conditions. In 2007, Carole Jenny co-authored another position statement from the AAP COCAN, “The Evaluation of Suspected Child Physical Abuse.”¹² In this new statement, all references to “presumption” were dropped. Instead of stating that shaking is the only cause of the triad, the authors acknowledged: “Most recent developments have addressed more accurate differentiation between inflicted and accidental injuries as well as detecting conditions that may mimic abusive injuries” and “Physicians must also consider that unusual events, including accidents, do happen to children and may produce injuries that are not characteristically seen from accidental causes. An injury pattern is rarely pathognomonic for abuse or accident without careful consideration of the explanation provided.”¹²

The term shaken baby syndrome was curiously absent, and at no point in this 2007 statement was it asserted that abusive shaking was a valid cause of subdural hematomas or brain injury, let alone the unique cause of the triad. This new statement by Jenny and COCAN went on to acknowledge that “[in criminal proceedings] cases must be proven ‘beyond a reasonable doubt’”—ie, no longer presumed and, thus, no longer shifting the burden of proof to the accused. Given this new standard, Dr. Block’s statement, “there is no credible medical evidence to support the notion that shaking does not cause these injuries,” has not only reverted to a “shift of the scientific burden of proof,” but also has failed to validate the shaking mechanism with scientific experimental research.

The statement also said:
“Physicians are expected to testify to the facts…and may be asked to render opinions regarding…mechanisms of injury…Pediatricians should not testify to anything that is beyond their level of knowledge…Physicians act primarily as scientists… and educators in legal settings rather than as child advocates.”¹²

The 2007 statement represents a paradigm shift from the position asserted in the AAP’s 2001 statement.

The AAP COCAN published its newest position statement “Abusive Head Trauma in Infants and Children” in 2009.¹ This paper asserts that shaking has the potential to cause injury, but specifically avoided defining “injury.” The authors also acknowledge that impact can cause injury. The 2009 statement does not mention the pathognomonic triad for abusive shaking. Instead, it “recommends adoption of the term ‘abusive head trauma’ as the diagnosis used in the medical chart to describe the constellation of cerebral, spinal, and cranial injuries that result from inflicted head injury to infants and young children.”

What many pediatricians and pathologists considered settled science: in 2001 has become unsettled. Evidence-based inquiry demands solid experimental evidence and new clinical research uncontaminated by the errors of the 2001 COCAN position statement. This controversy is acknowledged in the 2009 COCAN statement. Clearly, this evolution from 2001 to 2009 was much more than “a name change of shaken baby syndrome to AHT.” Instead of trying to “shift focus away from mechanism of injury,” COCAN needs to address the issue directly.

In 2007, Carole Jenny and COCAN set the standard for pediatricians to be scientists in the court room.¹² Science rejects past presumptions and assertions and demands reproducible validation. If exceptions exist, even single exceptions, then reasonable doubt has been generated. It cannot be dismissed, and old science can no longer be safely asserted.

In 2009, child abuse became a recognized subspecialty of pediatrics. If it is to maintain credibility as a valid subspecialty, it must base its positions on reproducible experimental confirmation and clinical research derived from clinical case series. Researchers like John Plunkett have issued the challenge. Now let the AAP either embrace new revelations or answer with solid, properly disinterested science.

John Galaznik, M.D., FAAP
Student Health Center, College of Community Health Sciences
University of Alabama, Tuscaloosa

References
1. Christian CW, Block R, American Academy of Pediatrics Committee on Child Abuse and Neglect. Pediatrics. 2009;123:1409-11.
2. American Academy of Pediatrics Newsletter of the Section on Child Abuse and Neglect, 2007;19(4):9.
3. American Academy of Pediatrics Committee on Child Abuse and Neglect. Shaken baby syndrome: rotational cranial injuries—Technical Report. Pediatrics. 2001;108(1):206-10.
4. Christian CW, Taylor AA, Hertle W, Duhaime AC. Retinal hemorrhages caused by accidental household trauma. J Pediatr. 1999;135(1):125-7.
5. Plunkett J. Fatal pediatric head injuries caused by short-distance falls. Am J Forensic Med Pathol. 2001;22(1):1-12.
6. Goldsmith W, Plunkett J. A biomechanical analysis of the causes of traumatic brain injury in infants and children. Am J Forensic Med Pathol. 2004;25(2):89-100.
7. Bechtel K, Stoesel K, Leventhal JM, et al. Characteristics that distinguish accidental from abusive injury in hospitalized young children with trauma. Pediatrics. 2004;114(1):165-8.
8. Lantz PE, Sinal SDH, Stanton CA, Weaver Jr RG. Perimacular retinal folds from childhood head trauma. BMJ. 2004;328(7442):754-6.
9. Obi E, Watts P. Are there any pathognomonic signs in shaken baby syndrome? JAAPOS. 2007;11:99-100.
10. Lueder GT, Turner JW, Paschall R. Perimacular retinal folds simulating nonaccidental injury in an infant. Arch Ophthalmol. 2006;124(12):1782-3.
11. Kivlin JD, Currie ML, Greenbaum J, et al. Retinal hemorrhages in children following fatal motor vehicle crashes. Arch Ophthalmol. 2008;126(6):800-4.
12. Kellogg ND, Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics. 2007;119(6):1232-41.

Missed Diagnoses

Kudos for covering the debate about shaken baby syndrome (SBS) in your first-rate issue on domestic violence. Infant abuse is a reality, alas, and the cranial symptoms that define SBS can follow child battering. The belief that the triad can result only from abuse, however, has not been proven and is contrary to our own experiences.

In the decade we’ve been attending SBS conferences, we’ve watched the common knowledge evolve away from the institutional certainty that can still shift the burden of proof from the state to the defendant. In our work with the accused, we’ve seen blind faith in the triad tear apart benign families and send innocent people to prison. In the worst cases, sick children go without the medical care they need because the diagnosis stops with SBS.

Tammy Fourman and Daniel Crow in Ohio, for example, accused of shaking their infant son in 1996, were exonerated six years later when their next baby was correctly diagnosed with Menkes disease, a genetic disorder that mimics SBS. By then, Fourman’s two other children had already been adopted out by social services.

Alejandro Mendez in Pennsylvania spent two years in the county jail before pediatrician and genetic visionary Dr. D. Holmes Morton studied the records and realized that Mendez’s son had died from a vitamin K deficiency, which could have been treated easily.

A 32-year-old wife and mother in California spent six years in prison after a friend’s daughter choked to death under her care. The medical examiner who declared the case a homicide conceded that the paramedic had reported pulling a rubber band out of the baby’s throat, but insisted that only a violent shaking could cause the SBS triad.

Our files bulge with murkier cases, in which doubt and suspicion inevitably worsen the pain of a child’s death or disability. We welcome the light that Dr. Plunkett and his colleagues bring to this arena.

Sue Luttner
Technical writer
Palo Alto, California
Susan Weston
Education writer
Anchorage, Alaska

Pot Calling the Kettle Black

The statement made by the members of the International Advisory Board for the National Center on Shaken Baby Syndrome in your January 2010 issue is the pot calling the kettle black. All the biomechanical studies indicate you cannot generate enough force to cause brain damage by shaking without also causing devastating neck injuries. It is the advisory board members who rely on the epidemiological data ignoring the fact that the results are all based on circular reasoning. If A + B + C = SBS and the diagnosis is thusly made, then obviously every case of SBS will have A + B + C. When the advisory board members realize that A + B + C can equal something else, they might approach the scientific method.

I can certainly understand the need for the members of the International Advisory Board for the National Center on Shaken Baby Syndrome to write such a letter. Like Sudden Infant Death Syndrome (SIDS) experts, they are experts in the unknown or nonexistent.

Harry J. Bonnell, M.D.
San Diego
Biomechanical Basis

The 12 authors of the letter “Evidence Outweighs Belief” (January 2010) include physicians, an attorney, and the executive director of the National Centers for Shaken Baby Syndrome. As a biomechanical engineer who has spent my career studying central nervous system injury in infants and young children, it is with great concern that I read the disparaging ad hominem directed toward Dr. John Plunkett and, specifically, the biomechanical work with which he has been involved.

The authors of the letter state: “Ms. Ledger reports that “Plunkett believes that the United States is still far off in setting justice straight.” What a shame it would be for the memory of dead babies and for the parents of babies killed by other caregivers if “setting justice straight” meant accepting a minority opinion totally without biomechanical, epidemiologic, or biological confirmation.

It is a tragedy that children die from injuries, whatever the cause. However, this highly evocative and pandering statement ends with a particularly absolute, yet untenable, flourish: the authors conclude that Dr. Plunkett’s views are “totally without biomechanical, epidemiologic, or biological confirmation.” Dr. Plunkett’s views regarding the potential for serious and fatal brain injury in the pediatric population as a result of short falls have been, and continue to be, borne out in the biomechanical literature, some of which he has contributed. This contribution includes the recent publication of a biomechanical reconstruction of a fatal short fall that was captured on videotape.¹ The idea that Dr. Plunkett’s views are without biomechanical confirmation ignores the evidence-based science and the laws of physics.

In contrast, there has never been published in the peer-reviewed literature a witnessed account of shaking an infant that documents the findings typically associated with shaking; there are no experimental models of shaking that demonstrate the pathognomonic outcome touted by the “majority” opinion; there are no published experimental models of vitreous traction that confirm the purported relationship between shaking and the production of the retinal pathology that, hitherto, has formed the foundation of the diagnosis of shaken baby syndrome. There is no biomechanical evidence to support the long-held notion of shaken baby syndrome and the “triad” of injuries identified with shaking. In fact, the absolute certainty of shaken baby syndrome and the triad has been abandoned recently by the American Academy of Pediatrics in their May 2009 statement regarding abusive head trauma in children.²

The revision of the AAP statement regarding the previously resolute and unflinching diagnosis of shaking tacitly reflects the inevitability of the science presented by Dr. Plunkett. Although one may choose to disagree with his views, Dr. Plunkett and his indefatigable pursuit of evidence-based medicine reminds us all that evidence must outweigh belief.

Kirk L. Thibault, Ph.D.
Biomechanical engineer
Essington, Pennsylvania

References
1. VanEe C, Raymond D, Thibault K, Hardy W, Plunkett J. Child ATD reconstruction of a fatal pediatric fall. Paper No. IMECE2009-12994. Proceedings of the ASME 2009 International Mechanical Engineering Congress & Exposition, IMECE2009. Lake Buena Vista, Florida. November 13-19, 2009,
2. Christian C, Block R, American Academy of Pediatrics Committee on Child Abuse and Neglect. Abusive head trauma in infants and children. Pediatrics. 2009;123;1409-11.

Source:

Minnesota Medicine

http://www.minnesotamedicine.com/CurrentIssue/LettersMarch2010/tabid/3355/Default.aspx