SHAKEN BABY SYNDROME

1. SHAKEN BABY SYNDROME Dr Andra le Roux-Kemp Institute of social & cultural anthropology, FreieUniversitÄt berlin & faculty of law, Stellenbosch University Dr LenÉ burger Division of Forensic Medicine, Department of pathology, Faculty of Medicine and health sciences, Stellenbosch University & western cape forensic pathology service

2. INTRODUCTION • Shaken Baby Syndrome • Violent & repetitive shaking of an infant (<2 years) and the causative role of the relative impact upon the release of shaking that causes intracranial injuries and haemorrhages, including retinal haemorrhages and that can lead to severe disabilities or even the death of the child • Also referred to as Whiplash Shaken Infant Syndrome or Abusive Head Trauma • Triggered by • inconsolable crying of a child • high levels of frustration of parent/carer • behaviour contradicting expectations of the parent/caregiver

3. HISTORY • 1946 • John Caffey – case studies of children with multiple fractures and subdural hematomas • 14 November 1956 • Virginia Jaspers sentenced to 10-22 years’ imprisonment after admitting that she violently shook baby Jennifer Malkan • “…causing her head to bob back and forth after which the baby lost her breath and her eyes were funny in her head…” • 1962 • Henry Kempe – battered child syndrome and abusive head trauma • 1971 • Norman Guthkelch – describe shaking as a mechanism for intracranial injuries in infants and young children • 1974 • John Caffey – Whiplash Shaken Infant Syndrome • “vigorous manual shaking of infants by the extremities or shoulders, with whiplash-induced intracranial and intraocular bleeding, but with no external signs of head trauma”

4. HISTORY II • 1985 • Head trauma – most frequent cause of permanent damage or death among abused infants / children • 2009 • Abusive Head Trauma is the leading cause of death from trauma and a major cause of disability in children <2 years • 20 – 30 per 100 000 infants under the age of 1 year • BUT since 1987 • The relationship between shaking and intracranial injury has come under intense scrutiny and criticism

5. DIAGNOSING SHAKEN BABY SYNDROME • The triad • Subdural haemorrhage • Retinal haemorrhage • Encephalopathy • Long bone fractures • No external sign of impact – Ontario triad

6. DIAGNOSING SHAKEN BABY SYNDROME • The triad • Subdural haemorrhage • Retinal haemorrhage • Encephalopathy • Long bone fractures • No external sign of impact – Ontario triad

7. DIAGNOSING SHAKEN BABY SYNDROME • The triad • Subdural haemorrhage • Retinal haemorrhage • Encephalopathy • Long bone fractures • No external sign of impact – Ontario triad

8. Subdural haemorrhage: The anatomy & pathology

9. Subdural haemorrhage: The anatomy & pathology

10. Subdural haemorrhage: The anatomy & pathology

11. Retinal haemorrhage: The anatomy & pathology

12. Retinal haemorrhage: The anatomy & pathology

13. Encephalo-pathy: The anatomy & pathology

14. THE TRIAD • Encephalopathy • Intraparenchymal shears • Subarachnoid haemorrhages • Diffuse axonal injury • Hypoxic ischemic injury • Diffuse brain swelling

15. ASSOCIATED PATHOLOGY Warning Rib fractures Long bone fractures

16. Associated pathology

17. Associated pathology

18. ASSOCIATED PATHOLOGY

19. ASSOCIATED PATHOLOGY V

20. MEDICAL HISTORY No history of trauma ‘Minor’ trauma Stories change as time goes on Shaking (?)

21. OUTCOMES Fatality unknown – 11% to 23% ? Roughly 1/3 good outcome 1/3 mildly to moderately disabled 1/3 severely disabled

22. OTHER VOICES • Duhaime 1987 • Shaken impact syndrome • Runyan 2008 • Between 2% - 4.4% of parents admit to shaking their children < 2 to discipline them (USA) • 42% children < 3 in slums of India

23. OTHER VOICES • Geddes • Very little axonal injury • Neck injury • Sub-/intradural haemorrhage • Hypoxia

24. OTHER VOICES

25. TRADITIONAL MODEL

26. GEDDES MODEL

27. WHERE ARE WE NOW? • 1996: triad caused by shaking useless: • Motor vehicle accident • Fall from a multi-story building • Jenny 2011: The triad is a myth! • Guthkelch 2012: “Shaken Baby Syndrome is an undesirable phrase and that there was not a vestige of proof when the name was suggested that shaking, and nothing else, caused the triad.”

28. DIFFERENTIAL DIAGNOSIS Other trauma – even minor Bleeding disorders Vascular lesions in brain Birth injuries and re-bleeds Infectious diseases Metabolic abnormalities Hypoxia

29. LITIGATING SHAKEN BABY SYNDROME • Questions? • Amount of force • Duration of shaking • Nature of the shaking • Correlation between the shaking of a child & the injuries that manifest • Early prominent cases • 1998 • Louise Woodward (USA) • Helen Stacey (UK) • 1999 • Louise Sullivan (UK)

30. UNITED STATES OF AMERICA • Cavazos v Smith 132 S.Ct. 2 (31 October 2011) • Shirley Ree Smith, grandmother of Etzel Smith accused of causing his death • Battle between the experts • Prosecution • Brain haemorrhages; bruise and abrasion on the lower back of the baby’s head • Shaking itself was so severe that the brain directly tears in vital areas, causing death with very little bleeding • Defence • No retinal haemorrhage; minimal subdural/subarachnoid haemorrhage, no brain swelling and no fractures, sprains or other indications of trauma • California Court of Appeal • Guilty • Ninth Circuit court • Not guilty – no physical evidence of tearing or shearing and no other evidence supporting death by violent shaking • US Supreme Court • Majority – Guilty • Minority – Not guilty • Medical evidence not conclusive and non-medical evidence not indicative of Shaken Baby Syndrome

31. UNITED KINGDOM • R v Harris & others [2005] EWCA Crim 1980 (21 July 2005) • Four appeals against four different convictions based on the triad of injuries associated with Shaken Baby Syndrome • New evidence – Geddes I, II & III and the ‘unified hypothesis’ • Geddes I, II & III and the ‘unified hypothesis’ • Dr Jennian Geddes: “the unified hypothesis was never advanced with a view to being proved in court” • Minimal force necessary • Unknown and would probably never be known • If everyday accidents caused this particular pathology, such cases would be extremely common instead of quite rare. • Obligations of expert witnesses • Independent • Objective and unbiased opinions • Also disclose dissenting facts and opinions • Also disclose when research findings are inconclusive • Should be allowed to change their mind

32. SOUTH AFRICA • The triad of encephalopathy, subdural haemorrhages & retinal haemorrhages are not dispelled • BUT the presence of the triad alone – or its individual components – are not enough to diagnose abuse/shaken baby syndrome • SA Willers & AM Willers (No. 14/5829/95) • Couple was convicted of the abuse of four of their five children • Injuries – extradural haematoma, various bone fractures, rib fractures, bruises • Importance of case • Not one of the injuries was witnessed by anyone other than the accused • After 8 weeks of medical expert testimony no clarity as how any one of the injuries had occurred was reached • Pattern of injuries was important • Rarity of finding large bruises or fractures of long bones and ribs in very small infants who are non-mobile was accepted by the court as being indicative of non-accidental injury

33. RECOMMENDATIONS: COLLECTING INFORMATION • Collect as much information as possible • Physical, environmental & historical context • Be sensitive to risk factors • Male infants under the age of 6 months • Parental risk factors: Parental age, educational level, marital status, welfare status, employment status, history of substance abuse, mental health problems, history of spousal abuse and/or domestic violence, previous referral to child protection services • Confessions • Few confessions relative to the large number of alleged shaking injury cases • Clinical definitions of ‘shaking’ in medical literature and how it is understood by lay people who are experiencing severe stress and trauma are ambiguous • Coercive interrogation techniques • Plea-and-sentence-agreements

34. RECOMMENDATIONS: RAISING AWARENESS Shaking as an appropriate response More socially acceptable and physically less dangerous Usually have no intention of hurting the child Awareness campaigns should be coupled with programmes focussing on early detection and intervention

35. CONCLUSION • “While we support…[the] commitment to the prevention of child abuse, this commitment should not substitute subjective beliefs for objective scientific evidence. Instead, the commitment must be to getting it right…it is inappropriate for medical professionals to diagnose shaking or abusive head trauma based solely or primarily on the presence of subdural haemorrhage, retinal haemorrhage and/or encephalopathy. When a child abuse referral or diagnosis is made based on these findings, it should be clearly disclosed that there are many possible causes for these findings; that the issues are complex and poorly understood; and that shaken baby syndrome diagnosis based exclusively or primarily on these findings rests on good-faith beliefs and hypotheses, rather than science.” • Findley, Barnes, Moran, and Squier‘Shaken baby syndrome, abusive head trauma, and actual innocence: Getting it right’ Houston Journal of Health Law and Policy (2012) Vol. 12, 209-312, 300.