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Shaking Wrong Beliefs

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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.