BMJ  2004;329:741-742 (25 September), doi:10.1136/bmj.329.7468.741-c

Letter

The evidence base for shaken baby syndrome

Response to Reece et al from 41 physicians and scientists

EDITOR—Reece et al have implied that child abuse is a particularly difficult area in which to conduct research.¹ This difficulty does not justify circular reasoning, selection bias, imprecise case definition, unsystematic review publications, or conclusions that overstep the data.^{2-5 w1-w3}

Geddes and Plunkett described the use of evidence based medicine in evaluating the causes of head injury in infants and children.^{w4 w5} Evidence based medicine is the conscientious, explicit, and judicious use of scientific evidence in making medical decisions and cautions against unsystematic, untested reasoning and intuition based clinical applications. It integrates scientific principles and clinical experience with valid, current research.^w6

While much of clinical medicine still relies on observation, it is critical that these observations are verified and validated. Often, the clinician must be more deliberate than the experimentalist who uses a planned systematic approach. The clinical researcher may have to await the natural sequence of events—deducing relationships that lie below observed phenomenon, being more logical and less dogmatic, and avoiding the fallacy of mistaking correlation with causation.^w7 If the principles of science and evidence based medicine are not critically applied to observational studies, a set of formulated beliefs among like-minded people may be reinforced, leading to misconceptions and misinterpretations. When this occurs, the primary principle of medicine—first, do no harm—may be violated.

Child abuse in any form is always unacceptable. However, if errors in diagnosis, false accusations, and wrongful convictions result from untested and unverified beliefs, then we have done harm.

Critically evaluating one's own understanding is far more constructive than criticism of those who differ. If we can approach differences objectively and resolve them with rational analysis, then we have moved decisively towards answering difficult questions.

Wake Forest University Health Sciences, Winston-Salem, NC 27157, USA plantz{at}wfubmc.edu

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Details of the other 40 signatories and all competing interests are available on bmj.com, as are references w1-7.

This letter is signed by another 40 physicians and scientists (see bmj.com for details).

Competing interests: See bmj.com

References

1. Reece RM. The evidence base for shaken baby syndrome. BMJ 2004;328: 1316-7. (29 May.)[Free Full Text]
2. 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.[Abstract]
3. Ewing-Cobbs L, Kramer L, Prasad M, Canales DN, Louis PT, Fletcher JM, et al. Neuroimaging, physical, and developmental findings after inflicted and noninflicted traumatic brain injury in young children. Paediatrics 1998;102: 300-7.[Abstract/Free Full Text]
4. Feldman KW, Bethel R, Shugerman RP, Grossman DC, Grady MS, Ellenbogen RG. The cause of infant and toddler subdural haemorrhage: a prospective study. Paediatrics 2001;108: 636-46.[Abstract/Free Full Text]
5. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. JAMA 1999;281: 621-6.[Abstract/Free Full Text]

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