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EDITOR'S CHOICE: Richard Smith The sudden death of a child BMJ 2004; 328: 0-g [Full text]

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Tissue retention

CA Johnson   (6 February 2004)

Doubtful death

Tom H Hughes-Davies   (11 March 2004)

Re: The sudden death of a child

C. Alan B. Clemetson, M.D., New Orleans, LA 70125   (17 July 2004)

None so blind as paediatricians that won't see

Michael D Innis   (20 July 2004)

The sudden death of a child

C. Alan B. Clemetson, M.D.   (26 July 2004)

Tissue retention 6 February 2004
CA Johnson, Parent LA9 Send response to journal: Re: Tissue retention	I suspect that the controversy over tissue retention needs addressing. It was not the organ and tissue retention per se which caused pain for bereaved families, rather that they were not informed. A few families may object to organ retention after burial on religious grounds, but most simply wish to be informed and allowed to give consent. Indeed parents faced with the sudden loss of a child usually ask for all possible investigations to be carried out. I hope we are not facing a misunderstanding as to the appropriate use of tissue retention. It would be most ironic if professionals made another mistake because they failed to consult with parents again. Competing interests: None declared
Doubtful death 11 March 2004
Tom H Hughes-Davies, Retired paediatrician Breamore Marsh, Fordingbridge, SP6 2EJ Send response to journal: Re: Doubtful death	When a patient dies it is reasonable to ask the next of kin whether they wish to ask for further examination to confirm or reveal the cause. On their generosity and consent rests the post mortem examination which has contributed so much to medical knowledge. Otherwise a doctor has no standing. All action and decision rests with the coroner to whom he has a duty to report any suspicion. Certainly he has no moral or legal right to mount a raid to secure the scene of possible crime. He himself may be involved in the child's care, and should be further involved only at the request of the coroner, who may prefer neutral advice. History shows the danger of Enthusiasm from Manichee to Clark. Competing interests: None declared
Re: The sudden death of a child 17 July 2004
C. Alan B. Clemetson, M.D., Professor Emeritus 5844 Fontainebleau Drive, New Orleans, LA 70125 Send response to journal: Re: Re: The sudden death of a child	The commentary by Richard Smith, editor of the BMJ, reminded us of the need for thorough investigation of the causes of infant deaths. His emphasis was placed on the need for identification of any medical cause. Otherwise, one or the other of the parents could be accused of murder, if there is any suspicion of child abuse. "...families must also be protected from false or inappropriate accusations." Geddes and Plunkett (1) wrote an excellent article questioning the significance of the pathological findings upon which the diagnosis of Shaken-Baby-Syndrome is based. In reply to their article, I submitted a rapid response entitled "Shaken Baby", or Barlow's Disease Variant? (2). Moreover, I proposed two simple blood tests which can allow diagnosis of and treatment for variants of Barlow's disease. Subsequent rapid responses by physicians who have expert knowledge of this field -- including Yazbak (3) of the United States, Taylor (4) of the United Kingdom, Hoffer (5) of Canada, and Innis (6) and Nehrlich (7) of Australia -- have been supportive of my proposal. The important works of Kalokerinos (8) and Buttram (9) demonstrate conclusions similar to mine. Several other concerned colleagues have also expressed interest and support for my designation of two essential blood tests related to capillary fragility. Some rapid responses have been less enthusiastic, but it would be difficult for any critics to oppose the need for simple laboratory tests to make an accurate medical diagnosis in an infant displaying signs suggestive of shaken-baby-syndrome. Any attempts at prosecution for such a charge, without direct evidence, should in future call for dismissal in light of insufficient evidence, if a Barlow's Disease Variant has not been considered. Furthermore, prosecution of such cases will not be successful, if the results of plasma ascorbic acid and whole blood histamine analyses are not available to be placed in evidence before the court. (1) Geddes JF, Plunkett J. The evidence base for shaken baby syndrome. BMJ 2004; 328 (7442):719-720. (2) Clemetson CAB. "Shaken baby", or Barlow's disease variant? bmj.com 2004; 328 (7442):719-720, 19 June 2004. (3) Yazbak FE. Clemetson syndrome. bmj.com 2004; 328 (7442):719-720, 23 June 2004. (4) Taylor KB. Clemetson's work. bmj.com 2004; 328 (7442):719-720, 5 July 2004. (5) Hoffer A. Re: "Shaken baby", or Barlow's disease variant? bmj.com 2004; 328 (7442):719-720, 24 June 2004. (6) Innis MD. Re: Study first, judge later. bmj.com 2004; 328 (7451):1309-1312, 30 June 2004. (7) Nehrlich HH. Patience instead of anger and condemnation. bmj.com 2004; 328 (7442):719-720, 25 June 2004. (8) Kalokerinos A. Medical Pioneer of the 20th Century. Biological Therapies Publishing Pty. Ltd., Braeside, Melbourne, Victoria, Australia, 2000. (9) Buttram H. Vaccines, vitamin C depletion and shaken baby syndrome. Redflagsdaily.com, 26 August 2004. Competing interests: None declared
None so blind as paediatricians that won't see 20 July 2004
Michael D Innis, Director Medisets International Home 4575 Send response to journal: Re: None so blind as paediatricians that won't see	Editor, How can investigators distinguish the 10% of cases where abuse may be a factor from the 90% where it is not, asks Richard Smith Professor Clemetson has provided the answer many times but his message has not been heeded. There is a need he says “ for simple laboratory tests to make an accurate medical diagnosis in an infant displaying signs suggestive of shaken-baby-syndrome.” Vaccines are responsible for approximately half the cases of alleged Shaken Baby Syndrome that have been referred to me personally and others (1,2,3,4,5,6) have had similar experiences. The tests Professor Clemetson recommends in these circumstances are plasma ascorbic acid and whole blood histamine analyses If Paediatricians remains blind to the fact that adverse vaccine reactions are a substantial factor in the false diagnosis of Shaken Baby Syndrome, despatching a regiment of Paediatricians to investigate the death of a child is absolutely futile. Michael Innis References. 1 Clemetson CAB. "Shaken baby", or Barlow's disease variant? bmj.com 2004; 328 (7442):719-720, 19 June 2004. 2. Yazbak FE. Clemetson syndrome. bmj.com 2004; 328 (7442):719-720, 23 June 2004. 3. Hickman M www.redflagsdaily.com 4. Schneibner V.Shaken Baby Syndrome Diagnosis on Shaky Ground. Journal of Australasian College of Nutrition & Environmental Medicine Vol 20. No 2 August 2001 5 Kalokerinos A. Medical Pioneer of the 20th Century. Biological Therapies Publishing Pty. Ltd., Braeside, Melbourne, Victoria, Australia, 2000. 6 Buttram H. Vaccines, vitamin C depletion and shaken baby syndrome Redflagsdaily.com, Competing interests: I have advised some accused.
The sudden death of a child 26 July 2004
C. Alan B. Clemetson, M.D., Professor Emeritus 5844 Fontainebleau Drive, New Orleans, Louisiana 70125 Send response to journal: Re: The sudden death of a child	Sixty years ago, when I was in medical school, I was taught that one has to consider two different aspects in evaluating the cause of a bleeding tendency. They were the blood coagulation factors on the one hand, and the strength or fragility of the smallest blood vessels on the other; but only coagulation studies have been reported in most of the NAI or “Shaken-Baby-Syndrome” cases being adjudicated. Both pressure and suction techniques to determine capillary fragility were useful in some earlier research studies; but the results are somewhat unreliable because arteriolar spasm, due to anxiety or pain, can sometimes give rise to false values. Studies of plasma ascorbic acid and whole blood histamine concentrations, which are inversely related to one another, are much more useful. Indeed, blood histamine has proven to be a very good indicator of vitamin C status, as it is elevated even in mild ascorbate depletion, which is found in about 30 percent of an outwardly normal adult population (1). Today, unfortunately, many physicians think they have done their duty when they order blood to be sent to the haematology laboratory for thorough coagulation studies, completely forgetting to arrange for fresh blood samples to be sent to the biochemistry laboratory for same-day whole blood histamine and plasma ascorbic acid analyses. When a physician investigates infants with retinal petechiae or subdural haemorrhages, which may be suspected as being the result of Non- Accidental-Injury, Shaken-Baby-Syndrome, or Child Abuse, these chemical analyses are absolutely essential. Could this frequent omission be because the paediatricians forget to order these two simple chemical analyses, or is it because the hospital chemistry laboratories are not yet equipped to perform these tests on demand and on the same day? Either way, something must be done about this situation -- and soon - - because Barlow’s disease, or infantile scurvy, can so easily be mistaken for child abuse (2). The laboratory results must be available the same day. The very integrity of many families is dependent on a proper and immediate diagnosis. References 1) Clemetson, C.A.B. Histamine and ascorbic acid in human blood. J. Nutrition 1980; 110:662-668. 2) Clemetson, C.A.B. Child abuse or Barlow’s disease? Pediatrics International 2004; 45:758. Competing interests: None declared