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LETTERS: James LeFanu and Rioch Edwards-Brown Patterns of presentation of the shaken baby syndrome: Subdural and retinal haemorrhages are not necessarily signs of abuse BMJ 2004; 328: 767 [Full text]

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Retinal Haemorrhages are not diagnostic of the {mythical) Shaken Baby Syndrome.

Michael D Innis   (14 August 2007)

Retinal Haemorrhages are not diagnostic of the {mythical) Shaken Baby Syndrome. 14 August 2007
Michael D Innis, Director Medisets International Home 4575 Send response to journal: Re: Retinal Haemorrhages are not diagnostic of the {mythical) Shaken Baby Syndrome.	To the Editor, With regard to the diagnosis of Shaken Baby / Shaken- Impact Syndrome Retinal Haemorrhages are still thought by some to be virtually diagnostic of the condition. Unless the Royal Colleges take steps to rectify this situation many innocent carers are likely to victims of this misconception. Professor Roger Byard [1] in discussing the deaths of Sally Clark’s children says “The initial cause of Harry’s death, based on a collection of typical and not-so-typical findings, was reported as shaken-impact syndrome. The diagnosis of retinal haemorrhage, which was quite crucial to support the possibility of shaking, was, however, incorrect. The retinal vessels were found, on independent review, to be merely congested. Retinal haemorrhages had also not been present when Harry had been examined at the hospital where resuscitation was attempted. Although not a recognised feature of shaken-impact syndrome,8 cerebral laceration was also used to support a diagnosis of shaking. However, these injuries were subsequently determined to be postmortem artefact arising at the time of brain removal. Given the unreliability of these findings and the absence of typical features of shaken-impact syndrome, such as retinal haemorrhages, subdural haemorrhages and axonal damage, the cause of death was changed to suffocation. (emphasis mine) The “diagnosis of retinal haemorrhage, which was quite crucial to support the possibility of shaking” is a commonly held belief which I believe should be dispelled as it is speculative and hence unscientific. Recently Rutty et al; [2] reported a case of Vitamin K deficiency with subdural and retinal haemorrhages mimicking non-accidental injury. He pointed out the importance of a full haematological investigation including tests for ‘Protein Induced by Vitamin K Absence/Abnormality (PIVKA -II). This test should always be done in addition to the Prothrombin Time to avoid misinterpreting retinal haemorrhages and attributing them to the Shaken-Impact Syndrome. Because fractures are often associated with Retinal Haemorrhages is cases of alleged child abuse, the blood levels of carboxylated and undercarboxylated Osteocalcin help to identify those fractures which result from Vitamin K deficiency.[3] False allegations of Shaken Baby/ Shaken-Impact Syndrome will be avoided if these measures are adopted world wide. Michael D Innis FRCPA; FRCPath. References: 1. Byard RW Viewpoint Unexpected infant death: lessons from the Sally Clark case MJA 2004; 181 (1): 52-54 2.Rutty GN, Smith CM, Malia RG. Late-form Hemorrhagic Disease of the Newborn: A Fatal Case Report With Illustrations of Investigations That May Assist in Avoiding the Mistaken Diagnosis of Child Abuse. Amer J Forensic Med Path. 1999; 20(1):48-51. 3.Conway SP, Wolfe SP, Brownlee KG, White H et al; Vitamin K Status Among Children With Cystic Fibrosis and Its Relationship to Bone Mineral Density and Bone Turnover. PEDIATRICS. 2005;115; 1325-1331.. Competing interests: I fear the myth of the Shaken Baby Syndrome may ovetake my children and grandchildren.