Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Unexplained Fractures
- Peter Ehrhardt (4 November 2008)
-
Re: Unexplained Fractures - Explained
- Michael D Innis (6 November 2008)
-
"Unexplained" fractures
- John W Puntis (12 November 2008)
-
unexplained fractures
- Peter Ehrhardt (13 November 2008)
-
Re: "Unexplained" fractures - Explained
- Michael D Innis (13 November 2008)
-
Re: Re: "Unexplained" fractures - Explained
- Alison Jayne Stevens (9 December 2008)
-
'Unexplained' fractures explained
- Dr Viera Scheibner PhD (12 December 2008)
-
Our tunnel view may miss a child abuse
- Khalid Alkhouly (16 December 2008)
-
When to suspect child maltreatment
- Theo Fenton (17 December 2008)
|
|
|||
|
Peter Ehrhardt, 1. Consultant Paediatrician 2. Designated Doctor for Safeguarding Burnley General Hospital BB10 2PQ
Send response to journal:
|
Editor I'm disappointed in James le Fanu. He's always managed to give off the aura of someone who is cultured and presumably well read. Now, to my dismay, I learn that he seems not to be. I wonder what he thinks has changed in the 21st Century? We know that, in antiquity, 'responsible' parents beat their children: we know that 'responsible' parents beat their children more recently, in the 18th & 19th Centuries: and we know this from reading the writers of those eras. We know that 'responsible' parents beat their children in the 20th Century - we've been there, trying to pick up the pieces. Why on earth should we imagine that 'responsible' parents have stopped beating their children in the 21st Century? Peter Ehrhardt Competing interests: 1. I meet a great many children who have been beaten by their parents 2. I don't know how, when I meet a parent, I can identify whether he or she is 'responsible'. |
|||
|
|
|||
|
Michael D Innis, Medicolegal Consultant Home 4575
Send response to journal:
|
Editor, Regarding “unexplained” fractures in allegedly abused children Peter Ehrhardt wants to know “what has changed in the 21st century”. The change is fractures can now be explained by nutritional deficiencies of Vitamins K or C (1,2,3,4,5,6,). The 20th century explanation of fractures in the medical aberration called Shaken Baby or Shaken/Impact Syndrome is a thing of the past and should be relegated to the scrap heap of history. Michael Innis References; 1. Koshihara Y, Hoshi K. Vitamin K2 enhances osteocalcin accumulation in the extracellular matrix of human osteoblasts in vitrio. J Bone Miner Res 1997;12(3):431-438 2. Latzin P, Griese M, Hermanns V, Kammer B. Sternal fracture with fatal outcome in cystic fibrosis Thorax 2005; 60:616 3.Vermeer C. Review Article Gamma-Carboxyglutamate-containing proteins and the vitamin k-dependent carbpxylase.Biochem J 1990;y 266:625- 636 4. Innis MD. Vitamin K Deficiency Disease J Orthomol Med 2008;23: 15 -20 5. Weatherall, Ledingham IGG, Warrell DA. Oxford Text Book of Medicine Second Edition Vol 1 Ch 17 page 36. Battered baby. 6.Clemetson CAB. Child Abuse or Barlow’s Disease Med Hypotheses 2002; 59(1): 52-56 Competing interests: As previously declared |
|||
|
|
|||
|
John W Puntis, Consultant Paediatrician Leeds General Infirmary LS2 9NS
Send response to journal:
|
Dr Innis provides a number of less than useful references to support his unorthodox views on the role of nutrient deficiencies in 'unexplained' childhood fractures. It should be clear to Dr Innis that to cite evidence of vitamins having an affect on bone metabolism (not contentious in itself) is poles apart from establishing causality of vitamin deficiency in ‘shaken baby syndrome’. In fact, it’s a bit like saying that because Victoria Climbie had skin lesions at the time of her death she must have had Kawasaki’s disease (1). His views also seem to disregard the possibility that even children with nutritional deficiencies can be subject to non-accidental injury. Dr Erhardt may feel, like Dennis Healey, no more than that he has been ‘savaged by a dead sheep’. Unfortunately the obfuscation of science by some proponents of 'orthomolecular medicine' such as Dr Innis could ultimately harm vulnerable children. 1. Kawasaki disease unrecognised. BMJ rapid responses, September 2007 Competing interests: I look after children with nutritional deficiencies, and occasionally those with non-accidental injury |
|||
|
|
|||
|
Peter Ehrhardt, Consultant Paediatrician Burnley General Hospital BB10 2PQ
Send response to journal:
|
Editor I read the contribution from Innes with alarm and incredulity I have however now seen that he came up with equally surprising views regarding the death of Victoria Climbie May I suggest that he records his competing interests as 'I believe that the lesions noted on Victoria Climbie were due to Kawasaki disease'? Your readers will then have further information when considering the import of what Innes writes. thankyou Peter Ehrhardt Competing interests: I see a great many children who have been injured by their parents |
|||
|
|
|||
|
Michael D Innis, Medicolegal Consultant Home 4575
Send response to journal:
|
Editor, Overturning the conviction of Angela Cannings for killing two of her children, Lord Justice Judge said that medical science was "still at the frontiers of knowledge" about unexplained infant deaths (1). Biochemists investigating the role of Vitamin K in the body are at that frontier of knowledge when it comes to explaining fractures, bruises retinal and intracerebral haemorrhages in these children. The Medical Profession, or more specifically “designated doctors” must abandon the mantra “THINK DIRTY” and take heed of what Dr Puntis calls “a number of less than useful references ” if they are not to find themselves before the GMC for false allegations of child abuse. Before accusing a parent or care giver of murder they must heed the advice in the “less than useful references” and exclude a deficiency of Vitamin K by performing a PIVKA test and a test for Undercarboxylated Osteocalcin . This will protect them from being struck off the Register. As regards Victoria Climbie he attributes a nonsensical conclusion to me - “because Victoria Climbie had skin lesions at the time of her death she must have had Kawasaki’s disease.” It was not that the child had skin lesions but the type of lesions and other clinical features which were typical of Kawasaki disease in my experience. However, instead of snapping at my heels, he can prove I am wrong by persuading the authorities to release the Laboratory findings and show the characteristic blood changes of Kawasaki Disease - Neutrophilia, Lymphopenia, AST and ALT both increased with AST > ALT - were not present. Michael Innis Reference 1 Dyer C Parents convicted of killing to have their cases reviewed BMJ 2004;328:183 (24 January), doi:10.1136/bmj.328.7433.183 Competing interests: As previously declared |
|||
|
|
|||
|
Alison Jayne Stevens, BTTA Nurse Nursing Bank UHL
Send response to journal:
|
I was accused of child abuse and inflicting injuries to my youngest son back in 1986, a spiral fracture of the tibia was confirmed, after he had jumped from the side of the bath and landing awkwardly.
He was taken too the local casualty department, after having problems weight bearing and being in a lot of visible pain.
We were questioned by various medical personnel, with reference to how the fracture occurred, and was told by a paediatrician, that the leg injury was caused by non accidental injury. There were no signs of trauma to the right leg, no bruising, swelling, or external marks of any description. My husband and I returned home, after leaving our son on the ward for observation, after his leg had been put into plaster. On returning to the hospital several hours later, we were informed by nursing staff that Social Services had been informed and had taken him from hospital on a Place of Safety Order, into foster care. The evidence given to the court, with reference to the care proceedings, was from a paediatric radiologist, who was given a set of x rays and asked to make an opinion on how he thought the injury occurred. We later found out that this professional had not even seen our son. Our son was later returned to us. Social Services and the powers to be said, that the “incident could have been accidental”, he was later found to be suffering from OI and he had the classic symptoms of brittle bone disease - shortness in stature with blue sclera to the whites of his eyes. The false allegation has ruined my life for ever and I now despair for my Baby Granddaughter, who looks like she may have some signs of this disease, which will continue too cause conflicting medical evidence, because within the mild forms of OI, x rays of bones appear to look normal and there is still no real blood test that can confirm the bones of contention. Competing interests: None declared |
|||
|
|
|||
|
Dr Viera Scheibner PhD, Scientist/Author Retired Blackheath NSW Australia
Send response to journal:
|
Dear Editor, Once upon a time, more precisely in 1946, John Caffey, published an article "Multiple fractures in the long bones of infants sufferring from subdural haematoma" (Am J Roentgenology; 56: 163-173). In this article he considered fractures in the long bones as a complication of the infantile subdural haematoma associated with the fractures of the cranium. Even though his own illustrations (x-ray photographs) show what is generally considered typical scurvy fractures, he denied any "roentgen signs of scurvy". Without much ado, Caffey concluded that "The fractures appear to be of traumatic origin but the traumatic episodes and the causal mechanism, remain obscure". Indeed, in 1972 ("On the theory and practice of shaking babies" Am J Dis Child; 124 (2): 161-169), Caffey proceeded to speculate that "all of these metaphyseal avulsions appeared to result from indirect traction, stretching, and sheering, acceleration-deceleration stresses on the periosteum and articlular capsules, rather than direct, impact stresses such as smashing blows on the bone itself". Then, without a shred of evidence, he called these findings "traumatic involucra" which commonly accompany the metaphyseal avulsions and involve the same terminal segment of the same shaft. He thought that such injuries develop due to traction-rupture of abundant normal perforating blood vessels, which are severed at the junction of the internal edge of the periosteum with the external edge of the cortex. It is difficult to understand why such classical scurvy fractures as shown in Caffey's own photographs were misinterpreted even in his time; however, Caffey admitted in his 1965 article "Significance of the history in the diagnosis of traumatic injury in children" (J Pediatrics; 67 ((5): 1008-1014) that "It is still a wonder to me that Ross Golden welcomed me, a pediatrician without either formal of informal training or experience in radiology, into his department of radiology and highly trained radiologists." Why, indeed? The fact remains that Caffey made a mess of things which even the years of supposedly professional radiology have not rectified. The sooner the rectification begins the better for not only thousands of victims of Caffey's (and his followers') obvious ignorance and closed mind, but also for those formally trained radiologists who blindly follow misinterpretations of a formally untrained Caffey. Hiller (1972), a formally trained Australian radiologist, demonstrated that Caffey's misunderstood bizarre fractures are in fact caused by scurvy, even though he did not explain what actually caused scurvy in the affected babies ("Battered or not - the reappraisal of metaphyseal fragility". Am J Roentgenol Radiol Therapy & Nuclear Medicine; 114 (2): 241-245). According to Hess' far ahead of his time book (1920. Scurvy past and present. Philadelphia and London J.B. Lippincott Company: 279pp), one of the symptoms of scurvy are haemorrhages such as into the gums, frenulum, skin and bones, into the stomach, intestines (with fatty infiltration of the liver), into the eye, under the conjunctiva or into the anterior chamber leading to the destruction of the eyeball. He described petechial haemorrhages into the lungs, pericardium and elsewhere, meningeal bleeding, which may give rise to apoplexy, haemorrhaging into scapula, periosteum and jonts; infantile scurvy (which may by acute or subtle, sub- acute or latent), with bizarre fractures of the long bones, ribs (separation at the costo-chondral junctions resulting in beading), scapula, cranium, separation of the epiphyses of the head of the humerus, and partial or complete separation of the lower ends of the femur, bleeding into muscles or between the muscle planes, joints, heart characterised by moderately dilated ventricles, and right hypertrophy, the heart muscle pale and tough, the cardiorespiratory syndrome, oedema etc. etc. etc. Scurvy affects all systems of the body. Scurvy in the twentieth and twenty first century? These days people generally think that nobody suffers scurvy, which used to be identified with long sea voyages during which the sailors were deprived of any fresh fruit and vegetables. The reality is far from such idealised perceptions. Most people probably have only marginal reserves of vitamin C and this applies particularly to babies and small children. Moreover, administration of vaccines depletes the marginal vitamin C reserves very quickly and this results in an acute scurvy. Vaccines of the kind given to babies as early as at birth (hepB vaccine) and DPT, Polio, Hib and pneumococal vaccines at 6-8 weeks, 2 and 4 months and other vaccines later on, contain beside adjuvants and preservatives, pertussis, diphtheria and tetanus, measles, mumps rubella toxins which are treated with formaldehyde to lower their virulence and toxicity. However, all of these treated toxins (toxoids), bacteria and viruses have the ability to revert back to their original toxicity and virulence by passage in the injected individuals, as demonstrated by Samore and Siber (1992. Effect of pertussis toxin on susceptibility of infant rats to Haemophilus influenzae Type b. J Infect Dis; 165: 945-948) and as early as in the sixties by Gerber et al. (1961. Inactivation of vacuolating virus (SV40) by formaldehyde. Proc Soc Exp Biol & Med; 108:205-209) and Fenner (1962. The reactivation of animal viruses. BMJ; July 212: 135-142). Two Czech researchers, Pekarek and Rezabek, demonstrated already in 1959 (An endocrinological test for inocuity of the pertussis vaccine. J Hyg Epidemiol Microbiol Immunol; 3: 79-84) that when rats are injected with pertussis vaccine, they develop an acute scurvy. My comment is that the difference between rats and human species is in that rats produce their own vitamin C and recover, while human babies do not produce their own vitamin C and may not recover unless they are given large doses of vitamin C (sodium ascorbate). By the way, vitamin C is essential for the production of collagen which is essential for the bones and connective tissues. Many of those who have been involved in the study of shaken baby syndrome (according to a California judge, it is a factitious diagnosis carefully fabricated by medical profession) have been rather shy or silent about the administered vaccines, even though those vaccine injections are as a rule the only documented facts. Without revealing the vaccination status of the affected babies, the whole issue is not going to be resolved. In court cases when parents are accused of injuring their child, it amounts to withholding vital information. Indeed, more recently some judges in Australia threw out the accusations of SBS because of insufficient evidence (of the alleged shaking or whether shaking can actually cause the observed injuries). One can't convict a person based on an opinion; medical opinions are subject to errors and changes. In a normal ordinary murder case people cannot be convicted on someones' opinion; in cases of SBS the accused parents are effectively convicted on someone's opinion. The picture is really crystal clear, at least for people who really study medical literature right from the first and original articles. If you set out to study the ancient Rome, you should read the authors who lived in the ancient Rome and not those who did not and who, inevitably base their perceptions of the ancient Rome on second and third hand information. Everybody is familiar with the school children's game "The Chinese whispers": the original word totally changes before it reaches the last person in a line. In medicine, for some reason which escapes me, many authors think that they not only don't have to, but they must not study older published information. Their patients may suffer. Moreover, due to the known inevitable political interference, political correctness may delay the truth for centuries. Yes, I am referring to The Holly Inquisition. However, these days we have a freedom of speech and the truth is allowed to prevail. Why not see and reveal it? Competing interests: None declared |
|||
|
|
|||
|
Khalid Alkhouly, General Surgeon, HDSJH, NB, Canada
Send response to journal:
|
Child abuse has its own proportions as a social and medical problem. The number of abused and neglected children in the United States rose from 1.4 million in 1986 to 2.9 million in 1993.[1] We all may agree that its actual incidence is unknown and many cases are unreported. Unfortunately, the problem is still identified in retrospect after a history of repetitive trauma has been established. [2, 3] Awareness of the skeletal signs of abuse in children is important for physicians as well as the other injury patterns in order to diagnose and intervene appropriately. Whereas the incidence of non-accidental fractures decreases with increasing age, the incidence of accidental fractures increases with increasing age up to 12 years.[4] Civil suits have been filed against physicians for failure to report acts of child abuse. Maliciously reporting abuse when it is not the cause of injury, however, may expose an individual to the risk of litigation. The caregiver's account of the injury is often vague. The degree of physical injury may be inconsistent with the history given [5, 6, 7] and often the reported time of injury does not correlate with the obvious age of the injury. A delay in seeking treatment is often noted. However, a history of repeated trauma with the child treated in several different facilities should arouse suspicion. The parents' response to the situation may be inappropriate. They may become overly involved. [8] Any condition that interferes with parent-child bonding and contact increases the risk of child abuse. Premature infants, hyperactive children or children with disabilities are more likely to suffer abuse.[9] Because infanticide occurs most often in the first few months of life, intervention during pregnancy and the postpartum period is recommended.[10] Early identification and intervention are essential. Recognition of signs of neglect, sexual abuse, or emotional maltreatment may lead the treating physician to consider non-accidental injury as a possibility. References: 1. Anonymous : Child Maltreatment 1994: Reports from State to the National Center on Child Abuse and Neglect, Washington, DC, National Center on Child Abuse Neglect, U.S. Government Printing Office, 1996. 2. Gross R.H., Stranger M.: Causative factors responsible for femoral fractures in infants and young children. J Pediatr Orthop 1983; 3:341- 343. 3. Jackson G.: Child abuse syndrome: The cases we miss. BMJ 1972; 2:756-757. 4. Worlock P., Stower M.: Fracture patterns in Nottingham children. J Pediatr Orthop 1986; 6:656-660. 5. Abuse Child : Guidelines for Intervention by Physicians and Other Health Care Providers, Seattle, Washington State Medical Association, 1990. 6. Everything You Always Wanted To Know about Child Abuse and Neglect, Washington, D.C., National Center on Child Abuse and Neglect, 1991. 7. Helfer R.E., Slovis T.L., Black M.: Injuries resulting when small children fall out of bed. Pediatrics 1977; 60:535-553. 8. Green F.C.: Child abuse and neglect, a priority problem for the private physician. Pediatr Clin North Am 1975; 22:329-339. 9. Albert M.J., Dvaric D.M.: Injuries resulting from pathologic forces: Child abuse. In: MacEwen G., Kasser J.R., Heinrick S.D., ed. Pediatric Fractures: A Practical Approach to Assessment and Treatment, Baltimore: Williams & Wilkins; 1993: 388-400. 10. Overpeck M.D., Brenner R.A., Trumble A.C., et al: Risk factors for infant homicide in the United States. N Engl J Med 1998; 339:1211-1216. Competing interests: None declared |
|||
|
|
|||
|
Theo Fenton, Consultant Paediatrician Mayday University Hospital, Croydon
Send response to journal:
|
Yesterday, the National Institute for Health & Clinical Excellence (NICE) posted draft guidelines "When to suspect child maltreatment" on it website (see
here). They are out for consultation until 10 February. The Guideline Development Group members agree that "A prospective comparative study of fractures in physical abuse, conditions leading to bone fragility and those resulting from accidental trauma to encompass a study of metaphyseal fractures specifically is needed because the existing evidence base does not fully account for differential diagnosis of fractures in the infant and toddler age group" (page 47 of the full guideline, and page 29 of the NICE guidline).
Competing interests: None declared |
|||