Court of Appeal issues guidance on shaken baby syndromeBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c3318 (Published 21 June 2010) Cite this as: BMJ 2010;340:c3318
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Court of appeal issues guidance on SBS
Clare Dyer BM.com 21 June 2010.
It is illogical that thousands of parents worldwide, from all
educational, economic, social, ethnic, religious and philosophical
backgrounds would know how to exactly shake babies to achieve the same
injuries, and always after, never before vaccination (or after
antibiotics and antipyretics.
The administered medications are documented, unlike the presumed
shaking; even the admitted shaking was usually an effort to revive the
unconscious (or dead) baby.
1. There is no need for considering the “unknown cause”; the typical,
presumed inflicted, injuries are linked to known events.
2. Re: “conflicting medical evidence”; a tacit consensus among
medical doctors about the presumed abusive nature of the injuries
contradicts ample published medical evidence. The Australian Immunisation
Handbook (2008) lists 4 pages of serious vaccine reactions, including
3. The experts as advocates or straying outside their area of
expertise? The prosecution witnesses are more likely advocates against
the accused parents, and against the rule of evidence. Why, when
medically qualified, don’t they recognise vaccine injuries and deaths?
Kirschner and Stein (1985. The mistaken diagnosis of child abuse. A
form of medical abuse? Arch Dis Child; 139: 873-875) wrote “…the treating
physicians…mistook life-threatening or postmortem artifacts for inflicted
injury… the involved physicians failed to make a correct diagnosis… lack
of experience with severe childhood illnesses and death but also an
attitude of suspicion and/or hostility… contributed to these
Documented vaccinations cannot be excluded as the cause of the observed
injuries and death.
The lack of external signs of physical injuries may mean the lack of
Bruises have alternative explanations: thromboyctopenia and scurvy.
4. The failure to recognise scurvy by medically qualified persons is
Gilman and Tanzer (1932. Subdural hematoma in infantile scurvy.
JAMA; 99 (12): 989-991) wrote “The hemorrhagic diathesis of scurvy has
been recognized since the time of Hippocrates. Hemorrhage occurs…beneath
the periosteum of the long bones and into joint spaces but…involves the
skin, mucous membranes, orbits and serous cavities... Hemorrhage
associated with the meninges during the active scorbutic state…deserves
note… Willis, an English physician, in a treatise on scurvy published in
1668, mentioned the occurrence of intracranial hemorrhage in a case of
“Sutherland in 1894 described the case of a rachitic and scorbutic
infant of 14 months who developed one month before death rigidity of the
right arm, followed by an intermittent tonic spasm of the muscles of this
arm and conjugate deviation of the eyes to the right.” “The autopsy
revealed a dense, fibrinous mass, loosely adherent to the undersurface of
the dura. The spinal canal likewise revealed a deposit of soft, reddened
gelatinous material lying just beneath the dural covering.”
A 2 year old girl presented rigidity of the neck, dilated pupils,
deviation of the head and eyes to the left and spasmodic contractions of
the muscles of both arms… Sammis in 1919 described “a general clonic
convulsion followed by death. Autopsy revealed a blood clot over the left
postcentral gyrus… between dura and arachnoid.”
Follis (1942. Sudden death in infants with scurvy. J Pediatrics; 20
(3): 347-351) described sudden deaths in infants with scurvy. “In three
of these infants death came suddenly and quite unexpectedly. At autopsy
all showed bone changes indicative of severe vitamin C deficiency: two had
hypertrophy of the right ventricle of the heart.”
Hiller (1972. Battered or not - a reappraisal of metaphyseal
fragility. Am J Roentgenol, Radium Therapy & Nuclear Med; 114 (2):
241-246), demonstrated that Caffey’s (1946. Multiple fractures in the
long bones of infants suffering from chronic subdural hematoma. Am J
Roentgenol; 56 (2): 163-173.) “fractures” are the typical signs of
Pekarek and Rezabek (1959 (An endocrinological test for inocuity of
the pertussis vaccine. J Hyg, Epidemiol, Microbiol, and Immunol; 3: 79-
84), injected rats with pertussis vaccine, causing an acute scurvy.
Clemetson (2002. Barlow’s disease. Med Hypotheses; 59 (1): 52-56)
wrote “The classical form of Barlow’s disease of infantile scurvy, with
bruises, broken bones and sores that will not heal…seems to be
reappearing… when infants with borderline vitamin C depletion are
assaulted with too many inoculations at one time…it is now sometimes
mistakenly diagnosed as child abuse.”
Bettelheim et al. (1989. Toxigenic Escherichia coli associated with
sudden infant death syndrome. Med J Australia; 151: 538) established a
strong association between heat-labile enterotoxigenic and verotoxigenic
strains of E. coli and SIDS.
Ileal and colonic gut segments were obtained from 46 (of 52) cases;
heat-labile enterotoxigenic strains were present in eight babies;
verotoxigenic strains in 10 babies; one baby had a strain both
verotoxigenic and heat-labile enterotoxin; two babies had a strain each
carrying heat-labile enterotoxigenic and Vero-cell cytotoxin. 21 (46%)
of the 46 SIDS were carrying toxigenic strains. Few toxigenic strains
were isolated from fecal specimens from 20 age- and contemporaneously
matched babies hospitalised for non-gastric enteropathy without received
antibiotic therapy, indicating a causal relationship between toxigenic E.
coli and SIDS.
Without known vaccination status, their findings are still important;
Goldwater (1992. Reappraisal of the SIDS enigma: An epidemiological and
clinicopathological approach. J Paediatr, Child Health: 28 (Suppl 1): S21
-S25) wrote “… serum from SIDS cases (but not from control babies) is
often lethal when injected intraperitoneally into mice…”
Goldwater et al. (1990. Sudden infant death syndrome: a possible
clue to causation. Med J Australia; 153: 59-60) wrote “The high levels of
XLFDPs seen in sera from SIDS cases most probably reflect a massive
consumptive coagulopathy… This would concur with our finding that
toxigenic Escherichia coli (particularly verotoxin-producing strains) are
isolated from the intestinal content of SIDS cases significantly more
often than from age-matched controls who died from established causes or
from live age- and contemporaneously matched babies’ fecal samples.
Their Table invariably shows much higher XLFDP levels in SIDS infants
The application of this published research, could save a lot of
parents from false accusations of child abuse.
Competing interests: No competing interests
Peter Ehrhardt says he is "aware of a number of cases of babies who
have died, where there is believable evidence of Shaken Baby Syndrome, but
also other injuries remote from the head, such as rib and long bone
fractures, and bruising. It is interesting that Plunkett, whilst covering
a wide range of issues, does not address this fairly common clinical
He argues trauma has caused part of the damage to the baby (fractures
and bruising) and it is therefore probable that trauma has caused the
remaining damage (subdural bleeding, retinal haemorrhage and
Ehrhardt expresses the commonly held erroneous belief of several
doctors in the UK and elsewhere who are unfamiliar with the
pathophysiology of Haemostasis and Osteogenesis and ignore the role of
Vitamins C, D and K in these processes.
Several authors [1-6]have drawn attention to the false claims of
doctors alleging Shaken Baby Syndrome, Child Abuse, Non-accidental
Injury, Abusive Head Injury or whatever the latest version is and it was
obviously not necessary for Dr Plunkett to comment further. He assumed
your "designated doctors" would be familiar with the recent literature.
Apparently they are not.
1.Clemetson CAB Vaccinations, Inoculations and Ascorbic Acid. J
Ortho Mol Med(1999) vol 14 No 3 137 – 142
2. Rajakumar K. Scurvy ww.emedicine.com/pedtopic2073.htm
3. Geddes JF, Plunket J The evidence base for shaken baby
syndrome We need to question the diagnostic criteria BMJ 2004;328:719-
720 (27 March)
4.Clemetson CAB Barlow’s disease. Medical Hypotheses (2002);59(1) 52
5. Kalokerinos A. Every Second Child. Thomas Nelson (Australia)
Ltd: Sydney 1974. Keats Publishing Inc New Canaan CT 1981
6. Innis MD. Vitamin K Deficiency Disease. Jour Orthomol Med
I have published my views on this subject in Peer reviewed Journals
Competing interests: No competing interests
Plunkett says - Shaken Baby Syndrome 'does not exist'. His
justification appears to be that cases of Shaken Baby Syndrome occurring
have not been witnessed.
I am aware of a number of cases of babies who have died, where there
is believable evidence of Shaken Baby Syndrome, but also other injuries
remote from the head, such as rib and long bone fractures, and bruising.
It is interesting that Plunkett, whilst covering a wide range of issues,
does not address this fairly common clinical scenario.
Here I do not wish to become embroiled in discussion of just how the
death has occurred, and what have been the exact mechanisms which caused
the death: I wish merely to point out that trauma has caused part of the
damage to the baby (fractures and bruising) and it is therefore probable
that trauma has caused the remaining damage (subdural bleeding, retinal
haemorrhage and encephalopathy).
It does seem that Plunkett's 'does not exist' assertion is nonsense.
I do some medico legal work, including cases of non accidental head injury
Competing interests: No competing interests
The Court of Appeal decisions and guidance on shaken baby syndrome
(SBS) (1) reported by Claire Dyer (2) are disturbing. The Justices’
justification for the decisions and guidance indicates a basic
misunderstanding of the nature of medicine and scientific evidence.
Lord Justice Moses’ criticism of Dr. Jan E. Leestma as “fundamentally
flawed” is fundamentally flawed. Dr. Leestma wrote the original textbook
of forensic neuropathology in 1986. The CRC Press published the second
edition in 2009 (3). The new edition includes a unique chapter on injury
biomechanics and more than one thousand references not included in the
first edition. Most of the new references have been published during the
past ten years. Dr. Leestma not only has a current understanding of the
medical literature, he has published several articles in the peer-reviewed
literature since 2000. The statement that he had “not systematically
reviewed the literature since the mid-1990s” is baffling. How could he
have written the new edition of his textbook without the required reading?
Further, he had not only read “Geddes I and II” at the time they were
published in 2001, he knows Geddes personally. Leestma is correct
regarding APP-positivity in an anoxic background. The lack of an
appropriate control group in most published studies, including Reichard,
precludes verifiable statements regarding the significance of isolated
brainstem axonal damage and its relationship to clinical signs and
The Justices clearly do not understand the nature of an autopsy and a
consultative practice in the USA. An autopsy is merely a technique to
examine and remove organs from a body. The prosector documents his or her
findings with a report, photographs, and microscopic slides. The
documentation allows anyone, including the person who initially performed
the autopsy, to review the findings months and occasionally years later.
Studying these organs with an unaided eye and microscope does not require
that one actually perform the autopsy. Dr. Leestma has personally
examined over twenty thousand brains during his 45-plus year career. He
does not need to perform another autopsy or personally examine another
brain to make diagnoses based on the gross and microscopic findings. It
is incorrect to state that his knowledge emerges “from studies of the
literature which excluded the important material contained in Geddes I and
II and Reichard”. Geddes herself will tell you that medical science
simply does not know how to interpret isolated brainstem axonal damage in
the face of hypoxic-ischemic injury.
Experience is valuable. However, a physician must differentiate
experience (anecdote) from evidence. He or she must link experience to
the scientific method. Eminence-based medicine is not evidence-based
medicine, as emphasized by the US National Academy of Sciences report
regarding scientific testimony in the Courts (4). Dr. Al-Sarraj’s “up-to-
date experience” may merely allow him to repeat an initial error with
increasing confidence (5). His denigration of biomechanical studies is
absurd. He may not understand injury biomechanics, but others do. The
Justices note that the Court in the Cherry appeal described the science of
biomechanics as “complex, developing and (as yet) necessarily uncertain”.
The science may be complex and developing, but it is by no means
uncertain. Biomechanics is the fundamental tool for injury evaluation.
One learns biomechanics by studying biomechanics, not by performing
autopsies. If Al-Sarraj and others doubt the biomechanical science behind
our understanding of injury mechanism, they must be willing to use non-
seatbelt and non-airbag-equipped vehicles, allow their children to ride
unrestrained in the front seat of their automobile, play on swings over
asphalt surfaces, and engage in contact sports and recreational activities
without appropriate protective gear. The advances made through the
science of biomechanics as it relates to our understanding of injury
mechanism and prevention in these everyday activities is the same
scientific, evidence-based approach used to evaluate pediatric brain
injuries in cases of alleged abuse. The brain is not sensitive to the
intent behind the injurious forces acting upon it. The same laws of
physics apply to accidental and non-accidental injury, regardless of what
Al-Sarraj and others might believe.
Whether a proposed expert is still in practice is unimportant.
Consultation is the practice of medicine. Consultation involves the same
skills as examining a living patient or performing an autopsy. Whether or
not someone has recently seen a case in his own clinical practice is also
immaterial. Leestma and others have not seen a case of shaken baby
syndrome (SBS) in the last fifteen years for the simple reason that SBS
does not exist, regardless of the “experience” of Al-Sarraj et al. There
has never been a witnessed shaking in which a child suffered any injury.
There is no scientifically acceptable evidence that shaking a child can
cause subdural bleeding, retinal hemorrhage, or an encephalopathy. The
only evidence is the “confession” literature. However, none of the
published “confession” studies includes specific details of the
“confession”, the circumstances under which it was obtained, and a
correlation of the “confession” with the actual injuries (6-8). It is
noteworthy in this regard that at least 20 percent of those found to be
factually and indisputably innocent through the work of the Innocence
Project had “confessed” to the crime in question (9). It may be possible
to kill a young infant or neonate by shaking, but the mechanism of injury
will be major structural neck damage, not cerebral damage or subdural
bleeding. The author of two recent Law Review articles has called shaken
baby syndrome “the next innocence project” (10-11). Changing the name
from “SBS” to “abusive head trauma”, as recently adopted by the American
Academy of Pediatrics (12), does not alter the issue.
Widely held but incorrect beliefs in medicine are not uncommon. For
example, the established view until recently was that stress and too much
acid caused chronic gastritis and peptic ulcers. Therapy followed belief,
and included both medical and surgical intervention. Two future Nobel
Prize winners used the scientific method (including application of Koch’s
postulates) to disprove the prevalent belief in 1982. The extent that a
view is “widely held” is not a valid criterion to evaluate a medical
opinion. What is relevant is application of the scientific method to
assess the belief. The Courts must “critically evaluate the reasoning
process by which the experts connect data to their conclusions in order
for courts to consistently and rationally resolve the disputes before
them” (13). The Courts must examine the steps used to go from A to B, not
the experience or pedigree of the person giving the opinion. Lord Justice
Moses, referring to defense witnesses, states, “such experts are, usually,
engaged only in reviewing the opinions of others”. Nonsense. Case review
is an intense, detailed, and thoughtful process. It is not a brief
clinical encounter. When we review a potential infant injury, we examine
the birth records, the well-baby records, all hospitalization records, the
police reports and scene investigation data including photographs, and all
autopsy findings (if a death occurred) including photographs and
microscopic slides. The “opinions of others” is secondary. We defer to
evidence, not opinion. The Justices’ “sound reasons relating to his
[Leestma’s] experience in comparison with Dr. Al-Sarraj for rejecting what
he told us” are not sound at all.
The Justices would do well to remember William Harvey’s admonition
almost 400 years ago: “I tremble lest I have mankind at large for my
enemies, so much doth wont and custom become a second nature. Doctrine,
once sown, strikes deep its root, and respect for antiquity influences all
men. Still, the die is cast, and my trust is in my love of truth, and the
candour of cultivated minds.” (William Harvey, On the motion of the heart
and blood in animals, 1628.)
1. Dyer C. Court of Appeals issues guidance on shaken baby syndrome.
BMJ 2010; 340:3318.
2. Royal Courts of Justice, Case No: 2007/6546/D4, available at
www.bailii.org/ew/cases/EWCA/Crim/2010/1269.html. Last accessed June 26,
3. Leestma JE. Forensic Neuropathology (Second Edition) CRC Press,
Taylor and Francis Group, 2009.
4. Available at:
http://www.nationalacademies.org/morenews/20090218.html. Last accessed
June 26, 2010.
5. Wilkins B, Sunderland RS. Head injury – abuse or accident? Arch
Dis Child 1997;76:393-7.
6. Leestma JE. Case analysis of brain-injured admittedly shaken
infants. Am J Forens Med Pathol 2005;26:199-212.
7. Leestma JE. SBS: Do confessions by alleged perpetrators validate
the concept? J Am Phys Surg 2006;11:14-16.
8. Starling SP, Patel S, Burke BL, Sirotnak AP, Stronks S, Rosquist
P. Analysis of perpetrator admissions to inflicted traumatic brain
injuries in children. Arch Pediatr Adolesc Med 2004;158:454-8.
9. Available at: http://www.innocenceproject.org/index.php. Last
accessed June 26, 2010.
10. Tuerkheimer D. The next innocence project: shaken baby syndrome
and the criminal courts. Wash Law Rev 2009;87:1-58. Available at:
http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1354659. Last accessed
June 26, 2010.
11. Tuerkheimer D. Criminal justice at a cross roads: Science-
dependant prosecution and the problem of epistemic contingency. Alabama
Law Rev 2010 (in press). Available at:
http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1579394. Last accessed
June 26, 2010.
12. Christian CW, Block R; Committee on Child Abuse and Neglect;
American Academy of Pediatrics. Abusive head trauma in infants and
children. Pediatrics 2009;123:1409-11.
13. Brock v. Merrell Dow Pharmaceuticals, Inc., 874 F 2nd 307 (5th
John Plunkett, M.D.
Welch, Minnesota USA
Patrick D. Barnes, M.D.
Stanford, California USA
Thomas L Bohan, PhD, JD
Immediate Past President,
American Academy of Forensic Sciences.
Peaks Island, Maine USA
Harry J. Bonnell, M.D.
San Diego, California USA
Thomas Carlstrom, M.D.
Des Moines, Iowa USA
James T. Eastman, M.D.
Madison, Wisconsin USA
Steven Gabaeff, M.D.
Clinical Forensic Medicine/Emergency Medicine.
Sacramento, California USA
John G. Galaznik, M.D.
Northport, Alabama USA
Horace B. Gardner, M.D.
Manitou Springs, Colorado USA
Julie Mack, M.D.
Hershey, Pennsylvania USA
Marvin E. Miller, M.D.
Dayton, Ohio USA
Janice Ophoven, M.D.
Pediatric Forensic Pathologist.
Woodbury, Minnesota USA
Peter J. Stephens, M.D.
Burnsville, North Carolina USA
Shaku Teas, M.D.
Chicago, Illinois USA
Kirk L. Thibault, PhD.
Lester, Pennsylvania USA
Larry E. Thibault, Sc.D.
Lester, Pennsylvania USA
Ronald H. Uscinski, M.D.
Washington, D.C. USA
Many but not all of us have consulted and testified for the defense in alleged infant injury cases.
Competing interests: No competing interests