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Rapid response to:

Editorials

The evidence base in child protection litigation

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7560.160 (Published 20 July 2006) Cite this as: BMJ 2006;333:160

Rapid Response:

Child Abuse -Misdiagnosed

Editor,

Dr Chadwick suggests, “A well developed evidence base exists for
child abuse medicine that is suitable for use in litigation for child
protection …. Kempe and colleagues reiterated that doctors could and
should infer abuse on the basis of certain medical findings of injury. The
"battered child syndrome" that they defined is still a valid concept based
on observational research.”

In essence this so-called “evidence base” is characterized by acute
encephalopathy with subdural and retinal haemorrhages, occurring in a
context of inappropriate or inconsistent history and commonly accompanied
by other apparently inflicted injuries(1). These other apparently
inflicted injuries being bruises, and fractures often of various ages.

What the proponents of this “evidence base” are forgetting, ignoring
or are unaware of, is deficiencies of Vitamin C and/or K can and do
produce identical signs and symptoms in vulnerable infants. Deficiencies
of Vitamin D can result in fractures.

Professor Alan Clemetson and Dr A. Kalokerinos have drawn the
attention of the profession to the origin and consequences of Vitamin C
deficiencies in Western Societies (2,3). Others have suggested the need to
supplement the diet of children with Vitamin D

Less well known are the origins and consequences of Vitamin K
deficiency. Apart from Haemorrhagic Disease of the Newborn little or no
thought has been given to the fact that it is a cofactor for the
carboxylation of osteocalcin and is essential for the mineralization of
bone(4). When reduced or absent fractures may occur.

It is a lack of knowledge of the causation of these nutritional
deficiencies and their effects, coupled with the injunction to “think
dirty” that is responsible for the misdiagnoses of “child abuse” so
common in the Western World.

Unless Paediatricians take more care with the investigation of these
children by becoming familiar with newer Laboratory tests such as PIVKA-
II, Undercarboxylated Osteocalcin and Blood Histamine levels innocent
people are bound to suffer.

Michael Innis FRCPA;FRCPath

References
1. Harding B, Risdon RA, Krous HF Shaken baby syndrome
BMJ, Mar 2004; 328: 720 - 721

2.Clemetson CAB Is it “Shaken Baby,”or Barlow’s Disease Variant. A A
P S 2004;Vol 9 No 3:

3. Kalokerinos A. Every Second Child. 1981 pp 3 –165 Thomas Nelson
(Australia )

4. 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 Vol. 115 No. 5 May 2005, pp.
1325-1331

Competing interests:
As previously declared

Competing interests: No competing interests

24 July 2006
Michael D Innis
Director Medisets International
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