SPECIAL REPORTS
 

SHAKEN BABY SYNDROME: WHERE ARE WE TODAY?

I am frankly quite disturbed that what I intended as a friendly suggestion for avoiding injury to children has become an excuse for imprisoning innocent parents.
Dr. Norman Guthkelch. Originator of the shaken baby hypothesis

The Shaken Baby Syndrome is a fabricated diagnosis and has no place in medical jurisprudence.
Haematologist Michael D. Innis

B

ritain’s first Paediatric Neurosurgeon, Dr Norman Guthkelch, wrote a seminal paper published in the British Medical Journal in 1971.1 His work is frequently credited as being the genesis of the Shaken Baby Syndrome hypothesis. He has enjoyed a long and distinguished career, having worked for many decades in the British National Health Service, moving to Pittsburgh Children’s Hospital in the United States during the 1970’s.

Together with 34 other international experts, Dr. Guthkelch has signed an “open letter” expressing deep concern over the links between Shaken Baby claims and Miscarriages of Justice.

open letter on shaken baby syndrome

The experts joined together under the auspices of the International Public Health Research Group, and represent a diverse array of fields, including medicine, child protection, psychology, epidemiology, biomechanics, physics, engineering, research, medical journalism, law, social work, and criminology to sign the open letter to draw attention to the widespread problem of the misdiagnosis of Shaken Baby Syndrome.

The group states that the construct of what is commonly known as “Shaken Baby Syndrome” is not backed by solid science, and that it has never been scientifically validated.

They explain that, “Generally speaking SBS involves the ‘Triad’ of symptoms of retinal haemorrhages, subdural haemorrhages and ischaemic encephalopathy being interpreted as signs of child abuse.” They continue on to explain that,

Parents and carers in many countries have been falsely accused of injuring or killing a child and face allegations of child abuse, manslaughter or murder when the claims of SBS have been made. Many such accused parents and carers are given long prison sentences and their children are permanently removed from their families. In some jurisdictions, they can even be sentenced to death.

To date, the group asserts, the scientific research which has been conducted casts considerable doubt on the SBS construct. Moreover, while this diagnosis continues to be used, babies are denied the investigations they need to establish the correct cause, treatment and prevention of recurrence, of their symptoms and signs. According to a prepared release,

The experts who signed the letter also point out that the SBS hypothesis does not have the undivided support of the relevant professional community, an essential consideration in the assessment of expert testimony. Despite the lack of substance, claims that the baby has been shaken can result in draconian consequences in the Criminal and Family courts. Those found in either type of court to have abused children will be unlikely ever again to be allowed to care for their own or anyone else’s children.

The letter itself states that, “Many courts are making insufficiently informed and consequentially, frequently wrong decisions with dire and chronic consequences for parties who may well have done nothing wrong.”2

The signatories to the letter call for sensible debate about SBS in the courts, which they claim in many cases is currently being suppressed.

“I want to do what I can to straighten this out before I die,” Dr. Guthkelch says, “even though I don’t suppose I’ll live to see the end of it.”3

SHAKEN BABY SYNDROME IN PERSPECTIVE

Dr. Steven C. Gabaeff conducted an extensive review of the literature on shaken baby syndrome, concluding that the diagnosis lacks an adequate evidence base. In reporting his results in Western Journal of Emergency Medicine, Gabaeff explained, “While we must always be mindful of child abuse, which is certainly real and pervasive, we must exercise appropriate restraint to avoid a form of iatrogenic abuse. When children are removed inappropriately from their families, sometimes permanently, based on a specious connection between physical findings and mechanism, there is certainly harm.”4

The accuracy of a child’s medical diagnosis ought be the paramount consideration, and this presents as something of a double-edged sword. As a survey of 16 Canadian child and youth protection programs explains, “A false-negative determination puts the child at risk of reinjury and possibly death, whereas a false-positive determination may lead to the inappropriate removal of a child from their home and subject a family to false accusations, with all the attendant social, emotional and legal implications.”5

As Michelle Ward and colleagues from the Canadian Paediatric Society, Child and Youth Maltreatment Section explain, “Failing to recognize physical abuse can predispose to further injury or even death and identifying abuse where it has not occurred may lead to unnecessary child protection or legal interventions, stress for the family and/or a delay in diagnosing an underlying medical disorder.”6

The impacts of an erroneous diagnosis of shaken baby syndrome on children and families have long been recognized by the profession. Writing in Archives of Disease in Childhood, Champion and Lee explained in 1999 that, “Misdiagnosis might not only expose the family to the risk of false accusation of child abuse, but may have disastrous consequences for the child.”7

They describe a case of an inherited metabolic disorder being misdiagnosed as shaken baby syndrome, noting that the disorder in question “is a potentially treatable condition if diagnosed when neurodevelopment is normal, before metabolic decompensation, which characteristically leaves a severe, irreversible, dystonic movement disorder.”

SBS – WHERE ARE WE TODAY?

As doctors Rachel Berger and Thomas McGinn explain in a recent edition of Pediatric Critical Care Medicine, “Determining when to screen for Abusive Head Trauma can be difficult; a plethora of data demonstrate that physicians’ decisions about when to screen for child abuse, in general, and AHT, in particular, are biased by patient race and socioeconomic status and professional experience.”8

As of 2014, clear standards for the identification of the retinal hemorrhages hypothesized to be related to SBS had yet to emerge. As a group of physicians specializing in Ophthalmology explains it, much of the problem is that many investigators “have used their own, unvalidated, unique systems to grade or describe hemorrhages for the purpose of single studies in a wide variety of conditions associated with retinal hemorrhage.”

Their ultimate conclusions was that, “Perhaps the greatest limitation to the development of any retinal hemorrhage documentation tool is the absence of a ‘gold standard.’ Even experienced examiners may differ at the bedside as to the type of hemorrhage or whether a given area has a certain number of hemorrhages.”9

As of 2014, there was a “lack of definitive evidence from studies conducted to date” concerning the suitability of certain inflammatory markers that are routinely used as forensic markers of traumatic head injury. Esther Jack and colleagues arrive at this conclusion after investigating 33 cases of non-traumatic infant deaths, finding that the inflammatory markers frequently associated with inflicted traumatic head injury were present in all 33 cases. Their findings support what they describe as “the recommendation of cautious interpretation” with respect to such findings in forensic cases.10

A hastily drawn finding of shaken baby syndrome may well prove fatal, as the opportunity to provide life-saving treatments may be obscured.

Writing in the peer reviewed journal Clinical Medicine Research, retired Haematologist Michael D. Innis describes a recent case involving a child alleged to have been murdered by being shaken to death. His report “concerns a child who was vaccinated with the MMR and other vaccines and developed autoimmune diabetes and associated Tissue Scurvy a week later which was misdiagnosed as Shaken Baby Syndrome and the carer found guilty of murder and incarcerated.”

The child was subsequently found to have hyperglycemia, implying insulin deficiency and concomitant Tissue Scurvy. Innis explains that, “No Laboratory Investigations were done when the bruise was noticed which is very unusual and an opportunity to treat the disorder was missed.”

After a thoroughgoing analysis of the literature, Innis arrives at the conclusion that, “The Shaken Baby Syndrome is a fabricated diagnosis and has no place in medical jurisprudence.”11

While some progress seems to have been made outside of the United States, the nation has itself been slow to respond to emerging scientific evidence, Deborah Tuerkheimer noted in 2009. In announcing the formation of what she described as the next Innocence Project in Washington University Law Review, Tuerkheimer explained that,

Outside the United States, this scientific evolution has prompted systemic reevaluations of the prosecutorial paradigm. In contrast, our criminal justice system has failed to absorb the latest scientific knowledge. This is beginning to change, yet the response has been halting and inconsistent.12

HOW WE ARRIVED HERE

Throughout the 1980s, the child protection industry came increasingly to rely on a “multidisciplinary” approach to child protection. Once informal arrangements came to be replaced with formal memorandums of understanding between the physicians calling in their suspicions, the child protective services agencies, the police, and the prosecutors.

The concept of child protection “teams” is not entirely new. As the National Association of Children’s Hospitals and Related Institutions explains it, “The first child maltreatment teams in America were established at Children’s Hospital of Pittsburgh and Childrens Hospital Los Angeles during the late 1950s. Since then, children’s hospitals across the country developed programs – from exhaustive efforts of single physicians, to centers of excellence staffed by dozens of experts – that set the standard for medical intervention.”13

The two most glaringly obvious problems with this approach are cross-contamination of ideas, and the groupthink that has the effect of putting everyone on the same proverbial page.14

The end result of this approach is one in which the child protection authorities have come to rely heavily on the suspicions of the physicians, with one effectively confirming the other’s suspicions in a circuitous manner.15. The police, in turn, rely upon the combined weight of the medical suspicion and the CPS “finding.” The prosecutor, in turn, has a winning case complete with a cadre of well-paid experts waiting in the wings for their next paycheck.

For unsuspecting parents who may already be grieving over the loss of a child, this is a recipe for disaster. As professor Tuerkheimer explains it, “Once a child protection team has made an SBS diagnosis, suspected perpetrators -those with the child when symptoms appeared – are aggressively prosecuted. Each year, an estimated thousand plus defendants are convicted, most of murder, annually.”16

Convictions in such cases are quite nearly a given. Tuerkheimer cites one estimate of 95% of defendants prosecuted in SBS cases in the United States as being convicted, with 90% of them serving life sentences.17

Just how high the combined rate of error may actually be between the reporting physicians and the investigative caseworkers is suggested by physicians who describe a rare medical condition known as Toe-Tourniquet Syndrome in Annals of The Royal College of Surgeons of England. The condition refers to the constriction of a hair around an appendage – typically around a toe or a finger. Lohana and colleagues explain, “Because of the relative rarity of the condition, questions about child abuse frequently arise. In a survey of healthcare and child protective services in Miami, 83% of child welfare workers and 45% of public health nurses misinterpreted this as intentional injury.”18

Many calls for a more cautious approach to reporting have been expressed by medical professionals over the course of time.

Dr. John Eby wrote of a case involving a Canadian family that was nearly destroyed by undeserved accusations of abuse. They found themselves traveling to find a dermatological specialist who was capable of providing their child with the diagnosis of a rare skin disorder. Dr. Eby cautioned that, “Although it is essential that we as physicians not miss a case of child abuse, it also behoves us to be relatively certain of the diagnosis before plunging families into the severe emotional trauma that can result from an unwarranted investigation.”19

CLOSE-UP
TEN YEARS OF EXPERIENCE

Wheeler and Hobbs noted in British Medical Journal that, “Fifty children who were referred to the child abuse team in Leeds over the 10 years 1976-86 with suspected non-accidental injury were found to have conditions which mimicked non-accidental injury.” Among these children, nine were found to have had impetigo, five had blue spots. Five children who presented with multiple bruising had haemostatic disorders, while eight children were found to have bone disorders.

Only ten percent – five of the 50 children – had been previously abused physically. Four showed some evidence of neglect. Finally, one child displayed evidence of a non-accidental injury as well as a condition mimicking abuse.20

Similarly, Patterson explained in British Medical Journal that, “Over the past 10 years I have seen, both in England and abroad, 35 infants who seemed to have had a temporary, severe osteogenesis imperfecta-like disorder. In most cases the initial diagnosis was child abuse, but in three the initial diagnosis was osteogenesis imperfecta because the fractures occurred in hospital.”21

By 2005, it was clear that “research has undermined the validity of retinal and subdural haemorrhages as being characteristic of shaken baby syndrome,” James Le Fanu explained in Journal of the Royal Society of Medicine. By that time, he explains, an evidence-based review had identified “serious data gaps, flaws of logic and inconsistency of case definition” in the relevant scientific work.22

Regarding the professional experience of the reporting physician, there are several factors that come into play, not the least of which is that many emergency room physicians are ill-prepared to handle pediatric emergencies. The results of a comprehensive national survey of emergency departments released in 2013 concluded that, “millions of children in need of emergent health care present to EDs at facilities that do not have specialized pediatric services or the ability to treat severe cases of common pediatric conditions.”23

This serves well to explain the growing reliance on child protection teams during the diagnostic process, as once the child protection team “confirms” the suspicion, the physician is relieved of the onerous task of conducting any further diagnoses.

CONFRONTING BIAS AND DISPROPORTIONALITY

As doctors Rachel Berger and Thomas McGinn have noted, reporting biases in hospitals are both frequent and problematic.

In seeking to unravel the continuing debate concerning racial disproportionality in the child welfare system, Natalie Cort and colleagues examined the wide disparities in reporting and intake, as well as what they describe as the complicated link between the racial and economic disparities. They explain in Journal of Public Health Management and Practice that, “Examination of hospital reporting practices have demonstrated a tendency to over-report minorities and poor families to CPS, in comparison to middleclass, Caucasian families.”24

Indeed, none other than Eli Newberger – a physician with sterling credentials as a child saver – noted as long ago as 1985 that, “If the reporting of child abuse is as biased by class and race as these data suggest, there is a clear need for a critical review of the system as well as the process of reporting.”25

Sarah Font and colleagues examined a national sample of 1,461 child protective services investigations in the United States, seeking to clarify the differences between black and white families with regard to caseworker ratings of risk and harm to the child, and the probability that a case would ultimately be substantiated for maltreatment. They found that “relative to white caseworkers, black caseworkers are more likely to rate black children at subjectively higher risk of harm than white children and are also more likely to substantiate black families for maltreatment.”26

Cort and colleagues explained that, “contrasting study findings indicated that Caucasian children from families receiving public assistance were reported to CPS at higher rates than African American children from similarly economically disadvantaged families.” Thus, a class-based – as distinguished against a purely racial bias – may be an operative factor in many cases.

CAUTIOUS OPTIMISM

A 2011 investigation by National Pubic Radio, ProPublica, and PBS Frontline “has found that medical examiners and coroners have repeatedly mishandled cases of infant and child deaths, helping to put innocent people behind bars,” NPR’s web site explains.

“We analyzed nearly two dozen cases in the United States and Canada in which people have been accused of killing children based on flawed or biased work by forensic pathologists, and then later cleared,” the site continues on to explain.27

In that portion of the series under the heading of Post Mortem: Death Investigation In America, under the heading of Rethinking Shaken Baby Syndrome, one may find an interview with Norman Guthkelch, the pediatric neurosurgeon who is credited with first describing the condition of shaken baby syndrome in young children.

Dr. Guthkelch spoke out publicly “for the first time about his concerns regarding how that diagnosis is used,” says NPR Investigative Journalist Joseph Shapiro “He worries that it is too often applied by medical examiners and doctors without considering other possible causes for a child’s death or injury.”

The report continues on to explain that

Guthkelch is concerned that there are too many cases like the one he recently reviewed in Arizona. A defense attorney asked him to look at the case of a father who has spent 10 years in prison after being convicted of killing his 5-month-old son by shaking him.

After reviewing the trial record and medical reports, Guthkelch said he was troubled to see that the medical examiner’s autopsy had concluded that the baby died of shaken baby syndrome while discounting other possible causes: A month prior to the child’s death, the boy had been admitted to the hospital with uncontrolled seizures. The baby had also briefly been in the neonatal intensive care ward after a difficult birth.

To Guthkelch, this suggests the boy may have instead died from natural causes.

To be sure, there are some conflicting numbers that cannot be reconciled. The National Center on Shaken Baby Syndrome asserts that there are about 1,200 to 1,400 cases a year of severe or fatal head trauma from child abuse. The FBI, on the other hand, reports about 500 homicides a year of children under the age of 5, from all causes, the report notes.

Guthkelch encourages doctors to be particularly cautious when medicine enters the courtroom. Medical knowledge changes over time, however the criminal justice system wants some level of certainty with which to determine the accused party’s guilt or innocence.

“In a case of measles,” says Guthkelch, “if you get the diagnosis wrong, in seven days’ time it really doesn’t matter because it’s cleared up anyhow. If you get the diagnosis of fatal shaken baby syndrome wrong, potentially someone’s life will be terminated.”

CONCLUSION

Shannon L. Carpenter and colleagues from the Hematology/Oncology and Committee on Child Abuse and Neglect provided a technical note from the American Academy of Pediatrics in April of 2013, calling for a more cautious approach to the interpretation of childhood injuries.28

They begin with the observation that, “Child abuse might be suspected when children present with cutaneous bruising, intracranial hemorrhage, or other manifestations of bleeding. In these cases, it is necessary to consider medical conditions that predispose to easy bleeding/bruising.”

They further explain, “The list of congenital and acquired bleeding disorders that could potentially be confused with abusive injury is extensive: hemophilia, von Willebrand disease (VWD), disorders of fibrinogen, vitamin K deficiency, factor XIII and other factor deficiencies, thrombocytopenia, leukemia, aplastic anemia and other bone marrow infiltrative or failure syndromes, and platelet function abnormalities, among others.” Regarding intracranial hemorrhages specifically, they provide these timely words of caution to practitioners:

Multiple studies have assessed the roles of history, clinical and radiographic findings, and outcomes in making the diagnosis of abusive head trauma. In a recent study of ICH in bleeding disorders, ICH was the presenting event in 19.2%. However, no studies have addressed how to differentiate whether patients who present with ICH in the absence of trauma or with a history of minimal trauma have a bleeding disorder either causing or contributing to the clinical findings. No studies have systematically compared the presentation, clinical findings, patterns of ICH, or presence of retinal hemorrhages between bleeding disorders and/or collagen disorders and abusive head trauma. Therefore, for children presenting with ICH but without other findings strongly suggestive of abuse, such as fractures, significant abdominal trauma, burns, or patterned bruising, an evaluation for other medical conditions causing or contributing to the findings is necessary. Additionally, physicians must recognize that although evidence of old inflicted injury, such as healing fractures, could support the diagnosis of abuse, healing injuries may be unrelated to recent bruising or ICH. Physicians must assess their own comfort in making and supporting the diagnosis of abuse in the absence of an extensive laboratory evaluation.29

As Colin R. Paterson, Formerly of the Department of Medicine, University of Dundee, Scotland, explains: “It was, at one time, assumed that, when a child was found to have fractures that the parents could not explain, the cause was inevitably a non-accidental injury. In recent years however it has become increasingly clear that a wide variety of bone disorders may present with unexplained fractures in young children. These include osteogenesis imperfecta, vitamin D deficiency rickets, scurvy, copper deficiency, Menkes’ syndrome, bone disease of prematurity and, more controversially, temporary brittle bone disease. The review outlines the various disorders that need to be considered in such cases. It also outlines the factors that have in the past played a part in contributing to the misdiagnosis of abuse and the avoidable damage to otherwise normal families.”30

Putting to rest once and for all the SBS/AHT diagnosis is only the beginning of what will likely be a multi-year-long quest for balance. Evidence continues to mount revealing that many of the “unmistakable” signs of child abuse such as fractures, bruising, and intracranial hemorrhages may well be due to inherited metabolic or bone deficiencies, vitamin deficiencies, and a significant number of other underlying medical conditions, rather than intentionally inflicted injuries.31

The misdiagnosis of child abuse inflicts harm not only on the scores of innocent people languishing in prisons at tremendous fiscal costs to the taxpayer. It inflicts great harm on children by virtue of needless separation from their families – certainly among the most traumatic of events that any child could be asked to endure. Worse, it may have lifetime consequences for them by virtue of an ailment that may have been appropriately identified and treated at any early stage in their lives being left untreated. For an unknown number of children – but certainly a significant number – the misdiagnosis of child abuse may prove to be a fatal one; either by virtue of the missed opportunity to providing life-saving medical treatment in a timely and appropriate manner, or by virtue of their experience in a foster care system that to this day may be most appropriately described as Dickensian in terms of the horrors that it is capable of inflicting on children.

1. Guthkelch AN. Infantile subdural haematoma and its relationship to whiplash injuries. British Medical Journal. 1971;2:430–31.

2. Wrennall, L. Bache, B. Pragnell, C. et al 2015 Open Letter on Shaken Baby Syndrome and Courts: A False and Flawed Premise, Argument & Critique, Received Jan. Published Feb.

3. Dr. Guthkelch initially expressed his concerns in an open forum on National Public Radio in a story entitled Rethinking Shaken Baby Syndrome aired on Morning Edition on June 29, 2011. The story was part of a joint investigation on Shaken Baby cases conducted by National Public Radio, PBS Frontline, and ProPublica. Prior to that, he had cautioned physicians not to interpret his findings as broadly as they had. See for example Guthkelch AN. The shaken infant syndrome. Serious effects of shaking were described in 1971. Letter. British Medical Journal. 1995;310(6994):1600 (describing the effects of shaking as “an ill defined action whose sequelae do not seem to be as firmly established in the literature as the authors would have us believe”).

5. Bennett S, Plint AC, MacKay M. A survey of the 16 Canadian child and youth protection programs: A threadbare patchwork quilt. Paediatrics & Child Health 2007;12(3):205-209.

6. Ward MG, Ornstein A, Niec A, Murray CL, Canadian Paediatric Society, Child and Youth Maltreatment Section. The medical assessment of bruising in suspected child maltreatment cases: A clinical perspective. Paediatrics & Child Health. 2013;18(8):433-437.

7. Champion, M., Lee P. Abuse or metabolic disorder? Letter to editor. Archives of Disease in Childhood 1999;80(1):100.

8. Berger R, McGinn T. Deciding whether to screen for abusive head trauma: Do we need a clinical decision rule? Pediatric critical care medicine 2013;14(2):230-231.

9. Levin AV, Cordovez JA, Leiby BE, Pequignot E, Tandon A. Retinal Hemorrhage in Abusive Head Trauma: Finding a Common Language. Transactions of the American Ophthalmological Society 2014;112:1-10.

11. Innis, M. Tissue Scurvy Misdiagnosed as Shaken Baby Syndrome Homicide. Clinical Medicine Research. 2014; 3(1): 6-8.

12. Tuerkheimer, D. The Next Innocence Project: Shaken Baby Syndrome and the Criminal Courts, Washington. University Law Review .2009; 87:1-58. It is indeed telling that the Innocence Project found itself compelled to allocate resources toward this very specific category of convictions.

13. National Association of Children’s Hospitals and Related Institutions “Defining the Children’s Hospital Role in Child Maltreatment.” This guidance document was intended to provide a comprehensive set of guidelines, which were subsequently endorsed by the American Academy of Pediatrics and the National Children’s Alliance. A companion document “Children’s hospitals child abuse services: 2005 survey findings,” detailed staffing and financial resources dedicated at the time to the prevention and treatment of child abuse at NACHRI member hospitals. Both of these documents came to be seen as important resources intended to assist hospitals and community partners in addressing child abuse and neglect.

14. See for example Wrennall, L. Clinical Medicine: Pediatrics 2008:1 1-12 (“The potential for ‘Groupthink’ to produce ‘risky shift’ judgment in the context of Child Protection multidisciplinary teams, needs to be considered”). The role of child protection teams cannot be overemphasized in the present climate. See for example Hasbani DM, Topjian AA, Friess SH, et al. Nonconvulsive Electrographic Seizures are Common in Children With Abusive Head Trauma. Pediatric critical care medicine: a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2013;14(7):709-715 (“Children less than or equal to 2 years old with evidence of abusive head trauma determined by neuroimaging, physical examination, and determination of abuse by the Child Protection Team”); Shein SL, Bell MJ, Kochanek PM, et al. Risk Factors for Mortality in Children with Abusive Head Trauma. The Journal of pediatrics. 2012;161(4):716-722.(“Defining whether an injury is the result of abuse based on the conclusion of a Child Protection Team is frequently used in studies of abusive head trauma”); Ornstein A, Dipenta JC. Abusive head trauma in infants and why we CAN afford to prevent it. Paediatrics & Child Health. 2011;16(2):e9-e10 (reviewing “nine recently admitted patients who were diagnosed with AHT as established by a multidisciplinary child protection team”); Foerster BR, Petrou M, Lin D, et al. Neuroimaging evaluation of non-accidental head trauma with correlation to clinical outcomes: A review of 57 cases. The Journal of pediatrics. 2009;154(4):573-577 (describing “a review of Child Abuse Review Committee case lists, log books and interesting case books. All of these cases were evaluated by the ‘Child Protection Team’ at our institution”).

15. Perhaps the best illustration of how inextricably intertwined child protective services agencies and hospitals have become is that of the “Child Protection Consultation Team” at at Massachusetts General Hospital providing training to child protection caseworkers. I discuss this phenomenon in the blog entry Boston Children’s Hospital to be Investigated by Department of Public Health, February 4, 2013. The head of the team – Dr. Alice Newton – has more recently come under scrutiny for her role as an “expert” in the controversial Aisling Brady McCarthy case. See McGovern, B. Doctor in Irish nanny case stands by work. Boston Herald, August 8, 2014 (noting that Alice Newton “is a key prosecution witness in the case against nanny Aisling Brady McCarthy. Newton determined that a baby in McCarthy’s care died as a result of shaken baby syndrome”). See also Johnson, O. ‘Shaken baby’ doubters give cases another look. Boston Herald. August 9, 2014 (“The New England Innocence Project is looking at ‘several’ Bay State cases where a person was convicted of murder following a diagnosis of shaken baby syndrome, saying the science behind that conclusion is not sound – the same argument now being made by lawyers for an Irish nanny accused of killing a baby in her care”). Consider this in light of Good Morning America having aired a story entitled A Look Back at the Shaken Baby Case in October of 2007, reflecting back on the murder trial of British au pair Louise Woodward, citing Alice Newton as saying that 75 percent of shaken baby cases involve parents, and men are more often the perpetrators. Consider this also in the context of Carey Goldberg reporting in the Boston Globe in an article entitled “Shaken baby cases on the increase” on March 19, 2009, that shaken baby cases had “at least doubled in the last few months” at both Massachusetts General Hospital and Boston Children’s Hospital, quoting Dr. Alice Newton as a spokesperson. As of early 2013, Newton held a position on both hospital’s child protection teams. Newton became an something of an international celebrity in 2013 for having filed a child abuse report alleging “medical abuse” in the case of Justina Pelletier, whose case opened the window on an what has since come to be known as “medical kidnapping” cases.

16. Tuerkheimer supra note 7 at 5, fn 24.

17. Id.

18. Lohana P, Vashishta GN, Price N. Toe-Tourniquet Syndrome: A Diagnostic Dilemma! Annals of The Royal College of Surgeons of England 2006;88(4):W6-W8. See also Oates RK. Overturning the diagnosis of child abuse. Archives of Disease in Childhood 1984;59(7):665-666 (“Three cases, one of bullous impetigo, one of a Mongolian spot, and one of constriction of the toe by a hair, were mistakenly diagnosed as cases of child abuse”).

19. Eby J. Investigating presumed child abuse. CMAJ: Canadian Medical Association Journal 1988;139(1):8.

20. Wheeler DM, Hobbs CJ. Mistakes in diagnosing non-accidental injury: 10 years’ experience. British Medical Journal (Clinical research ed.) 1988;296(6631):1233-1236.

21. Paterson CR. Child abuse or copper deficiency? British Medical Journal (Clinical research ed.) 1987;295(6591):213.

22. Le Fanu J. Wrongful diagnosis of child abuse—a master theory. Journal of the Royal Society of Medicine. 2005; 98(6):249-254. See also LeFanu J, Edwards-Brown R. Patterns of presentation of the shaken baby syndrome: Subdural and retinal haemorrhages are not necessarily signs of abuse. BMJ : British Medical Journal. 2004;328(7442):767 (“These findings necessarily raise disturbing questions about the validity of the opinions expressed by medical experts in the courts”)

23. Sullivan AF, Rudders SA, Gonsalves AL, Steptoe AP, Espinola JA, Camargo CA. National survey of pediatric services available in US emergency departments. International Journal of Emergency Medicine 2013;6:13. This survey includes a the history of efforts to improve emergency care for children in the United States, an effort started in earnest in 2001. As of 2013, the authors found “little change in pediatric emergency services compared to earlier estimates.”

24. Cort NA, Cerulli C, He H. Investigating Health Disparities and Disproportionality in Child Maltreatment Reporting: 2002-2006. Journal of public health management and practice 2010;16(4):329-336.

25. Hampton RL, Newberger EH. Child abuse incidence and reporting by hospitals: significance of severity, class, and race. American Journal of Public Health 1985;75(1):56-60.

26. Font SA, Berger LM, Slack KS. Examining Racial Disproportionality in Child Protective Services Case Decisions. Children and youth services review 2012;34(11):2188-2200.

27. Thompson, A.C., Shapiro, J. Bartlett, S. and Lee, C. The child cases: Guilty until proved innocent. National Public Radio. June 28, 2011.

28. Carpenter SL, Abshire TC, Anderst JD, American Academy of Pediatrics, Section on Hematology/Oncology and Committee on Child Abuse and Neglect. Technical Report: Evaluating for suspected child abuse: Conditions that predispose to bleeding. Pediatrics. 2013;131(4):e1357–73.

29. Id.

30. Colin R. Paterson, R. A. Turner, and H. O. Rogers, “Bone Disease and Fractures in Early Childhood,” Child Abuse. Hauppauge, NY: Nova Science Publishers, 2012, 27–52.

31. Renaud A, Aucourt J, Weill J, et al. Radiographic features of osteogenesis imperfecta. Insights into Imaging. 2013;4(4):417-429; Boyce AM, Gafni RI. Approach to the Child with Fractures. The Journal of Clinical Endocrinology and Metabolism 2011;96(7):1943-1952 (“There is no ‘gold standard’ for the evaluation and treatment of children with fractures and low bone mineral density); Edelu B, Ndu I, Asinobi I, Obu H, Adimora G. Osteogenesis Imperfecta: A Case Report and Review of Literature. Annals of Medical and Health Sciences Research 2014;4(Suppl 1):S1-S5 (noting the importance of clinical screening for purposes of genetic counseling and in cases of suspected child abuse). Kemp AM, Maguire SA, Nuttall D, Collins P, Dunstan F. Bruising in children who are assessed for suspected physical abuse. Archives of Disease in Childhood 2014;99(2):108-113 (reporting that only three published comparative studies existed that “investigated differences in the distribution, number, pattern and appearance of bruises between children who were abused and those who had unintentional injuries”).