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Prometheus shaken baby debate
Abstract and Figures
The editor of the journal Prometheus organised a debate about shaken baby syndrome. Following the editor's informative introduction, there is a proposition paper by Waney Squier, "Shaken baby syndrome: causes and consequences of conformity". Then there are responses to Squier's paper from ten commentators, written independently. The result is a fascinating range of perspectives on this controversial issue.
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The shaken baby syndrome was originally proposed in the 1970s without any formal scientific basis. Once data generated by scientific research was available, the hypothesis became controversial. There developed essentially two sides in the debate. One side claimed that the clinical triad of subdural haemorrhage, retinal haemorrhage, and encephalopathy, or its components, is evidence that an infant has been shaken. The other side stated this is not a scientifically valid proposal and that alternative causes, such as low falls and natural diseases, should be considered. The controversy continues, but the contours have shifted. During the last 15 years, research has shown that the triad is not sufficient to infer shaking or abuse and the shaking hypothesis does not meet the standards of evidence‐based medicine. This raises the issue of whether it is fit for either clinical practice or for the courtroom; evidence presented to the courts must be unassailable.
What this paper adds
There is insufficient scientific evidence to assume that an infant with the triad of subdural haemorrhage (SDH), retinal haemorrhage, and encephalopathy must have been shaken.
Biomechanical and animal studies have failed to support the hypothesis that shaking can cause SDH and retinal haemorrhage.
Patterns of retinal haemorrhage cannot distinguish abuse.
Retinal haemorrhages are commonly associated with extracerebral fluid collections (including SDH) but not with shaking.
Infants can develop SDH, retinal haemorrhage, and encephalopathy from natural diseases and falls as low as 1 foot.
The shaking hypothesis and the literature on which it depends do not meet the standards of evidence‐based medicine.
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A scientific paradigm typically embraces research norms and values, such as truth-seeking, critical thinking, disinterestedness, and good scientific practice. These values should prevent a paradigm from introducing defective assumptions. But sometimes, scientists who are also physicians develop clinical norms that are in conflict with the scientific enterprise. As an example of such a conflict, we have analyzed the genesis and development of the shaken baby syndrome (SBS) paradigm. The point of departure of the analysis is a recently conducted systematic literature review, which concluded that there is very low scientific evidence for the basic assumption held by Child Protection Teams: when certain signs are present (and no other "acceptable" explanations are provided) the infant has been violently shaken. We suggest that such teams have developed more value-based than scientific-based criteria when classifying SBS cases. Further, we suggest that the teams are victims of "groupthink," aggravating the difficulties in considering critics' questioning the criteria established by the teams.
A look at nonaccidental injury and abusive head trauma in children with a focus on Shaken Baby Syndrome.
Since the publication of the Swedish systematic literature review on the diagnostic accuracy of the triad of signs and symptoms and shaken baby syndrome (1), several authors have commented on the arguments for classifying most previous studies as having a high risk of bias (2‐4). The main reason for this classification is that scientists have used the clinical judgments of child protection teams as the reference test when classifying shaken baby cases (1). Since the diagnostic tests depend on this reference test, the outcome will be a high risk of bias (5,6).
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Many of the comments on our systematic literature review on shaken baby syndrome (1) have focused on our criticism of how child protection teams' classification of study cases and controls are used as gold standard and the faulty circular reasoning associated with that (2,3). Some commentators have also questioned how reasonable it is to focus on the triad of retinal hemorrhages, This article is protected by copyright. All rights reserved.
Beware the majority opinion
Decisions about the reliability of all expert witnesses should be left to the courts, but the General Medical Council currently exercises an unacceptable level of control over medical expert witnesses. The problem was highlighted in the recent case of the paediatric neuropathologist Waney Squier.1 Shaken baby syndrome describes a hypothesis to explain a triad of thin layer subdural haematomata, retinal haemorrhages, and encephalopathy in babies whose carers are being investigated for possibly inflicting intentional injury. Most doctors prepared to give evidence on the syndrome believe in the hypothesis, although there is little or no scientific support for this belief.2 Whereas it is the scientist’s duty to attempt to prove even popular hypotheses wrong, danger awaits any doctor challenging majority opinion when it comes to shaken baby syndrome.
Squier was struck off the Medical Register for dishonestly giving evidence in cases of alleged shaken baby syndrome after she expressed doubt that the forces from shaking were sufficient to cause the syndrome. A panel of the Medical Practitioner Tribunal Service found she had dishonestly gone beyond her expertise. The High Court on appeal …