Shaken Baby Syndrome’ – a response by Dr Waney Squier
Dr Waney Squier responds to a recent article in Family Law Week.
On 25 February 2010, Family Law Week published an article by John Tughan which referred to the judgment in Re S [2009] EWHC 2115. We have received a letter from Dr Waney Squier, who is mentioned in the article and judgment.
Dr Squier has offered to write an article on this subject. The editors of Family Law Week do not consider that it is an appropriate forum in which to debate matters of complex medical disagreement. Instead we publish the following letter by Dr Squier. Family Law Week itself does not hold a view on matters of medical expertise, and so the views expressed are those of Dr Squier.
Dr Squier has offered to write an article on this subject. The editors of Family Law Week do not consider that it is an appropriate forum in which to debate matters of complex medical disagreement. Instead we publish the following letter by Dr Squier. Family Law Week itself does not hold a view on matters of medical expertise, and so the views expressed are those of Dr Squier.
Department of Neuropathology
Level One West Wing
John Radcliffe Hospital
Oxford OX2 6QY
April 9th 2010
Level One West Wing
John Radcliffe Hospital
Oxford OX2 6QY
April 9th 2010
Dear Sir,
In February 2010 Family Law Week published a review by Mr Tughan of the judgment of Mrs Justice King in Re S [2009] EWHC 2115, (Family Law Week: February 2010). I appreciate the opportunity to respond.
The remarks of Dr Al-Sarraj cited in the article are both inaccurate and unrepresentative.
I do not believe that hypoxia alone causes subdural bleeding as I have pointed out on many occasions, both in reports for the Court and in my academic publications; it's a bit more complicated than that. This was put to me in the course of the trial; my response was that I have never stated this and do not believe this.
These issues are far too serious to be matters of faith; medical opinion must be based not on belief, but on empirical observation and peer-reviewed, objective, scientific evidence.
It is a matter of objective evidence that the blood vessels of the infant dura are immature and far more extensive than in later life.
It is a matter of objective evidence that bleeding into the young infant dura is common.
It is a matter of objective evidence that sick, hypoxic ventilated infants may develop impaired blood clotting. This predisposes to, or exacerbates, bleeding.
Only by considering the entirety of the evidence and the highly complex physiopathology specific to the young infant brain and its blood supply can a valid opinion be reached.
Central to so many of these cases, and so frequently trivialised, is a prolonged period of hypoxia with subsequent resuscitation and brain swelling. It is these features which set babies with the "triad" (of retinal and subdural bleeding and encephalopathy) apart from cot deaths. A study presented last month to the American Academy of Forensic Science indicates that these are the critical factors associated with retinal haemorrhage (1). The same study has not been undertaken with respect to subdural bleeding, although multicentre studies, comparing in-hospital with out-of-hospital cardiac arrest, have confirmed the devastating effects on the brain of prolonged collapse followed by resuscitation (2).
I also challenge the statement that I am the only one of 40-44 neuropathologists in this country who holds this belief. Not only, as noted above, do I not hold this belief, but the statistic is misleading. To my knowledge, there are only 5 neuropathologists who regularly become involved with the study of infant brains in the forensic setting; this is reflected in their attendance at a meeting at the College of Pathologists in December 2009 (3). Among these 5 only two of us devote a significant part of our daily diagnostic practice to the study of brains of infants dying from the whole spectrum of natural diseases. This has been my majority practice for 30 years. The others have no such daily experience. It was clear from the meeting at the College that there is considerable divergence of opinion and that I am by no means alone in my views. The other 35 or so neuropathologists have not to my knowledge been canvassed, nor would they have sufficient experience of paediatric brain injury and the rapidly evolving literature to form an objective opinion.
I am accused of clinging to a hypothesis; on the contrary my views, shared by hundreds around the world, continue to evolve. They are based on the incontrovertible evidence provided by the tissue I see daily on the microscope slides and informed by research and critical examination of the scientific literature. What is staggering is that "mainstream medical opinion" has remained just that, opinion; supported not by evidence but by forty years of repetition.
Shaking as a cause of subdural bleeding has not been supported by biomechanical research; as long ago as 1988 Duhaime wrote ""shaken baby syndrome" is a misnomer, implying a mechanism of injury which does not account mechanically for the radiographic or pathological findings"(4). It is inconsistent with the anatomy of the infant head and, despite an estimated 70,000 cases diagnosed in the UK and USA, has never been independently witnessed to cause the collapse of a previously well baby. The mainstay of the hypothesis is confession evidence (5).
If not shaking, then impact must be considered. If there is no evidence of impact or violence (autopsy means seeing for oneself), then this consideration must be ranked, pragmatically, with all the other potential causes of collapse and according to the facts of the specific case.
Any attempt by the courts to simplify these issues will lead to misunderstanding. The difficulties of presenting scientific evidence in the courts have been discussed by Tuerckheimer (6), who stresses "the tensions which thrive where science and criminal justice meet" and specifically that ""Because it is fully constructed by and dependent on medical expertise, Shaken Baby Syndrome (SBS) raises in stark form the problems that arise when science outpaces law..."
Progress has been made over the past decade. Today, as Mr. Tughan correctly observes, the "triad" is no longer accepted as diagnostic of non-accidental injury but is instead viewed "as a mere hypothesis." Mrs. Justice King is equally correct in recognising that we do not yet know the full range of natural and accidental causes for the triad.
Meanwhile, I will continue to strive to "[t]hrow light into corners that were . . . dark."
If lawyers are unwilling to question opinion that is validated only by repetition, or to delve beneath the legal issues and explore the science, there will be miscarriages of justice. And slings and arrows will continue to be directed at the messengers.
Yours faithfully
Dr Waney Squier
Consultant Neuropathologist
In February 2010 Family Law Week published a review by Mr Tughan of the judgment of Mrs Justice King in Re S [2009] EWHC 2115, (Family Law Week: February 2010). I appreciate the opportunity to respond.
The remarks of Dr Al-Sarraj cited in the article are both inaccurate and unrepresentative.
I do not believe that hypoxia alone causes subdural bleeding as I have pointed out on many occasions, both in reports for the Court and in my academic publications; it's a bit more complicated than that. This was put to me in the course of the trial; my response was that I have never stated this and do not believe this.
These issues are far too serious to be matters of faith; medical opinion must be based not on belief, but on empirical observation and peer-reviewed, objective, scientific evidence.
It is a matter of objective evidence that the blood vessels of the infant dura are immature and far more extensive than in later life.
It is a matter of objective evidence that bleeding into the young infant dura is common.
It is a matter of objective evidence that sick, hypoxic ventilated infants may develop impaired blood clotting. This predisposes to, or exacerbates, bleeding.
Only by considering the entirety of the evidence and the highly complex physiopathology specific to the young infant brain and its blood supply can a valid opinion be reached.
Central to so many of these cases, and so frequently trivialised, is a prolonged period of hypoxia with subsequent resuscitation and brain swelling. It is these features which set babies with the "triad" (of retinal and subdural bleeding and encephalopathy) apart from cot deaths. A study presented last month to the American Academy of Forensic Science indicates that these are the critical factors associated with retinal haemorrhage (1). The same study has not been undertaken with respect to subdural bleeding, although multicentre studies, comparing in-hospital with out-of-hospital cardiac arrest, have confirmed the devastating effects on the brain of prolonged collapse followed by resuscitation (2).
I also challenge the statement that I am the only one of 40-44 neuropathologists in this country who holds this belief. Not only, as noted above, do I not hold this belief, but the statistic is misleading. To my knowledge, there are only 5 neuropathologists who regularly become involved with the study of infant brains in the forensic setting; this is reflected in their attendance at a meeting at the College of Pathologists in December 2009 (3). Among these 5 only two of us devote a significant part of our daily diagnostic practice to the study of brains of infants dying from the whole spectrum of natural diseases. This has been my majority practice for 30 years. The others have no such daily experience. It was clear from the meeting at the College that there is considerable divergence of opinion and that I am by no means alone in my views. The other 35 or so neuropathologists have not to my knowledge been canvassed, nor would they have sufficient experience of paediatric brain injury and the rapidly evolving literature to form an objective opinion.
I am accused of clinging to a hypothesis; on the contrary my views, shared by hundreds around the world, continue to evolve. They are based on the incontrovertible evidence provided by the tissue I see daily on the microscope slides and informed by research and critical examination of the scientific literature. What is staggering is that "mainstream medical opinion" has remained just that, opinion; supported not by evidence but by forty years of repetition.
Shaking as a cause of subdural bleeding has not been supported by biomechanical research; as long ago as 1988 Duhaime wrote ""shaken baby syndrome" is a misnomer, implying a mechanism of injury which does not account mechanically for the radiographic or pathological findings"(4). It is inconsistent with the anatomy of the infant head and, despite an estimated 70,000 cases diagnosed in the UK and USA, has never been independently witnessed to cause the collapse of a previously well baby. The mainstay of the hypothesis is confession evidence (5).
If not shaking, then impact must be considered. If there is no evidence of impact or violence (autopsy means seeing for oneself), then this consideration must be ranked, pragmatically, with all the other potential causes of collapse and according to the facts of the specific case.
Any attempt by the courts to simplify these issues will lead to misunderstanding. The difficulties of presenting scientific evidence in the courts have been discussed by Tuerckheimer (6), who stresses "the tensions which thrive where science and criminal justice meet" and specifically that ""Because it is fully constructed by and dependent on medical expertise, Shaken Baby Syndrome (SBS) raises in stark form the problems that arise when science outpaces law..."
Progress has been made over the past decade. Today, as Mr. Tughan correctly observes, the "triad" is no longer accepted as diagnostic of non-accidental injury but is instead viewed "as a mere hypothesis." Mrs. Justice King is equally correct in recognising that we do not yet know the full range of natural and accidental causes for the triad.
Meanwhile, I will continue to strive to "[t]hrow light into corners that were . . . dark."
If lawyers are unwilling to question opinion that is validated only by repetition, or to delve beneath the legal issues and explore the science, there will be miscarriages of justice. And slings and arrows will continue to be directed at the messengers.
Yours faithfully
Dr Waney Squier
Consultant Neuropathologist
Reference List
(1) Matshes E. Retinal and Optic Nerve Sheath Hemorrhages are not Pathognomonic of Abusive Head Injury. 10 A.D. Feb 24; 2010.
(2) Moler FW, Meert K, Donaldson AE, Nadkarni V, Brilli RJ, Dalton HJ, et al. In-hospital versus out-of-hospital pediatric cardiac arrest: a multicenter cohort study. Crit Care Med 2009 Jul;37(7):2259-67.
(3) Royal College of Pathologists. Report of a Meeting on the Pathology of Traumatic Head Injury in Children. 2009.
(4) Duhaime AC, ennarelli TA, Sutton LE, Schutt L. The "Shaken Baby Syndrome" : a misnomer? J Paediatric Neurosciences 1988;4(2):77-86.
(5) Christian CW, Block R. Abusive head trauma in infants and children. Pediatrics 2009 May;123(5):1409-11.
(6) Tuerckheimer D. Criminal Justice at a Crossroads: Science-Dependent Prosecution and the Problem of Epistemic Contingency. Alabama Law Review 62. 2010. 1-8-2010.
Ref Type: Journal (Full)
(2) Moler FW, Meert K, Donaldson AE, Nadkarni V, Brilli RJ, Dalton HJ, et al. In-hospital versus out-of-hospital pediatric cardiac arrest: a multicenter cohort study. Crit Care Med 2009 Jul;37(7):2259-67.
(3) Royal College of Pathologists. Report of a Meeting on the Pathology of Traumatic Head Injury in Children. 2009.
(4) Duhaime AC, ennarelli TA, Sutton LE, Schutt L. The "Shaken Baby Syndrome" : a misnomer? J Paediatric Neurosciences 1988;4(2):77-86.
(5) Christian CW, Block R. Abusive head trauma in infants and children. Pediatrics 2009 May;123(5):1409-11.
(6) Tuerckheimer D. Criminal Justice at a Crossroads: Science-Dependent Prosecution and the Problem of Epistemic Contingency. Alabama Law Review 62. 2010. 1-8-2010.
Ref Type: Journal (Full)
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