Shaken baby syndrome needs a rethink

Accusations are often levelled at those who challenge the science behind Shaken Baby Syndrome (now known as Abusive Head Trauma). Those seeking to silence anyone who questions this orthodoxy often go well beyond name-calling including publication censorship, and legal and professional registration challenges.

However, I am compelled to take that risk, because thousands of innocent parents and caregivers throughout the world have been accused of abusing children, convicted and given long jail sentences or even sentenced to death, and thousands more have had their children removed from their care. This is based on the testimony of highly credentialled medical expert witnesses who believe in the Abusive Head Trauma (AHT) orthodoxy, but lack a scientific foundation for those beliefs. With the best of intentions, paediatricians have wrongly equated physical findings as evidence of child abuse, with devastating consequences.

An important new book, Shaken Baby Syndrome: Investigating the Abusive Head Trauma Controversy, seriously challenges the scientific validity of SBS. It reports that contrary to prevailing beliefs, the ‘triad’ of brain swelling, subdural haemorrhage, and retinal haemorrhage (often defined as AHT) is not diagnostic of child abuse, but results from hypoxia (lack of oxygen) in the brain.

A long and growing list of natural conditions such as various convulsive states – certain haemorrhagic diseases, infectious diseases, metabolic disorders, immunological diseases, skeletal diseases and vascular malformations – can all result in these hypoxic findings. So can non-abusive accidental factors such as short falls from a couch or bed.

Vigorous shaking should first cause damage to the neck or spine, but no neck injury is seen in cases defined as AHT. There are no documented, independently witnessed shaking events that have resulted in the findings associated with AHT either, and witnessed shaking events have never led to AHT-associated findings.

Scientific studies all report that shaking a baby generates biomechanical forces well below those considered necessary to cause the purported AHT injuries, and detailed microscopic studies of the brains of infants diagnosed with non-accidental injury find that the majority do not have torn nerve fibres (the assumed mechanism of brain damage in AHT cases), but predominantly have hypoxia – a failure of oxygen supply.

Shaken Baby Syndrome provides careful, evidence-based analyses by 50 world-leading professionals from 16 different medical, scientific and legal disciplines from over 20 countries globally. It aims to pursue that truth, and challenge the orthodoxy. The book acknowledges that child abuse is a pervasive societal issue that has only recently received the consideration it deserves, and effective child protection systems are essential to detect and protect abused children.

Sometimes parents and caregivers do inflict intentional head trauma on infants and cause severe injuries. This book does not present the claim that violently shaking or abusing a child is safe. Abusive behaviours are dangerous and must be prevented, and perpetrators must be criminally prosecuted. However, Shaken Baby Syndrome should help courts make the best informed decisions in each case, by understanding the real state of current scientific knowledge regarding AHT and its limitations.

I was invited to contribute a chapter on mandatory reporting of child maltreatment – that is, professionals working in health, educational, or social settings being mandated to report to authorities whenever they encounter a child they suspect may be abused or neglected. There is a call for mandatory reporting in New Zealand. However, in effect this is already in place as Te Whatu Ora has a Memorandum of Understanding with Oranga Tamariki and the police to report all children and young people admitted to hospital with suspected child abuse or neglect or both.

We could, and I would recommend, take a better approach to the way we intervene in cases of suspected child abuse. Nordic and northern European countries have family support-oriented child welfare systems. If child maltreatment is suspected, an investigation is not to determine whether an allegation is correct, but to examine family functioning, including parent-child interactions, and offer support to address issues rather than impose intrusive state intervention.

Social workers assess in relation to what might be expected to be a “good-enough” childhood or family life, rather than against gold-standard parenting. Open-care measures are prioritised, with provision of a wide range of psychosocial, financial, and practical supportive services. These flexible services are often embedded within, and normalised by, broad child welfare and public health services. Removal of children from their families is a last resort and mainly on a voluntary basis.

In contrast, New Zealand has a stand-alone, adversarial child protection-oriented service, demanding children are protected from harm that might be inflicted by parents and other relatives. Removal of children from their homes is seen to be warranted, as it is 'better to be safe than sorry'. The implications of this are of particular concern where authorities too often leap to the conclusion that the presence of retinal and subdural haemorrhage and brain swelling is diagnostic of AHT.

The fact the parents deny the occurrence of any traumatic event is interpreted as giving a false history, and this is too often assumed as evidence that they cannot be trusted with the care of their children. Their denial means they present an ongoing risk, and removing children justified as a way to keep them safe from dangerous parents. Where the children have died, those deemed responsible are to be held criminally liable.

New Zealand paediatricians are committed to the AHT orthodoxy. Challenging this is considered heresy. However, it is not a medical diagnosis; it is the diagnosis of a crime, a statement that an illegal act has taken place. Likewise the term ‘abusive head trauma’ presupposes an action with malicious intent. These emotive labels should have no place masquerading as a medical diagnosis. Mandatory reporting will only increase the risk of miscarriages of justice and children removed to foster homes in such circumstances.

I am likely to be accused of somehow supporting child abuse. I hope good-thinking readers will understand that this could not be further from the truth. We need to do better, stop seeing AHT as a prima facie case of abuse, where there may be other reasons that have caused the brain to swell, and these need to be investigated thoroughly.

Child abuse should always be considered, but natural and accidental causes should also be openly considered to explain the findings.