Tuesday, August 2, 2016

Physician statement on the Louise Woodward case

Massachusetts Society for the Prevention  of Cruelty to Children issues the following statement for doctors questioning au pair defense experts:

 "As physicians who specialize in the diagnosis and treatment of victims of
 child abuse, we feel compelled to speak out regarding the scientific evidence
 as portrayed in the trial of Louise Woodward for the murder of eight month old
 Matthew Eappen.  Both in the United States and in England, media publicity
 surrounding the case has led to considerable sentiment that she was convicted
 despite allegedly irrefutable scientific evidence presented by the defense
 that the infant's injuries had occurred days to weeks earlier.  Many in the
 media and the public have failed to credit the jury in this case with having
 had the intelligence to understand that the prosecution put forward well
 established medical evidence that overwhelmingly supported a violent
 shaking/impact episode on the day in question, when Matthew was in the sole
 custody of Ms. Woodward.  The hypothesis put forward by the defense that minor
 trauma caused a "re-bleed" of an earlier head injury can best be characterized
 as inaccurate, contrary to vast clinical experience and unsupported by any
 published literature.  The "re-bleed" theory in infants is a courtroom
 diagnosis, not a medical diagnosis, and the jury properly rejected it.

 Infants simply do not suffer massive head injury, show no significant
 symptoms for days, then suddenly collapse and die.  Whatever injuries Matthew
 Eappen may or may not have suffered at some earlier date, when he presented to
 the hospital in extremis he was suffering from proximately inflicted head
 injuries that were incompatible with any period of normal behavior subsequent
 to the injury.  Such an injury would and did produce rapidly progressive, if
 not immediate, loss of consciousness.

 The shaken baby syndrome (with or without evidence of impact) is now a
 well characterized clinical and pathological entity with diagnostic features
 in severe cases virtually unique to this type of injury -- swelling of the
 brain (cerebral edema) secondary to severe brain injury, bleeding within the
 head (subdural hemorrhage), and bleeding in the interior linings of the eyes
 (retinal hemorrhages).  Let those who would challenge the specificity of these
 diagnostic features first do so in the peer-reviewed literature, before
 speculating on other causes in court.  Indeed, the courtroom is not the forum
 for scientific speculation, but rather the place where only, according the
 U.S. Supreme Court in Daubert vs. Merrill Dow, peer reviewed, generally
 accepted, and appropriately tested scientific evidence should be presented.

 We wholeheartedly endorse a panel of medical experts to offer a
 scientifically based analysis of the Shaken Baby Syndrome and would suggest
 that this panel also review the medical testimony offered in this case and
 others so that some guidelines can be established for the courts on future
 admissibility of scientifically supportable medical testimony."

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  1. A day after the British au pair Louise Woodward was released from prison, specialists in child abuse from around the country challenged her lawyers' assertion that the medical evidence supported her claim of innocence in the death of an 8-month-old boy in her care…

    One defense lawyer, Barry Scheck, suggested that a blue-ribbon panel be appointed to examine the science and possible overdiagnosis of shaken baby syndrome.

    But that idea was scoffed at by some medical experts, who said the syndrome has already been solidly examined clinically and been the topic of perhaps 200 research papers.

    ''In point of fact, that's ridiculous,'' said Dr. Randell Alexander, a University of Iowa pediatrics professor who is one of the country's foremost experts on the topic. ''Why don't we appoint a panel to look at strep throat?''

    Both the pediatricians who wrote the letter and the defense agreed, however, that the time has come for some kind of peer review process that would police scientific testimony and discipline colleagues who deviated from the truth.

    Certainly, such peer review might have helped at the Woodward trial. Even Judge Hiller Zobel, who reduced Ms. Woodward's conviction from second-degree murder to involuntary manslaughter and released her on Monday after sentencing her to time served, did not undertake to rule decisively on what the medical experts had said…(continued)

  2. (continued)Medical experts for the defense testified that the age of blood clots found in 8-month-old Matthew Eappen's brain appeared to be about three weeks old; that in post-mortem photographs, the baby's skull-fracture appeared to be knitting together, indicating it, too, was old; that the baby had no neck injuries or obvious bruising when he was taken into the hospital, indicating he had not been manhandled or brutally shaken; and that a brain scan showed no swelling at the site of the skull fracture, meaning his head could not have been recently slammed against a hard surface.

    In essence, then, the defense argued that a relatively mild impact on or around Feb. 4, the day Matthew Eappen was taken to the hospital, could have re-aggravated an old injury and led to the baby's death.

    Unlike the jury, Judge Zobel appeared to accept that scenario when he allowed, in his decision, that Ms. Woodward may have been only rough with the baby.

    But pediatric experts on child abuse who were not involved in the Woodward trial said today that everything known about children's injuries did not jibe with such a picture.

    Dr. Jan Bays, chairwoman of the American Academy of Pediatrics' Committee on Child Abuse and Neglect, said she had not followed the Woodward trial closely, but it appeared to involve ''a classic history'' of shaken baby syndrome.

    Dr. Bays said that when a child, like Matthew, has trouble breathing, is bleeding in its brain and eyes and has a fractured skull, ''these injuries are definitely not caused by a three- to five-foot fall off a counter or being dropped out of Mom's arms.''

    ''It's violent shaking,'' she said, ''so violent that anyone witnessing it would know this was very dangerous to this baby.''
    Furthermore, she and others said, it was impossible that Matthew Eappen could have incurred a severe brain injury three weeks before Feb. 4 and continued to function more or less normally.

    Dr. Alexander, who has written several papers on shaken baby syndrome, said he also discounted the ''re-bleed'' theory because it was not bleeding that kills a shaken baby anyway, but rather the swelling of its brain tissue, which puts pressures on the parts of the brain that control vital functions and brings death.

    ''You die of massive brain swelling and that takes a massive injury to do that,'' he said. Studies have shown that to incur the level of head injury found in shaken-baby syndrome, he said, children must fall from second-story windows or be caught in car crashes without seat-restraints.


  3. Holed up in a Boston hotel after her sentence was commuted, a then 19-year-old Woodward sent out a statement saying she thought medical science would eventually clear her name. “I am confident that the future direction of this case, including the ongoing efforts by my lawyers to investigate further the science underlying the case, will further justify Judge [Hiller] Zobel’s decision,” the statement read. “I pray that further investigation into the scientific evidence convinces the Eappen family that I did their son no harm.”

    Ten years later, Sunil and Deborah Eappen are not convinced. Neither are most physicians. Dr. Robert Reece, a Tufts University pediatrician who is one of the nation’s most respected authorities on shaken baby syndrome, says, “The information that was presented at trial on the prosecution side was correct” – an opinion that lines up with those of the vast majority of doctors who study SBS.

    But Woodward was prescient in one respect: There has been a groundswell of scientific research since her trial, and some of it calls into question the facts of the syndrome. Deborah Eappen says the research can offer people an all-too-easy “defense mechanism,” a way to avoid contemplating the horror of child abuse by explaining it away as something else. It can be a literal defense mechanism, too; many of those who doubt the diagnosis regularly testify in court. The arguments, however, have persuaded a small but vocal minority of doctors, including a radiologist who testified against Woodward and some who have never testified at all. At times, their debates with mainstream pediatricians can devolve into outright fights, the sort seen often in court but less so in the usually placid prose of medical journals. The bickering can seem like little more than he-said-she-said. But it may be rooted in something more significant: an argument about what constitutes evidence, in both medicine and law; why those two standards sometimes differ; and, when they do, which should prevail...(continued)

  4. (continued)Brain scans and autopsies provide doctors with the second clue in suspected shaken baby cases. They tell the story of what most doctors think happened under Matthew’s crown of black curls. In the brain, the syndrome is not a single injury, but a cataclysmic cascade of events that begins as the gelatinous gray matter bangs against the inside of the skull. The strain shears the fragile walls of tiny blood vessels crossing the brain’s surface, and the branches that connect the nerve cells are stretched to the breaking point. If cells in the brain stem are among those damaged, the body may quickly lose control over heart rate, respiration, blood pressure, and temperature. The baby’s breathing then falls off tempo, depriving the brain of oxygen – a stress the organ can bear only for several minutes before it starts to swell. Pressed against bone, the nerve cells now begin to implode, leaking chemicals into the brain tissue that are toxic outside the cell walls. Once this breakdown begins, the brain cannot resist, and it fails...

    One of those who set off in pursuit of explanations was Dr. Patrick Barnes, a radiologist who was working at Children’s Hospital Boston at the time. Barnes treated Matthew Eappen and testified in the Woodward case for the prosecution. In the following years, though, he made a turnaround in his views that left many of his colleagues astonished. He now regularly testifies for defendants in SBS cases, arguing that caregivers can be wrongly blamed and sometimes sent to prison when rare medical conditions and previous injuries cause bleeding in infants’ brains. Speaking about Barnes, Reece says, “I don’t know what’s going on in his brain – it’s a mystery to all of us.”...

    Barnes argues that he and others are trying to bring that sort of scientific rigor to a field sorely lacking it. “The diagnosis and management of child abuse has escaped evidence-based medicine and a good methodology for 30 or 40 years,” he says. “It’s supposed to be founded in the scientific method and biostatistical analysis.”

    But Block calls this argument a “smoke screen.” Most evidence-based medicine, he argues, is founded on randomized trials, while child abuse studies can never be. “The main thing we don’t know is what happens inside a real brain, a real head – and we will never know,” he says. “How are you going to find out? Are you going to take 100 babies and shake half of them and see what happens?”


  5. Plunkett cites "anecdotal evidence of children who have suffered clearly accidental head injuries from short distance falls" to emphasize the point that children may suffer such severe head injuries with minimal trauma. Curiously, he also states that a review of the literature of short falls shows a total of 3,056 cases of short falls with 9 fatalities. Seven of these were reported by Chadwick et al., who stated that these deaths were suspicious and that the history was probably falsified. Aoki and Masuzawa reported 2 deaths out of 26 falls allegedly occurring at home, but there were no witnesses to these falls other than the caretaker. Additionally, Chadwick and Salerno studied 338 children who experienced short falls, each of which occurred in a situation in which multiple witnesses were present (most of the cases were from day care centers with multiple caretakers). The most serious injury occurred in a 2 1/2-year-old who fell 5 feet onto a concrete walk and was unconscious for approximately 1 minute. A computed tomography scan of the head showed no injury, and he recovered fully in 1 hour.

    Reiber reported 19 cases of injuries from short falls (5-6 feet or less). In no cases were there witnesses other than the caretaker. He felt that 14 (74%) represented an inflicted trauma, whereas 3 had unexplained retinal hemorrhages or other evidence of battering. He opined that in two cases the history of an accidental fall was genuine but did not state why, because, as in the other cases, there were no corroborative witnesses.(continued)

  6. (continued)Hall et al. also reported a series of severe and fatal injuries from short falls. Only two of the falls in their series were witnessed by someone besides the caretakers (medical personnel in each case). These children appeared well after the fall and did not receive medical care until they returned subsequently with fatal head injuries. One of their conclusions was that short falls in children may be fatal. However, even in the two falls witnessed by medical personnel, because there was no immediate treatment, there was a subsequent opportunity for an assailant to fatally injure the children. Joffe and Diamond pointed out that although Hall and coauthors stated that the falls were less than 3 feet, they admitted they did not have prehospital and hospital records in order to make this conclusion. In Hall's series there was a high frequency of delay in seeking medical care for the fatally injured children. In their letter of response, Hall et al. concluded that despite the history of a trivial fall, a child should be observed for evidence of a severe head injury.

    Plunkett states that a lucid interval may occur after development of an injury that becomes fatal. The three papers that he cites to support this concept include one in which one of three cases cited allegedly had a 4-day lucid interval before being admitted to the hospital. However, there was no reason to believe that the babysitter could not have assaulted the child at any period subsequent to the 4 days, including immediately prior to admission. The other two citations by Plunkett used to support his lucid interval theory were a letter to the editor that he wrote disputing the conclusion of a study published by Willman et al. who found 1 "lucid interval" in 95 fatally head-injured children. This one case involved an epidural hematoma. The final citation by Plunkett is a court case, and in none of his three citations is there scientific evidence for a lucid interval.

    In their response to Dr. Plunkett's letter to the editor, Willman et al. emphasized that in cases of child abuse the histories are obviously unreliable, and therefore the only reliable data to determine whether a lucid interval exists after a fatal head injury are accidental injuries in which the time and circumstances are known. Dr. Plunkett in his letter had stated that biomechanics of motor vehicle crashes and abusive injuries (shaking, direct impact, and falls) were different. Willman and associates pointed out, and this has been my experience, that the pattern of injuries seen in children fatally injured in motor vehicle accidents is often quite similar to that seen in abusive injuries. A demonstration of diffuse axonal injury in shaken babies is further evidence for the immediate loss of consciousness in shaken babies.

    Cohle SD, Foster A, Cottingham SL. Shaken baby syndrome. Am J Forensic Med Pathol. 2000 Jun;21(2):198-200.