Shaken baby syndrome – recent controversies in Sweden

It really takes me by surprise, the sheer tone and volume of the debate that has unleashed in Sweden on shaken baby syndrome. The debate basically concerns whether there is such a thing as shaken baby syndrome or not. In a country, where a debate, just as fierce, took place on if putting a child into timeout is a violation of children’s rights, the evidence of the existence of a medical condition due to shaking an infant and thus causing brain damage has been questioned by the Swedish Supreme Court, resulting in several verdicts of acquittal. The American Paediatric Association recommends that we abandon the name shaken baby syndrome and use abusive head trauma instead, to indicate that more than one form of traumatic abuse can cause severe brain damage. Nevertheless, people still use the term shaken baby syndrome and so will I for now. IMG_0002 It is indeed, the mechanism behind the brain injuries that has been questioned. Forensic specialists have argued that biomechanical studies have not been able to substantiate the injury mechanism believed to be causing brain damage in shaken baby syndrome. They argue that haemorrhages present differently in simulation experiments or that neck injuries should be observable for shaking fierce enough to cause brain damage. The problem is that this is a technical discussion, although admittedly vital in court cases when decisions about guilt and intent have to be made. But what I mean by that the discussion is technical is that we know that shaking an infant is really dangerous. So it’s not like we can say – oh look, because we can’t prove that this infant’s injuries are without doubt due to abuse through shaking, and only that, we can now tell parents that it is safe to shake their infants. Because it really is not. My colleagues in other countries barely understand the debate. Among paediatricians this syndrome has long been an accepted and known entity. The way the diagnosis is made is by ruling out every other possible medical or traumatic explanation. Abuse is never the first thing that comes to mind. There is really a rather compelling number and size of population-based studies where abuse by shaking or a combination of shaking and impact have been linked to brain haemorrhage and injury along with retinal bleeding. Symptoms include apnoe or reduced consciousness and these infants often have other injuries, such as rib or long bone fractures. But this is beside the point. Luckily, the Swedish Council on Health Technology Assessment has launched a project on abusive head trauma and will try to figure out the state of the science in the field. My point is that Swedish journalists have been so keen on and so biased in this debate. I think the reason is that journalists were quick to identify with the accused parents. I find this quite unprofessional and believe that journalists should become aware of their own anxieties that are raised by such accusations, instead of letting their defence mechanisms lead them to decide that the parents are right and the system is wrongdoing them. In one of the most popular daily radio news programs, a convicted father, still in jail, was given 7 minutes of prime media time to give his account and state his innocence. He said the infant had several fractured ribs, two long bone fractures, one of which was older, as well as brain haemorrhage. He said he had accidentally jumped back and sat on the infant when it was lying on the sofa, while he was playing with the older sibling. The paediatrician defending the existence of shaken baby syndrome was given much less time and no one questioned the raving implausibility of the infant’s multiple injuries (old and new) in relation to the father’s story. Given the current situation, the guy might even get acquitted. Dropped charges against parents apparently make much better headlines than the realities of a disabled child who survived abusive head trauma. The dead children don’t have a voice either. I worry that this debate is going to result not in protecting innocent parents, but in throwing out abused babies with the bathwater. I hope to be proven wrong.

For now, however, things are not looking good. The public debate has gone so far as to question the very existence of AHT as a diagnosis. So much so that the Swedish Paediatric Association felt obliged to prepare a communiqué to support AHT as a diagnosis and assert that Sweden is no exception when it comes to the occurrence of such cases.

10 thoughts on “Shaken baby syndrome – recent controversies in Sweden

  1. I recall reading your blog a couple years ago, and just thought I would mention that the Swedish Council on Health Technology Assessment has more or less come to the conclusion that SBS is hogwash. In one article I read, it was stated that out of the 3700 papers that they reviewed, only 3 were of “medium quality.”

    No one wants abused children to become abused again, including me. But this diagnosis has wrongly imprisoned hundreds of people. I began a page on Facebook and shortly after that, I invited to people to join my group. In about 1 year, I have had more than 100 cases join. These are just the ones who find me.

    The concept you state, about ruling everything else out, is, quite simply, wrong. I’m sure that some physicians do an excellent job, but others do not. In fact, I just attended a trial where the pediatrician, Dr. Tammy (Drew) Graves stated that retinal hemorrhages are “pathognomonic” of abuse. Abuse was not the last conclusion they came to, but rather, the first.

    I’m still waiting for the English translation of the report out of Sweden, and I fully expect a lot of backlash from the pediatric and prosecution communities. No one likes to be wrong. And certainly, no one wants to be so wrong for so long. But that is the case, here, and eventually this particular form of denailism will largely be put to rest. In the meantime, we will continue to send innocents to prison for life, and remove children from non-abusive, loving parents.

    I am not happy about the fact that this may, in some circumstances, let the guilty go free, and I’m sure you are not, either. I’ve done my best to fix this mess, and I hope you will now as well. Set aside your preconceived notions and read the report. Googling “skakvåld” should take you to it. Google translate can do most of the rest.

    1. Hi, I just read the report. Unfortunately, the way the question was posed – whether or not the “triage” is specific/pathognomic of AHT – was not very helpful for clinicians dealing with potential child abuse cases in their emergency departments. They don’t see the triad, they see the kids. So the report might have solved a legal problem, whereas it was of no help clinically. So most probably this debate will be continued, but hopefully it will lead to some sound research to try and understand what it is we are seeing and how we can avoid doing more harm than good when dealing with unexplained hemorrhages and fractures in infants.

  2. I think the key is to work with the Innocence Network to root out the many wrongful convictions that have occurred as a result of this diagnosis. Denying the devastation that these false accusations cause has created this climate. The Goudge inquiry in Canada was a worthwhile step in the right direction, but also keep in mind that these prosecutions were taking place at a much lower rate. Those who are fighting for the medical and legal field to take another look at SBS are also trying to get the National Academy of Sciences to take a look as well.

    Ruling out other known possibilities may be how doctors generally make diagnoses, but this is NOT the proper way to make a legal conclusion. Imagine if you are suspect #15, and suspects 1 through 14 have been ruled out. Sorry, you’re guilty by default? This is madness. It’s not science. And it’s not justice.

  3. Hello,
    What is questioned is not whether it is harmful o shake the child, what is questioned by the small group as you call them , is that the damage that these ” experts” have presented as conclusive proof that it is precisely in these cases is about shaking violence actually can occur in other circumstances and medical conditions , and that those who examined the records can see clearly that these experts withholding important facts and information that specifically highlights the fact that in the cases, it is not about shaking violence against children , child abuse is a major problem but it must be the last statement and not the first who these experts come to.

  4. “So it’s not like we can say – oh look, because we can’t prove that this infant’s injuries are without doubt due to abuse through shaking, and only that, we can now tell parents that it is safe to shake their infants. Because it really is not.”

    The problem with this kind of comment is that it becomes immediately flagged as a red-herring. Nobody is arguing whether or not shaking a baby is a good idea, so dealing in these kind of logical fallacies draws doubts as to whether you are actually confident in the arguments you are making.

    This is about the confidence we have in convictions – whether we can be confident beyond a reasonable doubt whether certain types of injuries truly are the result of shaking a child. When we devolve into logical fallacies and misrepresentations, we do ourselves a disservice.

    Unless there can be a robust causation found for the injuries, for instance, in the case you outline above, our legal and even moral systems demand we presume the innocence of the accused.

    1. Well, I think there is a real risk of a logical fallacy there, but not the way you interpret it. Because shaking a baby has not been proved as a cause of injury in a number of high-profile recent Swedish cases it could be interpreted by the public as it would not be that dangerous to shake an infant. I haven’t seen any journalist or lawyer making the point that shaking an infant is a big red NO NO as loud and clear as I think is vital from a public health perspective.

    1. Thanks for that post, I can see who your favorite people in the semi-health sector are ;). But seriously, I guess we all have to be on the watch out for dangerous skeptics. What beats me is how they can get hold of a whole legal system. I guess the good news would be that this post was also quite intensely shared so there is hope for a counterforce to rise!

    2. I apologize, somewhat, for responding two years later, but this post actually points out the “real issue.” The controversy has never been one in which the accused says, “I shook my baby, sure, but that’s not why it is dead.” Rather, it is one in which doctors state, “We have found these findings, RH and SDH. We tested for X, Y, and Z, all of which came back negative. Therefore, you shook your baby to death.”

      The recent report out of Sweden has, more or less, said that while Shaking may cause SDH + RH, it is a fallacy to conclude SDH + RH therefore Shaking. This is what many of us have been saying for years, but have been marginalized.

      The significance of this report, I’m quite sure, will be downplayed, but it is, nevertheless, very significant in the world of actual innocence. I just hope the U.S. and U.K. soon take these findings into consideration.

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