SBS: Onrario: Shaken baby convictions cause ‘concern’

 Mar 14 2011

 

Allison Cross Staff Reporter

 

Problems with four “shaken baby” death cases have sparked concern over possible miscarriages of justice. Two of these cases included testimony before a jury by disgraced former pathologist Charles Smith. Criminal convictions were levied in all four cases, according to an Ontario review of child fatalities. “We’ve notified the parties involved and we’re prepared to expedite (legal) proceedings if the parties decide to (take it to court),” said Attorney General Chris Bentley, in an interview. “I won’t presume to know what they will or won’t wish to do.” Bentley has also forwarded the findings to Ontario’s chief prosecutor. The “Shaken Baby” Death Review Committee report, released Monday, comes on the heels of a series of recent child death exonerations prompted by Smith’s faulty forensic pathology work. The review examined 48 criminal convictions that relied on evidence of abusive head trauma — commonly referred to as shaken baby syndrome. The cases in question took place between 1986 and 2006, and were examined by medical and legal experts, including Dr. Michael Pollanen, the province’s chief forensic pathologist. Forty-eight cases were whittled down to 10. Those 10 underwent a more in-depth review by an international medical panel. The review itself was launched in 2008 at the recommendation of Justice Stephen Goudge, who headed the Inquiry into Pediatric Forensic Pathology in Ontario. That inquiry was prompted by mistakes Smith made in 20 child death investigations, 12 of which resulted in convictions. Goudge’s final report called on the province to review shaken baby deaths from the past 25 years to determine if any wrongful convictions resulted from evidence of shaken baby syndrome — a diagnosis some have called a questionable science. An evolution in the science surrounding the injury, and the subsequent controversy, warranted a thorough review of shaken baby death cases, the Goudge Report said. Monday’s report explained why the four cases were a cause for concern. Two cases contained “atypical features,” and the medical panel could not agree on whether the cause of death was the result of head trauma. In the third case, the panel agreed head trauma was the cause of death, but couldn’t agree on whether a short fall could have caused the injuries. In the fourth case, the panel determined that although the diagnosis of head trauma was accurate, the expert evidence and medical opinion on which the diagnosis was based during trial was incorrect. Bentley would not name the individuals involved in the four cases and said it will be up to them whether they come forward to the public. None of those convicted in the cases are currently in custody, the report says. Lawyer James Lockyer said Monday he “might have expected a few more” than four cases to raise concerns. Lockyer, director of the Association in Defence of the Wrongly Convicted, has worked on the cases of several Ontarians who were exonerated after being wrongly convicted based on Smith’s testimony. Depending on how those convicted in the four cases decide to proceed, Bentley said his ministry could, for example, help the cases move through the Ontario Court of Appeal more quickly than normal. “As the Charles Smith cases were reviewed, we worked with counsel who had been retained to speed matters up,” he said. In terms of how individuals will be supported and compensated, Bentley said that will be determined if and when any of those convicted in the four cases come forward. Child advocate Suzan Fraser would like to see a firm commitment from the government to help surviving children affected by any miscarriage of justice due to pathology errors. “This was a review by adults of the criminal cases regarding the rights of adults,” said Frazer, a lawyer in Toronto. “What remains missing for me . . . is the potential for kids to have been affected by the work of pathology in a way that wasn’t criminal. Maybe they were separated from their parents or their families. We still don’t have any commitments from the government to look at their interests and how they were affected.” http://www.thestar.com/news/crime/article/953990--shaken-baby-convictions-cause-concern-report

SIDS: Canada: or Infanticide

Adrian Humphreys, National Post · Mar. 2, 2011 |

A young mother who “did not take well to motherhood” and killed two of her four children three years apart has avoided significant punishment after “infanticide” was upheld as a defence, even when evidence points to murder. The only way out, the Ontario Court of Appeal said Wednesday in a landmark ruling, was for Parliament to revisit a law the Crown prosecutor suggested was outdated and unsound.

The emotional case of the double killing, one of a child who did not stop crying and another who had minor medical issues, was the first thorough appellate examination of the 57-year-old wording of the law.
The ruling noted that Crown prosecutor Jennifer Woollcombe had argued that the concept of infanticide “rests on discredited medical opinions and assumptions about the plight of young unwed mothers that do not accord with present reality, and constitutes an unacceptable devaluation of the worth of a newborn child.”
And although the court upheld it, the infanticide law — based on a 1922 English provision that has itself since been abandoned — did not emerge unscathed.
The woman, who cannot be identified because of the Youth Criminal Justice Act, had a troubled childhood and had previously received mental health treatment before becoming pregnant while in high school.
In 1998 she gave birth and, as the court of appeal notes, “did not take well to motherhood.” Six weeks later, her son’s crying made her angry. When he would not stop, she smothered him in his crib with blankets and a plastic bed sheet. She left the room and turned up some music.
The killing went undetected, with the cause of death being attributed to Sudden Infant Death Syndrome.
In 2001 she had a second child with a different father. There appeared to be no problems associated with that experience.
About a year later, she gave birth yet again. When the third child was 10 weeks old, she smothered him in his crib as well and again her culpability went undetected after another finding of SIDS.
She had a fourth child in 2003. That seems to have gone well.
A year later, however, when she was in a mental health treatment centre, she confided to a doctor she had killed two of her children. She also described the incidents in her journal.
She was charged with first-degree murder.
At trial, the judge acquitted her of murder, instead finding her guilty of infanticide for both killings. She was sentenced to 18 months in custody, followed by three years probation and an order that, for the next 20 years, she notify a child welfare agency if she becomes pregnant.
The Crown appealed the murder acquittals, saying that all essential elements of first-degree murder had been proved. The Crown argued infanticide should only be applied if the elements of murder are not proved.
The appeal focused on parsing the wording of the Criminal Code detailing what constitutes murder, manslaughter and infanticide, the three categories of culpable homicide. The Crown also, however, attacked the validity of the infanticide provision itself.
The court of appeal noted that position, but concluded they must work with the words of the Criminal Code that are passed by the government.
“If the Criminal Code makes infanticide a partial defence to murder, it is not for the court to decide whether that partial defence reflects sound criminal law policy or should be reconsidered in light of advancements in medical knowledge and/or changed social circumstances. Those are matters for Parliament,” said Justice David Doherty, who wrote the judgment on behalf of a unanimous panel of three judges.
A spokeswoman for Rob Nicholson, Minister of Justice and Attorney General of Canada, left the door open for a review of infanticide but declined to specifically address the issue.
“Our government is always interested in improving and updating our laws,” said Pamela Stephens, press secretary for the minister.
A noted mental health specialist said such a review would be in keeping with modern legal reform in other countries, suggesting it was a relic of a time long past.
“It came about to deal with the appalling situation for young unwed mothers in the Victorian era, to keep young mothers in distress from being hung if they killed a child,” said Sandy Simpson, a forensic psychiatrist and head of the law and mental health program at both the Centre for Addiction and Mental Health and the University of Toronto.
“The test as it generally exists in Commonwealth countries tends to draw on some of that historical heritage; some of which does not fit with what we know about the patterns of mental illness and how it effects young mothers.”
Canada adopted its law from a 1922 English law but the infanticide provision has since been abandoned in England, replaced with a general law of diminished responsibility that can apply to a variety of special circumstances rather than a special law for these specific circumstances.
“To call it discredited is unfair but our modern understanding of the epidemiology of major depression or major mental illness in the period of pregnancy and delivery doesn’t support a huge rise in people becoming depressed… but some women can certainly develop a significant and serious depression in those days, weeks and months after giving birth,’’ said Dr. Simpson.
“Child bearing and lactation have lost their specificity in our understanding of it directly contributing to depression.”
http://www.nationalpost.com/news/Changing+infanticide+court/4374619/story.html

SBS: 2003 Article: Shaken baby syndrome in Canada: clinical characteristics and outcomes of hospital cases

Abstract

Background

Shaken baby syndrome is an extremely serious form of abusive head trauma, the extent of which is unknown in Canada. Our objective was to describe, from a national perspective, the clinical characteristics and outcome of children admitted to hospital with shaken baby syndrome.

Methods

We performed a retrospective chart review, for the years 1988–1998, of the cases of shaken baby syndrome that were reported to the child protection teams of 11 pediatric tertiary care hospitals in Canada. Shaken baby syndrome was defined as any case reported at each institution of intracranial, intraocular or cervical spine injury resulting from a substantiated or suspected shaking, with or without impact, in children aged less than 5 years.

Results

The median age of subjects was 4.6 months (range 7 days to 58 months), and 56% were boys. Presenting complaints for the 364 children identified as having shaken baby syndrome were nonspecific (seizure-like episode [45%], decreased level of consciousness [43%] and respiratory difficulty [34%]), though bruising was noted on examination in 46%. A history and/or clinical evidence of previous maltreatment was noted in 220 children (60%), and 80 families (22%) had had previous involvement with child welfare authorities. As a direct result of the shaking, 69 children died (19%) and, of those who survived, 162 (55%) had ongoing neurological injury and 192 (65%) had visual impairment. Only 65 (22%) of those who survived were considered to show no signs of health or developmental impairment at the time of discharge.

Interpretation

Shaken baby syndrome results in an extremely high degree of mortality and morbidity. Ongoing care of these children places a substantial burden on the medical system, caregivers and society.

Abusive head trauma accounts for 95% of fatal or life-threatening injuries attributed to child abuse.^1,2 Accidental intracranial injury is rare in children aged less than 1 year.^3,4 In a report from the United States, child abuse cases represented 1.4% of admissions and 17% of deaths in a pediatric intensive care unit.⁵ All these children had sustained head trauma, had the youngest age (average of 9 months) and had the highest trauma severity index and mortality rate (53%) compared with other children admitted to the intensive care unit who had not been abused. Most life-threatening cases of abusive head trauma in children aged less than 2 years have been reported to be associated with shaken baby syndrome (SBS).⁶

SBS is an extremely serious form of abusive head trauma that occurs when a child is subjected to rapid acceleration, deceleration and rotational forces, with or without impact, resulting in a unique constellation of intracranial, intraocular and cervical spinal cord injuries.^3,7,8,9,10 Presenting complaints are often nonspecific, hence, it is important that all health care providers are able to recognize the clinical features that constitute SBS.^9,11 The outcome is often devastating with 15%–27% of children dying as a result of their injury and more than one-third having serious neurological consequences.^12,13,14 Survivors often require long-term multidisciplinary medical care, specialized education, adaptive housing, vocational training and the involvement of child welfare authorities.⁴ The consequences for those infants exposed to SBS who do not come to medical attention are unknown.

Our knowledge of SBS, derived from child welfare and hospital cases, has focused on relatively small populations of injured children in the United States or the United Kingdom. Barlow and Minns estimated an annual SBS incidence of 24.6 per 100 000 children aged less than 1 year.¹⁵ Estimated numbers of cases of SBS, however, represent the “tip of the iceberg” of a much larger group of injured children, because many cases, with less severe forms of injury, may not be identified or brought to medical attention. Our objective was to describe the key characteristics and outcomes of children admitted to hospital with SBS in Canada.

We evaluated all cases of SBS for the years 1988–1998 that were reported to the child protection teams at 11 tertiary care pediatric hospitals. These hospitals are responsible for a large part of pediatric care in Canada with over 90 000 admissions annually, representing an estimated 85% of tertiary care pediatric beds.¹⁶ The institutional review board of each participating centre approved the research proposal.

SBS is a recognized diagnosis.^8,9 In this study, SBS was defined as any form of intracranial, intraocular or cervical spine injury as a result of a substantiated or suspected shaking, with or without impact, in a child aged less than 5 years. We relied on the diagnosis assigned by the physician responsible for child protection at each hospital and/or that recorded on the discharge summary. These health care providers are responsible for managing cases of suspected child maltreatment, working in association with community child welfare authorities and the police. The diagnosis of SBS made according to the records at the treating hospital was accepted as noted. ICD-9 codes (1988 to March 1996 — 995.5, E967.0, E967.1, E967.9; April 1996 to 1998 — 995.55, 995.54, E967.0, E967.9) were also examined at each hospital to confirm that we had identified all cases.¹⁷

We used a structured data collection form developed and piloted at the Children's Hospital of Eastern Ontario (CHEO). From the medical records we reviewed and abstracted the admission history and physical examination, physician and nursing progress notes, child protection team/welfare authority notes, consultation notes and clinical reports (discharge, radiology). Data on patient demographics, clinical presentation, injury characteristics, past medical history, investigations, family composition, perpetrator and outcome were also extracted. Outcome definitions were developed for the health of the child at discharge (“well” meaning no documented health or developmental impairment; “neurological impairment” meaning documented abnormal neurological findings on physical or developmental assessment; “visual impairment” meaning documented proven or suspected visual impairment).

A single research assistant was trained to review and abstract the information from the medical charts (with the exception of data from the Hôpital Sainte-Justine, Montréal, Que., where a second research assistant abstracted the medical information documented in French) and to enter the information in duplicate into the database. Ten randomly selected cases of abusive head trauma at CHEO were reviewed by the research assistant and an independent assessor (W.J.K.) for the diagnosis of SBS, clinical features and outcome (κ = 0.79). The final data collection form was then revised and the research assistant travelled to each institution to complete the form.

We measured severity of the injury using the modified Pediatric Cerebral Performance Category (PCPC) 6-point scale (from 1 = normal to 6 = brain death).¹⁸ The PCPC scale provides outcomes for functional morbidity and cognitive impairment after critical illness or injury for pediatric intensive care patients when more extensive psychometric testing is not feasible. The scale is reliable and valid and is associated with several measures of morbidity (length of stay in the pediatric intensive care unit, total hospital costs and discharge care needs), severity of injury (pediatric trauma score) and functional outcome at 1-month and 6-month follow-up of pediatric intensive care patients.¹⁹ Ratings on the Glasgow Coma Scale (GCS) on presentation that measures patient performance in 3 areas, eye opening, verbal ability and motor ability, were also collected.^20,21

Summary statistics were tabulated for the whole group and for each study site. Descriptive statistics are presented for continuous variables, with frequency counts and percentages presented for categorical variables. Subjects' characteristics were compared using the Mann-Whitney test for ordinal or interval scale variables and the χ² test for categorical variables for children who died as a result of SBS and in cases in which the certainty of the perpetrator was coded as definite. Using results from the univariate analysis, 2 independent models were developed using backward stepwise logistic regression for the association between children who died and certainty of perpetrator with presenting complaints, injuries, previous maltreatment and outcome.

Results

The 364 children identified with SBS (median age 4.6 months, range 7 days to 58 months), 56% of whom were male, are presented by pediatric centre in Table 1. Clinical features and past medical history (Table 2) revealed nonspecific presenting complaints (seizure-like episode, decreased level of consciousness or respiratory difficulty), and most of the children (95%) did not have an underlying chronic medical or physical problem. The 307 charts containing perinatal information (mean gestation 37 weeks, mean birth weight 2880 g) noted a difficulty with the pregnancy for 16% of the children (88% were born at < 36 weeks' gestation) and 17% were discharged from hospital after their mother.

Table 2

Of the 364 children, 86% had subdural effusion, 42% had cerebral edema and 76% had retinal hemorrhages, of which 83% were bilateral (Table 3). Retinal hemorrhage was associated with more severe injury such as death (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.9–2.6), subdural hemorrhage (OR 3.2, 95% CI 2.8–3.5) and neurological injury (OR 1.7, 95% CI 1.3–2.0). Cervical spine injuries were infrequently recorded (4%). The Glasgow Coma Scale on admission was documented for 86 (24%) children (median age 5.2 months, range 14 days to 38.6 months) with a median value of 6 (normal ≥13 on a scale of 3–15). Imaging studies performed included CT scanning (96%) and MRI (24%). In 98% of cases, an abnormality was reported: subdural hemorrhage/effusion (CT: 79% of scans, MRI: 87% of images), subarachnoid hemorrhage/effusion (CT 32%, MRI 23%) and/or intracranial hemorrhage (CT 63%, MRI 44%). A skeletal survey, that is, a comprehensive radiographic evaluation, was performed in 301 children (82%) and a bone scan in 105 children (29%), as a result of which in 46% of cases and 51% respectively an abnormality was reported.

Table 3

The mean household size was 3.4 people, and the mean number of children per family was 1.7. The mean age of the primary caregiver was 23.7 years (range 15–40 years), with 68% of the parents being either married or living as common-law spouses. Incomplete chart documentation did not allow an estimate of socioeconomic status, employment history or level of education. The medical chart documented poverty (undefined) in 87 families (28%), and an unsafe or inappropriate environment was noted in 73 (20%). A past medical history and/or clinical evidence of previous maltreatment was noted in 220 children (60%), and 80 families (22%) had had previous involvement with child welfare authorities. The biological father (43%), followed by the biological mother (26%), was most often identified as the responsible caregiver with the child at the time of the injury, even though the primary caregiver was usually the biological mother (67%), followed by “other” (35%: 18% babysitter, 17% unknown) and then the biological father (18%).

The perpetrator was identified in 240 cases (66%), with the biological father being the most common (50%), followed by the stepfather/male partner (20%) and then the biological mother (12%). Overall, the perpetrator was male in 72% of the cases; 15% of perpetrators had a previous charge or suspicion for maltreatment of a child in their care. Although the degree of certainty about the perpetrator was considered definite in 96 (40%) cases (where the perpetrator was seen to shake the child or admitted to the assault), this was not associated with the presenting complaint, injury, previous maltreatment or outcome. In almost two-thirds of cases (64%), there was an ongoing police investigation, 26% of the perpetrators had criminal charges laid and 7% were convicted for the assault.

Sixty-nine children died (19%) as a direct result of the shaking injury. Children who died were slightly older than survivors (median age 7.8 v. 4.3 months), and death was associated with a decreased level of consciousness (OR 3.2, 95% CI 2.4–4.0) or respiratory difficulty (OR 2.5, 95% CI 1.8–3.2) on presentation; bruising (OR 2.3, 95% CI 1.5–3.1) on examination; and cerebral edema (OR 3.9, 95% CI 3.1–4.7) or subdural hematoma (OR 2.5; 95% CI 1.7–3.3) on imaging. Of the 295 survivors, only 65 (22%) were felt to be “well” (absence of health or developmental impairment) at the time of discharge, with 162 (55%) having a persistent neurological deficit and 192 (65%) having visual impairment. The PCPC scale, assessed at both the time of admission and at discharge, revealed that only 21 children (7%) were rated “normal,” whereas 143 children (48%) had a moderate or severe degree of disability and 34 (12%) were in a coma or vegetative state. Of the survivors, 251 (85%) required ongoing multidisciplinary care. Review of placement at discharge revealed that 42% of the children were taken into foster care, whereas 43% returned home with their biological parent(s) and a further 14% were placed with a close family member.

Interpretation

Our findings are consistent with previously published data on SBS^10,11,12,13 in highlighting the young age of the victims, the slight preponderance of boys, the high rate of male perpetration and the extremely high degree of mortality and morbidity. Presenting signs and symptoms are often nonspecific, which means that health care providers must have a high index of suspicion when infants and young children present with subtle neurological signs such as lethargy or decreased level of consciousness. Although a significant number of children had evidence of severe trauma with external bruising or fractures, or both, up to 40% of children had no external sign of injury.

Many of these injured children have serious neurological and developmental consequences including profound mental retardation, spastic quadriparesis or severe motor function impairment. These children require long-term involvement of multiple specialists and child welfare authorities. At the time of discharge, the PCPC scale, which is associated with functional outcome at 6-month follow-up,^{19,22,23,24,25} revealed that 60% of survivors had a moderate or greater degree of disability. This outcome, though already cause for concern, may be an underestimate, because there may be a symptom-free interval of 12–18 months before the development of neurological or developmental difficulties.²⁶ Further, the long-term outcome, especially with regard to subtle neurological injury, and for those exposed to SBS who do not come to medical attention, is unknown.

Although this study highlights the devastating effects of SBS, there are several limitations that should be noted. First, the SBS cases are a highly selected sample from admissions to tertiary care pediatric hospitals. These results may not reflect the number of shaken children in the community. Therefore, we are not able to estimate the incidence of SBS. Second, the data collection was retrospective and lacked a comparison group, making it difficult to identify factors that may be associated with SBS. Third, SBS was defined and classified at each participating hospital, and we did not perform an independent assessment to confirm the diagnosis. Fourth, the information obtained was limited to the quality of the documentation in the medical record. Many of the children described here were extremely ill when admitted, and certain elements of the admitting history may not have been reviewed in detail or documented, including sociodemographic and perinatal information. Fifth, the data collection occurred during a time period when the recognition and diagnosis of SBS was evolving and it is possible, especially early in the study, that SBS cases were not identified. Finally, while we have probably accounted for most of the more serious injuries, as these were children admitted to hospital in tertiary care pediatric centres, cases that resulted in death before hospital admission may not have been included.

A major challenge for researchers is to develop approaches to measure the incidence and risk factors for SBS, given that the injury and its circumstances are often clouded in secrecy. Our study suggests that a minimum of 40 cases of SBS occur annually in Canada, from which 8 children will die, a further 18 will have permanent neurological injury requiring life-long assistance and 17 will be taken into foster care. We also believe that this represents only the tip of the iceberg and that many other cases are not detected.¹⁴ The magnitude of this injury requires a national strategy, such as that recommended in the recently released Canadian Joint Statement on Shaken Baby Syndrome.²⁷ This strategy should include population-based surveillance to establish the incidence of SBS and address risk factors by comparing SBS cases with carefully chosen controls. Prevention strategies, based on incidence data and vulnerability factors, may then be developed, implemented and assessed at the community level.

In summary, the outcome of SBS is devastating to the child; ongoing care of these children places a substantial burden on the medical system, caregivers and society. Physicians need to be aware of the nonspecific clinical presentation. Further work is required to establish the true incidence of SBS, identify vulnerable children, and to develop and evaluate prevention strategies.

β See related news article page 207

Acknowledgments

We thank Corinne King, Joanne Blagdon and Elaine Orrbine for their administrative support and Ron Ensom and Doris Lariviere for review of the manuscript and editorial comments.

Footnotes

This article has been peer reviewed.

Contributors: Dr. King was responsible for the study conception and design and oversaw the acquisition, analysis and interpretation of data. Ms. MacKay was involved in the study conception and design and assisted with the acquisition, analysis and interpretation of data. Dr. Sirnick was involved in the study conception and design. Dr. King drafted the manuscript; all of the authors revised the article for important intellectual content and gave final approval of the version accepted for publication. All members of the Canadian Shaken Baby Study Group were involved in the study design and data acquisition, revised the article for important intellectual content and gave final approval of the version accepted for publication.

This study was funded by the Rick Hanson Institute, the Neurotrauma Foundation and the Ontario Ministry of Health and Long-Term Care (grant no. ONPR-10). The report was presented at the Pediatric Academic Society Meeting held in Boston in May 2000.

Competing interests: None declared.

Correspondence to: Dr. W. James King, Division of Pediatric Medicine, Children's Hospital of Eastern Ontario, 401 Smyth Rd., Ottawa ON K1H 8L1

References

1. Levitt CJ, Smith WL, Alexander RC. Abusive head trauma. In: Reece RM, editor. Child abuse: medical diagnosis and management. Philadelphia: Lea and Febiger; 1994. p. 1-22.

2. Coury DL. Recognition of child abuse. Notes from the field. Arch Pediatr Adolesc Med 2000;154:9-10. [PubMed]

3. Billmire M, Myers PA. Serious head injury in infants: Accident or abuse? Pediatrics 1985;75(2):340-2. [PubMed]

4. American Academy of Pediatrics, Committee on Child abuse and Neglect. Shaken baby syndrome: rotational cranial injuries [technical report]. Pediatrics 2001; 108(1):206-10. [PubMed]

5. Irazuzta JE, McJunkin JE, Danadian K, Arnold F, Zhang J. Outcome and cost of child abuse. Child Abuse Negl 1997;21(8):751-7. [PubMed]

6. Bruce DA, Zimmerman RA. Shaken impact syndrome. Pediatr Ann 1989; 18: 482-94. [PubMed]

7. Duhaime AC, Alario AJ, Lewander WJ, Schut L, Sutton LN, Seidl TS, et al. Head injury in very young children: mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age. Pediatrics 1992;90:179-85. [PubMed]

8. Caffey J. On the theory and practice of shaking infants: its potential residual effects of permanent brain damage and mental retardation Am J Dis Child 1972;124:161-9. [PubMed]

9. Duhaime AC, Christian CW, Rorke LB, Zimmerman RA. Nonaccidental head injury in infants — the “shaken-baby syndrome.” N Engl J Med 1998; 338:1822-9. [PubMed]

10. Case ME, Graham MA, Handy TC, Jentzen JM, Monteleone JA. Position paper on fatal head injuries in infants and young children. Am J Forensic Med Pathol 2001;22(2):112-22. [PubMed]

11. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. JAMA 1999;281:621-6. [PubMed]

12. Duhaime AC, Gennarelli TG, Thibault LE, Bruce DA, Margulies SS, Wiser R. The shaken baby syndrome. A clinical, pathological, and biomechanical study. J Neurosurg 1987;66:409-15. [PubMed]

13. Ludwig S, Warman M. Shaken baby syndrome: a review of 20 cases. Ann Emerg Med 1984;13:104-7. [PubMed]

14. Sinal SH, Ball MR. Head trauma due to child abuse: serial computerized tomography in diagnosis and management. South Med J 1987;80:1505-12. [PubMed]

15. Barlow KM, Minns RA. Annual incidence of shaken impact syndrome in young children. Lancet 2000;356:1571-2. [PubMed]

16. Law B, MacDonald N, Halperin S, Scheifele D, Dery P, Jadavji T. The immunization monitoring program active (IMPACT) prospective five-year study of Canadian children hospitalized for chicken pox or an associated complication. Pediatr Infect Dis J 2000;19:1053-9. [PubMed]

17. International classification of diseases, 9th revision (clinical modification). 5th ed. Washington: US Department of Health and Human Services; 1996. Cat no 86-72897.

18. Fiser DH. Assessing the outcome of pediatric intensive care. J Pediatr 1992;121:68-74. [PubMed]

19. Fiser DH, Long N, Roberson PK, Hefley G, Zolten K, Brodie-Fowler M. Relationship of pediatric overall performance category and pediatric cerebral performance category scores at pediatric intensive care unit discharge with outcome measures collected at hospital discharge and 1- and 6-month follow-up assessments. Crit Care Med 2000;28(7):2616-20. [PubMed]

20. Jennett B, Teasdale G. Aspects of coma after severe head injury. Lancet 1977;1:878-81. [PubMed]

21. James HE. Neurologic evaluation and support in the child with an acute brain insult. Pediatr Ann 1986;15:16-22. [PubMed]

22. Fischer H, Allasio D. Permanently damaged: long-term follow-up of shaken babies. Clin Pediatr 1994;33:696-8.

23. Ewing-Cobbs L, Brookshire B, Scott MA, Fletcher JM. Children's narrative following traumatic brain injury: linguistic structure, cohesion and thematic recall. Brain Lang 1998;61:395-419. [PubMed]

24. Barlow KM, Thompson E, Minns RA. Neurological outcome of non- accidental head injury. Eur J Paediatr Neurol 1999;3(A):139-40.

25. Duhaime AC, Christian CW, Moss E, Seidl T. Long-term outcome in infants with the shaking-impact syndrome. Ped Neurosurg 1996;24:292-8.

26. Bonnier C, Nassogne MC, Evrade P. Outcome and prognosis of whiplash shaken infant syndrome: late consequences after a symptom free interval. Dev Med Child Neurol 1995;37:943-56. [PubMed]

27. Health Canada. Joint statement on shaken baby syndrome. Ottawa: Minister of Public Works and Government Services; 2001. Available: www.hc-sc.gc.ca/hppb/childhood-youth/cyfh/child_and_youth/physical_health/shaken_baby.html (accessed 2002 Dec 9).

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC140423/

SIDS: Canadian: Former charity head charged with fraud

The former head of a St. Catharines-based charity that helps families deal with sudden infant death syndrome is accused of stealing more than $170,000 from the organization.
The St. Catharines woman was arrested Thursday by Niagara Regional Police after an investigation was launched more than 20 months ago into alleged fraud at the Canadian Foundation for the Study of Infant Deaths.
Police said they were contacted by the national foundation's board of directors that alleged its acting director had issued a number of unauthorized cheques between January and November 2008.

The board also alleged the employee had used the foundation's credit cards for unauthorized purchases during the same period. The employee was fired, police said.
Mary Darlene MacCormick, 50, is charged with four counts of fraud over $5,000 and one count of identity fraud.
MacCormick founded the Niagara chapter of the Canadian Foundation for the Study of Infant Deaths after her grandson died of sudden infant death syndrome 20 years ago.
http://www.stcatharinesstandard.ca/ArticleDisplay.aspx?e=2843262

SIDS: Sudden Infant Death Syndrome (SIDS) Awareness Month

October 2010

October is Sudden Infant Death Syndrome (SIDS) Awareness Month. It is an opportunity to learn how to reduce the risk of SIDS and unintentional injury while an infant is sleeping by promoting  Safe Sleep.
The Government of Canada is committed to working with its partners to raise awareness of SIDS and to educate Canadians on how to create safe sleep environments. SIDS refers to the sudden death of an infant of less than one year of age, which remains unexplained even after a full investigation. In Canada, many jurisdictions now use the broader term Sudden Unexpected Infant Death (SUID) which includes SIDS and infant deaths from unintentional injury, enabling a better understanding of the risks associated with unsafe infant sleep environments. Examples of unsafe sleep environments include an infant sleeping on a couch or an infant sleeping in a cluttered crib.
Since the launch of Safe Sleep campaigns in Canada, surveys have shown that parental awareness of the need to place infants on their backs to sleep has increased substantially.  Largely due to Back to Sleep initiatives, this practice has contributed to the 50 per cent decrease in the rate of SIDS observed in Canada between 1999 and 2004.
The Public Health Agency of Canada (PHAC) recently released the  Safe Sleep for Your Baby parent brochure.  This new brochure recommends that parents and child care providers adopt the following four practices to create a safe sleep environment for babies:

1. Provide a smoke free environment - both before and after birth
2. Always place your baby on his or her back to sleep - night time and nap time
3. Place your baby to sleep in a crib next to the adult's bed for the first six months
4. Provide a safe crib environment that has no toys or loose bedding (use only a fitted sheet)

On September 29, 2010, Health Canada launched a public consultation soliciting the views of Canadians on a proposed prohibition of the future sale, advertisement and importation of the traditional style of drop-side cribs in Canada. Canadians are invited to provide Health Canada with comments on the proposed options for regulatory action regarding cribs, cradles and bassinets.
In addition, Health Canada will undertake a multi-year project on safe infant sleep to raise awareness of SIDS in First Nations and Inuit communities.  This project will build on the success of the national  Back to Sleep campaign through a culturally-relevant and community-based approach.
I encourage all expectant and new parents, their families and friends, and child care providers to become familiar with the risks associated with Sudden Unexpected Infant Death (SUID) and to learn about how to create safe sleep environments for babies.
For more information about safe sleep environments please visit the Public Health Agency of Canada or read  A Baby's Safe Sleep Environment brochure.  Additional information on SIDS and creating a safe sleep environment for infants is available through the  Canadian Foundation for the Study of Infant Deaths.
Leona Aglukkaq
Minister of Health
Government of Canada
http://www.hc-sc.gc.ca/ahc-asc/minist/messages/_2010/2010_10_01-b-eng.php

SBS: STATES SHOULD REVIEW ALL CONVICTIONS AS IS CURRENTLY UNDER WAY IN ONTARIO

SHAKEN-BABY SYNDROME: STATES SHOULD REVIEW ALL CONVICTIONS AS IS CURRENTLY UNDER WAY IN ONTARIO; DEBORAH TUERKHEIMER

"What’s needed is a comprehensive study of shaken baby syndrome to resolve the outstanding areas of disagreement. The National Academy of Sciences, which last year issued a comprehensive report on the scientific underpinnings of forensic science, would be the ideal institution to undertake such a study.

In the meantime, however, there remains the question of justice. In Ontario, an official investigation concluded that there are deep concerns about the science underlying the triad, and now the province is reviewing all convictions based on shaken baby syndrome. Similar inquiries should be conducted on a statewide level here in the United States." (Publisher's note: Ms. Tuerkheimer is referring to the Goudge Inquiry which reviewed many case of the disgraced pathologist Dr. Charles Randal Smith.")

DEBORAH TUERKHEIMER; OP-ED; NEW YORK TIMES; Deborah Tuerkheimer, a professor of law at DePaul University, is a former assistant district attorney in Manhattan."

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Background: The inquiry focused largely on the flawed work of Dr. Smith — formerly the province's chief pediatric pathologist and a self-styled member of the prosecution team — whose "errors" led to innocent people being branded as child murderers. The 1,000-page report by Justice Stephen Goudge slammed Dr. Smith, along with Ontario's former chief coroner and his deputy, for their roles in wrongful prosecutions and asked the province to consider compensation. The provincial coroner's office found evidence of errors in 20 of 45 autopsies Dr. Smith did over a 10-year period starting in the early 1990s. Thirteen resulted in criminal charges. William Mullins-Johnson, who was among those cases, spent 12 years in prison for the rape and murder of his four-year-old niece, whose death was later attributed to natural causes. In another case, Dr. Smith concluded a mother had stabbed her seven-year-old girl to death when it turned out to have been a dog mauling. Several of the cases involved the harm caused to innocent persons because of Smith's use of the so-called "shaken-child syndrome" to ground a finding of criminality. The inquiry heard that Dr. Smith's failings included hanging on to crucial evidence, "losing" evidence which showed his opinion was wrong and may have assisted the accused person, misstating evidence, chronic tardiness, and the catastrophic misinterpretation of findings. The cases, along with other heart-rending stories of wrongful prosecutions based in part on Smith's testimony, also raised a host of issues about the pathology system and the reliance of the courts on expert evidence."

http://smithforensic.blogspot.com/2010/09/shaken-baby-syndrome-states-should.html

SBS: disabled survivor

A few minutes of male rage were all it took to strip the potential of a healthy life from baby Phoenix Laver.
How often have health experts warned people never to shake babies? Infants’ neck muscles are weak and their brains are undeveloped.
Shaking a crying baby to make it stop is both dumb (you think the baby’s going to get the message?) and potentially catastrophic.
You can a kill an infant in a couple of seconds if you shake it hard enough. The whiplash effect can cause blood vessels to bleed into the brain. It’s akin to throwing your baby off the roof.
Now three years old, Phoenix has epilepsy and cerebral palsy because of the 2007 assault and could face visual difficulties, seizure disorders and behavioural problems down the road.
Michael Bagley, the man who changed Phoenix’s life forever, pleaded guilty to aggravated assault on Monday just as his trial was to begin. His sentencing hearing is in January.
What can the 32-year-old possibly say in his defence? That he lost it because his girlfriend’s baby wouldn’t stop crying? Who can possibly feel sorry for this man?
He didn’t put Phoenix in his crib, close the door and let him cry for a while. He didn’t call his girlfriend or take a few deep breaths to calm down.
Instead, Bagley threw the six-month-old on the couch, shook him repeatedly and tossed him onto a bed three times. (Phoenix hit the bed with his head.) Then he dropped the tot into his crib and abruptly picked him up again so that Phoenix’s head hit the side of the crib.
The seriously ill infant was whisked to hospital the next day.
Single moms might want to listen up. A couple of months ago, I wrote a piece on the so-called Cinderella effect — that step-parents abuse and kill children at much higher rates than birth parents.
This is not to suggest most step-parents and boyfriends are potentially dangerous.
Far from it. But if you’re living with or dating a guy with a hot temper or weak coping skills, your fussy baby and his inability to handle the situation appropriately could put your baby at risk.
“You have to picture the scenario in which these situations actually take place,” says Dr. Louis Francescutti, an emergency doctor and University of Alberta injury researcher.
Typically, a guy who meets a single mom is interested in her, not her kids, he says.
“It’s lack of care, lack of love, lack of compassion, lack of skills,” he says.
He added he suspects there are far more instances of shaken baby syndrome (SBS) than we think because so many cases may be undiagnosed.
“I think what we’re seeing is the tip of the iceberg, unfortunately,” he says.
“How many kids go to school with learning disabilities because somebody’s shaken their head … and the health-care system never found out about it?”
Since 2000, 27 children have died in Alberta from non-accidental traumatic head injuries, according to the office of the chief medical examiner. Last year, alone, there were five such deaths, a troubling uptick.
Years ago, former Oilers tough guy Georges Laraque was the poster boy for a local SBS public awareness campaign.
You may remember the eye-catching image of Laraque holding a baby. The tag line? “Are you tough enough to be gentle?”
Susan Patenaude, co-ordinator of the Alberta Network for Safe and Healthy Children, a provincial child-abuse initiative, thinks it’s time for another hard-hitting campaign.
Young men constitute the highest risk group for baby-shaking, she adds.
“The challenge is that people often have heard … that you shouldn’t shake a baby, but they don’t understand what happens. It’s a pretty devastating result.”
http://www.calgarysun.com/comment/columnists/mindelle_jacobs/2010/09/17/15381116.html

SBS: Newfoundland, Canada trial

The injuries an 11-month-old boy in Corner Brook sustained before dying in 2007 are consistent with shaken-baby syndrome, according to an eye doctor who testified Wednesday at a murder trial in western Newfoundland.
Jeffery Tippett, 35, is charged with second-degree murder in the death of Tameron Rose.
Pediatric ophthalmologist Dorothy Bautista was called as an expert witness at Tippett's trial in Corner Brook. She examined the baby's eyes the day after he was sent to the Janeway Hospital in St. John's in 2007.
Tameron died on Jan. 31, 2007. He had been admitted the previous day to Western Memorial Hospital in Corner Brook. Bautista said the baby had injuries that were most likely caused by shaking.
She ruled out infection, diabetes or leukemia as the cause of the injuries, and said the degree of bleeding she saw is consistent with a fall on the head from a three-storey building.
Jeffrey Tippett, 35, is on trial in Corner Brook on a charge of second-degree murder. (CBC)She said her investigation showed that Tameron had some bleeding in his left eye and moderate to severe bleeding in his right eye.
The defence is scheduled to cross-examine Bautista on Wednesday afternoon on her conclusion that the baby's injuries were caused by shaking.
Tippett's trial began Sept. 16 with evidence from the boy's mother, Maria Rose. She told the court that her son was pleasant and did not cry unless he was being bothered by his teething.
Tippett was babysitting the boy before he was taken to hospital with brain injuries.
About 30 witnesses are expected to be called in his trial, which has been delayed several times.
In September 2009, an entire jury was dismissed.
Last Wednesday, the trial was briefly postponed while authorities sought out a 12th juror. A publication ban is in effect on the events that led to the jury being short of a full complement.
http://www.cbc.ca/canada/newfoundland-labrador/story/2010/09/22/nl-bautista-tipett-922.html

SBS: British Columbia: SHAKEN BABY CASE EXPECTED TO TAKE THREE WEEKS IN PROVINCIAL COURT

Sep 7, 2010
IN PROVINCIAL COURT THIS MORNING...THE CROWN HAS REVEALED THAT AN "EXTENSIVE UNDERCOVER OPERATION" WAS MOUNTED, TO GATHER EVIDENCE IN THE SUSPECTED ASSAULT OF AN INFANT IN FOSTER CARE. PROSECUTOR NILS JENSEN LAID OUT THE STORY IN HIS OPENING REMARKS AT THE AGGRAVATED ASSAUILT TRIAL OF AVTAR BASI. BASI IS ACCUSED OF SHAKING AND CAUSING CATASTROPHIC BRAIN INJURIES TO AN ELEVEN WEEK OLD BABY, IN THE CARE OF HIS COMMON-LAW WIFE, WHO RAN A LICENCED DAY CARE IN CENTRAL SAANICH. IN THE SPRING OF LAST YEAR, ABOUT SIX MONTHS AFTER THE INCIDENT, BASI AND THE WOMAN WERE BEFRIENDED BY TWO UNDERCOVER OPERATIVES, POSING AS ANOTHER COMMON-LAW COUPLE. BY JUNE THEY HAD OBTAINED WHAT THE CROWN LABELS A "TEARFUL" ADMISSION OF THE CIRCUMSTANCES. DEFENCE LAWYER JOHN GREEN SAYS HE WILL PRESENT EVIDENCE CHALLENGING THAT INTERPRETATION, AS WELL AS MEDICAL EVIDENCE CHALLENGING THE PREVAILING WISDOM CONCERNING "SHAKEN BABY SYNDROME". HE SAYS THERE HAS BEEN DISAGREEMENT AMONG DOCTORS IN RECENT YEARS ABOUT THE AMOUNT OF FORCE REQUIRED TO CAUSE SUCH INJURIES, AND WILL ARGUE THERE WAS NO CRIMINAL INTENT IN THIS CASE. THE COURT WILL HEAR SIGNIFICANT MEDICAL EVIDENCE OVER THE COURSE OF WHAT IS EXPECTED TO BE AT LEAST A THREE WEEK TRIAL.
http://www.cfax1070.com/newsstory.php?newsId=15077

SIDS: Canada, Alberta: Probe into baby's 2004 death leads to further charge against Calgary mom

By Jason van Rassel, Calgary Herald August 28, 2010
Probe into baby's 2004 death leads to further charge against Calgary mom
Stacey Joy Bourdeaux accused of killing Sean Ronald Fewer in 2004


Stacey Joy Bourdeaux, 33, is charged with one count of second-degree murder in the 2004 death of her infant son, Sean Ronald Fewer. She has also been charged with one count of attempted murder, choking with intent and failing to provide necessities of life, relating to an incident in May 2010 involving another child.
When 10-month-old Sean Ronald Fewer died in 2004, authorities blamed natural causes and closed the case.
Six years later, they're calling it a homicide.
Calgary police revealed Friday they have charged Sean's mother, Stacey Joy Bourdeaux, with second-degree murder after re-examining the infant's death and determining he had been smothered.
The new investigation was sparked after police charged Bourdeaux, 33, with trying to kill her five-year-old son inside their Glenbrook townhouse three months ago.
Sean's killing would likely have gone undetected if it wasn't for the new allegations against his mother, homicide investigators said.
"There would have been nothing to draw police attention to the case," Staff Sgt. Rick Tuza said.
"The flags started to go up and we had to take another look at that 2004 case."
The decision was prompted by an incident May 27, when Bourdeaux arrived at Alberta Children's Hospital with her five-year-old son in apparent medical distress.
The child was "having problems breathing and struggling to stand up," Tuza said.
"Officials noted the symptoms were consistent with trauma rather than an illness."
Four days later, on June 1, police charged Bourdeaux with attempted murder, choking with intent and failing to provide the necessities of life.
Police are withholding the boy's name to protect his identity.
There was conflicting information about the boy's current condition, but sources said he will suffer from lasting injuries as a result of the assault.
The father of both boys, Ted Fewer, died three weeks earlier, on May 4, when he was electrocuted by an overhead power line near Strathmore.
Fewer, 48, and Bourdeaux were estranged at the time, sources said.
As investigators probed Bourdeaux's background, they discovered Sean's death on Dec. 27, 2004.
Police said Bourdeaux had called 911 to her home in the 4900 block of 35th Ave. S.W., where paramedics found Sean in a crib, not breathing. He died in hospital a short time later.
The initial investigation by police and the medical examiner at that time turned up no evidence of foul play, Tuza said.
"Based on information available at that time, the child's death was determined to be of natural causes and no criminal investigation was launched," Tuza said.
It was the right decision at the time, Tuza stressed, based on all the evidence available to authorities.
In the authoritative policing textbook, "Practical Homicide Investigation," retired New York police commander Vernon Geberth described the difficulty of detecting smothering deaths.
"Investigators should realize that fatal violence may be inflicted without any external signs of trauma," he wrote. "In any number of circumstances an injury may not be readily observed, such as . . . an asphyxiation where the victim has had a pillow held over the nose and mouth."
Although the medical examiner's office wouldn't comment specifically on the homicide case involving Sean Fewer, an official said determining the cause of a sudden infant death can be challenging.
"Even with the best scene investigation and autopsy, it can be difficult to determine cause of death," said Dr. Sam Andrews, deputy chief medical examiner for southern Alberta.
In trying to determine the cause of death, the medical examiner looks at the scene of the death, the medical history, autopsy results and several related tests -- including toxicology, blood cultures and microscopic tissue samples.
It's usually only after all those steps don't yield a definite cause of death that the medical examiner will classify it as sudden infant death syndrome," said Andrews.
"A SIDS diagnosis is an undetermined death. Really, we're admitting we don't know what caused the death," he said.
When police reinvestigated Sean's death in June, new information spared them from having to exhume the child's body, said Tuza.
"We interviewed the mother and she co-operated with our investigation," he said.
Bourdeaux appeared in provincial court Friday morning on the second-degree murder charge. She remains in custody.
Sean's death raises the number of homicides recorded in 2004 to 17.
http://www.calgaryherald.com/life/Probe+into+baby+2004+death+leads+further+charge+against+Calgary/3450781/story.html#ixzz0ysQFHbSo

SBS: Canada: Halifax man accused of shaking his two-month-old child

Halifax man accused of shaking his two-month-old child appeared in Halifax provincial court yesterday to hear his charges.Michael McNish, 27, was arraigned yesterday on one count of aggravated assault.According to police, an infant boy was brought into the IWK Health Centre in late June by his parents with injuries consistent with shaken baby syndrome. Police say they were called to the hospital by staff in the early morning hours of June 23 regarding the baby’s injuries, which led to an investigation by the Halifax Regional Police/RCMP Major Crime Unit.Two days later, police issued a release saying McNish had been charged.The child is expected to make a full recovery.McNish has been granted bail on several conditions and will appear in court again on Oct. 22 for election and plea.
http://www.metronews.ca/halifax/local/article/610433--man-in-court-over-baby-shaking