Shaken Baby and Sudden Infant Death Syndromes: SBS and SIDS review article

Showing posts with label SBS and SIDS review article. Show all posts

Thursday, 18 November 2010

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 SBS¹⁰^,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

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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]

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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.

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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: Bedsharing and maternal smoking in a population-based survey of new mothers.

Pediatrics. 2005 Oct;116(4):e530-42.

Lahr MB, Rosenberg KD, Lapidus JA.

Disability Determination Services, Oregon Department of Human Services, Salem, OR 97305-1350, USA. lahr_mdmph@web-ster.com

Abstract

OBJECTIVE: Sudden infant death syndrome (SIDS) remains the number 1 cause of postneonatal infant death. Prone infant sleep position and maternal smoking have been established as risk factors for SIDS mortality. Some studies have found that bedsharing is associated with SIDS, but, to date, there is only strong evidence for a risk among infants of smoking mothers and some evidence of a risk among young infants of nonsmoking mothers. Despite the lack of convincing scientific evidence, bedsharing with nonsmoking mothers remains controversial. In some states, nonsmoking mothers are currently being told that they should not bedshare with their infants, and mothers of infants who died of SIDS are told that they caused the death of their infant because they bedshared. The objective of this study was to explore the relationship between maternal smoking and bedsharing among Oregon mothers to explore whether smoking mothers, in contrast to nonsmoking mothers, are getting the message that they should not bedshare.
METHODS: Oregon Pregnancy Risk Assessment Monitoring System surveys a stratified random sample, drawn from birth certificates, of women after a live birth. Hispanic and non-Hispanic black, non-Hispanic Asian/Pacific Islander and non-Hispanic American Indian/Alaskan Native women, and non-Hispanic white women with low birth weight infants are oversampled to ensure sufficient numbers for stratified analysis. The sample then was weighted to reflect Oregon's population. In 1998-1999, 1867 women completed the survey (73.5% weighted response). The median time from birth to completion of the survey was 4 months. Women were asked whether they shared a bed with their infant "always," "almost always," "sometimes," or "never." Frequent bedsharing was defined as "always" or "almost always"; infrequent was defined as "sometimes" or "never."
RESULTS: Of all new mothers, 35.2% reported bedsharing frequently (always: 20.5%; almost always: 14.7%) and 64.8% infrequently (sometimes: 41.4%; never: 23.4%). Bedsharing among postpartum smoking mothers was 18.8% always, 12.6% almost always, 45.1% sometimes, and 23.6% never; this was not statistically different from among nonsmoking mothers. Results for prenatal smokers were similar. When stratified by race/ethnicity, there was no association between smoking and bedsharing in any racial or ethnic group. In univariable and multivariable logistic regression, there were no statistical differences in frequent or any bedsharing among either prenatal or postpartum smoking mothers compared with nonsmokers; the adjusted odds ratio for postpartum smokers who frequently bedshared was 0.73 (95% confidence interval [CI]: 0.42-1.25) and for any bedsharing was 1.05 (95% CI: 0.57-1.94). Results for prenatal smoking were similar. This is the first US population-based study to look at the prevalence of bedsharing among smoking and nonsmoking mothers. Bedsharing is common in Oregon, with 35.2% of mothers in Oregon reporting frequently bedsharing and an additional 41.4% sometimes bedsharing. There was no significant association between smoking and bedsharing for either prenatal or postpartum smokers among any racial or ethnic group. Smoking mothers were as likely to bedshare as nonsmoking mothers. The frequency of bedsharing in Oregon was similar to estimates from other sources. Our study has the advantage of being a population-based sample drawn from birth certificates, weighted for nonresponse.
CONCLUSIONS: Although a number of case series have raised concerns about the safety of mother-infant bedsharing, even among nonsmoking mothers, this has not yet been confirmed by careful, controlled studies. There have been 9 large-scale case-control studies of the relationship between bedsharing and SIDS. Three case-control studies did not stratify by maternal smoking status, but found no increased risk for SIDS. Six case control studies reported results stratified by maternal smoking status: 1 study, while asserting an association, provided an unexplained range of univariable odds ratios without CIs; 3 found no increased risk for older infants of nonsmoking mothers; and 2 found a risk only for infants <8-11 weeks of age. Despite the preponderance of evidence that bedsharing by nonsmoking mothers does not increase the risk for SIDS among older infants, the recent specter of bedsharing as a cause of SIDS, based on uncontrolled case series and medical examiners' anecdotal experience, has led some medical examiners to label a death "suffocation" or "overlay asphyxiation" simply because the infant was bedsharing at the time of death. This "diagnostic drift" may greatly complicate future studies of the relationship between bedsharing and SIDS. Epidemiologic evidence shows that there is little or no increased risk for SIDS among infants of nonsmoking mothers but increased risk among infants of smoking mothers and younger infants of nonsmoking mothers. It seems prudent to discourage bedsharing among all infants <3 months old. Young infants brought to bed to be breastfed should be returned to a crib when finished. It would be worthwhile for other researchers to reanalyze their previous data to evaluate the consistency of the interaction of young infant age and bedsharing. Large controlled studies that include infants who are identified as dying from SIDS, asphyxia, suffocation, and sudden unexplained infant death, analyzed separately and in combination, are needed to resolve this and other issues involving bedsharing, including the problem of diagnostic drift. Recommendations must be based on solid scientific evidence, which, to date, does not support the rejection of all bedsharing between nonsmoking mothers and their infants. Cribs should be available for those who want to use them. Nonsmoking mothers should not be pressured to abstain from bedsharing with their older infants; they should be provided with accurate, up-to-date scientific information. Infants also should not co-sleep with nonparents. In Oregon, if not elsewhere, the message that smoking mothers should not bedshare is not being disseminated effectively. Because it is not known whether the risk caused by smoking is associated with prenatal smoking, postpartum smoking, or both, bedsharing among either prenatal or postpartum smokers should be strongly discouraged. Much more public and private effort must be made to inform smoking mothers, in culturally competent ways, of the very significant risks of mixing bedsharing and smoking. Public health practitioners need to find new ways to inform mothers and providers that smoking mothers should not bedshare and that putting an infant of a nonsmoking mother to sleep in an adult bed should be delayed until 3 months of age.
http://www.ncbi.nlm.nih.gov/pubmed/16199682

Thursday, 21 October 2010

SBS: Shaken Baby Syndrome: evolving law and the quest for justice

Oct 12

MARILYN STOWE

Children tend to cause more problems than any other area of family law. Few areas change so much, or are as nuanced and complex. I’ve recently read a wealth of legal articles and cases that illustrate the breadth of issues affecting them, but there is one type of case in particular that speaks to my own personal experience.

In many ways the real reason children cases cause so much difficulty is because the professionals involved care so deeply about their welfare. At times we seem to collectively become their guardians, as they cannot protect or speak for themselves. They are wholly innocent in matters of which they have little, if any, comprehension, and they are often terribly vulnerable.
These cases include children born to rich but unmarried and bickering parents, with the financial figures involved for the reasonable support of these children akin to telephone numbers. Children currently permitted under our law to be taken by one parent to another country, and so effectively ending any relationship with the other parent (see my recent post for an example). And those who become embroiled in dramatic cases of child abduction, or are at the centre of arguments involving legal principles that are more complicated than they could ever understand.
Shaken Baby Syndrome
But there is one type of case that stands out for me. These cases cover the topic of babies who die or are gravely injured after falling victim to the phenomenon called Shaken Baby Syndrome. These are babies who never make it past infancy, or if they do may be disabled for life. They are shaken and sustain a type of whiplash injury, usually when a carer or parent can not cope any longer with a crying child. The three classic injuries (known as the triad) caused by this syndrome are haemorrhages in the eyes, bleeding around the brain and swelling of the skull.
When I was a student, working on a placement at a criminal law firm, I went with one of the partners to visit a female client on remand at Risley Prison in Lancashire. The client explained how she had killed her baby. She had taken the child and on more than one occasion thrown it backwards behind her head and then upwards, with the baby banging its head on the ceiling. According to the autopsy, the baby had first been blinded and then died. When the police came to arrest the mother and her boyfriend, who was jointly charged with murder, they found excrement smeared on the walls of their home.
It was such a hideous case that I have never forgotten its details. The dull woman, the offhand way she described killing her baby, the condition of her home from the photographs I saw, and the shocking images from the baby’s autopsy – whose pain and terror can’t even be imagined.

Guilt beyond reasonable doubt
There was no dispute as to what happened to that baby. But there have been other cases in which a baby has died or been badly injured, and where it has been very difficult to prove exactly what did happen and therefore the guilt of the defendant. Every professional involved in these cases is acutely aware of their duty to the child and wishes to secure a just outcome. The judge is tasked with deciding what to admit as evidence, as well as summing up medical evidence for the jury. In turn members of the jury have to be sure that the English standard of guilt beyond reasonable doubt is met after assessing the medical opinions they hear. One expert may have one view, while another may have a different opinion entirely. Whose evidence should the jury accept in the face of a flat denial from the defendant?
These cases bring forth a whole host of other questions. What should happen in a criminal trial where there is only medical evidence on which to rely? How can a jury be certain beyond reasonable doubt that the person in the dock is guilty or innocent? Making the wrong call will lead to a miscarriage of justice, from which a wrongly convicted defendant may never fully recover.
A report on Sudden Unexpected Deaths in Infancy was published in September 2004 and led by The Royal College of Pathologists and The Royal College of Paediatrics. It was much needed, directly following as it did a raft of cases involving mothers prosecuted for the alleged murder of their infant children. These children had died suddenly, and where incriminating evidence was limited to medical opinion, public opinion was on the whole strongly in favour of their guilt. However the medical evidence soon became hotly disputed. The credentials of experts, both their knowledge in specific areas and their competency, were called into question. Extreme theories had been propagated by some of them and demonstrated to be inaccurate. Statistical evidence was given where the expert involved was not a qualified statistician. Ultimately, women were convicted of murdering their babies and languished in prison on the strength of this evidence. As information concerning a number of cases emerged, public opinion swiftly changed.
Sally Clark and establishing medical expertise
I had something to do with putting this situation right, although I stumbled into it. I was involved in the case of Sally Clark, one of the first mothers to be freed by the Court of Appeal. The argument centred on medical evidence given in the trial and the deliberate failure by a medical witness to disclose a microbiology report relating to one of the dead infants. After the trial and the failure of a subsequent appeal, I became voluntarily involved and subsequently managed (using my well known charm!) to persuade the relevant hospital to produce this report. It had been withheld by the medical expert for the prosecution. Crucially, it showed the child had most likely died of a virus. Sally was released from prison, although she never recovered from her ordeal and died shortly afterwards. Other mothers were subsequently acquitted, but their lives were also traumatically affected. It was clear the conduct of medical experts needed to be examined.
The 2004 Report, chaired by Baroness Kennedy, set out a checklist of matters to be established about a medical expert before their evidence is admitted in court. In particular doctors were warned “not to fly their personal kites or push a theory from the far end of the medical spectrum”. Questions to be asked of potential expert witnesses included:

Are they still in clinical practise?
Are they expert in the specific field on which they are giving evidence?
Have they recent clinical experience of the specific type of case?
To what extent is the expert’s view widely held?

Establishing that the expert is in clinical practise at the time of his or her report is of great significance. It means theoreticians are unlikely to give medical evidence in cases of this nature.
The correct approach
The report and its recommendations were approved and mentioned along with other matters by Lord Justice Moses in a leading Court of Appeal judgment delivered this year: R v Henderson, Butler and Oyediran (2010) EWCA 1269. The court had to consider two infant deaths, one caused by manslaughter and the other by murder, as well as a case of grievous bodily harm. All three cases involved similar facts and alleged that Shaken Baby Syndrome had been the cause of death or injury. All three were heard one after the other and medical evidence was divided about the causes. Were the defendants telling the truth, or were they lying? All three had been convicted by juries in the lower courts.
The judgement of Lord Justice Moses is complex but gives valuable guidance to other courts in which similar cases are heard. The court accepted an important starting point, one that was originally stated in the Angela Canning case of 2004 (another of the cases from that period mentioned above), that “even where every known cause has been excluded, the cause may still remain unknown”. This is an important principle of jurisprudence because it does not assume, as experts in the past have done, that a dead child is necessarily a murdered child. However, while that might be fine if the defendant is innocent, it may not be if there has indeed been wrong doing. With this in mind, how can a defendant be proved guilty beyond reasonable doubt?
Expert evidence may be the only evidence relied upon to prove that the defendant was lying in their account of how the injuries or death occurred. Lord Justice Moses stated that a conviction could only be safe if the case proceeded on “a logically justifiable basis, for accepting or rejecting the expert evidence”. This is central to what he called “the correct approach.” In each of the three cases, he applied the logic of medical expert evidence to the facts. Defendants who were alleged to have killed their infants had their convictions upheld in both cases. In the third case, where the child had fully recovered by the time of trial, the conviction was quashed. It was said that the recovery “was powerful evidence which told against shaking and in favour of an unknown cause”.
Sometimes new medical evidence comes to light after the trial has taken place. In truth such information is only likely to offer a new opinion, since it is unlikely that medical reports will ever again remain hidden in cases of this type. The Court of Appeal has now made it clear that an appeal in these cases is not a second bite of the cherry or an opportunity to hear from yet more new experts. Only rarely would the court permit repetition, or near repetition, of evidence to the same effect by another expert. The defence should not seek to “put a defence case which should have gone to the original jury”.
Managing the case
The case management of a prosecution and defence in such cases is therefore vitally important. It calls for experienced counsel able to identify both the issues on which the court can concentrate, and the evidence on which it can resolve those issues. It is not the type of case for novices, as far too much hinges upon the outcome.
In the Sally Clark case I have often wondered why the misleading statistical evidence given by one expert was not more robustly challenged. I believe it should have been excluded by the judge and wonder why the medical report I obtained, known all along to have existed, was never more thoroughly ferreted out by all concerned and produced to the court. I’m certain that had it been, a conviction would have been avoided. But hindsight is a wonderful thing. Coming late to the case, I simply asked myself: “If she wasn’t a killer, what had caused the deaths?” A medical answer seemed to be the only logical answer, and when the missing report came to light my deduction proved to be correct.
As I’ve mentioned above, I don’t think such a report would be withheld nowadays. I also believe that experts in these cases are more likely to err on the side of caution in providing evidence.
The courts cannot always help though. The quality and extent of the evidence will vary. As Lord Justice Moses pointed referenced R v
Harris and Others (2005) EWCA crim 1980 when he said that a triad of injuries “is a strong pointer to non-accidental head injury”. But also went on to say that no appellate jurisprudence could provide authority for a medical proposition.
What it now boils down to is how the case is managed from both sides: what evidence is obtained and how it is presented; how well medical evidence in the case is focussed; and whether the evidence the expert gives makes logical sense to the jury. There are those experts who argue Shaken Baby Syndrome doesn’t exist. There are those who point to the injuries sustained by a baby and say that it can be nothing else. The competency of experts may also now be taken into account in order to assess differing opinions, as was outlined in Baroness Kennedy’s report. But the overall role of the judge in instructing the jury to deal with conflicting evidence cannot be over emphasised. For example, a judge may ask the jury to consider certain questions: Do they believe the expert has gone outside his area of expertise? Can they point to a recognised peer-reviewed source to support their opinion?
Of course even the best summing up from the judge, and a logical argument in relation to the medical evidence, doesn’t guarantee the jury will come back with the right result, but the rights and wrongs of trial by jury are a different set of issues altogether. Nevertheless, in as much as it is humanly possible we now have a powerful legal system, which at all levels strives to obtain justice for those small children who are unable to obtain it for themselves. A system of which we can all be extremely proud.