A Sojourn in the Abyss: Hypothesis, Theory, and Established Truth in Infant Head Injury Marvin Miller, Jan Leestma,

Patrick Barnes, Thomas Carlstrom, Horace Gardner, John Plunkett, John Stephenson, Kirk Thibault, Ron Uscinski, Julie Niedermier and John Galaznik Pediatrics 2004;114;326 DOI: 10.1542/peds.114.1.326

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pediatrics.org/cgi/content/full/114/1/326

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2004 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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A Sojourn in the Abyss: Hypothesis, Theory, and Established Truth in Infant Head Injury
To the Editor.
Dr Blocks criticism1 of the work by Geddes is disturbing. The response by Pediatrics Editor Lucey2 is equally disturbing, because Pediatrics typically gives a balanced perspective of controversial issues. Geddes, a neuropathologist with many years experience examining infant brains, observed that she was not finding traumatic brain injury in infants thought to be victims of inflicted trauma/shaken-baby syndrome. She was not alone in her observations, as the co-authors of her articles attest.3,4 She found anoxic axonal damage rather than traumatic brain injury, except for a small number of cases in which there were significant impact injuries such as skull fractures. A number of the infants in her study also had evidence for axonal injury in the brainstem but no other structural damage, suggesting that primary brainstem damage may lead to an anoxic event. Interestingly, her group of infants with morphologic evidence for brainstem damage included a number of children who apparently died suddenly and unexpectedly and were not resuscitated, suggesting that the observed brainstem damage significantly preceded the collapse of the infant and death. Thus far, there is no problem from the child abuse professionals perspective except that Geddes et al were suggesting that violent shaking may not be necessary to cause the observed pathology. In fact, her studies were widely cited in the presentations at the 4th National Shaken Baby Syndrome Conference in Salt Lake City, Utah, in 2002 and at the Shaken Baby Syndrome Conference, Edinburgh, Scotland, in 2003. Geddes had found the holy grail: the evidence that shaking caused direct neck damage. The problem (and Blocks ire) arose when Geddes et al published a subsequent article suggesting that hypoxia, not violence, was the common denominator in the pathology of many cases of both assumed inflicted injury and deaths due to natural causes. The article was published as a hypothesis paper, as reference to the actual print title of the work will confirm.5 The authors conclusions are supported by the observations. (We urge those interested to look at the actual publication photographs rather than a photocopy and decide for themselves.) Her hypothesis is testable and, if repeated and confirmed, will be a significant advance in understanding cascade or secondary phenomena that may lead to symptoms and death hours and perhaps days after the primary event. Physicians should be troubled by Geddes work and the other studies that question the causes of traumatic brain injury in children. However, it is not the scientific bases for these studies that should concern us but rather the implications of these findings to the public. If shaking is not the cause of traumatic brain injuries/ shaken-baby syndrome, then many thousands of parents/caretakers have been unjustly accused and convicted for the past 30 years. Families, finances, and reputations have been destroyed. If the mechanism(s) that cause(s) subdural hematoma and retinal hematoma may be other than inflicted trauma, then the floodgates would open for these prior cases to be revisited in our legal system. Perhaps Blocks criticism and Luceys acquiescence of Geddes unfashionable work has a political rather than a scientific basis. Drs Block and Lucey may find that the Geddes hypothesis paper is junk science and that Neuropathology and Applied Neurobiology and the British Medical Journal are lax in their publication standards. However, these are well established, peer-review journals, and many neuropathologists, forensic pathologists, neurosurgeons, and biomechanical engineers have found her observations and conclusions reasonable and provocative. To accuse the editors of these journals of sloppy standards is disingenuous. We urge the pediatrics and general medical communities to read the relevant literature, including studies that may have conclusions different from the perceived truth, and decide for themselves what is and what is not junk science.68

Marvin Miller, MD Department of Pediatrics Wright State University School of Medicine Dayton, OH 45404 Jan Leestma, MD Nyxis Neurotherapies Chicago, IL 60622 Patrick Barnes, MD Department of Pediatric Neuroradiology Stanford University Medical Center Palo Alto, CA 94305 Thomas Carlstrom, MD Department of Neurosurgery Iowa Methodist Medical Center Des Moines, IA 50309 Horace Gardner, MD Department of Pathology Regina Medical Center Manitou Springs, CO 80829 John Plunkett, MD Department of Pathology Regina Medical Center Hastings, MN 55033 John Stephenson, BM, DM Department of Paediatric Neurology Royal Hospital for Sick Children G3 8SJ Glasgow, Scotland Kirk Thibault, PhD Biomechanics Inc Philadelphia, PA 19112 Ron Uscinski, MD Department of Neurosurgery George Washington University School of Medicine Olney, MD 20832 Julie Niedermier, MD Columbus, OH 43214 John Galaznik, MD Northport, AL 35476

REFERENCES
1. Block RW. Fillers [letter]. Pediatrics. 2004;113:432 2. Lucey JF. Fillers [letter]. Pediatrics. 2004;113:432 433 3. Geddes JF, Hackshaw AK, Vowles GH, Nickols CD, Whitwell HL. Neuropathology of inflicted head injury in children. I. Patterns of brain damage. Brain. 2001;124:1290 1298 4. Geddes JF, Vowles GH, Hackshaw AK, Nickols CD, Scott IS, Whitwell HL. Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants. Brain. 2001;124:1299 1306 5. Geddes JF, Tasker RC, Hackshaw AK, et al. Dural haemmorhage in non-traumatic infant deaths: does it explain the bleeding in shaken baby syndrome? Neuropathol Appl Neurobiol. 2003;29:14 22 6. American Academy of Pediatrics, Committee on Child Abuse and Neglect. Shaken baby syndrome: rotational cranial injuriestechnical report. Pediatrics. 2001;108:206 210 7. Donohoe M. Evidence-based medicine and shaken baby syndrome. Part I: literature review, 1966 1998. Am J Forensic Med Pathol. 2003;24:239 242 8. Lantz PE, Sinai SH, Stanton CA, Weaver RG Jr. Perimacular retinal folds from childhood head trauma. BMJ. 2004;328:754 756

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LETTERS TO THE EDITOR Downloaded from www.pediatrics.org by on March 16, 2010

A Sojourn in the Abyss: Hypothesis, Theory, and Established Truth in Infant Head Injury Marvin Miller, Jan Leestma, Patrick Barnes, Thomas Carlstrom, Horace Gardner, John Plunkett, John Stephenson, Kirk Thibault, Ron Uscinski, Julie Niedermier and John Galaznik Pediatrics 2004;114;326 DOI: 10.1542/peds.114.1.326
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