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PEDIATRICS Vol. 114 No. 1 July 2004, pp. 326

A Sojourn in the Abyss: Hypothesis, Theory, and Established Truth in Infant Head Injury

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

To the Editor. —

Dr Block’s 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 professional’s 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 Block’s 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 Block’s criticism and Lucey’s 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.^6–8

REFERENCES

1. Block RW. Fillers [letter]. Pediatrics. 2004;113 :432[Free Full Text]
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[Abstract/Free Full Text]
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[Abstract/Free Full Text]
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[CrossRef][Web of Science][Medline]
6. American Academy of Pediatrics, Committee on Child Abuse and Neglect. Shaken baby syndrome: rotational cranial injuries—technical report. Pediatrics. 2001;108 :206 –210[Abstract/Free Full Text]
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[CrossRef][Web of Science][Medline]
8. Lantz PE, Sinai SH, Stanton CA, Weaver RG Jr. Perimacular retinal folds from childhood head trauma. BMJ. 2004;328 :754 –756[Free Full Text]

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PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics

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