Abusive head trauma and the triad: a critique on behalf of RCPCH of ‘Traumatic shaking: the role of the triad in medical investigations of suspected traumatic shaking’

Abstract

The Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) has recently published what they purported to be a systematic review of the literature on 'isolated traumatic shaking' in infants, concluding that 'there is limited evidence that the so-called triad (encephalopathy, subdural haemorrhage, retinal haemorrhage) and therefore its components can be associated with traumatic shaking'. This flawed report, from a national body, demands a robust response. The conclusions of the original report have the potential to undermine medico-legal practice. We have conducted a critique of the methodology used in the SBU review and have found it to be flawed, to the extent that children's lives may be put at risk. Thus, we call on this review to be withdrawn or to be subjected to international scrutiny.

Shaken baby syndrome is real

“…One must seriously question the credibility of any study that blatantly gives credence to widely discredited references [10][11][12][13][14]. Other issues with the study include: (1) an artificially constrained gold standard of "admitted or confessed traumatic shaking or other trauma" ("other trauma" not defined); (2) a suboptimal search strategy; (3) a broad dismissal of the literature without adequate definition of inclusion/exclusion criteria for doing so; (4) rejection of cases with non-centralnervous-system findings -"did not include studies whose focus was on infants also suffering from fractures, bruises or other signs of trauma" [15]; (5) use of "retinal hemorrhage" as a generic term; (6) discounting of child protection team evaluation as "circular," criteria not defined; (7) exclusion of references with fewer than 10 cases relative to "the triad" but inclusion of references with fewer cases, and even reports of a single case, as evidence for alternative diagnoses, with no assessment of quality; (8) use of "the triad" as a strawman and thus asking a clinically irrelevant question -ignoring that the diagnosis is never based on "the triad" only, but rather on a comprehensive multidisciplinary evaluation [16][17][18]; (9) panel composition not inclusive of pertinent expertise -no pediatric radiologist, no pediatric neuroradiologist, no pediatric ophthalmologist, no child abuse pediatrician; (10) refusal of offered external peer review by multiple organizations with subject matter expertise, including the American Academy of Pediatrics (AAP), the American Society of Pediatric Neurosurgeons (ASPN), the British Society of Paediatric Radiology (BSPR), the European Society of Paediatric Radiology (ESPR), the Norwegian Pediatric Association (NPA), the Royal College of Paediatrics and Child Health (RCPCH) and the Society for Pediatric Radiology (SPR) [17,18]. Essays by Saunders et al [17] and DeBelle et al [18] fully expose the many methodological flaws of the SBU study [7] and subsequent Acta Paediatrica paper [8].…”

“…Essays by Saunders et al [17] and DeBelle et al [18] fully expose the many methodological flaws of the SBU study [7] and subsequent Acta Paediatrica paper [8]. DeBelle et al [18] described the SBU study as "flawed, to the extent that children's lives may be put at risk" and called for the withdrawal of the study "for the sake of unbiased protection of children. "…”

“…Numerous authors have appropriately questioned the validity of the SBU study [9,[17][18][19][20][21][22][23][24][25]. Responses from the SBU authors to these challenges demonstrate the biases and lack of objectivity of the SBU author group [15,[26][27][28][29][30][31][32][33][34][35].…”

Easier to see the speck in your critical peers’ eyes than the log in your own? Response to Debelleet al

“…Once again a group of paediatricians1 has made critical comments about our systematic review of the shaken baby literature 2 3. Surprisingly, however, this time the criticism includes accusations of circular reasoning!…”

“…Surprisingly, because the main reason that we assessed the shaken baby studies as biased was that they were based on circular reasoning 2 3. Even though it may be easier to observe ‘the speck in your friend’s eye than the log in your own’, it is remarkable that Debelle et al 1 avoid criticising circular reasoning within their own research area. On the contrary, the authors maintain that the clinical investigations of suspected cases of shaken baby syndrome (SBS)/abusive head trauma (AHT are based on ‘rigorous assessment’, ‘comprehensive clinical investigations’ and ‘sound clinical, evidence-based practice, with the child’s interest at its core1’.…”