Insufficient evidence for ‘shaken baby syndrome’ – a systematic review

Abstract

Shaken baby syndrome has typically been associated with findings of subdural haematoma, retinal haemorrhages and encephalopathy, which are referred to as the triad. During the last decade, however, the certainty with which the triad can indicate that an infant has been violently shaken has been increasingly questioned. The aim of this study was to determine the diagnostic accuracy of the triad in detecting that an infant had been shaken. The literature search was performed using PubMed, Embase and the Cochrane Library up to October 15, 2015. Relevant publications were assessed for the risk of bias using the QUADAS tool and were classified as having a low, moderate or high risk of bias according to predefined criteria. The reference standards were confessions or witnessed cases of shaking or accidents. The search generated 3773 abstracts, 1064 were assessed as possibly relevant and read as full texts, and 30 studies were ultimately included. Of these, 28 were assessed as having a high risk of bias, which was associated with methodological shortcomings as well as circular reasoning when classifying shaken baby cases and controls. The two studies with a moderate risk of bias used confessions and convictions when classifying shaken baby cases, but their different designs made a metaanalysis impossible. None of the studies had a low risk of bias. Conclusion: The systematic review indicates that there is insufficient scientific evidence on which to assess the diagnostic accuracy of the triad in identifying traumatic shaking (very low-quality evidence). It was also demonstrated that there is limited scientific evidence that the triad and therefore its components can be associated with traumatic shaking (low-quality evidence).

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’

“…The identification of AHT is challenging, and any attempt to improve this, as proposed in the recently published Swedish Agency for Health Technology Assessment and Assessment of Social Service’s report (SBU)1 and summarised by Lynøe et al 2, is welcome. However, there are many flaws and misconceptions in this systematic review (SR) that, if left unchallenged, have the potential to adversely affect infants who suffer AHT.…”

Shaken baby syndrome is real

“…A recent systematic review from the Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) has questioned the existence of shaken baby syndrome [7,8]. This study has many issues, beginning with legitimate questions of bias in its conception and backing [9].…”

“…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]. 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.…”

“…Shaken baby syndrome denialists conveniently exclude abusive head trauma cases with associated skeletal trauma [7,8,50]; however, abusive head trauma in the form of shaken baby syndrome is frequently accompanied by skeletal trauma [3,[51][52][53]. Others [54][55][56] have put forth rickets and vitamin D deficiency as an explanation for the skeletal findings of child abuse even though such findings are clearly not caused by rickets [57][58][59][60][61].…”

Initial response of the European Society of Paediatric Radiology and Society for Pediatric Radiology to the Swedish Agency for Health Technology Assessment and Assessment of Social Services’ document on the triad of shaken baby syndrome

“…As such, we make it clear that we have not yet had access to a formal translation of the report. The published review article [5] summarizes the SBU's findings but does not provide sufficient detail. For example, the quality ratings of the rejected papers are not given and the article is predominantly an overview of the two papers the authors accepted as being of sufficient quality for inclusion in their systematic review.…”