2. A Sojourn in the Abyss: Hypothesis, Theory, and Marvin Miller, MD
Established Truth in Infant Head Injury Department of Pediatrics
Wright State University School of Medicine
Dayton, OH 45404
To the Editor.—
Dr Block’s criticism1 of the work by Geddes is disturbing. The
Jan Leestma, MD
response by Pediatrics Editor Lucey2 is equally disturbing, because Nyxis Neurotherapies
Pediatrics typically gives a balanced perspective of controversial Chicago, IL 60622
issues. Geddes, a neuropathologist with many years’ experience
examining infant brains, observed that she was not finding trau- Patrick Barnes, MD
matic brain injury in infants thought to be victims of inflicted Department of Pediatric Neuroradiology
trauma/shaken-baby syndrome. She was not alone in her obser- Stanford University Medical Center
vations, as the co-authors of her articles attest.3,4 She found anoxic Palo Alto, CA 94305
axonal damage rather than traumatic brain injury, except for a
small number of cases in which there were significant impact Thomas Carlstrom, MD
injuries such as skull fractures. A number of the infants in her Department of Neurosurgery
study also had evidence for axonal injury in the brainstem but no Iowa Methodist Medical Center
other structural damage, suggesting that primary brainstem dam- Des Moines, IA 50309
age may lead to an anoxic event. Interestingly, her group of infants
with morphologic evidence for brainstem damage included a Horace Gardner, MD
number of children who apparently died suddenly and unexpect- Department of Pathology
edly and were not resuscitated, suggesting that the observed Regina Medical Center
brainstem damage significantly preceded the collapse of the infant Manitou Springs, CO 80829
and death. Thus far, there is no problem from the child abuse
professional’s perspective except that Geddes et al were suggest- John Plunkett, MD
ing that “violent” shaking may not be necessary to cause the Department of Pathology
observed pathology. In fact, her studies were widely cited in the Regina Medical Center
presentations at the 4th National Shaken Baby Syndrome Confer- Hastings, MN 55033
ence in Salt Lake City, Utah, in 2002 and at the Shaken Baby
Syndrome Conference, Edinburgh, Scotland, in 2003. Geddes had
John Stephenson, BM, DM
found the holy grail: the evidence that “shaking” caused direct
Department of Paediatric Neurology
neck damage.
Royal Hospital for Sick Children
The problem (and Block’s ire) arose when Geddes et al pub-
G3 8SJ Glasgow, Scotland
lished a subsequent article suggesting that hypoxia, not “vio-
lence,” was the common denominator in the pathology of many
cases of both assumed inflicted injury and deaths due to natural Kirk Thibault, PhD
causes. The article was published as a “hypothesis paper,” as Biomechanics Inc
reference to the actual print title of the work will confirm.5 The Philadelphia, PA 19112
authors’ conclusions are supported by the observations. (We urge
those interested to look at the actual publication photographs Ron Uscinski, MD
rather than a photocopy and decide for themselves.) Her hypoth- Department of Neurosurgery
esis is testable and, if repeated and confirmed, will be a significant George Washington University School of Medicine
advance in understanding cascade or secondary phenomena that Olney, MD 20832
may lead to symptoms and death hours and perhaps days after
the primary event. Julie Niedermier, MD
Physicians should be troubled by Geddes’ work and the other Columbus, OH 43214
studies that question the causes of traumatic brain injury in chil-
dren. However, it is not the scientific bases for these studies that John Galaznik, MD
should concern us but rather the implications of these findings to Northport, AL 35476
the public. If shaking is not the cause of traumatic brain injuries/
shaken-baby syndrome, then many thousands of parents/caretak-
ers have been unjustly accused and convicted for the past 30 years.
Families, finances, and reputations have been destroyed. If the REFERENCES
mechanism(s) that cause(s) subdural hematoma and retinal hema- 1. Block RW. Fillers [letter]. Pediatrics. 2004;113:432
toma may be other than inflicted trauma, then the floodgates 2. Lucey JF. Fillers [letter]. Pediatrics. 2004;113:432– 433
would open for these prior cases to be revisited in our legal 3. Geddes JF, Hackshaw AK, Vowles GH, Nickols CD, Whitwell HL. Neu-
system. Perhaps Block’s criticism and Lucey’s acquiescence of ropathology of inflicted head injury in children. I. Patterns of brain
Geddes’ “unfashionable” work has a political rather than a scien- damage. Brain. 2001;124:1290 –1298
tific basis. 4. Geddes JF, Vowles GH, Hackshaw AK, Nickols CD, Scott IS, Whitwell
Drs Block and Lucey may find that the Geddes’ hypothesis HL. Neuropathology of inflicted head injury in children. II. Microscopic
paper is “junk science” and that Neuropathology and Applied Neu- brain injury in infants. Brain. 2001;124:1299 –1306
robiology and the British Medical Journal are lax in their publication 5. Geddes JF, Tasker RC, Hackshaw AK, et al. Dural haemmorhage in
standards. However, these are well established, peer-review jour- non-traumatic infant deaths: does it explain the bleeding in ‘shaken baby
nals, and many neuropathologists, forensic pathologists, neuro- syndrome?’ Neuropathol Appl Neurobiol. 2003;29:14 –22
surgeons, and biomechanical engineers have found her observa- 6. American Academy of Pediatrics, Committee on Child Abuse and Ne-
tions and conclusions reasonable and provocative. To accuse the glect. Shaken baby syndrome: rotational cranial injuries—technical re-
editors of these journals of sloppy standards is disingenuous. We port. Pediatrics. 2001;108:206 –210
urge the pediatrics and general medical communities to read the 7. Donohoe M. Evidence-based medicine and shaken baby syndrome. Part
relevant literature, including studies that may have conclusions I: literature review, 1966 –1998. Am J Forensic Med Pathol. 2003;24:239 –242
different from the perceived truth, and decide for themselves what 8. Lantz PE, Sinai SH, Stanton CA, Weaver RG Jr. Perimacular retinal folds
is and what is not junk science.6–8 from childhood head trauma. BMJ. 2004;328:754 –756
326 LETTERS TO THE EDITOR
Downloaded from www.pediatrics.org by on March 16, 2010
3. 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
Updated Information including high-resolution figures, can be found at:
& Services http://www.pediatrics.org/cgi/content/full/114/1/326
References This article cites 7 articles, 5 of which you can access for free at:
http://www.pediatrics.org/cgi/content/full/114/1/326#BIBL
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![A Sojourn in the Abyss: Hypothesis, Theory, and Marvin Miller, MD
Established Truth in Infant Head Injury Department of Pediatrics
Wright State University School of Medicine
Dayton, OH 45404
To the Editor.—
Dr Block’s criticism1 of the work by Geddes is disturbing. The
Jan Leestma, MD
response by Pediatrics Editor Lucey2 is equally disturbing, because Nyxis Neurotherapies
Pediatrics typically gives a balanced perspective of controversial Chicago, IL 60622
issues. Geddes, a neuropathologist with many years’ experience
examining infant brains, observed that she was not finding trau- Patrick Barnes, MD
matic brain injury in infants thought to be victims of inflicted Department of Pediatric Neuroradiology
trauma/shaken-baby syndrome. She was not alone in her obser- Stanford University Medical Center
vations, as the co-authors of her articles attest.3,4 She found anoxic Palo Alto, CA 94305
axonal damage rather than traumatic brain injury, except for a
small number of cases in which there were significant impact Thomas Carlstrom, MD
injuries such as skull fractures. A number of the infants in her Department of Neurosurgery
study also had evidence for axonal injury in the brainstem but no Iowa Methodist Medical Center
other structural damage, suggesting that primary brainstem dam- Des Moines, IA 50309
age may lead to an anoxic event. Interestingly, her group of infants
with morphologic evidence for brainstem damage included a Horace Gardner, MD
number of children who apparently died suddenly and unexpect- Department of Pathology
edly and were not resuscitated, suggesting that the observed Regina Medical Center
brainstem damage significantly preceded the collapse of the infant Manitou Springs, CO 80829
and death. Thus far, there is no problem from the child abuse
professional’s perspective except that Geddes et al were suggest- John Plunkett, MD
ing that “violent” shaking may not be necessary to cause the Department of Pathology
observed pathology. In fact, her studies were widely cited in the Regina Medical Center
presentations at the 4th National Shaken Baby Syndrome Confer- Hastings, MN 55033
ence in Salt Lake City, Utah, in 2002 and at the Shaken Baby
Syndrome Conference, Edinburgh, Scotland, in 2003. Geddes had
John Stephenson, BM, DM
found the holy grail: the evidence that “shaking” caused direct
Department of Paediatric Neurology
neck damage.
Royal Hospital for Sick Children
The problem (and Block’s ire) arose when Geddes et al pub-
G3 8SJ Glasgow, Scotland
lished a subsequent article suggesting that hypoxia, not “vio-
lence,” was the common denominator in the pathology of many
cases of both assumed inflicted injury and deaths due to natural Kirk Thibault, PhD
causes. The article was published as a “hypothesis paper,” as Biomechanics Inc
reference to the actual print title of the work will confirm.5 The Philadelphia, PA 19112
authors’ conclusions are supported by the observations. (We urge
those interested to look at the actual publication photographs Ron Uscinski, MD
rather than a photocopy and decide for themselves.) Her hypoth- Department of Neurosurgery
esis is testable and, if repeated and confirmed, will be a significant George Washington University School of Medicine
advance in understanding cascade or secondary phenomena that Olney, MD 20832
may lead to symptoms and death hours and perhaps days after
the primary event. Julie Niedermier, MD
Physicians should be troubled by Geddes’ work and the other Columbus, OH 43214
studies that question the causes of traumatic brain injury in chil-
dren. However, it is not the scientific bases for these studies that John Galaznik, MD
should concern us but rather the implications of these findings to Northport, AL 35476
the public. If shaking is not the cause of traumatic brain injuries/
shaken-baby syndrome, then many thousands of parents/caretak-
ers have been unjustly accused and convicted for the past 30 years.
Families, finances, and reputations have been destroyed. If the REFERENCES
mechanism(s) that cause(s) subdural hematoma and retinal hema- 1. Block RW. Fillers [letter]. Pediatrics. 2004;113:432
toma may be other than inflicted trauma, then the floodgates 2. Lucey JF. Fillers [letter]. Pediatrics. 2004;113:432– 433
would open for these prior cases to be revisited in our legal 3. Geddes JF, Hackshaw AK, Vowles GH, Nickols CD, Whitwell HL. Neu-
system. Perhaps Block’s criticism and Lucey’s acquiescence of ropathology of inflicted head injury in children. I. Patterns of brain
Geddes’ “unfashionable” work has a political rather than a scien- damage. Brain. 2001;124:1290 –1298
tific basis. 4. Geddes JF, Vowles GH, Hackshaw AK, Nickols CD, Scott IS, Whitwell
Drs Block and Lucey may find that the Geddes’ hypothesis HL. Neuropathology of inflicted head injury in children. II. Microscopic
paper is “junk science” and that Neuropathology and Applied Neu- brain injury in infants. Brain. 2001;124:1299 –1306
robiology and the British Medical Journal are lax in their publication 5. Geddes JF, Tasker RC, Hackshaw AK, et al. Dural haemmorhage in
standards. However, these are well established, peer-review jour- non-traumatic infant deaths: does it explain the bleeding in ‘shaken baby
nals, and many neuropathologists, forensic pathologists, neuro- syndrome?’ Neuropathol Appl Neurobiol. 2003;29:14 –22
surgeons, and biomechanical engineers have found her observa- 6. American Academy of Pediatrics, Committee on Child Abuse and Ne-
tions and conclusions reasonable and provocative. To accuse the glect. Shaken baby syndrome: rotational cranial injuries—technical re-
editors of these journals of sloppy standards is disingenuous. We port. Pediatrics. 2001;108:206 –210
urge the pediatrics and general medical communities to read the 7. Donohoe M. Evidence-based medicine and shaken baby syndrome. Part
relevant literature, including studies that may have conclusions I: literature review, 1966 –1998. Am J Forensic Med Pathol. 2003;24:239 –242
different from the perceived truth, and decide for themselves what 8. Lantz PE, Sinai SH, Stanton CA, Weaver RG Jr. Perimacular retinal folds
is and what is not junk science.6–8 from childhood head trauma. BMJ. 2004;328:754 –756
326 LETTERS TO THE EDITOR
Downloaded from www.pediatrics.org by on March 16, 2010](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)