The evidence base for shaken baby syndrome
http://www.100md.com
《英国医生杂志》
EDITOR—It is difficult to understand how Reece et al could interpret our editorial as displaying "a worrisome and persistent bias against the diagnosis of child abuse in general." Child abuse exists, and we know and attest that it exists. The editorial does not discuss "child abuse in general."
Child abuse exists in many forms: our editorial addresses the diagnostic criteria for a specific type of abuse, the so-called shaken baby syndrome. We emphasise, as have Donohoe and Lantz et al,1 2 that the literature to support a diagnosis of shaken baby syndrome/inflicted head injury is based on imprecise and ill-defined criteria, biased selection, circular reasoning, inappropriate controls, and conclusions that overstep the data. If it is the questioning of the criteria that is worrisome, we will continue to do so and to cause worry.
We encouraged the readers to evaluate critically the evidentiary basis for a diagnosis of shaken baby syndrome in the light of the questions raised by the two papers. Of course Donohoe's study was limited and would retrieve only papers that included the words "shaken baby syndrome" in the title, key words, or abstract. The lack of scientific rigour that he identified is not restricted to infant head injury papers that specifically mention shaken baby syndrome. If Reece et al perform a critical review of the "number of qualified studies" that they assert would have been included by a wider search, they will encounter the same "data gaps, flaws of logic, and inconsistency of case definition" that were present in the literature studied by Donohoe. We would urge them to look again, for example, at the paper they cite by Alexander et al, where they will find all the above shortcomings.3
Finally, we are at a loss to explain or accept the authors' statement in their penultimate sentence: "Unfortunately, there remains considerable difficulty for some doctors to accept that children are abused." If the authors are suggesting that we are among those doctors, or are encouraging others to be so, their argument is a willful misinterpretation of what we have written. When there is new evidence that challenges an established conviction, medicine has the responsibility to critically evaluate the data, and if verifiable, reflect that change. We must have no vested interest in yesterday's belief. We are encouraging doctors to think clearly and critically, even in an area as emotive as child abuse. No more. And no less.
J F Geddes, retired (formerly reader in clinical neuropathology, Queen Mary, University of London)
London j.f.geddes@doctors.org.uk
J Plunkett, forensic pathologist
Regina Medical Center, 1175 Nininger Road, Hastings, MN 55033, USA
A full version of this letter is available on bmj.com
Competing interests: JFG and JP have given evidence in criminal cases at the request of both the prosecution and the defence.
References
Donohoe M. Evidence-based medicine and shaken baby syndrome. Part I:Literature review, 1996-1998. Am J Forensic Med Pathol 2003;24: 239-42.
Lantz PE, Sinal SH, Stanton CA, Weaver RG Jr. Perimacular retinal folds from childhood head trauma. BMJ 2004;328: 754-6.(27 March.)
Alexander RC, Sato Y, Smith W, Bennett T. Incidence of impact trauma with cranial injuries ascribed to shaking. Am J Dis Child 1990;144: 724-6.(Authors' reply)
Child abuse exists in many forms: our editorial addresses the diagnostic criteria for a specific type of abuse, the so-called shaken baby syndrome. We emphasise, as have Donohoe and Lantz et al,1 2 that the literature to support a diagnosis of shaken baby syndrome/inflicted head injury is based on imprecise and ill-defined criteria, biased selection, circular reasoning, inappropriate controls, and conclusions that overstep the data. If it is the questioning of the criteria that is worrisome, we will continue to do so and to cause worry.
We encouraged the readers to evaluate critically the evidentiary basis for a diagnosis of shaken baby syndrome in the light of the questions raised by the two papers. Of course Donohoe's study was limited and would retrieve only papers that included the words "shaken baby syndrome" in the title, key words, or abstract. The lack of scientific rigour that he identified is not restricted to infant head injury papers that specifically mention shaken baby syndrome. If Reece et al perform a critical review of the "number of qualified studies" that they assert would have been included by a wider search, they will encounter the same "data gaps, flaws of logic, and inconsistency of case definition" that were present in the literature studied by Donohoe. We would urge them to look again, for example, at the paper they cite by Alexander et al, where they will find all the above shortcomings.3
Finally, we are at a loss to explain or accept the authors' statement in their penultimate sentence: "Unfortunately, there remains considerable difficulty for some doctors to accept that children are abused." If the authors are suggesting that we are among those doctors, or are encouraging others to be so, their argument is a willful misinterpretation of what we have written. When there is new evidence that challenges an established conviction, medicine has the responsibility to critically evaluate the data, and if verifiable, reflect that change. We must have no vested interest in yesterday's belief. We are encouraging doctors to think clearly and critically, even in an area as emotive as child abuse. No more. And no less.
J F Geddes, retired (formerly reader in clinical neuropathology, Queen Mary, University of London)
London j.f.geddes@doctors.org.uk
J Plunkett, forensic pathologist
Regina Medical Center, 1175 Nininger Road, Hastings, MN 55033, USA
A full version of this letter is available on bmj.com
Competing interests: JFG and JP have given evidence in criminal cases at the request of both the prosecution and the defence.
References
Donohoe M. Evidence-based medicine and shaken baby syndrome. Part I:Literature review, 1996-1998. Am J Forensic Med Pathol 2003;24: 239-42.
Lantz PE, Sinal SH, Stanton CA, Weaver RG Jr. Perimacular retinal folds from childhood head trauma. BMJ 2004;328: 754-6.(27 March.)
Alexander RC, Sato Y, Smith W, Bennett T. Incidence of impact trauma with cranial injuries ascribed to shaking. Am J Dis Child 1990;144: 724-6.(Authors' reply)