Part I, Section I

Prosecutors build murder cases on disputed Shaken Baby Syndrome diagnosis

Interview

Mother acquitted of shaking a baby: ‘I would have committed suicide’

Part I, Section II

Doctors who defend shaking diagnosis dismiss scientific challenges

Interview

Prosecutor: ‘The public should know that this can kill’

Graphic

The unsettled science of Shaken Baby Syndrome

Part I, Section III

Mother released from prison: ‘It hurts too bad to remember’

Video

After five years in prison, a young mother is set free

Part I, Section IV

In Maryland, a baby collapses and a babysitter is blamed

Part I, Section V

Prosecutor to jurors: ‘Healthy babies just don't die’

Part I, Section VI

But that year, the case took a significant turn.

Interview

Babysitter once sentenced to 20 years in prison: ‘I’m not gonna say that I killed somebody’

Graphic

A breakdown of the dismissed cases

Graphic

Map: Parents and caregivers accused of shaking nationwide

Interview

Former medical examiner: ‘Alleged cases of pure shaking are unusual’

Part II, Section I

Doctors who diagnosed Shaken Baby Syndrome now defend the accused

Interview

Doctor who helped introduce the hypothesis behind Shaken Baby Syndrome: ‘I don’t think innocent people should be in jail’

Part II, Section II

A child abuse diagnosis raises questions, doubts

Interview

Accident reconstruction specialist: ‘We need to apply the science’

Part II, Section III

Engineers: Falls could be more dangerous than shaking

Graphic

A biomechanical look at shaking

Graphic

How much acceleration can be generated by shaking a 22-pound crash-test dummy

Part II, Section IV

Doctor: ‘What could be right about getting it wrong?’

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Shaken science

A disputed diagnosis imprisons parents

A child abuse diagnosis raises questions, doubts

You are reading one part of an investigative series on the disputed Shaken Baby Syndrome diagnosis that has put people behind bars.

In a bustling hospital in England in the early 1970s, pediatric neurosurgeon A. Norman Guthkelch discovered an alarming pattern among some infants and children: They had blood on the surface of the brain but no external signs of violence to the head.

One explanation came from social workers, who told Guthkelch that parents were disciplining their babies by shaking them. The idea made sense to the soft-spoken father of four, who had long suspected that some parents in northern England considered “a good shaking” far more acceptable than raising a hand to a child.

Guthkelch studied 23 assault cases and found that five children had bleeding on the surface of the brain, known as the subdural space, but no external marks on the head. He proposed that shaking could tear the veins inside the cranial cavity, triggering the bleeding.

Norman Guthkelch, pictured above, helped launch a discussion about the dangers of violent shaking in the early 1970s. Now, he worries the diagnosis of Shaken Baby Syndrome has been applied too often and has put innocent people in prison. (Photo by Bonnie Jo Mount/The Washington Post)

In May 1971, Guthkelch detailed his hypothesis in a two-page paper in the British Medical Journal: “One must keep in mind the possibility of assault . . . even when there are only trivial bruises or indeed no marks of injury at all.”

Over the next few years, prominent pediatric radiologist John Caffey at the University of Pittsburgh, who had spent decades studying head and bone injuries in children, came up with the term “whiplash shaken infant syndrome.” He cited case studies of shaking incidents and called for a national education campaign with the mantra:

Guard well your baby’s precious head,

Shake, jerk and slap it never,

Lest you bruise his brain and twist his mind,

Or whiplash him dead, forever.

Over time, the subdural bleeding, along with swelling of the brain and bleeding in the back of the eyes, became the classic markers of Shaken Baby Syndrome, though doctors also consider other signs of trauma as well as the accounts of caregivers.

In 1993, the American Academy of Pediatrics, noting the findings of Guthkelch and Caffey, declared Shaken Baby Syndrome “a clearly definable medical condition.”

“I am very confident that the science is well validated,” pediatrician Robert Block, past president of the academy, recently told The Post. “We have a long history of studying the science, of reviewing the work.”

But in the late 1980s, some doctors and biomechanical engineers had already begun to raise critical questions about whether Shaken Baby Syndrome was flawed science.

In 1987, a team of doctors and engineers from the University of Pennsylvania reported in the Journal of Neurosurgery that they had reviewed the cases of 57 children in Philadelphia with suspected shaking injuries, 13 of them fatal. In every fatal case, the shaking symptoms were accompanied by signs of blunt trauma to the head.

Though the researchers acknowledged their study was limited by a lack of information on the response of the infant brain, they concluded, “Shaking Baby Syndrome, at least in its most severe acute form, is not usually caused by shaking alone.”

In the late 1990s, concerns about Shaken Baby Syndrome were publicly aired during a contentious trial in Massachusetts, where 19-year-old British nanny Louise Woodward had been accused of killing a baby in her care. The case drew worldwide attention, with one journalist for the British Broadcasting Corp. describing the trial as “the clash of the medical men.”

Backed by a series of doctors — including Barnes, the pediatric neuroradiologist who would later challenge the diagnosis — prosecutors argued that a vicious assault by Woodward, which included violent shaking and a slam against a hard surface, had left 8-month-old Matthew Eappen with lethal head injuries, including a skull fracture.

But doctors who testified for the defense at the 1997 trial pointed out that the baby had no neck trauma and that the injuries appeared to be several weeks old. One of the doctors was Chicago neuropathologist Jan Leestma, who once was so convinced that Shaken Baby Syndrome was a valid diagnosis that he wrote about it in the first edition of a 470-page textbook he authored on the brain.

“I was wrong,” Leestma told The Post. “The original papers that espoused Shaken Baby were basically opinion papers with essentially no science applied to them.”

Woodward was found guilty of second-degree murder in October 1997. A month later, Superior Court Judge Hiller Zobel reduced the count to involuntary manslaughter and Woodward was freed from prison.

“After intensive, cool, calm reflection, I am morally certain that allowing this defendant on this evidence to remain convicted of second-degree murder would be a miscarriage of justice,” Zobel wrote.

After the trial, 50 doctors wrote a letter to the journal of the American Academy of Pediatrics asserting that the argument against shaking made by Woodward’s defense was “inaccurate, contrary to vast clinical experience and unsupported by any published literature.”

“The Shaken Baby Syndrome (with or without evidence of impact) is now a well-characterized clinical and pathological entity with diagnostic features in severe cases virtually unique to this type of injury,” the doctors wrote.

Four years after the Woodward trial, skeptical doctors from Minnesota to North Carolina to Britain began to challenge each of the conditions linked to shaking.

The most obvious symptom was the subdural bleeding, which had long been attributed to tears in the bridging veins that run from the surface of the brain to larger veins underneath the skull.

In 2001, a team of doctors in Britain reported that it had studied the brains of several dozen infants with inflicted head trauma, including those who were allegedly shaken, and found the subdural bleeding “trivial.”

In research papers that followed, Pennsylvania State University radiologist Julie Mack and other doctors suggested that the slight bleeding could have come from millions of much smaller blood vessels, similar to capillaries. Violent shaking was an unlikely cause of the bleeding because the tiny vessels were connected to the skull and would not shift from shaking.

“Every time we carefully examine the anatomy, we learn things,” said Mack, who has testified for the defense at shaking trials.

Doctors who support the Shaken Baby science criticize the studies, arguing that bridging veins are thin and can break easily. “That’s an interesting hypothesis, but there’s no proof,” said Carole Jenny, a pediatrician at the University of Washington.

Mack countered: “It is an established anatomic fact that the vessels can bleed without trauma and produce a subdural.”

Doctors have also investigated the origins of retinal hemorrhages, which Shaken Baby experts say have been observed in a majority of children with shaking injuries. A 2002 guide to investigating child abuse from the Department of Justice’s Office of Juvenile Justice and Delinquency Prevention called retinal hemorrhages “conclusive evidence of Shaken Baby Syndrome in the absence of a good explanation.”

North Carolina forensic pathologist Patrick Lantz has challenged the diagnosis of Shaken Baby Syndrome, saying natural conditions and accidents can produce identical symptoms in babies. (Photo by Bonnie Jo Mount/The Washington Post)

But in 2001, North Carolina forensic pathologist Patrick Lantz began to take a closer look at the conditions that can produce the bleeding. Lantz, a state medical examiner who once supported the Shaken Baby diagnosis, examined the eyes of more than 180 deceased children, including 116 infants. He found retinal hemorrhages in babies who had died from an obstructed airway, congenital heart disease and infections such as encephalitis and meningitis.

“If doctors see retinal hemorrhages, they say it’s abuse,” said Lantz, who has published four studies on the issue. “But it’s as scientific as a fortuneteller reading tea leaves.”

Jenny criticized Lantz’s findings, saying the bleeding he documented wasn’t as copious as the hemorrhaging seen in Shaken Baby cases. But Lantz said that the more extensive blood patterns are not exclusive to shaking. “If you look at other cases, you see them,” he said. “They’re there, but if you don’t look, you won’t find them.”

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