Tuesday, August 21, 2012

Doctor burnout: Nearly half of physicians report symptoms

By Janice Lloyd, USA TODAY

A national survey of physicians finds the prevalence of burnout at an "alarming" level, says a study out Monday.
  • The prevalence of burnout among doctors varies by specialty, a new study finds.
    Photo Disc
    The prevalence of burnout among doctors varies by specialty, a new study finds.
Photo Disc
The prevalence of burnout among doctors varies by specialty, a new study finds.
While the medical profession prepares for treating millions of patients who will be newly insured under the health care law, the Mayo Clinic (Rochester, Minn.) reports nearly 1 in 2 (45.8%) of the nation's doctors already suffer a symptom of burnout.
"The rates are higher than expected," says lead author and physician Tait Shanafelt. "We expected maybe 1 out of 3. Before health care reform takes hold, it's a concern that those docs are already operating at the margins."
Being asked to see more patients and not getting enough time with them create an atmosphere of "being on a hamster wheel," says physician Jeff Cain, president-elect of the American Academy of Family Physicians, which is not associated with the study. "We know when enough time is spent with patients that outcomes improve and costs are down."
Differences varied by specialty: Emergency medicine, general internal medicine, neurology and family medicine reported the highest rates. The authors note other studies show burnout can decrease the quality of care, lead to increased risk for errors and push doctors into early retirement, as well as cause problems in their personal lives.
"There have been other studies done on doctor burnout, but we assumed it was the surgical specialties who would be at primary risk," says Shanafelt. "Instead we found out it's the physicians on the front line of care who are at the greatest risk."
Also highlighted in the report: Physicians were more likely to complain of burnout than other U.S. workers. When asked about emotional exhaustion, 37.9% of physicians reported signs, compared with 27.8% reported by other workers surveyed.
Participants completed a 22-item Maslach Burnout Inventory questionnaire, considered the gold standard for measuring burnout. The issues examined were emotional exhaustion, depersonalization (treating patients as objects rather than human beings) and low sense of personal accomplishment. Of 27,276 physicians asked to participate, 7,288 (26.7%) responded. They had to report only one symptom to be included among those reporting burnout.
The burnout rate is nearly twice as high as in an earlier report by physician Mark Linzer, director of the Hennepin Healthcare System in Minneapolis. He is not associated with the Mayo study. He found 26.5% of doctors complain of burnout.
The doctors in the Linzer survey typically reported more than one symptom, but, if left untended, the doctors surveyed in the Mayo study could reach that point, too, he says.
"Control is the biggest predictor of burnout across the board," Linzer says.
Among control issues that add to stress:
•How many patients you see.
•How much time you have with them.
•How many different types of patients you might see in a short period.
•When you might have to release someone from the hospital.
He adds team-oriented approaches could help ease the pressure: "It used to be all about the clinician caring for the patient. Now it needs to be the clinician, nurse, care coordinator and others. When you start expanding the numbers of types of people who are caring for a patient, that helps a doctor and patient a lot."
Bottom line, says Linzer, "The Affordable Care Act is going to put more pressure on the front lines. This new study could be an important wake-up call the country needs to hear to build health care teams to meet the need."

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Giving babies antibiotics could lead to obesity: study

Aug. 21, 2012 2:06AM PDT

Giving babies antibiotics before the age of six months could cause them to be chubby children, according to a study published Tuesday.
"We typically consider obesity an epidemic grounded in unhealthy diet and exercise, yet increasingly studies suggest it's more complicated," said co-author Leonardo Trasande of the New York University School of Medicine.
"Microbes in our intestines may play critical roles in how we absorb calories, and exposure to antibiotics, especially early in life, may kill off healthy bacteria that influence how we absorb nutrients into our bodies, and would otherwise keep us lean."
The study adds to a growing body of research warning of the potential dangers of antibiotics, especially for children.
Preliminary studies have linked changes in the trillions of microbial cells in our bodies to obesity, inflammatory bowel disease, asthma and other conditions. However, direct causal proof has not yet been found.
This was the first study analyzing the relationship between antibiotic use and body mass starting in infancy.
The researchers evaluated the use of antibiotics among 11,532 children born in Britain's Avon region in 1991 and 1992 who are participating in a long-term study on their health and development.
They found that children treated with antibiotics in the first five months of their life weighed more for their height than those who were not exposed.
The difference was small between the ages of 10 to 20 months, but by 38 months of age, children exposed to antibiotics had a 22 percent greater likelihood of being overweight.
Timing appeared to matter -- children who received antibiotics from the ages of six to 14 months did not have a significantly higher body mass later in childhood, the study revealed.
And although children exposed to antibiotics at 15 to 23 months had slightly higher body mass indices by age seven, there was no significant increase in their likelihood of being overweight or obese.
"For many years now, farmers have known that antibiotics are great at producing heavier cows for market," co-author Jan Blustein, also of NYU, said in a press release.
"While we need more research to confirm our findings, this carefully conducted study suggests that antibiotics influence weight gain in humans, and especially children too."
The study was published in the International Journal of Obesity.

Monday, August 20, 2012

At least half of all parents tried over shaken baby syndrome have been wrongly convicted, expert warns


It is a case that haunts Dr Waney Squier and one any parent will find deeply distressing. 
Eleven years ago, Lorraine Harris stood trial at Nottingham Crown Court charged with manslaughter. Although described as a woman of good character and a careful and caring mother, she was accused of shaking her four-month-old baby Patrick to death two years earlier.
Neuropathologist Dr Squier wrote a report for the prosecution saying that the child was the victim of shaken baby syndrome (SBS). 
Impeccable record: Dr Waney Squier says she is determined not to be silenced
Impeccable record: Dr Waney Squier says she is determined not to be silenced
Lorraine, who vehemently protested her innocence, was convicted and jailed for three years.
Her punishment was not limited to incarceration, as tragic consequences rippled out from Patrick’s death. Lorraine wasn’t allowed to go to his funeral; a baby she gave birth to as she was starting her sentence was taken away for adoption; her partner left her and both her parents died while she was in prison. Her life fell apart.
By the time Lorraine’s appeal was heard in 2005, Dr Squier had become convinced the criteria she had used to define whether SBS had taken place were wrong. In a complete U-turn, she now appeared as an expert witness for the defence. Lorraine’s conviction was quashed.
It is difficult to imagine Lorraine’s feelings as she digested this news. Relief, perhaps, but the occasion could hardly be described as joyous. One of her children had died and she had not been allowed to grieve. Another child had been taken from her. And she would possibly never be free from the taint of the original conviction.
Ordeal: Lorraine Harris was accused of killing her baby son
Ordeal: Lorraine Harris was accused of killing her baby son
‘Her conviction was overturned but it was a hollow victory because her life had been completely devastated,’ says Dr Squier, who had helped right a wrong but could not erase the pain it had caused.
‘I did and sometimes still do feel terrible about what happened.
‘I now believe that half or even more of those who have been brought to trial in the past for SBS have been wrongly convicted. It is a frightening thought.’
It is indeed, and it is an extraordinary claim but one that should be taken seriously. Dr Squier, 63, is the most experienced paediatric neuropathologist in the country. She has spent 30 years researching baby brains and has a solid international reputation.
She has appeared countless times in court as an expert witness in cases of SBS, when a child is said to have been shaken so violently that it results in brain injury or death.
You would imagine that when such an eminent scientist says recent scientific developments show that, in the past, she and others have been wrong about SBS, she would be listened to. 
Instead Dr Squier has been on the receiving end of vicious attacks by some doctors, lawyers and police officers who do not like her views. She has even been referred to as a supporter of child abusers.
‘Why would I want to do that?’ she asks.
‘I have children of my own. I am chilled by the thought of getting it wrong because of the risk of sending babies back to abusive households, or taking them away from families, or putting people in prison.’ 
About 250 SBS cases go to court each year. Expert witnesses play a pivotal role in trials. Babies often do not have any symptoms other than bleeding to the head and eyes so, unlike most criminal cases, the opinion of the pathologist may be the only evidence to consider.
However, some convictions are controversial. The problem has been that there is no single agreed definition of SBS. Instead, for the past 30 years, the findings of a U.S. radiologist, John Caffey, have been used in courts.
These findings centre on three signs – swelling of the brain, bleeding between the skull and the brain, and bleeding in the retina – known collectively as the triad. If they are present then a conviction is likely.
But Dr Squier is one of a growing number of doctors who believe that relying on the triad alone is no longer enough.
‘Over the past ten years so much more has been discovered about how a baby’s brain develops in its first year and these developments have seriously undermined SBS,’ she explains.

‘Over the past ten years so much more has been discovered about how a baby’s brain develops in its first year and these developments have seriously undermined SBS.’

‘We now know, for example, that almost half of babies have a triad at birth, which can be caused by different factors.
‘In the past four years there have been several discoveries about the dura, the membrane covering the brain. It was thought that it was there to protect the brain from shock, but we now know it also has the very important function of controlling blood flow out of the brain. 
‘At birth the dura has huge blood channels that can leak – and not always as a result of trauma. They do, however, disappear during the child’s second year of life.
‘These findings are so significant that I now believe that half or even more of those who have been brought to trial in the past for SBS have been wrongly convicted. 
'I am also convinced we can virtually exclude shaking as a cause of death in babies unless, as well as bleeding in the brain, we have additional evidence of trauma, such as serious damage to the neck.
‘When a baby is shaken, the head will flop back and forth and the neck becomes the weak point. In other words, if you shake a baby so hard that it dies, it is the neck that is going to show the damage, not the brain.’
Although her view is gathering momentum worldwide, it has ignited an increasingly toxic argument between doctors, lawyers and police.
‘Some pathologists want to remain in an unchallenging comfort zone of an outdated theory,’ Dr Squier explains.
‘Some judges don’t like the fact that new scientific discoveries make convictions more complex, and the police don’t like them because it can prevent them from getting the convictions they want.
Fragile: Blood channels in an infant's brain can leak during the first year of life
Fragile: Blood channels in an infant's brain can leak during the first year of life
‘I think the police are so put-out that they are trying to ban me from court. It’s why I would like Justice Secretary Kenneth Clarke to set up an inquiry into the methods police have used to deter expert witnesses who challenge old mainstream beliefs. 
'This raises serious concerns that one side of the argument is not being heard and means there cannot be a fair trial.
‘If I am blocked from giving evidence in court, defendants already having to cope with the tragic death of a baby will not get the benefit of the new science. Equally, if the courts fail to accept that the mainstream view of 30 years ago can no longer be relied upon, there will be serious miscarriages of justice.’
Dr Squier, who is divorced with two grown-up daughters, is devoted to her work and, despite the pressure she is under, she speaks calmly. Born in Surrey, she qualified as a doctor at Leeds Medical School.
After spells in Bristol, Cornwall and London, she moved to Oxford in 1984 and took up a post as consultant pathologist at the John Radcliffe Hospital, where we talked.
‘Once I came here I specialised in baby brains,’ she explains. ‘I have looked at thousands and written more than 100 medical papers on normal brain development and what happens when things go wrong both in pregnancy and after birth. In the past 15 years, I have investigated many unexpected deaths.’
Her change of opinion was triggered ten years ago by pioneering work carried out by Jennian Geddes, a former consultant neuropathologist at the Royal London Hospital.
Geddes argued that, in a small number of cases, injuries associated with the triad can occur naturally; that some babies suffer from a lack of oxygen supply that triggers bleeding; and that there should be some signs that the baby suffered trauma.
‘A light went on in my head,’ Dr Squier says.
‘I became concerned that the whole basis for shaking was poor.’
She began to conduct her own investigations and found similar evidence to Geddes.
‘It made me feel guilty about my previous unquestioning acceptance of the shaking hypothesis.
‘All my cases are now based on a newer understanding of the science. I am happy with rigorous debate but take exception to attacks on my integrity and professionalism. It is intellectual laziness to apply the old triad diagnosis when symptoms can be explained by natural causes.’

'I am happy with rigorous debate but take exception to attacks on my integrity and professionalism. It is intellectual laziness to apply the old triad diagnosis when symptoms can be explained by natural causes.’

Dr Squier has an impeccable professional reputation so she was shocked early last year to receive a letter from the Human Tissue Authority, an organisation which ensures that doctors keep good records and have consent for everything they do.
‘The Metropolitan Police had raised concerns about the way I was handling post-mortem tissue and the possibility that unrecorded material was being stored, used and disposed of without the knowledge of the police. Fortunately, our procedures at John Radcliffe are absolutely robust, we know where every piece of tissue is, and no action was taken.
‘Then last June, I heard that a complaint on the same subject had been lodged against me with the General Medical Council.’
Dr Squier had to face an interim orders panel, which was set up after the conviction of Harold Shipman to protect the public and the profession from dangerous doctors. Her appearance was requested by the National Policing Improvement Agency and Detective Inspector Colin Welsh, lead investigator at Scotland Yard’s child abuse investigation command.
‘I barely slept for six weeks,’ she says.
‘It was a terrible experience but the hearing had barely got under way when it was dismissed and no restrictions were made on my practice.
‘However, the panel couldn’t remove the complaint lodged about me with the GMC and I don’t know whether it will take it forward. It is hanging over me like a dark cloud.
'I know the GMC will not approve of me speaking out but too much is at stake for me to stay silent.’ 
Unknown territory: Doctors are still learning how a baby's brain develops - and discoveries in just the last ten years have 'seriously undermined SBS' according to Dr Squier
Unknown territory: Doctors are still learning how a baby's brain develops - and discoveries in just the last ten years have 'seriously undermined SBS' according to Dr Squier
The accusations began to make sense following a conference on shaken babies, which took place in Atlanta, Georgia, last September.
DI Welsh, in a public lecture, talked disparagingly about prosecution cases that had failed largely due to expert defence witnesses.
He described a way of eliminating them from criminal and possibly family court trials, thus precluding alternative views being presented. He believed they confused the jury and possibly the judges with the complexity of science.
DI Welsh’s solutions included ‘questioning everything – qualifications, employment history, testimony, research papers presented by these experts, go to their bodies to see if we can turn up anything’.
Among the audience was lawyer Heather Kirkwood, who was so shocked that she took notes and has signed an affidavit that these notes are a true record.
She says: ‘In the past decade, we have learned that much of what we thought we knew about SBS was wrong, and that many of the babies that we thought were shaken were instead suffering from birth injuries, childhood stroke, or metabolic or infectious disease.
‘Now that we know we got it wrong, we need to get it right. Instead, many prominent advocates of shaken baby theory have resorted to attacking researchers such as Dr Squier, who is one of the world’s leading experts on the infant brain.
‘Families and children deserve better. To get it right, we need open, honest debate, not cover-ups or attacks on those identifying the problems and seeking solutions.’
Dr Squier was outraged to learn of DI Welsh’s comments.
‘It proved in my mind that the police have set out to remove me and two other neuropathologists who share the same view from the courts because we have stood in the way of their campaign to improve conviction rates. If an expert witness bases an opinion on reasonable scientific ground, even if the opinion is a minority one, it should not be excluded.
‘I am determined not to be silenced and if I can’t speak out in court, I shall do it in scientific papers. It cannot be fair to gag one body of opinion. The whole thing is a nightmare, not least because instead of researching vital things about babies, I have to spend time trying to clear my name.
‘Meanwhile, the number of court cases I have been asked to attend has plummeted from 30 a year a few years ago to five in the past year.
‘Some lawyers are still willing to instruct me because they believe I will give them an opinion based on the science. Others feel they can’t use me while the complaint is hanging over me.
‘The experience has made me feel like a whistleblower – on the one hand challenging all those who prefer the comfort of old mainstream opinion, and on the other struggling for my professional life.’
DI Welsh was unavailable for comment, but Scotland Yard said in a statement: ‘The Metropolitan Police did register concerns about certain practices of a doctor with the Human Tissue Authority in December 2009. The Metropolitan Police also agreed to provide any relevant information to the GMC following a report registered by the National Policing Improvement Agency with the GMC.’

Read more: http://www.dailymail.co.uk/femail/article-1382290/At-half-parents-tried-shaken-baby-syndrome-wrongly-convicted-expert-warns.html#ixzz248fRxNDa

Saturday, August 18, 2012

Judge impressed with Cinderella mom, scolds social workers for keeping kids away Read it on Global News: Global Edmonton | Judge impressed with Cinderella mom, scolds social workers for keeping kids away

 Thursday, November 10, 2011 5:59 PM
PRINCE ALBERT, Sask. - A Saskatchewan judge has scolded the province's child-welfare system for ignoring court orders to arrange regular visits between two children and their rehabilitated mother.
Court of Queen's Bench Justice Geoffrey Dufour said he was impressed with the young woman's remarkable turnaround from a prostitute and addict to a healthy and devoted mother. He recently ordered the children be returned to her this week.
Dufour was not as impressed by social workers. He issued an ultimatum: explain your blatant disregard for the courts or face further action, such as criminal charges of contempt of court.
"A court order trumps the ministry's discretion. It was obliged to comply with it. Full stop," Dufour wrote in his latest decision two weeks ago.
He described the 26-year-old woman as "a mother who has escaped a life of prostitution and squalor and bested addictions so that she might have the ability to parent her two children.
"Despite the odds and the recommendation of the Ministry of Social Services, she will have the opportunity to do so."
The judge recommended the department file a report explaining its mistakes by Feb. 1.
Andrea Brittin, an official with the ministry, said Thursday she can't comment on the case, including on whether the children are now living full-time with their mother at her apartment in Prince Albert.
She also wouldn't say whether a report on how the file was handled will be submitted to the judge. She said, in general, court orders regarding parental visits vary between being vague and specific.
"We are always continually reviewing our processes in order to ensure improvement of the services that we provide to children and families."
Court documents show the mother, who cannot be identified, grew up in a neglected household and was living on her own and selling her body for alcohol at age 14. She started injecting drugs at 16.
Her two children, a boy and girl who she has said were probably fathered by johns, were placed in foster care at birth. The woman was diagnosed as HIV positive after her first child was born and passed the disease onto her youngest child.
Dufour wrote that the woman has always indicated her children were important to her. She has never missed a scheduled visit, often arriving with a duffle bag full of toys, crafts and games.
It took several attempts to clean up her life, but she finally did. Dr. Leo Lanoie, who runs Prince Albert's methadone treatment program, told court she was a "model patient."
Lanoie also diagnosed the woman with attention deficit hyperactivity disorder and found she had been self-prescribing herself with Ritalin for years. He now prescribes her a slow-release form of the drug that helps her concentrate.
Psychologist Brian Chartier testified the woman poses a high risk to abuse and neglect her children because of her own childhood.
But the judge noted that Chartier fell asleep on the couch during one visit to the woman's home. A social services official later berated him and probably skewed his opinion by making it clear the ministry wanted the children to be put up for adoption, said Dufour.
He also questioned the testimony of a case worker who was concerned with the woman's ability to parent because she fed her children fast food from McDonald's and Kentucky Fried Chicken twice in one day. Dufour said after the worker raised concerns, the mother replaced the food with healthy alternatives, such as homemade barley soup.
He described the children as well-adjusted. The five-year-old boy is polite and inquisitive and the girl, nearly four, is spunky and does not yet require treatment for HIV.
Their mother has morphed from a dishevelled waif who appeared in court two years ago into a healthy, well-groomed and confident woman who plans on upgrading her education, said Dufour. The woman carried a well-thumbed and dog-eared parenting advice book with her into court and excitedly described how she would decorate her children's bedroom.
Dufour agreed the woman lacks parenting experience and a bond with her children. "Of course, she would have had more experience as a mother had the ministry complied with court orders."
— By Chris Purdy in Edmonton

Read it on Global News: Global Edmonton | Judge impressed with Cinderella mom, scolds social workers for keeping kids away 

Mass CPS corruption P2

Wednesday, August 8, 2012

U.S. Kids Woefully Low in Vitamin D | Yahoo! Health

U.S. Kids Woefully Low in Vitamin D | Yahoo! Health

According to Jonathan Mansbach, MD, assistant professor of pediatrics at Harvard Medical School in Boston and lead author of a new — and somewhat alarming — study on vitamin D levels in U.S. children, "Levels of vitamin D have been trending downward, but the reasons are all speculation at this point." What isn't speculation, thanks to Dr. Mansbach's study, published this week in the medical journal Pediatrics, is just how far they've fallen.

THE DETAILS: Dr. Mansbach and colleagues analyzed data (which they drew from the National Health and Nutrition Examination Survey) from what they deemed a "nationally representative sample" of U.S. children between the ages of 1 and 11 to estimate vitamin D levels for American children as a whole. Based on their analysis, the study authors concluded that 6.3 million children ages 1 to 11 in the U.S. (or, nearly 20 percent of all children in that age group) don't meet the American Academy of Pediatrics' minimal level of 50 nmol/L blood levels.

Optimal vitamin D levels in children haven't yet been determined, and, in fact, there's controversy even over what level of vitamin D should be considered deficient. But the data also showed that 24 million children ages 1 to 11 in the U.S. (approximately two-thirds of all children in that age-group) have levels below a more generous threshold of 75 nmol/L — including 92 percent of non-Hispanic black children, 80 percent of Hispanic children, and 59 percent of white children.

Are You Getting Enough Vitamin D?

WHAT IT MEANS: "On the basis of our nationally representative sample of U.S. children ages 1 to 11, we know now that there are millions of children with levels of vitamin D lower than some experts believe to be healthy," says Dr. Mansbach — "especially among non-Hispanic black and Mexican American children," whom the study authors speculate don't generate as much vitamin D through sunlight exposure as fairer-skinned children because increased skin pigmentation reduces vitamin D generation.

WHAT THAT MEANS: Vitamin D is essential for strong bones — and American children aren't getting enough. Beyond that, however, higher levels of vitamin D have been shown in some studies, note the study authors, to improve not only bone health but also to prevent cancer, autoimmune diseases, type 1 diabetes, infectious diseases, heart attacks, and childhood wheezing, as well. And, again, U.S. kids aren't getting high enough levels for those effects. Not even close.

Here's how to make sure your child has ample vitamin D — and the health benefits that come with it:

Since few foods contain natural vitamin D, the best way to make sure your child gets enough is through supplements. "The American Academy of Pediatrics recommends 400 International Units (I.U.) of vitamin D a day — the amount in most multivitamins formulated for children," says Dr. Mansbach. He also suggests speaking to your pediatrician about the appropriate level for your particular child, since it's unclear whether 400 I.U. is quite enough.

For instance, if your child is non-Hispanic black or Mexican American — the population in the study that had the lowest levels of vitamin D — or you live in a colder climate with little sunlight, you may need to consider giving 800 I.U. per day — but only under your doctor's supervision. "You cannot simply double up on your multivitamin supplement, since that would provide too much of some of the other vitamins and minerals," says Dr. Mansbach.

Get them in the sun — but cautiously

Tuesday, August 7, 2012

Child protective services human experimentation

Special report: The must-have vitamin


1 in 5 kids get little vitamin D, study says


CHICAGO (AP) — At least one in five U.S. children aged 1 to 11 don't get enough vitamin D and could be at risk for a variety of health problems including weak bones, the most recent national analysis suggests.
By a looser measure, almost 90 percent of black children that age and 80 percent of Hispanic kids could be vitamin D deficient — "astounding numbers" that should serve as a call to action, said Dr. Jonathan Mansbach, lead author of the new analysis and a researcher at Harvard Medical School and Children's Hospital in Boston.
The findings add to mounting evidence about vitamin D deficiency in children, teens and adults, a concern because of recent studies suggesting the vitamin might help prevent serious diseases, including infections, diabetes and even some cancers.
While hard evidence showing that low levels of vitamin D lead to disease or that high levels prevent it is lacking, it's a burgeoning area of research.
Exactly how much vitamin D children and adults should get, and defining when they are deficient, is under debate. Doctors use different definitions, and many are waiting for guidance expected in an Institute of Medicine report on vitamin D due next year. The institute is a government advisory group that sets dietary standards.
The new analysis, released online Monday by the journal Pediatrics, is the first assessment of varying vitamin D levels in children aged 1 through 11.
Previous studies in the journal this year found low levels were prevalent in U.S. teens, and also showed kids with low levels had higher blood pressure and cholesterol levels, and were more likely to be overweight.
The new analysis uses data from a 2001-06 government health survey of nearly 3,000 children. They had blood tests measuring vitamin D levels.
Using the American Academy of Pediatrics' cutoff for healthy vitamin D levels, 6.4 million children — about 20 percent of kids that age — have blood levels that are too low. Applying a less strict, higher cutoff, two-thirds of children that age, including 90 percent of black kids and 80 percent of Hispanics, are deficient in vitamin D.
A Pediatrics editorial says the strongest evidence about effects of vitamin D deficiency in kids involves rickets, a bone disease common a century ago but that continues to occur.
Rickets can be treated and prevented with 400 units daily of vitamin D, the editorial says. The pediatricians' group recently recommended that amount for all children, saying that most need vitamin supplements.
Mansbach says his study, funded by the National Institutes of Health, supports that recommendation.
Children can get 400 units daily by drinking four cups of fortified milk, or eating lots of fish, but many don't do that.
The body also makes vitamin D when sunlight hits the skin, but many children don't spend enough time outdoors. That's one reason why lower vitamin D levels are found in children living in colder climates and those with darker skin, which absorbs less sunlight.
On the Net:
Pediatrics: http://www.pediatrics.org

Monday, August 6, 2012

Shaken-Baby Syndrome Faces New Questions in Court

Eugene Richards/Reportage, for The New York Times
Noah Whitmer, now 2, with his parents, Erin and Michael Whitmer, can nod his head “yes,” but he is not yet talking. He wears a patch for a period of time each day to correct his vision.
At 4 months, Noah Whitmer was an easy baby. Super tranquilo,remembers Trudy Eliana Muñoz Rueda, who took care of Noah at her home day care center in Fairfax County, Va. Rueda and Noah’s mother, Erin Whitmer, both noticed when he stopped taking his bottle well and napping as usual in the middle of his fifth month, in April 2009. Whitmer thought this was because Noah had just started eating solid food. She and Rueda talked about it early on April 20, both of them hunched over Noah in his car seat when Whitmer dropped him off.


Eugene Richards/Reportage, for The New York Times
CAREWORN Trudy Rueda at the Fluvanna Correctional Center for Women in Virginia. She was convicted of shaking Noah Whitmer and sentenced to 10½ years in prison.
Eugene Richards/Reportage, for The New York Times
AFTERLIFE Audrey Edmunds, a mother of three, was in prison 11 years before her conviction for shaking and killing a 7-month-old baby was overturned. She now lives apart from her children in the lower level of a friend's home.
Eugene Richards/Reportage, for The New York Times
SISTERS Julie Baumer with a photo of her parents and her sister, Victoria. Baumer, who was caring for Victoria's son, was convicted of child abuse but later found not guilty at a second trial.

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That afternoon, after a morning in which Noah didn’t nap and drank only a couple of ounces of formula, Rueda says she prepared a bottle for him while he lay on a mat. In her native Peru, Rueda, who is 46, ran a travel agency and taught college courses for prospective tour guides. Her husband was trained as a lawyer. After they moved to the United States in 2001, the couple had a second child, and three years later Rueda converted her basement into a home day care center so she could work while spending time with her two kids. When Rueda sat down to feed Noah, her 13-year-old daughter was at school, her 5-year-old was upstairs watching TV and the four other children in her care were taking naps. Rueda’s sister-in-law, who spent the morning with the children while Rueda was at a doctor’s appointment, had just left the house. “Everything was calm and quiet,” Rueda, who has soft features and dark hair, told me in Spanish while her lawyer translated.
There are two irreconcilable versions of how that calm shattered. Rueda says that Noah was crying, and she picked him up, sat on the couch and gave him the bottle to help put him to sleep. While she was feeding him, she felt Noah’s arm go limp, and when she moved to take the bottle out of his mouth, he made a sound that she didn’t recognize. “I could tell something was happening,” she says. She stood up and put Noah on her shoulder, patting him on the back. “As I did this, his body tensed up in a ball. It was as if he was looking for air, and he couldn’t breathe.” Rueda put Noah on the floor and started C.P.R., at the same time reaching for her phone to call 911. She put the dispatcher on speakerphone so she could keep tending to Noah. “I said, ‘Please, please get someone here,’ ” she said. “I knew it could hurt him if there wasn’t enough oxygen going to his brain.”
Erin Whitmer’s account of the moments before Noah lost consciousness is entirely different. “Around 2:30 on April 20, 2009, Noah was shaken,” she wrote on her blog Noah’s Road, on the one-year anniversary of the incident. “He’d been crying. He needed something that his day care provider wasn’t providing him. Maybe he was tired of lying on the mat where she’d had him. Maybe he needed a hug, a laugh, a kind touch. Instead, she picked him up, her fingers gripping him tightly, feeling the softness of his velour pants and his cotton onesie under her fingers, and she shook him.”
Whitmer’s account of what Rueda must have done to Noah was based on evidence presented at Rueda’s trial and information from the doctors who treated him after he was rushed to Inova Fairfax Hospital. The doctors gave Noah aCT scan, which showed subdural hemorrhaging (bleeding in a space between the skull and the brain) and an ophthalmological exam revealed retinal hemorrhaging (bleeding at the back of the eyes). Also, his brain was swelling. For decades, these have been the three telltale signs linked to the kind of child abuse commonly called shaken-baby syndrome.
Noah had no external marks on his body — no bruises or cuts or fractures, no sign that he was forcefully gripped and no evident neck injury that would seem to result from vigorous shaking. But an M.R.I. confirmed the CT scan findings and showed that the subdural bleeding was extensive. The doctors at Inova Fairfax tested Noah for clotting disorders that can cause these kinds of hemorrhages. The tests came back negative. The doctors told Erin and Michael Whitmer, who are both 32, that they strongly suspected Noah was violently shaken in the moments before he stopped breathing. While Noah lapsed into acoma, police went to question Trudy Rueda. A day later, Rueda was arrested. She was charged with two felony counts: abuse of a child causing serious injury and cruelty to a child.
Before April 20, 2009, Noah was a healthy baby. Trudy Rueda also had nothing suspect in her past. In five years as a day care provider, she had a pristine record with state regulators — she had taken the classes required for her license and extra ones as well. She cared for a boy with autism and a girl with one arm, reportedly with calm and assurance. “She was more patient than all of us,” one mother testified at Rueda’s trial. A second said, “What she’s accused of now I could not begin to imagine Trudy doing.” And yet Noah emerged from her home with terrible and permanent injuries.
Between 1,200 and 1,400 children in the United States sustain head injuries attributed to abuse each year. Most of them are less than a year old. Usually, there’s not much dispute that these children were abused, because doctors discover other signs of mistreatment — cuts, bruises, burns, fractures — or a history of such injuries. There is no exact count of shaken-baby prosecutions, but law-enforcement authorities think that there are about 200 a year. In an estimated 50 percent to 75 percent of them, the only medical evidence of shaken-baby syndrome is the triad of internal symptoms: subdural and retinal hemorrhage and brain swelling.
For a year after Noah came out of his coma, he had as many as 32 seizures a day. Now he is 2, and his parents watch as his 1-year-old brother surpasses him developmentally. Noah sometimes nods his head “yes” and gives high fives, but he is not yet talking; doctors are not sure of his cognitive prognosis. Erin Whitmer, a slender woman with large brown eyes who chose Rueda for part-time day care after a careful search, cried when she found out that Rueda had been arrested. Now she says, “It will never completely leave me, the horror that I trusted my son with someone and she did this to him.”
At Rueda’s trial in January 2010, the prosecutor presented six doctors who testified that Noah’s brain scans showed he had been abused. The doctors’ reading of the scans were the main evidence that a crime had taken place, of its timing and even of Rueda’s state of mind, since they agreed that only an act of great violence could inflict such injuries. Two doctors who treated Noah in the hospital said that the baby’s scans showed that he had an acute subdural hemorrhage — the bleeding had begun suddenly — which was, as one doctor stated, “inconsistent with accidental trauma.” Another witness, Craig Futterman, a doctor at Inova Fairfax and president of the board of the Shaken Baby Alliance, put it more bluntly, “This child was shaken, or shaken and slammed against something.”
The usual explanation for how a caregiver can become an abuser is that in a moment of intense frustration, she snaps. The prosecutor, Gregory Holt, imagined for the jury a scenario in which Rueda was aggravated that she could not get Noah to stop crying: “Put him on the mat, put him on the chair, he’s not drinking his milk. Getting a little bit frustrated?” And he claimed that Rueda confessed to shaking Noah.
On the day of Noah’s injuries, Rueda spoke to the police without a lawyer and denied hurting him. The next day, Joslyn Waldron, a social worker for Virginia’s Child Protective Services, visited Rueda at home. Waldron knew that Noah’s doctors at Inova Fairfax suspected that he had been abused because of his symptoms. She and Rueda spoke together in Spanish while a detective, who did not speak Spanish, was present. At the trial, Waldron testified that Rueda confessed to shaking Noah when he was crying and before she gave him a bottle. The social worker said she wrote in her notes, “Might have shaken him about three times, but not sure” (using a standard Spanish word, sacudir, for shake).
As is protocol in her department, Waldron offered to tape the interview; Waldron says Rueda declined. Rueda has denied telling Waldron that she shook Noah. At the trial, she testified in heavily accented, halting English, frequently interrupting herself because she didn’t understand the questions. Rueda said that she told Waldron, “I probably moved kind of rough with Noah,” at the moment that she lifted him to give him the bottle, but that she had not gotten frustrated with the baby or harmed him.
When her lawyer asked her what she thought happened to Noah, Rueda answered: “I imagine the parents, we all want to know what happened. But I cannot give you an explanation about what I don’t know.”
The Whitmers dismissed Rueda’s denials of guilt. “It’s a complicated thing to look at someone who always smiled at you, to know that your baby loved her, and to know that because of her, you struggle each day to adapt to a new sense of reality,” Erin Whitmerwrote on her blog, which has had more than a million visits, after Rueda’s first criminal hearing. Michael Whitmer expressed his rage at Rueda’s next hearing by wearing a T-shirt he made. On the back is a picture of Noah taken in the hospital, with tubes coming out of his mouth and the words: “Ask me what happens when you shake a baby.”
At the trial, the prosecution presented one more piece of testimony against Rueda. The pediatrician who saw Noah in the I.C.U. told the jury that given the severity of the baby’s injuries, their “onset would have been very rapid, so it would have been within minutes of when the injury occurred.” This meant that the person with the baby right before he stopped breathing — Rueda — was necessarily the guilty party.
Rueda’s lawyer didn’t challenge this assumption directly. Medical experts, however, have begun to point out that clinical observations show that it’s possible for a child to have abrain injury and still remain conscious. The child may be lethargic or fussy or may not eat or sleep normally for hours or days, while the subdural hemorrhage and other injuries become more serious, ending in acute crisis. This has made some doctors wary of pinpointing the timing of a child’s injury — even when they are sure that abuse occurred — lest the wrong adult take the blame. “The police want us to time it within one to three hours,” says John Leventhal, a Yale pediatrics professor and medical director of the child-abuse programs at Yale-New Haven Children’s Hospital. “But sometimes we can only time it to within days.”
In this case, because Rueda had been at the doctor that morning and her sister-in-law stayed to help with lunch, she spent only about an hour alone with the children in the day care center before calling 911. Arguing that another adult had harmed Noah would have meant implicating Rueda’s sister-in-law, whom Rueda says she has never suspected, or the Whitmers, whom no one has accused. Rueda, her husband and their lawyers decided not to take this tack. The defense relied primarily on Ronald Uscinski, a neurosurgeon on the faculty of the medical schools of George Washington University and Georgetown. When he took the stand, Uscinski refuted all the prosecution experts who said that Noah’s hemorrhaging was acute — the sudden result of a new injury. Uscinski testified that he saw chronic subdural bleeding on the scans, which he said was the result of trauma at birth. “Rebleeds” like Noah’s, he testified, “can occur with minimal or no trauma. They can occur spontaneously.” On cross-examination, Uscinski said that he earned approximately $200,000, which was about 30 percent of his income, as an expert witness in 2009.
For the prosecution, Cindy Christian, a pediatrics professor at the University of Pennsylvania, who has published extensively about shaken-baby syndrome, rejected Uscinski’s reading of Noah’s brain scans. “That’s false, he did not have a rebleed from a chronic hematoma from birth,” she said. “There was no evidence of that.”
After five days of testimony, the jury deliberated for five hours and voted to convict. Virginia’s sentencing guidelines called for a minimum sentence of 3 years and a maximum of 15. The jury recommended 10½ years and Erin and Michael Whitmer took the stand in support of that punishment. “This is a life sentence for my son, for my wife, for me, and for our family,” Michael Whitmer told the jury.
“Really still, now, I can’t comprehend it,” Rueda told me, looking wan and bereft when I visited her at the Fluvanna Correctional Center for Women in Virginia. Rueda’s daughters have gone to live with her older sister in Peru while her husband works extra hours to support the family and pay for her appeal. Rueda can rarely speak to her children.“It is so hard to talk about this separation,” she said, and started to cry.
A dozen years ago, the medical profession held that if the triad of subdural and retinal bleeding and brain swelling was present without a fracture or bruise that would indicate, for example, that a baby had accidently fallen, abuse must have occurred through shaking. In the past decade, that consensus has begun to come undone. In 2008, the Wisconsin Court of Appeals, after reviewing a shaken-baby case, wrote that there is “fierce disagreement” among doctors about the shaken-baby diagnosis, signaling “a shift in mainstream medical opinion.” In the same year, at the urging of the province’s chiefforensic pathologist, the Ontario government began a review of 142 shaken-baby cases, because of “the scientific uncertainty that has come to characterize that diagnosis.” In Britain, after one mother’s shaken-baby conviction was overturned, Peter Goldsmith, then attorney general, reviewed 88 more cases. In 2006, he announced doubts about three of the convictions because they were based solely on the triad; in the other cases, Goldsmith said, there was additional evidence pointing to the defendant’s guilt.
A small but growing number of doctors warn that there can be alternate explanations — infections or bleeding disorders, for example — for the triad of symptoms associated with shaken-baby syndrome. Across the country, the group of lawyers that has succeeded in exonerating hundreds of people based on DNA evidence is now mounting 20 to 25 appeals of shaken-baby convictions. “No one wants child abuse,” says Keith Findley, a lawyer for the Wisconsin Innocence Project. “But we should not be prosecuting and convicting people in shaken-baby cases right now, based on the triad of symptoms, without other evidence of abuse. If the medical community can’t agree about all the conflicting data and research, how is a jury supposed to reach a conclusion that’s beyond a reasonable doubt?”
Much of the science of shaken-baby syndrome dates from the late 1960s, when a neurosurgeon named Ayub Ommaya conducted a brutal animal experiment to figure out how much acceleration it took to cause a head injury. Ommaya took more than 50 rhesus monkeys and strapped each one into a chair mounted on wheels, leaving their heads unsupported. He placed the chair on a 20-foot-long track, and an air-powered piston sent the monkeys zooming into a wall. Fifteen emerged with some kind of cerebral hemorrhage. Eight of those also had injuries to the brain stem or cervical cord.
Ommaya’s experiment involved neither shaking nor infants. Still, two pediatric specialists, John Caffey and A. Norman Guthkelch, each wrote a paper that pointed to the work as evidence that unexplained subdural bleeding in babies could occur without direct impact to the head and with or without a visible neck injury. In the 1980s, the term “shaken-baby syndrome” came into broad use, and a national prevention and awareness campaign was set in motion.
As the diagnosis of shaken-baby syndrome took hold in medicine, and prosecutors began to bring charges based on it, doctors testified that shaking could generate the same terrible force as throwing a child from a second-­story window. It turned out they were wrong. In 1987, a neurosurgeon named Ann-Christine Duhaime published a paper that included the autopsy results of 13 babies with symptoms associated with shaken-baby syndrome. In all of them she found evidence of trauma that was actually caused by impact. She teamed upwith biomechanical engineers to create infant-sized dummies equipped with sensors to measure acceleration.“We shook them as hard as we could, and we thought something was wrong, because the accelerations we measured were unexpectedly low,” Duhaime says. Instead, the force level shot up when the testers released the dummies after shaking them, even if they hit a soft surface like a bed or a couch.
Later experiments confirmed this finding and have made some doctors and biomechanical engineers skeptical that shaking alone can cause severe brain damage or death. At the same time, the experiments have not ruled this out, Duhaime says. Among other things, the dummies are not live children, and while their heads and necks can exhibit the effects of acceleration, impact on brain tissue is still hard to model.
Many doctors who treat child abuse say that decades of clinical observation, as well as confessions, show that it’s possible for shaking alone to cause the triad of subdural and retinal bleeding and brain swelling. A 2009 position paper from the American Academy of Pediatrics, written by Cindy Christian, recommends that doctors use the more general term “abusive head trauma” but also calls shaking an “important mechanism” of such trauma. Many doctors who testify for the defense agree that shaking could in theory cause the triad of symptoms but only if there is an injury to the neck or spinal cord, “where the breathing center is,” as one doctor puts it. It’s the absence of signs of this kind of an injury that makes some shaken-baby cases particularly fraught.
In 1993, Audrey Edmunds left her job as a secretary and started caring for children in her home near Madison, Wis. Like Trudy Rueda, Edmunds says that a baby she was taking care of, 7-month-old Natalie Beard, suddenly collapsed while drinking a bottle of milk; Natalie was propped up with the bottle in a car seat while Edmunds was out of the room getting her two daughters and another child ready for preschool. In the hospital, a CT scan showed that Natalie had the triad of shaken-baby symptoms but no spinal-cord injury. The baby died, and the doctors agreed that Edmunds, who was pregnant with her third child, had to be responsible. She was charged with first-degree reckless homicide.
At Edmunds’s trial, a librarian testified that she once heard a thump and then the cries of a child who was with Edmunds, but she didn’t see what had happened. Edmunds denied ever harming a child in her care. Her neighbors testified to her calm around children. Natalie “was a real fussy baby,” one said, “but Audrey was very patient with her.” Another day care provider in the neighborhood said, “I looked up to Audrey . . . when I started doing my day care.”
Still, the prosecution’s medical experts said that only Edmunds’s violence could explain Natalie’s injuries. A forensic pathologist, Robert Huntington, testified that the baby most likely had been abused at some point during the two hours before her collapse — which was when she was with Edmunds. The jury convicted Edmunds, and she was sentenced to 18 years; she went to prison two days after her youngest daughter’s first birthday.
A decade later, Edmunds had a hearing to determine whether she should have a new trial. Huntington this time took the stand on her behalf. When Keith Findley, her lawyer, asked whether Huntington was comfortable with his 1996 testimony, the pathologist said, “No, sir, no I am not.” He explained that in the years since her trial, he observed a child with subdural and retinal bleeding who was lucid for a period between her brain injury and her collapse. After that, he returned to the medical literature and found research to support this possibility. Huntington now believed that a “lucid interval is a distinct, discomforting but real possibility.” He said he could no longer precisely time the injury that caused Natalie’s death. For how long could Natalie have appeared relatively normal — fussy, but not obviously in crisis? “I’m sorry, I just don’t know,” Huntington said.
Huntington’s change of heart reflects a new explanation for the manifestation of brain injury in babies. In a 2001 study, the British neuropathologist Jennian Geddes found that most babies with the triad of shaken-baby symptoms suffered not from a rupture of the nerve fibers of the brain but rather from a lack of blood caused by oxygen deprivation to the brain’s cells.
The rupture of the brain’s nerve fibers is immediate and produces instant coma; the effects of oxygen deprivation can be slower and more subtle. This can explain how a child with the triad of shaken-baby symptoms could, for some period of time, seem fussy or lethargic or stop eating or sleeping well. In 2005, Christian co-wrote a study that concluded, “Although infrequent, young victims of fatal head trauma may present as lucid before death.”
This possibility introduces questions about whether the last person to care for a child before he or she stops breathing is necessarily guilty of abuse. In most cases of assault or murder, jurors could weigh this doubt in light of other evidence — witness testimony, perhaps, or the motive the defendant would have had to commit the crime. In shaken-baby cases, however, this kind of additional evidence is often absent. Doubts raised about the medical testimony loom large because it’s so central to the prosecution.
At Edmunds’s hearing for a new trial, five doctors joined Huntington on the side of the defense. Opposing them were four doctors for the prosecution. The Wisconsin Court of Appeals ruled in January 2008 that the disagreement among the physicians represented a shift in medical opinion and warranted a new trial: a jury would have to hear both sides. Edmunds called her daughters to tell them she was coming home. Six months later, prosecutors dropped the charges against her.
Audrey Edmunds’s successful appeal was built on a foundation laid by defense lawyers a decade earlier in the first big courtroom fight over shaken-baby syndrome. In that case, prosecutors in Massachusetts charged an English au pair, Louise Woodward, with the murder of 8-month-old Matthew Eappen, who stopped breathing in her care. Matthew had the triad of shaken-baby symptoms, along with a skull fracture. Woodward, who was 19, told the police that she shook Matthew lightly when she couldn’t wake him from a nap. Prosecutors decided that the shaking must have been violent. They also said that to cause the skull fracture, Woodward must have smashed Matthew’s head on a hard surface at a velocity of more than 25 miles per hour.
Woodward’s lead counsel was Barry Scheck, who went on to found the Innocence Project at Cardozo law school with Peter Neufeld. He enlisted seven medical experts, including Ommaya, the neurosurgeon who experimented with the rhesus monkeys, and Ronald Uscinski, a colleague. The defense’s theory was that Matthew’s skull fracture was three weeks old when he died, and that because of it, a slight jarring could have caused his fatal bleeding. Scheck didn’t try to explain how the fracture happened. “We didn’t know, so we didn’t claim anything,” he told me. But the defense experts testified that because tests showed no swelling at the site of the fracture, it had to be old.
The prosecution, for its part, lined up the doctors who treated Matthew at Children’s Hospital in Boston. Among them was Patrick Barnes, then a pediatric radiologist at Children’s. He had written, with another doctor, a chapter in a textbook that embraced the traditional theory of shaken-baby syndrome and shared the assumptions that pointed to Woodward’s guilt.
Barnes testified for the prosecution at the trial, saying Matthew’s brain scans showed his injuries were a result of shaking as well as a skull fracture. The prosecutors also asked Barnes to help them prepare for their cross-examination by briefing them on what to expect from the defense’s doctors. He spent evenings watching Court TV tapes of their testimony. He heard doctors from fields other than pediatrics — biomechanics,neurosurgery and neuropathology — discuss scientific findings about traumatic brain injury that contradicted his belief in the traditional method for diagnosing shaken-baby syndrome. He started to question his assumptions. “I’d been in lockstep with the child-abuse establishment for 20 years,” he told me. “For the first time, I saw that there were well-qualified experts on the other side giving opinions I’d never heard, that I knew nothing about.”
Woodward’s case ended in a stalemate. After the jury found her guilty of second-degree murder, the judge reduced the conviction to involuntary manslaughter and released her for time served. But a lasting legacy of that case was the eventual conversion of Patrick Barnes from an upholder of the medical orthodoxy surrounding shaken-baby cases to one of its strongest critics.
After Woodward’s trial, Barnes continued to think about his newfound doubts. He read widely in the medical literature. He started to look at brain scans brought to him by defense lawyers. In a New York case in which a father was being prosecuted, Barnes says, he found strong support in the medical literature for a diagnosis of infant stroke, which he thought was likely related to an infection like meningitis. Now he says that he sometimes sees other explanations for the triad of symptoms. “There are a number of things you have to look for in these children — infections, bleeding and clotting problems,” Barnes says. “Even now, I am most concerned about looking very carefully for predisposing or complicating medical conditions, in particular for infants younger than 6 months.”
Trudy Rueda’s lawyer asked Barnes to review Noah Whitmer’s brain scans before her trial. Barnes wasn’t able to testify because of a scheduling conflict, but he says the scans indicate that the baby had a thrombosis — a blood clot within a blood vessel. The prosecution’s doctors saw the thrombosis, too, but they claimed it was a result of abuse. To Barnes, the clotting suggested infant stroke, which can be triggered by an infection. He says the fact that Noah was not taking a bottle or napping normally in the days before he was hospitalized suggests that his condition could have been subtly deteriorating during that time. “It’s a very striking pattern,” Barnes says of the thrombosis. “The baby not eating well may reflect the process which starts this. Usually, it’s not a process that happens acutely and the baby crashes. It can start relatively slowly.”
Barnes also testified at Audrey Edmunds’s hearing challenging her conviction. He said that it was difficult to know for sure what had happened to Natalie Beard based on her scans; at the time of her death, hospitals were using CT scans, rather than also using M.R.I.’s, which provide more detail. But he did say that he saw the possibility of a thrombosis.
To a degree, some of the alternative explanations from defense-side doctors are accepted in the child-abuse field. A 2009 textbook that Cindy Christian co-edited includes a discussion of diseases and accidental injuries that can mimic the effects of abusive head trauma. Leventhal, the Yale pediatrician, told me about an unusual case involving an accidental fall. “A child who was sitting in a highchair and put his feet up on the table in front of him and rocked himself backward,” Leventhal said. “When the child was taken to the hospital, the ophthalmologist said, ‘This is shaken baby,’ because of the massive retinal bleeding. Luckily, there were seven people playing cards in the room when the baby fell.” Leventhal continued, “The subdural hematoma continued to bleed, and it turned out he had a previous bleeding disorder, a clotting problem.”
Leventhal and others in the child-abuse field emphasize that such hemorrhaging as a result of a fall is very rare. In order for doctors to determine what caused an injury, they begin with a list of alternatives, ruling out the ones that don’t match a patient’s symptoms until they arrive at a diagnosis, with a reasonable degree of medical certainty. But defense-side doctors like Barnes say that in a criminal case, physicians should be more careful about testing their assumptions, and they should give the possibility of an alternative explanation — a stroke, say, caused by an infection — more weight.
It’s on this question of probable causes that the doctors who testify in these cases split. Prosecution-side experts rely on a set of studies that indicate that when children have subdural bleeding and extensive retinal hemorrhaging, they are far more likely to have been abused than injured in any other way. In a 2010 paper in Pediatrics, Christian and the pediatric ophthalmologist Alex Levin concluded that the evidence supporting the “diagnostic specificity” of “severe” retinal hemorrhaging has significantly increased. “Some children have such severe retinal hemorrhaging that it is much more likely to be from abusive head trauma,” Christian told me. She testified to this at Rueda’s trial, because Noah Whitmer had severe retinal hemorrhaging. Levin similarly called Natalie Beard’s retinal bleeding “textbook severe” when he testified for the prosecution at Audrey Edmunds’s 2007 hearing. When the prosecutor asked him how significant these findings were for diagnosing shaken-baby syndrome, Levin answered: “Very important. We really don’t have any other cause for this particular kind of hemorrhaging and retinal findings.”
Defense experts, however, criticize the methodology of these studies. And even taken at face value, they say, the studies show that severe retinal hemorrhaging is far more common in abuse cases, not that it’s never found in any other circumstance. At the 2010 meeting of the American Academy of Forensic Sciences, the Canadian forensic pathologistEvan Matshes presented the results of a study, under peer review, of 123 autopsies performed on infants in Miami-Dade County who died under natural or accidental circumstances, or from homicides. Of the children with retinal hemorrhages, 53 percent died from accidental or natural causes, and 47 percent died as a result of homicide. Severe retinal hemorrhages were identified in some of the children in the accident group. Although the children in the homicide group were more likely to have severe retinal hemorrhages than the other groups, this finding could be explained by factors other than abuse, according to Matshes. The children in the homicide group had isolated head injuries and were more likely to be resuscitated for a period of time, he says. In the aftermath, they were more likely to develop brain swelling and bleeding disorders that may explain the severe retinal hemorrhaging. Matshes puts his conclusions like this, “It is simply incorrect to state that severe retinal hemorrhaging is diagnostic of abuse or shaking.” He is now working on a study that looks at whether infants with subdural and retinal hemorrhaging might in fact have neck injuries, which could indicate shaking, that go undetected, because doctors haven’t looked in the right place for them. Matshes and his team are conducting autopsies of the entire cervical spinal column, which is not usually dissected in shaken-baby cases. The goal is to determine whether injuries there could explain how shaking can cause brain damage or death — and whether this additional diagnostic tool might one day help distinguish which babies have in fact been abused, and which have subdural and retinal bleeding from other causes.
Underlying the clash over the medical research on shaken-baby syndrome is another one about human nature. How likely is an adult with no history of wrongdoing to do terrible harm to a child by violently shaking it? To pediatricians like Leventhal and Christian, the sad answer, born of experience, is that such a lapse is all too possible. When I described Trudy Rueda’s case to Leventhal, he told me about cases in which he had met and liked a parent or caregiver who ended up confessing to harming a child. Was there truly no indication that the adult in question was capable of such an act? The doctors who treat abused children insisted that sometimes, there isn’t. They described disturbing confessions, like one that made headlines in Florida last year after a 22-year-old mother told the police that she had shaken her 3-month-old baby and perhaps caused him to hit his head, because he wouldn’t stop crying while she was playing FarmVille. Leventhal cites a 2010 study that included 29 people who confessed in the French courts to shaking infants and who described the abuse as extremely violent.
Doctors like Barnes, on the other hand, emphasize that confessions are not always reliable. The exonerations of recent years have shown that people sometimes falsely admit to crimes because of police pressure or the promise of a plea bargain. In the first case from Canada’s shaken-baby inquiry to reach the Ontario Court of Appeal, the judges overturned the conviction of Dinesh Kumar, a 44-year-old father who pleaded guilty to shaking his 5-week-old son to death. Kumar says now that at the time of his guilty plea, he believed he had no hope of prevailing against the damning testimony of the state’s pathologist, who has since been discredited for giving error-riddled testimony based on botched autopsies.
In response to the critics who question the basis for some shaken-baby convictions, many in the child-abuse-treatment field have fired back with a critique of their own. Christian and Leventhal dismiss defense-side experts’ alternate explanations, like Uscinski’s theory that children suffer spontaneous rebleeds from birth injuries. “Every year they come up with a new alternate theory that we have to refute,” Christian says.
Normally, of course, this is how science progresses: One researcher comes up with a hypothesis, which others question and test. But shaken-baby cases are haunted by the enormous repercussions of getting it wrong — the conviction of innocent adults, on the one hand, and on the other, the danger to children of missing serious abuse. In one study, researchers looked into the deaths of five children who had head injuries that initially were misjudged to be accidents and found that four of them could have been prevented if an earlier pattern of abuse had been detected. If parents are the focus of a shaken-baby investigation, doctors must weigh this risk in helping the state determine whether a child should be removed from the home. “When babies are sent home with an injury that’s misattributed to an accident, we know that one-quarter to one-third of them will come back with another serious injury or, in some cases, death,” Leventhal says.
Barnes, who is now part of a child-abuse-protection team at Stanford, doesn’t dispute the need to investigate shaken-baby symptoms. But he says that most of his colleagues don’t present the science dispassionately. “They have built their careers, their entire standing on this issue.” His opponents, for their part, dismiss the defense experts as hired guns. “They’re aggrandizing themselves and making a lot of money testifying,” says Robert Block, the president-elect of the American Academy of Pediatrics. While it’s true that experts like Uscinski can make six figures a year testifying (he says he testifies free when a defendant cannot afford to pay him), it’s also the case that some witnesses for the prosecution are paid. Barnes no longer takes fees to testify in either criminal or custody cases. Neither did four of the other five defense experts who testified for Audrey Edmunds.
Last September, the fight among the doctors broke out in public on the Web, after Deborah Tuerkheimer, a former prosecutor and a law professor at DePaul, wrote a New York Times Op-Ed warning of wrongful convictions and calling on the National Academy of Sciences to referee the shaken-­baby-syndrome dispute. On the Web site CommonHealth, about 20 doctors commented, mostly to express outrage. One of them was Block. He wrote that Tuerkheimer had “been beguiled by a group of physicians who are using the courtroom to distort science, facts and reality.” And he denounced her for “furthering the cause of the so-called innocence project.”
Philipp Baumer was born after a difficult delivery and spent his first week in the newborn-intensive-care unit. His mother, Victoria, who had given up her last baby for adoption, struggled with drug addiction. Her sister Julie, who was 27 and a loan officer for a mortgage company, was helping take care of Victoria’s oldest child. She volunteered to adopt Philipp. “I didn’t want to see anyone else leave the family,” she told me in November when I met her in Ann Arbor, Mich.
When Philipp came home, neither Julie Baumer nor her parents could get him to take a bottle regularly. On Oct. 3, 2003, when he was 6 weeks old, Philipp was not able to keep down food for 12 hours, Baumer says. She called his pediatrician, who sent her to the emergency room at Mount Clemens Regional Medical Center outside of Detroit.
The E.R. doctor who saw Philipp found he was dehydrated and septic, gave him fluids andantibiotics and ordered a CT scan. But the test was canceled when Philipp was scheduled for transfer to the region’s specialty facility for pediatrics, Children’s Hospital of Michigan in Detroit. At Children’s, Philipp went straight to intensive care. But he waited 28 hours for the CT scan. By then, Philipp had been in the hospital for a total of 33 hours. The scan showed subdural bleeding, which was so extensive that his fontanelle (the soft spot on a baby’s head) was bulging. An ophthalmologist saw retinal bleeding. Philipp also had a skull fracture, although it was not near the site of the hemorrhage. In an emergency operation, a shunt was placed to relieve the pressure on Philipp’s brain, but it was too late to prevent severe damage. Philipp, who is now 7, has cerebral palsy; he cannot walk on his own, talk or see.
Four months after Philipp’s injuries occurred, Julie Baumer was charged with child abuse in the first degree. The prosecutor didn’t present a theory about why Baumer would have harmed Philipp, saying that it was the state’s job to show that Baumer intended to shake the baby, not what motivated her. Two doctors from Children’s Hospital testified for the prosecution: Steven Ham, the neurosurgeon who put in the shunt; and Cristie Becker, a radiologist who treated Philipp later. Becker said Philipp’s injuries were inflicted by shaking and timed them to “likely within 24 hours” of the CT scan. She said the skull fracture may have been an old birth-related injury. Looking at the scan, Ham said the fracture was new and that Philipp’s injuries were the result of blunt-force trauma that occurred “within the previous 12 to 24 hours.” He said he could pinpoint the timing based on “how sick the child was, and then the fact that in looking at the scan we could see fresh blood in the scan.”
Becker and Ham didn’t note in court that their 24-hour time frame meant that Philipp would have started hemorrhaging while he was at Children’s — and no longer in Baumer’s care. (When I called Becker, she said, “I don’t care to revisit that issue, and best of luck trying to find the truth in the midst of that trial.” Ham did not return my calls.) Baumer’s trial lawyer failed to point out this flaw in the prosecution’s case. The lawyer also did not find a defense expert who could read Philipp’s brain scans. Baumer had no money to hire one, and her lawyer didn’t know that he could have asked for court funds to cover the expense. In 2005, Baumer was convicted and sentenced to 10 to 15 years.
Baumer was raised Catholic, and in 2007, a nun saw her name on a prayer list and came to visit her in prison. When she heard her story, the nun asked Baumer if she needed a new lawyer and wrote on her behalf to Charles Lugosi, then a professor at the Catholic law school Ave Maria. Lugosi agreed to take Baumer’s case and enlisted the help of a former prosecutor, Carl Marlinga, who had opened a defense practice. Later, theUniversity of Michigan Innocence Clinic joined the defense.
The defense team sent Philipp’s brain scans to Patrick Barnes. At the bottom of the images, Barnes saw a distinctive bright triangle surrounding the major vein that brings blood in and out of the brain. To Barnes, the triangle clearly pointed to a diagnosis unrelated to abuse: Venous sinus thrombosis, or stroke, probably from an infection — an explanation similar to the one Barnes gave for Noah Whitmer’s injuries. Another radiologist and a forensic pathologist concurred with Barnes’s reading of Philipp’s scans. The defense experts also saw suggestions of an earlier smaller stroke, which could have triggered the feeding problems that led Julie to call Philipp’s pediatrician. This reading of the scans matched the time frame Becker and Ham had given at trial: Philipp could have started to show some symptoms, and then had a major stroke after he was admitted to the hospital. The defense experts agreed with Becker that the skull fracture was old. They said it was likely the result of Philipp’s difficult birth.
This testimony won Baumer a new trial. It also gave the defense team an answer to the question that hovers over every shaken-baby prosecution: What happened to hurt the child? During a trial, solving that mystery isn’t supposed to be the defense’s responsibility — the burden of proof rests with the prosecution. But a credible response makes it easier to lift the weight of the medical evidence from the shoulders of the defendant.
At Baumer’s second trial, which took place in October, the defense called neighbors and friends who testified that she was gentle and loving with children. The prosecution introduced no evidence to the contrary. Baumer has two drunken driving offenses on her record from the late 1990s, but they weren’t introduced at the trial.
Back on the stand, Ham and Becker now said they had misspoken about the time frame, and came up with new estimates: Becker said that Philipp’s internal bleeding could have begun five days before the CT scan, and Ham said one or two days. They both remained convinced that Philipp’s hemorrhages were inflicted. “Before they testified, they both said that it was their opinion from the beginning that the injuries occurred before Philipp came to the E.R.,” Richard Goodman, the prosecutor at the second trial, says. And the prosecution’s doctors disagreed with Barnes and the other defense-side experts that Philipp’s scans showed a thrombosis. On cross-examination, Baumer’s lawyer, Marlinga, asked Ham and Becker if they were trying to deflect criticism of the hospital for failing to give Philipp the care he needed because of the delay of his CT scan. The doctors denied that their revised testimony had anything to do with protecting the hospital.
The jurors began their deliberations by taking a poll. Nine out of 12 thought Baumer should be found not guilty. “For me, it came down to this: For the prosecution to be right, I was required to believe that a woman with no history or indication of violent tendencies or instability hit this baby’s head so hard that she fractured his skull, and shook him so hard that she caused extensive brain damage, while leaving no marks on him,” says Carman Minarik, a juror who is a minister at First United Methodist Church in Mount Clemens. “That just didn’t make a lot of sense to me.”
Sera Miller, a claims representative for the Social Security Administration, was one of the three jurors who thought at first that Baumer was guilty. She found the medical testimony dense and confusing. “I think we needed 12 doctors on that jury,” she said. After an afternoon of deliberations, she went home and couldn’t sleep. In the morning she decided that the defense had done enough to introduce reasonable doubt. The jury found Baumer not guilty.
When Philipp was 3 months old and ready to leave the hospital, he was put into foster care with Debi and Phil Zentz, who later adopted him and changed his name to Ben. When the second jury announced that it found Baumer not guilty, the Zentzes were in court. Baumer looked at Debi. “I was hoping for a bridge between the families,” Baumer says. Instead, Debi Zentz gave this statement to the press: “The verdict does not change our belief. Reasonable doubt does not equate to innocence.” When I called her in January, she said, “I have absolutely no doubt that Julie Baumer shook and horribly injured my son.”
The Whitmers also feel certain that Trudy Rueda harmed their son and that she wronged them by putting them through a trial. “We got to a point where we said that if she stands up and admits what she did, we might be able to put this behind us,” Michael Whitmer said. “But now, how do you forgive?”
He and his wife were sitting on a couch in their living room, in the Cape Cod-style house in Alexandria, Va., that Michael renovated by hand. Noah, his blue eyes sometimes focused and sometimes vacant, walked a bit unsteadily on the floor in front of us, picking up books and toys and putting them in his mouth. Noah can see now because a few months after his injury, he slept standing up for weeks to drain the blood from behind his eyes. His seizures have stopped, but only thanks to a strict and labor-intensive ketogenic diet. How could the Whitmers forgive, given the medical testimony from doctors they trust? Rueda’s conviction is now on appeal, with a hearing scheduled for mid-February.
As for Audrey Edmunds, she has been out of prison for about three years. Now 49, she is blond and slim, and when I met her at a mall near her home outside Minneapolis, she talked to me about her three daughters. She wore jeans and open-toed sandals and showed me pictures of her children at a Twins game and talked about the delight she takes in taking snacks to her youngest girl’s soccer practice. For a few minutes, her 11 years in prison seemed like a balloon she has let go.
But Edmunds does not live with her children. Her husband divorced her four years into her sentence; she says the separation was just too much for him. He stopped taking the girls to see her every week. When she got out of prison, she moved in with a friend and took a job at a Kwik Trip convenience store. Better work is hard to come by because of the time Edmunds served in prison. She also wants the early shift so she can see her kids in the afternoons. Sometimes, though, they go on a trip with their father and forget to call. “I was gone for so long,” she says.
Edmunds said, however, that she had to come to terms with the drive to prosecute her. As we walked through the mall, she pointed out a Dora the Explorer display she thought young kids would like. Then she turned away from it. “A baby has died,” she said simply. “They want to blame somebody.”
Emily Bazelon, a contributing writer, is a senior editor at Slate and the Truman Capote law-and-media fellow at Yale Law School.