by Richard Ruelas - Sept. 15, 2012 10:53 PM
The Republic | azcentral.com
Read more: http://www.azcentral.com/news/articles/20120904shaken-baby-fatalities-doubts.html#ixzz26caFCTUv
Drayton Witt kept insisting he had nothing to do with the death of his 4-month-old baby. He said it the night he brought the near-comatose infant into the emergency room on June 1, 2000. He said it during his sentencing, following his conviction on murdering the boy by shaking him. And he was still proclaiming his innocence as he started serving his 20-year sentence in 2002.
His lamentations didn't gain legal and medical weight until 2012. The Arizona Justice Project, a volunteer group of attorneys, filed a motion to toss out his murder conviction based on the evolving science around what was known as shaken-baby syndrome. The state did not file an argument in response. Witt was released on May 31, becoming the second Arizonan in the last two years to see his guilty verdict in a shaken-baby case erased.
Among those who helped secure Witt's freedom was the 97-year-old British pediatric neurosurgeon who, in 1971, first identified the trio of telltale symptoms that became accepted as proof that a baby had been violently shaken. Attorneys also secured a sworn statement from the medical examiner who originally ruled the baby died from being shaken. His revised conclusion was that the baby died of a disease.
Fifteen months earlier, in February 2011, a Buckeye man named Armando Castillo, 42, had his conviction overturned in the 1998 death of a toddler. Like Witt, Castillo maintained his innocence throughout. And, like Witt, Castillo would be imprisoned a long time before attorneys found medical evidence to back up his story.
In both cases, judges ruled that a jury would likely acquit each man after hearing the new medical understanding of the evidence.
The overturned convictions didn't erase the charges, just sent the cases back for a possible retrial. Prosecutors decided to keep pursuing murder charges in both cases. Castillo pleaded guilty to a reduced charge to avoid the risk of a retrial. Witt's murder trial is scheduled for 2013.
Maricopa County Attorney Bill Montgomery said that his office still believes that Witt was responsible for the death of the 4-month-old baby boy. "Obviously, we believed it the first time around," Montgomery said.
He said prosecutors now focus more on proving that a child was injured, not necessarily that he was shaken. Montgomery said speculation that suspected abused children died from diseases was just defense-attorney theories.
"I think we're still looking at cases where children were injured," Montgomery said. "How we prove that may change."
That's because a growing body of medical and legal experts, nationally and internationally, are casting doubt on what became known as shaken-baby syndrome. Pediatric neurologists and forensic pathologists say the long-held triad of symptoms -- bleeding on the brain, swelling of the brain and bleeding in the eyes -- thought to indicate a baby was violently and intentionally shaken could also be caused by a host of diseases, including infections.
DePaul University law professor Deborah Tuerkheimer, who wrote a 2009 study on the use of shaken-baby syndrome in courtrooms, said the easily spotted symptoms became not only a medical diagnosis but also a legal tool adopted quickly and used convincingly in courtrooms nationwide.
Physicians would testify that a shaken child would become unresponsive or go limp almost immediately after the abuse. So the last adult with the child would be the primary suspect. And the shaken-baby diagnosis also provided a motive: a frustrated caregiver looking to quiet a crying child.
Some shaken-baby cases included other signs of violent abuse, such as broken bones, bruises or fractures. But others, like in Witt's case, had no outward signs of injuries. Cases were built solely on the symptoms of shaken-baby syndrome.
"(The syndrome) did all of the work," Tuerkheimer said. Jurors would hear the experts testify with certainty and couple that with an "inclination to want to convict and hold someone responsible for such an awful outcome," she said.
In the last half of the 1990s, the Maricopa County Attorney's Office handled shaken-baby cases at the rate of two a week. During one stretch, it had a conviction rate, in non-fatal cases, of 84 percent.
Tuerkheimer said many of the defendants were convicted in emotional trials, while others took plea deals because they saw little chance of winning. She said there's no way to know whether the Witt and Castillo cases are isolated wrongful convictions or signs of a systemic flaw that will produce hundreds of reversals.
"No one has any sense of the numbers here," Tuerkheimer said.
Witt knows he is No. 2, the second shaken-baby conviction in Arizona to be vacated. But he figures the pattern that police and prosecutors followed in his case was repeated many more times.
"The system is flawed," he said. "I'm sure there's a lot of people like that."
* * *
Maria Holt's baby son, Steven, was just shy of being 5 months old on June 1, 2000. Dressed in a blue and white onesie, he slept in his car seat as Witt dropped Holt off for her evening shift as a waitress at the Bill Johnson's Big Apple restaurant in north Phoenix.
Witt, then 18, and Holt, then 20, had been boyfriend and girlfriend since they'd met two years before, but Steven had been conceived with another man during a breakup. Regardless, Witt saw the baby as his son; he was in the delivery room when Steven was born, and the child carried his last name. It was routine for Witt to care for Steven when Holt was at work; she often called home between tables to check in.
During one call around 8 or 9 that night, Witt told Holt he thought Steven might have had another seizure. His eyes appeared odd, Witt said, and he was fussy. Holt said to come get her at the restaurant and they would take the baby to the emergency room.
Steven had been a sickly baby, in and out of the hospital three times during his short life, including a six-day stay at Phoenix Children's Hospital just a month earlier when doctors couldn't get a bead on what was causing the baby's vomiting and seizures.
On this night, the boy stopped breathing during the 6-mile drive from the restaurant to Paradise Valley Hospital. Witt pulled over and climbed into the back seat to perform CPR while Holt took the wheel. At the hospital, doctors worked to get Steven breathing again. Then the baby's heart stopped. It took them about 30 minutes to stabilize him, after which he was flown to Phoenix Children's Hospital.
A doctor at Paradise Valley Hospital, in a report, diagnosed the cardiac arrest and said the baby was suffering from dehydration and possibly sepsis, a severe reaction to bacteria. He also expressed concern about brain injury caused by dehydration, too much acid in the blood, and not enough oxygen. There was no mention of suspected abuse.
Witt and Holt left Paradise Valley Hospital to drive to Phoenix Children's. Expecting another long hospital stay, they stopped by their home to pick up extra clothes.
* * *
The idea that violent shaking of infants could cause brain injury was first proposed in a medical-journal article in 1971. Not only did it gain acceptance in the medical community over the next two decades, it also seeped into popular culture. Child-abuse prevention groups started awareness campaigns; the phrase "shaken-baby syndrome" entered the Random House dictionary in 1996.
By 2001, the American Academy of Pediatrics produced a position paper on shaken-baby syndrome, saying that doctors should presume abuse in any baby under a year old who had head injuries absent obvious trauma, such as a car accident. The paper, published in the journal Pediatrics, said the "constellation" of injuries in a shaken baby could not result from an accidental trip or fall.
The article also offered a psychological profile of adults who shake a child. "Such shaking often results from tension and frustration generated by a baby's crying or irritability," the journal article said, "yet crying is not a legal justification for such violence." It went on to warn that shaken babies were often misdiagnosed, meaning doctors needed to be extremely vigilant to spot them.
After Steven arrived at Phoenix Children's Hospital, a doctor who evaluated him wrote that the baby had no bruising or skull deformities, but showed some bleeding in the eyes. The doctor also noted that "the infant is flaccid. There is no response to pain."
At 3 a.m., a pediatrician wrote on a progress report that the baby's symptoms "raise the possibility of non-accidental trauma."
Medical records show doctors knew their infant patient had been at the hospital a month before for projectile vomiting and flulike symptoms. But by 7 a.m., doctors felt sure of what they were looking at.
"The findings are most consistent with shaken baby, plus or minus hypoxia injury," read a doctor's progress report on the case. Hypoxia refers to an injury caused by lack of oxygen.
Steven's condition did not improve. At noon, doctors declared him brain dead. One wrote the following: "Mom is currently hugging the patient and we are planning to withdraw support and allow him to progress to cardiac death later on this afternoon. The police have been notified of the findings."
Steven was pronounced dead at 3:30 p.m. on June 2.
* * *
In a case where shaken-baby syndrome seems a possibility, events quickly and simultaneously move along parallel tracks: doctors working to save a baby, police working to find a suspect.
But once doctors and police believe they are dealing with a shaken-baby case, they often ignore evidence that might suggest a different reason for a baby's illness, said Christina Rubalcava, an attorney with the Arizona Justice Project.
"You're already locked in to what it is," said Rubalcava, an attorney with Osborn Maledon who volunteered her time on the Witt case. She says that in general, once a doctor sees the triad of symptoms, a call to child-welfare agencies and police becomes automatic. The belief in shaken-baby syndrome "is like gospel to them," she said.
But Kathy Coffman, a pediatrician at Phoenix Children's Hospital who specializes in abuse cases, denied that doctors automatically diagnose shaking and ignore disease or infections or other causes. "We go through all the factors to make sure we're not missing something," Coffman said.
Coffman, a pediatrician for 20 years, was not at Phoenix Children's Hospital when Steven was treated and would not comment specifically on this case. She now is the medical director of a specialized unit at the hospital, made up of doctors and social workers, that handles suspected cases of abuse. "I don't think anybody who works in this field, law enforcement or anybody, is cavalier about making these calls," she said.
"The absolute last thing I want to do," she said, "is have someone go to prison for something they didn't do."
In the early morning hours of June 2, Phoenix police interviewed Witt and Holt as they sat in a room near their child. The questions seemed accusatory from the start, Witt said, and he ended the interview. A worker with the state's child-protection agency, in a report written later that morning, would say officers described Witt as "short-tempered and volatile."
After Steven died and Witt and Holt were leaving the hospital to go home, they found their car missing; police had seized it from the parking lot to search it for possible evidence. Friends drove them home, where they found two officers, armed with a warrant, who had been searching the trailer since 11:30 a.m. -- 4 hours before Steven died -- to find evidence to build a case.
"One thing after another," Holt said. "It's heartbreaking."
The police left at 9:30 p.m. They had pulled up carpet samples and took some baby items. The next day, officers knocked on the door and asked to take Witt in for questioning.
"Let's go," Witt said. "I ain't got nothing to hide."
Witt is a man of few words and didn't offer many to police. When detectives questioned him about what happened to the baby, Witt replied that he didn't know and that they should ask the doctors.
Witt was booked into jail on charges of first-degree murder and child abuse. He would remain jailed until his trial.
Holt said the arrest was devastating. "I lose my son, and then I lose the man who's done nothing but love me and love my son," she said. She had support from her extended family but felt some friends slip away. When she visited Witt in jail, which was often, she worked to buoy his spirits: "You'll be home soon," she would say. "This is just a misunderstanding. We know the truth."
Witt had a public defender who tried to get a plea deal, but Witt refused to take it. "When they arrested me, I figured somewhere down the line they'd come to their senses and figure out the right stuff," Witt said. "But clearly they didn't."
The trial started in February 2002.
"Steven Witt lived only five months," the prosecutor, Dyanne Greer, told the jury in her opening statement, according to a transcript. "He died as the result of violent, severe shaking. ... He died at the hands of a person who was supposed to be the caretaker ... and that man, ladies and gentlemen, is Drayton Witt."
Holt was called to the stand; she would be the first witness. It would be her job to tell the couple's story: how they "just clicked" when they first met through a friend; how Holt's extremely protective dog immediately warmed up to Witt; how, when she became pregnant by another man, Witt treated the child as if he were his own. She also told the jury about the baby's history of illnesses and hospitalizations, which included a respiratory infection, pneumonia, seizures and vomiting, and how the medicine he was given only seemed to make him worse.
After Holt, four doctors and the medical examiner took the stand. Each testified that Steven's injuries were most likely caused by shaking. To the jury, the evidence would have seemed strong and specific: The boy had certain injuries that, in the absence of major trauma, were possible only if he had been shaken violently. And the narrow, medically accepted time frame of the onset of the baby's symptoms pointed to Witt.
Witt, seated at the defense table, still held out hope. But his defense attorney called only one expert to cast doubt on whether the injuries were caused by shaking. Karen Griest, a forensic pediatric pathologist and former New Mexico coroner, said that "shaken-baby syndrome is sort of a hot topic of debate in the medical community. It's sort of an evolving process to figure out what is going on."
In closing arguments, the prosecutor painted a picture for the jury of Witt shaking the child.
"The defendant knowingly grabbed Steven, shook him so violently that he started to seize," Greer said. "Drayton had to know that Steven was being violently injured while he was shaking him to death, inches in front of his face," she said.
Jurors found Witt guilty of second-degree murder. When it came time for Witt's sentencing in April 2002, he told the judge that although he had been an unruly teenager, he had turned his life around with Holt and Steven. But he was not apologetic.
"I am not sorry, for I didn't do no wrong," Witt said, according to a transcript of the hearing. "I came up here to tell you how much my son meant to me."
The judge sentenced him to 20 years.
* * *
Though Witt asked for protective custody in prison, he said the request was denied, and he was put into the general inmate population. Three years into his sentence, he was attacked in the recreation yard by three men with improvised knives. Witt tucked himself into a ball and tried to cover his head, but said he was stabbed some 70 times before it was over. Ten of those wounds went through one or the other of his hands.
Witt was flown to a Flagstaff hospital, where doctors did surgery to repair his hands. Holt was at work when she got the call from Witt's parents telling her of the attack. When she saw him in his hospital bed, she knew they had to get married.
"Just wanting to make sure that he knew that I was there," she said. "And no matter what, he knew that if it came to 2020, I might be old and gray, but that I would be the one standing by that gate (waiting) for him to come home."
The wedding was in September 2006. The groom wore orange, his "carrot suit," as Witt called it. Prison rules dictate what a bride may wear: A wedding dress must have a neckline above the collarbone and sleeves that cover the arms. And no orange; that color is reserved for inmates. In the end, Holt just bought a dress she liked -- it was maroon -- and pulled a T-shirt over it during the ceremony to cover enough bare skin.
Tradition endures even in the strangest of settings. Witt said he paced in his cell nervously before the ceremony, held just before visiting hours. He would get to wear his wedding band in prison, but the bride had to provide prison officials proof of purchase. Guards did allow the groom to kiss the bride.
"It's emotional, no matter what," Holt said.
At the time of the wedding, all of Witt's appeals had been denied and exhausted. It appeared he would be in prison until 2020.
* * *
In 2009, Deborah Tuerkheimer published her paper, "The Next Innocence Project: Shaken Baby Syndrome and the Criminal Courts" in the Washington University Law Review.
"In its classic formulation, SBS comes as close as one could imagine to a medical diagnosis of murder," Tuerkheimer wrote. "Prosecutors use it to prove the mechanism of death, the intent to harm, and the identity of the killer."
Also that year, the American Academy of Pediatrics revised its position paper on shaken-baby syndrome. It urged physicians to stop using that term and instead describe injuries as "abusive head trauma." The group said it urged adoption of the "less mechanistic term" to stop the focus on shaking. Instead, the journal said, doctors should look at a wider range of possible causes.
Witt's prison records show that he was a model inmate after his marriage. He had been moved into protective custody following his assault. While there, he met Armando Castillo, another man who had been convicted of shaking a child to death.
The Arizona Justice Project filed its motion in Castillo's case in April 2010; his conviction was vacated 10 months later. The project took up Drayton Witt's case in 2011, and the news was a blast of hope, Maria Witt said. "You get that light sparked back in your life."
Those working on Witt's case assembled a list of medical experts who reviewed Steven's autopsy photos and medical records. Most concluded that Steven's death was likely caused by a blockage in the vein that drained blood from his brain.
The attorneys also spotted a letter in the New York Times Magazine from Norman Guthkelch, the British pediatric neurosurgeon who first wrote about the symptoms that indicated a shaken baby. In the letter, a response to an article about the changing medical opinions about shaken-baby syndrome, Guthkelch defended his 1971 paper that concluded babies can get severe brain damage from shaking. The city under Guthkelch's name: Tucson.
The Project attorneys asked Guthkelch to look at the records in the case. He filed an affidavit in support of Witt, which marked his first legal involvement on behalf of a person trying to reverse a shaken-baby conviction.
"The death of Steven Witt is the type of case where a diagnosis of Shaken Baby Syndrome should not have been made," Guthkelch wrote. He said there were too many other possibilities that could explain the baby's death, and that while his process offers a possible explanation for some head injuries, any presumption that an injured child was shaken was a "distortion" of his theory.
Also key to the case was the affidavit of A.L. Mosley, the county medical examiner who performed the autopsy on Steven. Mosley was shown new analysis of his autopsy by doctors who spotted errors in his work. Most notably, doctors said, autopsy photos showed a blocked and swollen vein that was not noted in the report.
Mosley, in his affidavit, concluded that "if I were to testify today, I would state that I believe Steven's death was likely the result of a natural disease process, not (shaken-baby syndrome)."
Witt's attorneys filed the motion in February. The state did not file a response. The judge vacated Witt's conviction and ordered his release.
* * *
The newly cast scientific thought on shaken-baby syndrome is affecting other cases. A 2007 case against Lisa Randall, a day-care operator, originally filed as a death-penalty case, was tossed out before it reached trial. An expert hired by the prosecution in 2010 concluded that the child did not die from shaking as originally thought.
In 2009, prosecutors dropped murder charges against Craig Rettig in a shaken-baby case from 2004. The defendant's lawyer located experts who found that the baby died from striking his head on a coffee table, not from being shaken.
Also, in 2009, Keith Roberts asked that expert testimony about shaken-baby syndrome not be allowed in his trial on charges that he killed his infant son. The Maricopa County Attorney's Office argued that both sides should present their experts and leave it for the jury to decide. The judge agreed. Roberts took a plea offer the day before his trial was scheduled to begin. He was sentenced to eight years in prison.
Witt was released from custody wearing a jail-issued paper suit. He borrowed a cellphone from a passer-by to call his wife. It was 8 a.m. She had been told he wouldn't be released until noon. She broke speed-limit laws driving from the opposite end of town to get him.
Maria Witt said having her husband out of prison is validation.
"To finally have people believe in me," she said, "and be able to start the grieving process and what we missed out on, and be able to start on the life that we missed out on, is more precious than anything."
Drayton Witt, who is working on a construction crew, said he often feels like a modern-day Rip Van Winkle, awakening to find a world where so much is accomplished by cellular phone, or that there are self-checkout lanes at the grocery store.
Witt does not want to take a plea deal like his friend, Castillo, did. He hopes prosecutors drop the case before his trial next year.
He does not blame police or prosecutors for the decade he spent behind bars. He said officers and attorneys were just doing their job. And he always figured the truth would win out.
"You keep screaming," he said. "Eventually, someone will hear you."
Reach the reporter at richard.ruelas@arizonarepublic.com.
Read more: http://www.azcentral.com/news/articles/20120904shaken-baby-fatalities-doubts.html#ixzz26ca27TaF
Showing posts with label new research. Show all posts
Showing posts with label new research. Show all posts
Sunday, September 16, 2012
Wednesday, April 4, 2012
A RESOLUTION urging the members of the United States Congress to take necessary action to propose the Parental Rights Amendment to the United States Constitution for ratification; and for other purposes.
11 LC 35 2236ER
H. R. 738
- 1 -
House Resolution 738 By: Representatives Neal of the 1st, Weldon of the 3rd, Williams of the 4th, and Jasperse of the 12th
A RESOLUTION
1 Urging the members of the United States Congress to take necessary action to propose the
2 Parental Rights Amendment to the United States Constitution for ratification; and for other
3 purposes.
4 WHEREAS, the right of parents to direct the upbringing and education of their children is
5 a fundamental right protected by the Constitutions of the United States and the State of
6 Georgia; and
7
8 WHEREAS, our nation has historically relied first and foremost on parents to meet the real
9 and constant needs of their children; and
10 WHEREAS, the interests of children are best served when parents are free to make child
11 rearing decisions about education, religion, and other areas of a child's life without
12 government interference; and
13 WHEREAS, in 1972, the United States Supreme Court in Wisconsin v. Yoder held that "This
14 primary role of the parents in the upbringing of their children is now established beyond
15 debate as an enduring American tradition"; and
16 WHEREAS, in 2000, the United States Supreme Court in Troxel v. Granville produced six
17 different opinions on the nature and enforceability of parental rights under the United States
18 Constitution; and
19 WHEREAS, this more recent decision has created confusion and ambiguity about the
20 fundamental nature of parental rights in the laws and society of the several states; and
21
22 WHEREAS, the United Nations Convention on the Rights of the Child has been proposed
23 and may soon be considered for ratification by the United States Senate, which would11 LC 35 2236ER
H. R. 738
- 2 -
24 drastically alter this fundamental right of parents to direct the upbringing of their children;
25 and
26 WHEREAS, this convention has been acceded to by 192 nations world wide and has been
27 cited by United States courts as "customary international law"; and
28 WHEREAS, international influence is being exerted on the United States Supreme Court, as
29 demonstrated by the 2005 decision of Roper v. Simmons, where "the Court has referred to
30 the laws of other countries and to the international authorities as instructive for its
31 interpretation" of the United States Constitution; and
32 WHEREAS, Senator James DeMint of the State of South Carolina and Representative Peter
33 Hoekstra of the State of Michigan have introduced in the United States Congress an
34 amendment to the United States Constitution to prevent erosion of the enduring American
35 tradition of treating parental rights as fundamental rights. The amendment is outlined as
36 follows:
37 SECTION ONE: The liberty of parents to direct the upbringing and education of their
38 children is a fundamental right.
39 SECTION TWO: Neither the United States nor any State shall infringe upon this right
40 without demonstrating that its governmental interest as applied to the person is of the
41 highest order and not otherwise served.
42 SECTION THREE: No treaty may be adopted nor shall any source of international law
43 be employed to supersede, modify, interpret, or apply to the rights guaranteed by this
44 article; and
45 WHEREAS, this amendment will add explicit text to the Constitution of the United States
46 to protect in perpetuity the rights of parents as such rights are now enjoyed, without
47 substantive change to current state or federal laws respecting these rights; and
48 WHEREAS, the enumeration of parental rights in the text of the Constitution will preserve
49 and protect such rights from being infringed upon by the shifting ideologies and
50 interpretations of the United States Supreme Court and by treaties or international laws.
51 NOW, THEREFORE, BE IT RESOLVED BY THE HOUSE OF REPRESENTATIVES that
52 the members of this body affirm and support the Parental Rights Amendment to the United
53 States Constitution and strongly urge Congress to immediately take all such steps as may be11 LC 35 2236ER
H. R. 738
- 3 -
54 necessary through whatever means necessar
Friday, March 30, 2012
Embattled foster system draws new fire
Posted: 03/29/2012 10:23:01 PM PDT
Updated: 03/29/2012 10:24:10 PM PDT
The troubled county Department of Children and Family Services came in for new criticism on Thursday with a California State Auditor report pointing out flaws in the agency's handling of child abuse and neglect allegations.
The report said DCFS had a backlog of at least 3,200 investigations into initial complaints of abuse or neglect that had been open more than the maximum 30 days.
In addition, a review of cases from 2008-2010 found that in only 31 percent of the cases social workers did the appropriate assessments of a home before placing a child there.
"This delay resulted in nearly 900 children living in placements that the department later determined to be unsafe or inappropriate," the report stated.
The audit attributed many of the department's problems to high turnover in its management. The department has had four directors in one year and also saw a high turnover in key management positions, the report said.
"A general instability in management has hampered the department's ability to address its long-standing problems such as completing timely investigations and placement assessments," the review found.
"The turnover has impeded the department's ability to develop and implement a strategic plan that would have provided cohesiveness to its various initiatives and communicated a clear vision to department staff," it said.
Other problems found by the audit included failure to meet timelines on monitoring children in their homes, failure to conduct background checks before placing children with relatives, delays in assessments on homes and caregivers and failure to make proper notifications on placements.
At the same time, the state said it found there is hope for improvement as the Board of Supervisors approved the appointment of Philip Browning as director in February and he has begun making changes.
Browning said he found the audit helpful.
"We appreciate the state auditor's reviewing our operations and look forward to working with them to resolve the issues highlighted in their report," Browning said. "Once we have completed our review of the audit, we will respond to each concern."
Also, the state found the case workload was within established targets and employees responded positively to a survey about their work environment.
The state did make two specific recommendations that the agency needs to continue to monitor its backlog of investigations and deal with them in 30 days. Also, it recommended an assessment on whether more resources are needed to investigate allegations of abuse and neglect.
Supervisor Zev Yaroslavsky said much of the audit dealt with issues that were in the past and have since been resolved.
"We brought Philip Browning in and he's a turnaround artist," Yaroslavsky said. "He has already cut the backlog by two-thirds and he's making other changes.
"A lot of the findings were about old issues and we did have problems. But, I have to say I think the department is in better shape than it's been in a long time."
213-978-0390
Thursday, March 22, 2012
THE NEXT INNOCENCE PROJECT: SHAKEN BABY SYNDROME AND THE CRIMINAL COURT
Please Read This:
http://lawreview.wustl.edu/inprint/87/1/dtuerkheimer.pdf
"Every year in this country, hundreds of people are convicted of having
shaken a baby, most often to death. In a prosecution paradigm without
precedent, expert medical testimony is used to establish that a crime
occurred, that the defendant caused the infant’s death by shaking, and that
the shaking was sufficiently forceful to constitute depraved indifference to
human life. Shaken Baby Syndrome (SBS) is, in essence, a medical
diagnosis of murder, one based solely on the presence of a diagnostic
triad: retinal bleeding, bleeding in the protective layer of the brain, and
brain swelling.
New scientific research has cast doubt on the forensic significance of
this triad, thereby undermining the foundations of thousands of SBS
convictions. Outside the United States, this scientific evolution has
prompted systemic reevaluations of the prosecutorial paradigm. In
contrast, our criminal justice system has failed to absorb the latest
scientific knowledge. This is beginning to change, yet the response has
been halting and inconsistent. To this day, triad-based convictions
continue to be affirmed, and new prosecutions commenced, as a matter of
course."
http://lawreview.wustl.edu/inprint/87/1/dtuerkheimer.pdf
"Every year in this country, hundreds of people are convicted of having
shaken a baby, most often to death. In a prosecution paradigm without
precedent, expert medical testimony is used to establish that a crime
occurred, that the defendant caused the infant’s death by shaking, and that
the shaking was sufficiently forceful to constitute depraved indifference to
human life. Shaken Baby Syndrome (SBS) is, in essence, a medical
diagnosis of murder, one based solely on the presence of a diagnostic
triad: retinal bleeding, bleeding in the protective layer of the brain, and
brain swelling.
New scientific research has cast doubt on the forensic significance of
this triad, thereby undermining the foundations of thousands of SBS
convictions. Outside the United States, this scientific evolution has
prompted systemic reevaluations of the prosecutorial paradigm. In
contrast, our criminal justice system has failed to absorb the latest
scientific knowledge. This is beginning to change, yet the response has
been halting and inconsistent. To this day, triad-based convictions
continue to be affirmed, and new prosecutions commenced, as a matter of
course."
Monday, March 19, 2012
Oregon: Corruption Risk Report Card
http://www.stateintegrity.org/oregon
The story behind the score
The story behind the score
Oregon boasts strong disclosure laws. But it’s one of the few states with no campaign finance limits, and its gift ban is full of holes. Read more from SII State Reporter Lee van der Voo.
Saturday, March 17, 2012
Experts recommend vitamin D blood testing for all children
Updated: 2012-02-23 16:44:24 CST Category: Vitamin D Deficiency-Diagnosis and Treatment
All children should receive blood tests to measure their vitamin D levels, according to a team of experts from Johns Hopkins University. They say vitamin D deficiency is a common problem in youths that can lead to severe health issues.The group pointed to studies, which have indicated that 10 percent of U.S. children may have vitamin D deficiency and another 60 percent have insufficient levels of the nutrient. This is a serious problem because deficiency can lead to decreased bone density, stunted growth, metabolic dysfunction and cardiovascular issues.
Given the fact that the sun is the primary source of vitamin D, parents and pediatricians are urged to be extra vigilant against the problem during the winter months, when sun exposure tends to drop.
"Vitamin D deficiency can be a problem year round, but because sun exposure is critical for vitamin D synthesis and production, the winter months further exacerbate what is a perennial problem," said Dominique Long, a pediatric endocrinologist at Johns Hopkins.
A child's vitamin D levels can be assessed relatively easily with a simple blood test.
Monday, March 5, 2012
Adherence to Vitamin D Recommendations Among US Infants
http://pediatrics.aappublications.org/content/125/4/627.full
Adherence to Vitamin D Recommendations Among US Infants
- Cria G. Perrine, PhDa,b,
- Andrea J. Sharma, PhD, MPHb,
- Maria Elena D. Jefferds, PhDb,
- Mary K. Serdula, MDb,
- Kelley S. Scanlon, PhD, RDb
+Author Affiliations
ABSTRACT
OBJECTIVES: In November 2008, the American Academy of Pediatrics (AAP) doubled the recommended daily intake of vitamin D for infants and children, from 200 IU/day (2003 recommendation) to 400 IU/day. We aimed to assess the prevalence of infants meeting the AAP recommended intake of vitamin D during their first year of life.
METHODS: Using data from the Infant Feeding Practices Study II, conducted from 2005 to 2007, we estimated the percentage of infants who met vitamin D recommendations at ages 1, 2, 3, 4, 5, 6, 7.5, 9, and 10.5 months (n = 1952–1633).
RESULTS: The use of oral vitamin D supplements was low, regardless of whether infants were consuming breast milk or formula, ranging from 1% to 13%, varying by age. Among infants who consumed breast milk but no formula, only 5% to 13% met either recommendation. Among mixed-fed infants, 28% to 35% met the 2003 recommendation, but only 9% to 14% would have met the 2008 recommendation. Among those who consumed formula but no breast milk, 81% to 98% met the 2003 recommendation, but only 20% to 37% would have met the 2008 recommendation.
CONCLUSIONS: Our findings suggest that most US infants are not consuming adequate amounts of vitamin D according to the 2008 AAP recommendation. Pediatricians and health care providers should encourage parents of infants who are either breastfed or consuming <1 L/day of infant formula to give their infants an oral vitamin D supplement.
WHAT'S KNOWN ON THIS SUBJECT:
There have been few data on the prevalence of US infants meeting AAP vitamin D recommendations.
WHAT THIS STUDY ADDS:
We estimated the prevalence of breastfed, formula-fed, and mixed-fed infants who met the 2003 and 2008 AAP vitamin D recommendations. Most infants, not just those who are breastfed, will need to receive an oral vitamin D supplement to meet the 2008 AAP recommendation.
The role of vitamin D in calcium and phosphorus homeostasis and bone metabolism has been well established; however, the presence of vitamin D receptors in many cell types suggests that vitamin D has other physiologic functions.1 For example, vitamin D deficiency has been associated with respiratory infections, type 1 diabetes, cardiovascular diseases, and cancer in later life,1,–,3 which emphasizes the importance of vitamin D nutrition throughout the life span. In children, nutritional rickets typically occurs in severe cases of vitamin D deficiency, causing softening and weakening of the bones, and is associated with impaired growth, developmental delays, lethargy, and hypocalcemic seizures.4
In addition to being obtained through the diet, vitamin D is synthesized endogenously in the skin after exposure to ultraviolet light. The American Academy of Pediatrics (AAP) advises that children younger than 6 months be kept out of the sun altogether and that those aged 6 months or older wear protective clothing and sunscreen to minimize sun exposure.5 Some researchers recommend short episodes of sun exposure as a way of obtaining vitamin D; however, the safety of this method for infants with regard to future skin cancer is not known.6,7 In addition, one's ability to produce vitamin D is affected by latitude, season, sunscreen use, skin pigmentation, and air pollution, which make sun exposure an unreliable source of vitamin D. Thus, infants need to obtain vitamin D either primarily or entirely from their diet. In 1997, the Institute of Medicine (IOM) recommended that 200 IU/day be considered “adequate intake” of vitamin D for infants, although it did not have sufficient information to determine a recommended dietary allowance.8 In 2003, the AAP released vitamin D–consumption guidelines in line with those of the IOM and recommended that all children begin consuming 200 IU/day of vitamin D during their first 2 months of life.4
Although there currently is no national surveillance of nutritional rickets in the United States, cases of rickets among hospital patients continue to be reported.9,10 The prevalence of poor vitamin D status among US infants also remains high by most measures, although data on infant vitamin D status can be difficult to interpret because of a lack of consensus on optimal vitamin D levels or on what constitutes vitamin D deficiency. Depending on the definitions used, vitamin D deficiency has been reported in 10% to 65% and insufficiency in 40% to 56% of US neonates, infants, and toddlers,11,–,13 which suggests that vitamin D levels may not be optimal in these groups. Given the growing evidence that the level of vitamin D consumption it recommended in 2003 may not be sufficient, in November 2008 the AAP released a new recommendation that all children receive 400 IU/day of vitamin D from their first few days of life through adolescence.14 The IOM is also reviewing its current recommendations for vitamin D consumption and plans to release a report on the findings of this review in May 2010.
Although breast milk is the best single source of food for infants,15 it only contains <25 to 78 IU/L of vitamin D14 and, thus, is insufficient, by itself, to provide adequate levels of vitamin D for infants. Foods that are good sources of vitamin D include oily fish, egg yolks, and fortified foods such as infant formula and milk.16 Most infants, however, will not consistently consume these foods during their first year of life unless they are primarily fed infant formula. All infants require a supplemental source of vitamin D from an oral vitamin D supplement, fortified infant formula, or both.
Our objective for this analysis was to estimate the prevalence of adherence to both the 2003 and 2008 AAP vitamin D recommendations among infants during their first year of life. Because infants' level of vitamin D consumption would likely differ by the extent to which they were formula fed, we produced separate prevalence estimates for infants who were breastfed, formula fed, and “mixed fed” (both breastfed and formula fed).
METHODS
We analyzed data from the Infant Feeding Practices Study II (IFPS II), a longitudinal survey of US mothers of healthy singletons, followed from late pregnancy through the first year of their infant's life, which was conducted from 2005 through 2007 by the US Food and Drug Administration in collaboration with the Centers for Disease Control and Prevention.17 The sample was drawn from a consumer-opinion mail panel that was nationally distributed but not nationally representative. Women were recruited in their third trimester of pregnancy; mothers at least 18 years of age, mothers and infants without medical conditions that would affect feeding, and infants who were born after at least 35 weeks' gestation and weighed at least 5 lb were included in the study. Extensive details of the IFPS II methodology, the IFPS II sample, and a comparison of the IFPS sample with a nationally representative sample of women from the National Survey of Family Growth (NSFG) have been published previously.18 Generally, IFPS II participants were older and more educated, had a higher income and fewer children, were breastfed longer, and were more likely to be white than those in the NSFG sample.
Each IFPS II participant was mailed 1 prenatal and 10 postnatal questionnaires at approximately monthly intervals that asked about various infant feeding and care practices. We analyzed data collected about infants at ages 1, 2, 3, 4, 5, 6, 7.5, 9, and 10.5 months as if the data were from separate cross-sectional surveys; sample sizes ranged from 1952 mothers of infants at 3 months to 1633 mothers of infants at 10.5 months. Regarding supplement use, mothers were asked on each monthly questionnaire, “Which of the following was your baby given in vitamin or mineral drops or pills at least 3 days a week during the past 2 weeks? If your baby was given drops or pills that contained more than 1 of the items listed, please mark each of the separate items.” If the mother checked the box for vitamin D, the infant was categorized as having received an oral vitamin D supplement. Thus, our estimate of vitamin D supplementation was not of daily administration, but of a minimum of 3 days per week.
On each of the postpartum surveys, mothers were also asked to estimate the average number of ounces of formula their infants consumed at each feeding (response options were 1–2, 3–4, 5–6, 7–8, and >8 oz) and the average number of feedings per day or week for both breast milk and formula. In our analyses, we used the midpoint of the formula consumption response options reported (1.5, 3.5, 5.5, 7.5, and 8.5 oz) and the average number of feedings per day to estimate average daily formula consumption, converting ounces to milliliters. We also used the reported frequency of breast milk and formula feedings to divide infants into 3 mutually exclusive feeding-practice groups: breast milk (consumed breast milk only); mixed (consumed breast milk and formula); and formula (consumed formula only). These classifications referred only to consumption of breast milk and formula; infants may also have been consuming other foods or liquids, such as water or juice. Almost no children consumed cow's milk until 10.5 months of age. Fourteen percent of infants at 10.5 months were consuming any cow's milk; for half of these infants, consumption frequency was less than once per day. When we compared the results of our analysis for all infants aged 10.5 months with results for the same group excluding those reported to have consumed any cow's milk, we found no significant differences.
The IFPS II data were collected from 2005 to 2007, at which time the 2003 AAP recommendation would have been current. We used both the 2003 and 2008 recommendations in this analysis to obtain estimates of the prevalence of infants who were meeting the 2003 recommendation and the prevalence of infants who would meet the 2008 recommendation without any behavior changes. Infants' multivitamin and vitamin D–only preparations available in the United States supply 400 IU/day; thus, infants who receive an oral vitamin D supplement would obtain enough vitamin D to meet both the 2003 and 2008 recommendations.14 Therefore, we classified infants as meeting the 2003 recommendation (which recommended beginning supplementation at 2 months of age and thus does not apply for infants younger than 2 months) if they were either receiving an oral vitamin D supplement or consuming at least 500 mL/day of vitamin D–fortified infant formula, which in the United States is fortified at a level of 400 IU/L.14 We classified infants as having met the 2008 recommendation (which applies to infants beginning within their first few days of life) if they were either receiving an oral vitamin D supplement or consuming at least 1 L/day of formula.4,14
RESULTS
At 1 month of age, 43% of the infants were breastfed, 32% were mixed fed, and 26% were formula fed (Table 1). With increasing age, the percentage of infants who were breastfed decreased, and the percentage who were formula fed increased; by 10.5 months of age, 27% of the infants were breastfed, 11% were mixed fed, and 62% were formula fed. Throughout the first year of life, mean formula intake ranged from 310 to 352 mL/day in the mixed-fed group, with little variation by age, and from 770 to 987 mL/day in the formula-fed group, with formula intake generally increasing with age until peaking at 4 to 6 months and then decreasing.
View this table:
TABLE 1
Percentage of Infants Fed According to Each of Three Feeding Practices by Age
Overall, only 4% to 7% of the infants were receiving an oral vitamin D supplement (Table 2), with infants 1 month of age having the lowest prevalence of supplement use. The prevalence of oral supplement use ranged from 5% to 13% in the breastfed group and from 4% to 11% in the mixed-fed group. Only 1% to 4% of the infants in the formula-fed group were receiving an oral supplement.
View this table:
TABLE 2
Percentage of Infants Who Received an Oral Vitamin D Supplement According to Feeding Practice by Age
We estimated that over the first year of life, 44% to 58% of infants met the 2003 AAP recommendation that they consume 200 IU/day of vitamin D, whereas only 11% to 25% would have met the 2008 recommendation of 400 IU/day of vitamin D (Table 3). Among breastfed infants, who must have received an oral vitamin D supplement to meet either of the AAP recommendations, only 9% to 13% were receiving enough vitamin D at 2 to 10.5 months of age to meet the 2003 or 2008 recommendation. The 2008 recommendation (but not the 2003 recommendation) applies to infants at 1 month; only 5% of 1-month-old infants who were breastfed received an oral vitamin D supplement and, thus, would have met the 2008 recommendation. Among mixed-fed infants, 28% to 35% met the 2003 recommendation, but only 9% to 14% would have met the 2008 recommendation; those who met the 2003 recommendation did so primarily through formula intake, whereas those who met the 2008 recommendation did so primarily with the use of an oral vitamin D supplement, suggesting that few mixed-fed infants consume enough formula to obtain 400 IU/day of vitamin D. More than 90% of formula-fed infants aged 2 to 7.5 months met the 2003 recommendation, as did >80% of formula-fed infants aged 9 and 10.5 months. However, only 20% to 37% of these infants would have met the new 2008 recommendation at any month of age. Because use of an oral vitamin D supplement was very low among formula-fed infants, most who were meeting the 2008 recommendation were doing so by consuming at least 1 L/day of formula. Thus, the pattern of formula-fed infants who achieved AAP 2008 recommended levels of vitamin D followed a pattern similar to that of formula intake, increasing with age until peaking at 4 to 6 months and then decreasing.
View this table:
TABLE 3
Percentage of Infants Who Met the 2003 AAP Vitamin D Recommendation and the Percentage Who Would Have Met the 2008 Recommendation According to Feeding Practice by Age
DISCUSSION
At the time the IFPS II data were collected, the 2003 AAP recommendation was the current guideline regarding vitamin D intake for the prevention of vitamin D deficiency and rickets. Although we found that most formula-fed infants were meeting the recommendation, we also found that only approximately one-tenth of breastfed infants and one-third of mixed-fed infants were meeting it. This poor adherence to the 2003 recommendation was because of both low prevalence of oral vitamin D supplement use and most mixed-fed infants not consuming enough formula to meet the recommended consumption level of 200 IU/day. Our estimates regarding the 2008 recommendation provide a sense of the prevalence of infants among the various feeding-practice groups who would meet the new recommendation if there was no change in behavior regarding vitamin D intake. Fewer than 15% of the infants in both the breastfed and mixed-fed groups would have met the 2008 recommended level of vitamin D consumption.
The difference in the percentage of infants who met the 2 recommended intake levels was particularly striking among formula-fed infants. Whereas most formula-fed infants were consuming the 500 mL/day of formula required to obtain 200 IU of vitamin D, only approximately one-third were consuming the 1 L/day required to obtain 400 IU. Among this group, adherence peaked at ∼4 to 6 months, which is when many infants would begin to consume complementary foods and reduce their formula intake. The 2008 AAP guideline suggests that most infants older than 1 month will consume the 1 L/day of formula required to obtain 400 IU/day of vitamin D14; however, our results did not support this assumption and indicated instead that most infants, not just those who are breastfed, would likely need to receive an oral vitamin D supplement to consume enough vitamin D to meet the 2008 recommendation.
The very low prevalence of oral vitamin D supplementation among infants is concerning if infants are to meet current recommendations. Results from the 1999–2002 National Health and Nutrition Examination Survey showed a similarly low prevalence of vitamin D supplement use among US infants: only 8.7% of infants aged 0 to 11 months had received a vitamin D supplement in the previous 30 days.19 Pediatricians and allied health care providers are uniquely positioned to help increase the percentage of infants who receive adequate amounts of vitamin D, because parents are more likely to give their children vitamin D supplements if they are advised to do so by a health care professional.20 It is unfortunate that many health care professionals are not recommending vitamin D supplements for infants.21,–,23 Reasons that they are not doing so include beliefs that rickets is rare,23 that infants receive sufficient sunlight,22,23 and that breast milk has adequate levels of vitamin D.21,–,23 Because physicians' knowledge of the AAP recommendations has been positively associated with the likelihood of their recommending vitamin D supplements,22 both health care providers and parents need to be educated about the AAP guidelines and the importance of vitamin D nutrition, including that infants should not be exposed to sunlight and, thus, need an alternate source of vitamin D.
Although the IFPS II included women from around the country, the sample was not nationally representative. Among other characteristics, women in this sample had achieved higher levels of education, had fewer children, and had breastfed longer than women in the NSFG,18 all of which may have been associated with formula and supplement use. Another limitation of our study was that all data were self-reported and required mothers to recall information about their infants' feedings over the previous 7 days and supplement use over the previous 2 weeks. Although the validity of this self-reported data is unknown, our estimates of daily formula intake among infants of IFPS II participants were consistent with, or only slightly higher than, those from other studies.24,–,27 Other study limitations included our inability to determine the exact quantity of vitamin D that infants obtained from oral supplements and our definition of supplement use as use of a supplement on at least 3 days/week rather than more frequently. Our estimates of the prevalence of supplement use would likely have been even lower had we used a definition that required more days per week of use. These data were collected from 2005 to 2007, so our estimate of meeting the 2008 AAP recommendation assumed no change in behavior since that time. Because new vitamin D research is continually being generated, it is possible that increased media attention on vitamin D has increased the use of vitamin D supplements among infants. Despite these limitations, IFPS II was one of the largest infant-feeding studies in the United States and provides valuable data that are not available from any other data source to date, including assessment of supplement use and food intake at multiple times points during the first year of life and at as early as 1 month of life.
According to the 2008 AAP recommendation, all breastfed, mixed-fed, and formula-fed infants who consume <1 L/day of formula should receive an oral vitamin D supplement. Our findings suggest that few infants are consuming at least 1 L/day of formula; thus, many may need to receive oral vitamin D supplements to meet the 2008 AAP recommendation that they consume at least 400 IU/day. This finding should be confirmed in other studies. Parents may need support in providing supplementation for their infants. Supporting adherence in this context is challenging because of the long duration of vitamin D supplementation, the lack of tangible health effects after starting supplementation, the need for an adult to administer the daily dose, and the need for a willing infant to accept the supplement. Overall, adherence to prescriptions from health care providers is poor, even among adults, and is generally worse the longer the regimen duration is.28 Pediatricians and other health care providers can support and promote daily oral vitamin D supplementation of infants by explaining to parents the purpose and benefits of vitamin D supplementation, reminding parents at each visit to give vitamin D supplements to their children, suggesting that parents develop a daily intake routine to help them remember to administer the supplement, asking parents about any adverse effects of supplementation or barriers to giving their infants supplements, and helping parents to overcome any barriers that they report.29
CONCLUSIONS
We found that most infants, not just those who are breastfed, may require an oral vitamin D supplement daily, beginning within their first few days of life, to meet the 2008 AAP recommendation that infants consume at least 400 IU/day of vitamin D.
ACKNOWLEDGMENTS
This study was funded by the US Food and Drug Administration, Centers for Disease Control and Prevention, Office of Women's Health, National Institutes of Health, and Maternal and Child Health Bureau in the US Department of Health and Human Services.
FOOTNOTES
- Accepted November 24, 2009.
- Address correspondence to Cria G. Perrine, PhD, 4770 Buford Hwy NE, MS K-25, Atlanta, GA 30341. E-mail: cgregory@cdc.gov
- The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
- Funded by the National Institutes of Health (NIH).
- FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- Funded by the National Institutes of Health (NIH).
- AAP =
- American Academy of Pediatrics •
- IOM =
- Institute of Medicine •
- IFPS II =
- Infant Feeding Practices Study II •
- NSFG =
- National Survey of Family Growth
REFERENCES
- Copyright © 2010 by the American Academy of Pediatrics
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