Doctors in a Dilemma
by Charles PragnellThursday, May 1st, 2008
Paediatricians and their opinions in child protection matters, especially in Courts, are coming under increasing scrutiny and challenge. Why are they so often so wrong?
Many of the leading Paediatricians in the UK who are engaged in child protection cases appear to be in a state of confusion and uncertainty regarding their future role as expert witnesses in legal proceedings concerning alleged child abuse.
This has largely come about after medical evidence in recent criminal and civil cases was exposed as lacking in scientific rigour and on occasions to be little more than fanciful speculations and theories which had little basis in medical research. These theories have come under increasing scrutiny and challenge by Courts, the media, and by other, more discerning professionals engaged in child protection work.
In particular, Munchausen Syndrome By Proxy, Shaken Baby Syndrome, Repressed Memory Syndrome, Satanic Ritual Abuse, Parental Alienation Syndrome, Dissociative Disorder, and a wide range of similar labels have been seriously questioned in professional and media circles and have been found wanting in scientific authenticity and can be seriously questionable regarding their validity and utility.
Medical theories of child abuse such as Shaken Baby Syndrome appear to have been used as a first choice in a differential diagnosis by some paediatricians called in after a child has died of indeterminate causes. If faced with very sick children and overtly anxious parents, paediatricians have at times - without undertaking a thorough and exhaustive examination of all of the possible causes of the child’s illness - blamed the parents for the children’s illnesses – Fabricated or Induced Illness in Children.
In these instances possible causes which paediatricians are failing to consider include :
*Cisapride/Propulsid, for example, was withdrawn by the UK Government after at least five recorded deaths of children and several hundred children had been caused serious harm. The manufacturer, Jannsens, have offered $US90m in damages to families worldwide.)
Many paediatricians refuse to consider vaccine damage as a possible cause of a child’s illness despite valuable and credible personal testimony from parents and the most recent medical research which is exposing this link.
A classic example of serious medical error in this respect was the case of Megan Armstrong in Northumberland in England. Based on the evidence of two paediatricians, social workers were prepared to place Megan’s name on the Child Protection At Risk Register and to apply for a Court Order to remove her from her parent’s care. The paediatricians claimed that her failure to thrive was caused by her parent’s lack of care. The day after this decision was taken Megan was seen by another specialist who found that she had a brain tumour in her frontal temporal lobe and which was not only affecting her normal growth and development, but also was causing her eyesight to deteriorate.
There are many, many other similar examples including the children of Sally Clark and Angela Cannings.
Some paediatricians are not prepared to accept other possibilities of diagnosis and are often single-minded in their accusation that a child’s illness or injury is child abuse. Nor are they prepared to request a specialist advice from such as a geneticist, haematologist, or a toxicologist who could give other explanations.
Often the matter has to reach a Court before other medical experts can challenge the Paediatrician’s opinions, when these matters could have been resolved without the cost and time involved and the trauma and heartache for the child and the family. More commonly in Courts however, the errors of diagnosis by paediatric expert witnesses go unchallenged as defence lawyers have difficulties finding an alternative expert witness who is willing to challenge the diagnosis.
Some of the most common errors and shortcomings of Paediatricians in making a differential diagnosis and arriving at a conclusion of child abuse which have been brought to public attention by Dr Michael Innis, a retired Haematologist are listed below.
“A Bleeding Nose in an infant is evidence of attempted suffocation”.
A Haematologist can provide at least twenty possible explanations as to why a child may suffer a nose bleed and attempted suffocation will not be one of them. Yet one Paediatrician in England asserted that a father had murdered a child after seeing a television programme in which a father said the child had had a nose bleed.
“Bruises on the back of an infant must be inflicted since the infant is not mobile enough to bruise itself”.
Spontaneous bruising and bleeding are a feature of a disorder of haemostasis of which the commonest at this age are Vitamin C and K deficiencies and Alloimmune Thrombocytopenia. All should be checked by a Haematologist.
“Posterior rib fractures are highly indicative of non-accidental injury and are most commonly sustained as a result of compression of the chest as the baby is held as it is shaken.”
This is a direct quotation from a Court case in England. This speculation (or better described as a myth or fabrication) is particularly distressing as fractures of different ages are then held to be evidence of repeated episodes of shaking. There is good evidence that without adequate Vitamin K bones are liable to spontaneous fractures and appropriate tests for Vitamin K Deficiency Disease should be carried out before such accusations are made .
“Abused infants may have bleeding around the brain and in the eyes – the alleged hallmarks of SBS - but most also bear signs of the violence which killed them such as fractures, bruises, burns, malnutrition or neglect.”
Regrettably this is the commonly held opinion of medical experts giving evidence for the Prosecution in cases of alleged child abuse. It ignores the fact that fractures and bruises can result from deficiencies of Vitamins C and/or K [1,2] and these deficiencies are not necessarily the result of neglect. In fact Vitamin C deficiency is not uncommonly iatrogenic as the result of the number of vaccines given to these infants[3,4]. Vitamin K deficiency is often due to immaturity or infection of the liver.
Rutty et al  have warned of the possibility of mistaking retinal and subdural haemorrhages for child abuse but the message does not seem to have registered in some circles.
As regards fractures and bruises found on a child. It is absurd to demand a detailed explanation from a parent for many such injuries. How is a parent expected to explain such injuries to a doctor? How can a 20 year old distressed and bewildered mother be expected to say to a doctor,
“You know, Doctor, there are several Vitamin K dependent proteins in the body which require to be carboxylated by the enzyme gamma-glutamyl carboxylase before they become functional. Without Vitamin K, these proteins, some of which control haemostasis and prevent bruising, and others which control mineralization of bone and prevent fractures, cease to be carboxylated and hence bruises and fractures are likely to occur. And what is more, Doctor, last week you gave my baby an antibiotic for his cough. That could have destroyed the Vitamin K 2 forming bacteria in his gut thereby adding to his problem of a lack of Vitamin K to protect him from bruises and fractures.
That is my explanation doctor. I hope you can understand it and don’t report me to the police or social services. They may take my baby away and kill all my dreams.”
If the doctor cannot explain it, he should consult the literature on the subject.
So-called “burns” on a child are also often misinterpreted by medical experts. In one example an innocent man was sent to prison on the basis of flawed evidence by a medical expert who swore that the marks on the child were cigarette burns, whereas they were clearly the lesions of microscopic polyarteritis that one can see in Kawasaki Disease. The “burns” that Victoria Climbie was alleged to have suffered are also most probably of a similar origin. They will almost certainly show the characteristic findings of Kawasaki Disease – neutrophilia, lymphopenia, AST > ALT.
The Royal College of Ophthalmologists Working Party concluded in terms of the force required to cause retinal haemorrhages “..no absolute values can be given for the angular acceleration forces required to produce injury, but there is good evidence that they must be considerable.”
No one has ever observed such “angular acceleration forces” being applied to the infant. If it has not been observed, it is imagined and hence has no scientific validity. Rutty et al have drawn attention to retinal haemorrhages in Late Onset Haemorrhagic Disease of the Newborn .
False allegations of child abuse and child murder and consequent false imprisonment of parents and carers are rife in the English-speaking world and are largely the result of what can be described as “pseudological fantasies” and fanciful speculations of paediatricians.
Benefits and protection for patients and public, especially in the area of false accusations of child abuse are long overdue, and medical experts must continue to be challenged and exposed when they have failed to consider the widest possible differential diagnoses before reaching a conclusion of child abuse and to have undertaken the most exhaustive and detailed examination possible for other, more likely, causes of a child’s injuries or illness, utilising the expertise of other health professionals, rather than relying on their own, albeit limited, knowledge.
It is long overdue that the Royal College of Paediatrics and Child Health and other medical associations set up a formal system of verification and validation of theories of child abuse utilising the most up-to-date scientifically-based research from around the worlds, which would have some authenticity in Courts and would hopefully prevent maverick Paediatricians, Psychiatrists, and Psychologists simply inventing their own dogmatic pet theories or adopting the junk-research theories of others in their professions, to promote their own status in child protection work.
At the least it would ensure that a majority of these medical professionals were singing from the same song sheet and that the diagnosis of child abuse was not just a postcode lottery for children and their families.
Charles Pragnell DipSW. is a Social Care Consultant and Child/Family Advocate.
1 Innis MD. Vitamin K Deficiency Disease Jour Ortho Mol Med March 2008
2 Clemetson CAB. Caffey Revisited. A Commentary on the Origin of “Shaken Baby Syndrome” Jour Amer Phys & Surg vol 11; 2006: 20-21
3 Kalokerinos A. Every Second Child Thomas Nelson (Australia) Ltd 1974
4 Clemetson CA (2004) "Was it "shaken baby" or a variant of Barlow's disease?". A A P S 2004; Vol 9 No 3:
5 Rutty GN, Smith M, Malia RG. Late Form Hemorrhagic Disease of the Newborn. A Fatal Case Report with Illustrations of Investigations Which May Assist Avoiding the Mistaken Diagnosis of Child Abuse. Am J Forensic Med Path 1999; 20(1): 48-51