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LETTER TO EDITOR
Year : 2020  |  Volume : 5  |  Issue : 2  |  Page : 237-238

Beyond circular reasoning: Fishing the uncertainty behind shaken baby syndrome – Conceptual case report


Department of Paediatrics, Rajah Muthiah Medical College and Hospital, Chidambaram, Tamil Nadu, India

Date of Submission10-Dec-2019
Date of Acceptance23-Mar-2020
Date of Web Publication18-Dec-2020

Correspondence Address:
Dr. M Shuriya Prabha
Department of Paediatrics, Rajah Muthiah Medical College and Hospital, Chidambaram, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjhs.bjhs_78_19

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How to cite this article:
Prabha M S. Beyond circular reasoning: Fishing the uncertainty behind shaken baby syndrome – Conceptual case report. BLDE Univ J Health Sci 2020;5:237-8

How to cite this URL:
Prabha M S. Beyond circular reasoning: Fishing the uncertainty behind shaken baby syndrome – Conceptual case report. BLDE Univ J Health Sci [serial online] 2020 [cited 2021 Jan 16];5:237-8. Available from: https://www.bldeujournalhs.in/text.asp?2020/5/2/237/303978



Sir,

Even though few cases of child abuse with accumulation of blood on the brain surface had been documented earlier, it was Guthkelch,[1] who attributed its etiology to the translational forces due to vigorous shaking. In many instances, it goes undiagnosed because there are no obvious signs of external injury and the reasoning spectrum of the pediatrician is masqueraded by the incomplete history provided by the attenders. Owing to the dilemma in contemplating the exact pathogenesis of shaken baby syndrome, two hypotheses have been proposed. The classical hypothesis[2] necessitates adduction of two points of circumstantial evidence such as injuries being unwitnessed by the attender and incompatible history in the presence of triadic signs. The crucial point is that we cannot ascertain whether the force generated by manual shaking would be powerful enough to rupture the bridging veins and therefore solely rely upon the “confession” of parents. The alternative hypothesis by Geddes et al.[3] denies the traumatic etiology and proposes that minor bleeding in the subdural space might be due to the hypoxia associated with the presence of abnormal hemodynamic forces such as episodes of severe cough or convulsions.

The crucial issue associated with the shaken baby syndrome is that its diagnostic accuracy is diluted by the generalized assumption of the treating pediatricians.[4] Upon testing the credibility of the carer in cases of suspected shaking, if concrete acceptable explanations are not provided, it is presumed that the child has been violently shaken. The child protection teams of Western countries, which probe these cases, are criticized for being caught in circular reasoning fallacies.[5] In circular reasoning, the observer assumes the conclusion which he/she has to arrive at the end of arguments prior and this conclusion need not necessarily be substantiated logically. Factors such as lack of credibility in the history narrated by the carer (attributing trivial trauma to the triadic symptoms) or discrepancies in between events are enough to arrive at the diagnosis rather than evincing the history of shaking.

An? 18-month-old female child visited our hospital with low-grade fever and history of recurrent seizures and drowsiness on and off for 5 days. On examination, the child was responsive to pain with normal anterior fontanelle and reacting pupils. There was no significant history relating to bleeding diathesis, apneic episodes, or recent trauma. The routine hematological profile did not reveal any significant abnormalities which made me go with the provisional diagnosis of febrile seizures even when the fever is of low grade. As a part of central nervous system examination, computed tomography imaging was done and I could visualize a hyperdense area over the right parietal cortex suggestive of subdural hematoma. In order to check for any ocular counterpart, I sought ocular examination, which revealed multiple bleeding spots at both fundi. This conglomeration of clinical presentation made me suspect regarding shaken baby syndrome. For affirming my assumption, I revisited the parents to elicit further history. Upon deductive questioning, her mother revealed that the father used to agitate the child vigorously during the course of play and this was without any significant intention. Retrospectively, I sensed that the proceedings fitted into the realm of circular reasoning. Initially, my assumption was general which moved into the second stage of observation whereby the symptoms are made out. Finally, deductive conclusion was made which had completed the missing piece of the puzzle.

The critical point in arriving at the diagnosis was the history confessed by one of the parents, which was sufficient enough to act as the corroborative evidence for shaking to have taken place. Furthermore, the perpetrator was of limited patience toward handling his child. Had I missed out this accidental history, it is likely that circumstances would have led us to think in line with Geddes et al.[3] hypothesis attributing asphyxia and vigorous convulsive movements of febrile seizures to the triadic signs. We also need to analyze the case under legal and ethical dimensions. Although abuse in any form has to be dealt with zero tolerance, perpetrators of most cases cannot be taken into task because of the abovementioned reasoning fallacies and uncertain history.[6] In addition, in a case like this, the motive of the carer is not to inflict injuries and it is principally due to the vulnerable personality. I conclude by stating that the responsibility of pediatrician is to scrutinize the details of such cases to the fullest extent by adopting a structured questioning approach which is of great help for the child.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Guthkelch AN. Infantile subdural haematoma and its relationship to whiplash injuries. Br Med J 1971;2:430-1.  Back to cited text no. 1
    
2.
Ommaya AK, Faas F, Yarnell P. Whiplash injury and brain damage: An experimental study. JAMA 1968;204:285-9.  Back to cited text no. 2
    
3.
Geddes JF, Tasker RC, Hackshaw AK, Nickols CD, Adams GG, Whitwell HL, et al., Dural haemorrhage in non-traumatic infant deaths: Does it explain the bleeding in 'shaken baby syndrome'? Neuropathol Appl Neurobiol 2003;29:14-22.  Back to cited text no. 3
    
4.
Lynøe N, Elinder G, Hallberg B, Rosén M, Sundgren P, Eriksson A. Is accepting circular reasoning in shaken baby studies bad science or misconduct? Acta Paediatr 2017;106:1445-6.  Back to cited text no. 4
    
5.
Elinder G, Eriksson A, Hallberg B, Lynøe N, Sundgren PM, Rosén M, et al. Traumatic shaking: The role of the triad in medical investigations of suspected traumatic shaking. Acta Paediatr 2018;107 Suppl 472:3-23.  Back to cited text no. 5
    
6.
Adamsbaum C, Grabar S, Mejean N, Rey-Salmon C. Abusive head trauma: Judicial admissions highlight violent and repetitive shaking. Pediatrics 2010;126:546-55.  Back to cited text no. 6
    




 

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