The Swedish Agency for health technology-report about traumatic shaking: much ado about nothing?

Abstract

The 2016 Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) systematic review deals with the role of the 'triad' (subdural hematoma, retinal hemorrhages, and various forms of brain symptoms) in the medical investigation of suspected traumatic shaking. In this commentary we will not discuss the methodological shortcomings of the SBU-review but will concentrate on the effects of the review on the daily practice of protecting children and families in court procedures. In our opinion the report did not add anything to what was already known in clinical and forensic medicine. The SBU-review confirmed that shaking can cause the 'triad' and that there are other explanations for the 'triad' and its components. The report however did not provide a realistic list of these other explanations. The review reduced the discussion about inflicted head injury in young children to a discussion about the 'triad' and traumatic shaking, ignoring the fact that 'diagnosing' inflicted head injury concerns a complete clinical and forensic evaluation of all individual and combined findings, of which for example the presence of bruising or fractures, were excluded by the SBU-panel.

Denialism Preserves Scientific Controversies: a Case Study of Abusive Head Trauma Research

“…A systematic literature review of triad cases without external signs of trauma ( 6) was criticized by the proponents of the traditional SBS/AHT theories because the focus on isolated triad cases was considered irrelevant (10,29,30). However, a study compiled from four studies including triad cases both with and without external signs of trauma reported that of all alleged AHT cases, about 1/3, had no external signs of trauma (3,4).…”

Thresholds for the assessment of inflicted head injury by shaking trauma in infants: a systematic review

“…However, the diagnosis of inflicted head injury based on the presence of such symptoms is often debated, because these symptoms can also be caused by events other than abusive shaking [1][2][3][4]. No consensus has been reached yet regarding the question if shaking alone can actually cause these symptoms [5][6][7][8].…”

In order to ensure that evidence is unbiased it is sometimes necessary to retreat to the scientific ivory tower

“…Dr. Bilo maintains that the Swedish SBU report does not add anything new that might help him within forensic pediatrics [1]. This claim is, however, based on his personal interpretation of the SBU report and the research question addressed, namely: With what certainty can it be claimed that the triad, subdural hematoma, retinal hemorrhages and encephalopathy is attributable to isolated traumatic shaking [2]?…”

“…Dr. Bilo maintains that in real life infants with SDH, RH and encephalopathy usually also have external signs of trauma such as bruises and fractures [1]. According to Dr. Bilo, the fact that SBU focused on studies which included cases of the triad in the absence of external signs of injury, makes the SBU report futile.…”

“…Further, Dr. Bilo criticizes SBU for retreating to an ivory tower, isolated from real life issues about child abuse [1]. Quite correct -SBU and the expert panel deliberately retreated to the scientific ivory tower, followed standard procedures of health technology assessment, and neither ideological interests nor personal values were to be discussed.…”