Losing Patience. James Peinkofer
baby syndrome,” “child abuse” and “retinal hemorrhages.” There were sixty-six articles that met inclusion criteria. They found 53 to 80 percent incidence of RH with abusive head trauma. With proven severe accidental trauma, there was a 0 to 10 percent finding of RH. They reviewed mechanisms such as convulsions, chest percussion from CPR, forceful vomiting and persistent coughing. In the absence of any other condition known to cause retinal hemorrhaging, they found .7 percent, 2 percent, 0 percent and 0 percent respectively. So when these mechanisms are offered as an excuse for the diagnosis of retinal hemorrhage (as defense experts often attempt to suggest), it has been shown to be an extremely rare occurrence. Even then, these types of hemorrhages are not the kind seen in abuse—instead, they are light, confined to the posterior pole and few in number.7
Let’s now look specifically at various claims that have been utilized in the courtroom in recent years:
BIRTH TRAUMA
Birth trauma retinal hemorrhages exist. In fact, they are found in 30 to 4 0 percent of all births, but they are resorbed within two to four weeks. They are also light, small and confined to the posterior pole of the eye. When a three-month-old has diffuse retinal hemorrhages and the defense asserts that these were caused by birth, there are studies that show this is not plausible.
One particularly relevant study was recently published in France. Laghmari and his group prospectively reviewed over 2,000 newborns for the presence of retinal hemorrhages. In their study, they used indirect ophthalmoscopy within twenty-four hours after birth in all newborns at various hospitals. Overall, 31.8 percent of newborns had some form of retinal hemorrhages. These hemorrhages were confined to the posterior pole of the eye and were few in number and size. Vacuum-assisted births had the largest percentage of retinal hemorrhages (38 percent) and cesarean births had the fewest (20 percent). Infants with retinal hemorrhages were reexamined weekly until the hemorrhages resolved. Annual ophthalmologic follow-up was also scheduled in these children. Their most critical finding was that two-thirds of hemorrhages had disappeared by one week after birth. Retinal hemorrhages had resolved in all newborns within four weeks.8
INJURIES FROM FALLS
When Dr. Betty Spivack testified in a dual appellate hearing in Kentucky to determine if SBS was a verifiable diagnosis, she discussed retinal hemorrhages. She made the statement, “Retinal hemorrhages have a much stronger correlation with abusive head trauma than unintentional head trauma, even when the unintentional injury is severe.”9 So, if there is a fall from a great height, there may be retinal hemorrhages seen that are similar in number and magnitude to ones seen in shaking injuries. In a study from 2008, Kivlin and associates reviewed motor vehicle crashes.10 They studied ten children, younger than three years, who died in motor vehicle crashes. Eight had retinal hemorrhages which extended to the periphery. Three of the children had retinal folds, which are more commonly associated with a diagnosis of Shaken Baby Syndrome. Six had internal membrane bleeding, but none of them had any splitting (retinoschisis). Some even had optic nerve sheath hemorrhages. But what this study found was that one can’t blame major retinal hemorrhages on a short fall, a rebleed of an underlying condition or something trivial. There needs to be a severe injury—like violent shaking.
Also from 2008, Trenchs and his researchers conducted an important study that looked at retinal hemorrhages in head trauma resulting from short falls.11 There were 154 children who were studied and 80 percent of the falls were from a height equal to or less than four feet. The most common fall was from a stroller, followed by rolling off a bed. Ten percent had evidence of intracranial injury. Three children had retinal hemorrhages, all unilateral (one eye). All the hemorrhages were associated with an epidural hematoma, where there was also a midline shift to the brain. This is a severe injury where the epidural pushes onto the brain and it shifts to one side. Since only three patients had retinal hemorrhages (1.9 percent of the total), this equates to a very low chance of developing very specific retinal hemorrhages due to a low fall.
Vinchon and his team found that the lack of retinal hemorrhages in accidental falls, compared to severe findings in inflicted trauma, is statistically significant.12 This confirmed an earlier study of his.13 They found that, when confessed incidents of child abuse were studied next to accidental falls in public places, the predictive value of the presence of retinal hemorrhages was 96 percent. When combined with the presence of subdural hematomas and lack of impact the predictive value was 100 percent.
Not Just a Fall
I had dropped my eighteen-month-old son off at his babysitter (my brother’s wife, Amber) that morning and headed to work. My job was within walking distance from her house. I was at work at about 8 A.M. when I heard the page from the overheard speaker. I was in a friend’s office when I picked up the call. The babysitter was panicked and said that my son was unresponsive and I needed to get over there fast. My friend could see the panic in my eyes. I told her to tell my boss that I had an emergency and ran out the door. I didn’t even stop to get my purse or my car. I ran to her house. Her neighbor had called 911. I got there just as the medics did. I ran into the house and carried him out. He was limp and mumbling and I remembered how strange his eyes looked. It wasn’t until later that I understood he was having a seizure. The medics immediately put oxygen on him and transported him to the nearby telephone company’s parking lot where we were met by the life flight team. They immediately took my son to the back of the chopper and I didn’t see him again until we reached the hospital.
Amber had two children of her own. The boy was about nine months old and the older girl was eleven. The younger child was at home when the “accident” occurred and the older one was at school. Amber told me that my son had climbed on top of the highchair, had fallen off and hit his head. I believed her. He liked to climb and getting on the lid of his highchair was nothing unusual.
The medics who were the first to arrive were very reassuring. The life flight medics were all business. I couldn’t even recognize their faces after the flight until they stopped in to see how my son was doing in the hospital. They had a huge part in saving my son’s life. When we got to the hospital he was whisked to see a pediatric internist. I remember she was very cold to me. My face was probably swollen from crying, but she seemed to have no empathy and at the time I didn’t understand why. They told me and my partner that our child had to be rushed to brain surgery. He had a massive blood clot and his brain was swelling. We waited almost eight hours with family and friends. Amber waited too and she kept repeating to us that she was so sorry. We did nothing but reassure that everything would be fine and it was an accident. When surgery was over, they allowed only me, my husband and mother-in-law to visit him. His tiny head was completely wrapped in gauze like a turban. He was on a ventilator and had so many tubes coming out of his arms. It was like something out of a nightmare. I couldn’t imagine the pain my child had endured to require such medical intervention. The nurse was angry. She pulled his diaper off and started asking me where the red marks came from. There were bruises on his waistline area that matched perfectly to the fingertips of a small hand. I started crying, saying, “I don’t know. I don’t understand. Those bruises weren’t there this morning when I left him. I didn’t do it. My son’s dad would never hurt my son.”
The nurse began to soften as she was beginning to put the pieces together that we had nothing to do with the shaking. They asked me to keep what I saw to myself and not to share it with the people in the waiting area. I was so shell-shocked I still didn’t quite understand that Amber was a suspect. I left the room to collect myself and give our family and friends an update. That is when I saw two policemen step off the elevator. My partner’s mother grabbed my arm and said they were there to find out the truth. Amber was arrested that evening. I watched them take her out in handcuffs. After that initial evening, the hospital staff changed their attitude toward my family. The care they provided to my son was exceptional. Only special people can be members of the ICU staff and we met some amazing ones. My son was in a medically-induced coma for at least ten days and he had an ICP bolt in the back of his skull to monitor the pressure. He was in the hospital from the 28th of November until the 26th of December, when he was transported