Dear Authors,
Thank you for shedding light on the issue of cough and the
improbability of cough in the context of pertussis as seemingly unlikely
to produce RH. That aspect of your study is quite convincing.
While your prospective study provides valid information, it does not
qualify as a jumping off point to conclude that maltreatment is involved
in 75% of RH that are seen. You have relied on a retrospective study by
King in which children were preclassified as abused by unknown providers
using imprecise, undefined or unknown criteria. From clinical experience,
we know these diagnoses were most likely based on the presence of RH and
SDH. When this occurs, the use thereafter of RH or SDH as indicators of
abuse, is circular logic. It is a logical fallacy to conclude that the RH
that placed a child in an abuse group then becomes proof that they belong
in an abuse group.
RH is linked to increased intracranial pressure. This well
established connection was discussed at length in an article I published
this year (1) and has been general knowledge for more than 100 years since
Terson's work in 1900 and others since (2,3,4,5,6).
While cough alone may not be sufficient to cause RH, coughing in the
context of other comorbidities (pneumonia for example which concurrent low
oxygen states) may be sufficient to damaged already metabolically
compromised capillaries and cause them to leak (7).
That aside, the effort to segue from the absence of RH in pertussis
to RH as a valid diagnostic finding of maltreatment seems to redirect your
efforts to attempting to use, yet again, RH as an indicator of abuse.
Since there 1) has never been a witnessed shaking that has resulted
in RH and two videotaped shakings that produced no findings of RH or SDH
and 2) the link between increased ICP from non-shaken head impacted
children with SDH as been convincingly demonstrated numerous times and
most convincingly by Aoki 1984 (8), I ask why is the link between
increased ICP of any etiology and RH consistently ignored? Also why are
the diagnoses of others, in almost all cases relying on SDH and RH to
diagnose abuse, being used to reach conclusions that RH is associated with
abuse when a circular logic invalidating the link between RH and abuse
appears obvious?
Thank you for clarifying the invalidity of pertussis related cough as
a cause of RH, However, I hope that further investigation of the link
between increased ICP and RH will yield more insight into the etiology of
RH and delink it from an abuse narrative since so many innocent caregivers
languish in jail based on the use of RH as diagnostic of abuse.
Acknowledging the long history of the misuse of RH is also "essential to
safeguard the patient and his or her siblings" from the loss of a loving
caregiver. When accidents and medical problems are misdiagnosed as abuse,
based on the nonspecific finding of RH and SDH, dreadful consequences
arise.
Sincerely yours,
Steven C Gabaeff, MD
1. Gabaeff, S. Challenging the Pathophysiologic Connection Between
Subdural Hematoma, Retinal Hemorrhage and Shaken Baby Syndrome. West J
Emerg Med. 2011 May;12(2):144-58.
2. Terson PDA. Hemorrhage in the vitreous body during cerebral
hemorrhage. La Clinique Ophthalmologique 1900;22:309-12.
3. Medele RJ, Stummer W, Mueller AJ, Steiger HJ, Reulen HJ. Terson's
syndrome in subarachnoid hemorrhage and severe brain injury accompanied by
acutely raised intracranial pressure.J Neurosurg.1998 May;88(5):851-4.
4. Walsh FB, Hedges TR. Optic nerve sheath hemorrhage. Am J
Ophthalmol 1951;34:509-27
5. Muller PJ, Deck JHN. Intraocular and optic nerve sheath hemorrhage
in cases of sudden intracranial hypertension. J Neurosurg 1974;41:160-6
6. Reddy AR, Clarke M, Long VW. Unilateral retinal hemorrhages with
subarachnoid hemorrhage in a 5-week-old infant: is this nonaccidental
injury? Eur J Ophthalmol. 2010 Jan 5
7. Koto, T, et.al. Hypoxia Disrupts the Barrier Function of Neural
Blood Vessels through Changes in the Expression of Claudin-5 in
Endothelial Cells, American Journal of Pathology. 2007;170:1389-1397.
8. Aoki N, Masuzawa H. Infantile acute subdural hematoma: clinical
analysis of 26 cases. J Neurosurg 1984;61:273-80.
Conflict of Interest:
I have consulted in 1500 cases of abuse over 23 years and have been certified by the Los Angeles County Superior Court as an expert in child abuse for both the prosecution and defense.
Dear Authors,
Thank you for shedding light on the issue of cough and the improbability of cough in the context of pertussis as seemingly unlikely to produce RH. That aspect of your study is quite convincing.
While your prospective study provides valid information, it does not qualify as a jumping off point to conclude that maltreatment is involved in 75% of RH that are seen. You have relied on a retrospective study by King in which children were preclassified as abused by unknown providers using imprecise, undefined or unknown criteria. From clinical experience, we know these diagnoses were most likely based on the presence of RH and SDH. When this occurs, the use thereafter of RH or SDH as indicators of abuse, is circular logic. It is a logical fallacy to conclude that the RH that placed a child in an abuse group then becomes proof that they belong in an abuse group.
RH is linked to increased intracranial pressure. This well established connection was discussed at length in an article I published this year (1) and has been general knowledge for more than 100 years since Terson's work in 1900 and others since (2,3,4,5,6).
While cough alone may not be sufficient to cause RH, coughing in the context of other comorbidities (pneumonia for example which concurrent low oxygen states) may be sufficient to damaged already metabolically compromised capillaries and cause them to leak (7).
That aside, the effort to segue from the absence of RH in pertussis to RH as a valid diagnostic finding of maltreatment seems to redirect your efforts to attempting to use, yet again, RH as an indicator of abuse.
Since there 1) has never been a witnessed shaking that has resulted in RH and two videotaped shakings that produced no findings of RH or SDH and 2) the link between increased ICP from non-shaken head impacted children with SDH as been convincingly demonstrated numerous times and most convincingly by Aoki 1984 (8), I ask why is the link between increased ICP of any etiology and RH consistently ignored? Also why are the diagnoses of others, in almost all cases relying on SDH and RH to diagnose abuse, being used to reach conclusions that RH is associated with abuse when a circular logic invalidating the link between RH and abuse appears obvious?
Thank you for clarifying the invalidity of pertussis related cough as a cause of RH, However, I hope that further investigation of the link between increased ICP and RH will yield more insight into the etiology of RH and delink it from an abuse narrative since so many innocent caregivers languish in jail based on the use of RH as diagnostic of abuse. Acknowledging the long history of the misuse of RH is also "essential to safeguard the patient and his or her siblings" from the loss of a loving caregiver. When accidents and medical problems are misdiagnosed as abuse, based on the nonspecific finding of RH and SDH, dreadful consequences arise.
Sincerely yours,
Steven C Gabaeff, MD
1. Gabaeff, S. Challenging the Pathophysiologic Connection Between Subdural Hematoma, Retinal Hemorrhage and Shaken Baby Syndrome. West J Emerg Med. 2011 May;12(2):144-58.
2. Terson PDA. Hemorrhage in the vitreous body during cerebral hemorrhage. La Clinique Ophthalmologique 1900;22:309-12.
3. Medele RJ, Stummer W, Mueller AJ, Steiger HJ, Reulen HJ. Terson's syndrome in subarachnoid hemorrhage and severe brain injury accompanied by acutely raised intracranial pressure.J Neurosurg.1998 May;88(5):851-4.
4. Walsh FB, Hedges TR. Optic nerve sheath hemorrhage. Am J Ophthalmol 1951;34:509-27
5. Muller PJ, Deck JHN. Intraocular and optic nerve sheath hemorrhage in cases of sudden intracranial hypertension. J Neurosurg 1974;41:160-6
6. Reddy AR, Clarke M, Long VW. Unilateral retinal hemorrhages with subarachnoid hemorrhage in a 5-week-old infant: is this nonaccidental injury? Eur J Ophthalmol. 2010 Jan 5
7. Koto, T, et.al. Hypoxia Disrupts the Barrier Function of Neural Blood Vessels through Changes in the Expression of Claudin-5 in Endothelial Cells, American Journal of Pathology. 2007;170:1389-1397.
8. Aoki N, Masuzawa H. Infantile acute subdural hematoma: clinical analysis of 26 cases. J Neurosurg 1984;61:273-80.
Conflict of Interest:
I have consulted in 1500 cases of abuse over 23 years and have been certified by the Los Angeles County Superior Court as an expert in child abuse for both the prosecution and defense.