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Re: Neonatal shaken baby syndrome - historical inexactitudes

Dear Editor

I read with interest the article on Neonatal Shaken Baby Syndrome.[1] While a fascinating account of the sequence of events in this saga it is factually incorrect in several respects.

As the perinatal pathologist involved in the Birmingham series I raised the possibility that the brain damage was due to the effects of physiotherapy prior to the publication of our report. My co-authors felt that the suggestion was too speculative to be included. It is however of note that the physiotherapy regime was changed at this time as a precaution and as I remember I encountered only one further case until my retirement in 2000. At the time I presented the pathological data at several scientific meetings both in the UK and abroad suggesting physiotherapy was relevant and also discovered that the method used in Birmingham appeared to be unique in allowing free movement of the babies head during treatment of the chest.

Some years later I received a telephone call from Dr David Becroft the perinatal pathologist concerned with the New Zealand cases which pathologically appeared very similar to our own. They had no explanation for their cases at this time and I indicated that I had always been of the opinion that physiotherapy was responsible. As I understand it this resulted in changes in the physiotherapy regime in New Zealand and the disappearance of the lesion.

In retrospect I should have insisted that my hypothesis however speculative was included in our original paper or expressed the view in the correspondence columns at the time since it might have prevented or at least reduced the number of affected cases in New Zealand. Certainly today I would not have been so reticent. In the event it is gratifying that detailed clinical analysis of the cases confirmed my original opinion.

As to the pathology of the condition detailed unpublished studies of the affected brains in our series suggest the lesion is more akin to that of hydranencephaly than infantile shaken baby syndrome and leads me to raise the possibility that hydranencephaly may be the result of intra-uterine brain trauma.

D Ian Rushton MB ChB FRCPCH FRCP

Reference

(1) Williams AN, Sunderland R, Rosenbloom L and Ryan S. Neonatal shaken baby syndrome: an aetiological view from Down Under. Arch Dis Child Fetal Neonatal Ed 2002;87: F29-F30.

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Re: Re: Neonatal shaken baby syndrome - lessons to be learned

Dear Editor

Drs Williams and Sunderland[1] and the accompanying commentary from Drs Rosenbloom and Ryan[2] discuss a severe cystic brain lesion associated with chest physiotherapy in very preterm infants. Rosenbloom is correct that the topic lacks topicality, but mainly because neonatal chest physiotherapy is now used very little if at all. I disagree that there is an abundant literature detailing appropriate treatment and the absence of brain damage associated with neonatal chest physiotherapy. Older data suggested benefit,[3-5] but more recent publications demonstrate none.[6-8] The reported benefits were transient improvements in oxygenation and slight increased removal of secretions. The older studies are all too small to adequately address safety. Chest physiotherapy, by whatever method has little or no place in neonatal intensive care.

There are several lessons to be learned from the experience of the units who found these brain lesions. The first is that a treatment generally recognised as being beneficial may not be so, especially with other changes in care over the passage of time. Continued reassessment of the usefulness of treatment is needed. The second is that side effects can appear, even when a treatment has supposedly passed the test of time. Ongoing audit is needed. The third is that there is a dilemma that clinicians face in reporting complications. The first hospital to find this lesion did not further investigate the cause or report its suspicions.[9] The second hospital did.[10] That hospital has been subject to a long official public inquiry, law suites and had twenty medical, nursing and physiotherapy staff investigated by registration authorities, lasting 8 years. All this happened in the supposedly non-litigious medicolegal environment of New Zealand. There needs to be the ability to be open about complications and side effects and have an atmosphere of learning from, rather than blame for them.

I would like to correct one statement by Williams and Sunderland. In our nursery there was no change in the vigour of chest physiotherapy from the introduction of the technique in 1985 until we stopped all chest physiotherapy at the end of 1994. The cerebral lesions appeared from 1992 to 1994. From 1985, the same physiotherapist was teaching and supervising the technique. During those three years, babies who developed the brain lesion had more chest physiotherapy than matched concurrent controls, but considerably less than many infants in previous years. Why the brain lesion began to appear remains a mystery.

References

(1) Williams AN, Sunderland R, Neonatal shaken baby syndrome: an aetiological view from Down Under. Arch Dis Child 2002; 87: F29-30

(2) Rosenbloom L, Ryan S, Neonatal shaken baby syndrome: an aetiological view from Down Under. Commentary. Arch Dis Child 2002; 87: F30

(3) Finer NN, Boyd J. Chest physiotherapy in the neonate: a controlled study. Pediatrics 1978; 61: 282-85.

(4) Etches PC, Scott B. Chest physiotherapy in the newborn: effect on secretions removal. Pediatrics 1978; 62: 713-15.

(5) Tudehope DI, Bagley C. Techniques of physiotherapy in intubated babies with the respiratory distress syndrome. Aust Paediatr J 1980; 16: 226-28.

(6) Al-Alaiyan S, Dyer D, Khan B. Chest physiotherapy and post- extubation atelectasis. Pediatr Pulmonol 1996; 21: 227-30.

(7) Bloomfield FH, Teele RL, Voss M, Knight DB, Harding JE. The role of neonatal chest physiotherapy in preventing postextubation atelectasis. J Pediatr 1998; 133: 269-71.

(8) Bagley CE, Flenady VJ, Tudehope DI, Gray PH, Lamont A, Shearman A. The role of routine prophylactic post-extubation chest physiotherapy in neonates: a randomised controlled trial. Proc Perinatal Society of Australia and New Zealand, Brisbane. 2000; page 73.

(9) Rushton DI. Neonatal shaken baby syndrome – historical inexactitudes. [electronic response to Williams AN et al. Neonatal shaken baby syndrome: an aetiological view from Down Under] archdischild.com 2002 http://adc.bmjjournals.com/cgi/eletters/fetalneonatal;87/1/F29#139

(10) Harding JE, Miles FKI, Becroft DMO, Allen BC, Knight DB. Chest physiotherapy may be associated with brain damage in extremely preterm infants. J Pediatr 1998; 132: 440-44.

Send letter to journal:
Re: Neonatal shaken baby syndrome: an aetiological view from Down Under

Dear Editor

We are grateful to colleagues for their comments on our annotation.[1] We would stress that we merely abstracted the views of others so any criticisms (apart from our brevity) will be of the lawyers, doctors, nurses, physiotherapists and parents who contributed to the Royal Commission Report. We found it to be systematic, rational and objective.

We strongly refute any suggestion that any of the New Zealand professionals should be criticised let alone made scapegoats (witness our final paragraph). We are puzzled that Drs Rosenbloom and Ryan discount the quoted witness statements of the parents and involved clinicians. The lawyers and doctors are clear that the physiotherapy and nursing practices did occur and that the levels of head shaking were not monitored.

We are concerned with infant brain injuries not lung disease and consider this to be topical. We share colleagues’ concern at the need to base opinions on speculative presumption extrapolated from animal or accident research and are aware of the limited evidence that identifies the minimal forces needed to cause shaken brain damage in neonates or older infants. We found the reported experiences to be a helpful insight.

We are delighted that Dr Rushton (eLetter) has taken this opportunity to state he thought vigorous chest physiotherapy without supporting the head was responsible for the porencephalic lesions and to inform of his pivotal involvement in advising New Zealand colleagues. We understand there were earlier concerns that publishing the speculation about physiotherapy would open liability to litigation. Lawyers might consider the inference that fear of litigation led to suppression of information that might have prevented the New Zealand deaths and the dilemma facing clinicians who reported the cerebral implications of vigorous physiotherapy. Dr Knight reports (eLetter) their unit has been ‘subject to a long official public inquiry, law suits and had twenty medical, nursing and physiotherapy staff investigated by registration authorities, lasting 8 years.’

We do not accept criticisms of inaccurate references. The Cochrane review we both cited was last updated in 1997. There has been an updated review this year (dealing with lung not brain disease), which was unavailable to the editors or us at the time of submission. Dr Knight (eLetter) states there was no change in the vigour of chest physiotherapy from 1985 until the end of 1994 but he co-authored the paper [2] we cited that states that there was no policy to support the head during chest physiotherapy and no data on the extent the head moved during physiotherapy whether given by nurses or physiotherapists. The Royal Commission Report found no record of the vigour of chest percussion and understood there was considerable variation with no standardisation of training.

We recommend interested colleagues to read this Report and the publications of Knight and Harding et al before dismissing the possibility that vigorous chest physiotherapy without supporting the head may cause brain injuries in certain circumstances.

References

(1) Williams AN, Sunderland R, Neonatal shaken baby syndrome: an aetiological view from Down Under. Arch Dis Child 2002;87:F29-30

(2) Knight DB, Bevan CJ, Harding JE, et al. Chest physiotherapy and porencephalic lesions in very preterm infants. J Paediatr Child Health 2001;37:554–8.