Response Emmanuel Children’s Hospital

4. Veerman M, et al. Cost-effectiveness of RespiGam at a university teach-ing hospital.Pediatrics.1997;100:160 –161

5. Thakur BK, Wu LR, Schaeufele JF. RSV-IGIV therapy: a cost/benefit analysis.Pediatrics.1997;100:417

Shaken Baby Syndrome—A Forensic Pediatric

Response

To the Editor.—

As physicians who specialize in the diagnosis and treatment of victims of child abuse, we feel compelled to speak out regarding the scientific evidence as portrayed in the trial of Louise Wood-ward for the murder of 8-month-old Matthew Eappen. Both in the United States and in England, media publicity surrounding the case has led to considerable sentiment that she was convicted despite allegedly irrefutable scientific evidence presented by the defense that the infant’s injuries had occurred days to weeks earlier. Many in the media and the public have failed to credit the jury in this case with having had the intelligence to understand that the prosecution put forward well-established medical evi-dence that overwhelmingly supported a violent shaking/impact episode on the day in question, when Matthew was in the sole custody of Ms Woodward. The hypothesis put forward by the defense that minor trauma caused a “re-bleed” of an earlier head injury can best be characterized as inaccurate, contrary to vast clinical experience, and unsupported by any published literature. The “re-bleed” theory in infants is a courtroom “diagnosis,” not a medical diagnosis, and the jury properly rejected it.

Infants simply do not suffer massive head injury, show no significant symptoms for days, then suddenly collapse and die. Whatever injuries Matthew Eappen may or may not have suf-fered at some earlier date, when he presented to the hospital in extremis he was suffering from proximately inflicted head in-juries that were incompatible with any period of normal behav-ior subsequent to the injury. Such an injury would and did produce rapidly progressive, if not immediate, loss of con-sciousness.

The shaken baby syndrome (with or without evidence of impact) is now a well-characterized clinical and pathological entity with diagnostic features in severe cases virtually unique to this type of injury—swelling of the brain (cerebral edema) secondary to severe brain injury, bleeding within the head (subdural hemorrhage), and bleeding in the interior linings of the eyes (retinal hemorrhages). Let those who would challenge the specificity of these diagnostic features first do so in the peer-reviewed literature, before speculating on other causes in court. Indeed, the courtroom is not the forum for scientific speculation, but rather the place where only, according to the US Supreme Court in Daubert v Merrill Dow, peer-reviewed, generally accepted, and appropriately tested scientific evidence should be presented.

We endorse a panel of medical experts to offer a scientifically based analysis of the medical testimony offered in this case and others so that some guidelines can be established for the courts on future admissibility of scientifically supportable medical testi-mony.

David L. Chadwick, MD San Diego, CA

Robert H. Kirschner, MD Chicago, IL

Robert M. Reece, MD Boston, MA

Lawrence R. Ricci, MD Portland, ME

Randall Alexander, MD University of Iowa Mia Amaya, MD, MPH University of Alabama Birmingham, AL Judith Ann Bays, MD Emmanuel Children’s Hospital Portland, OR

Kirsten Bechtel, MD St Christopher’s Hospital Philadelphia, PA

Rebecca Beltran-Coker, MD

East Carolina University School of Medicine Greenville, NC

Carol D. Berkowitz, MD Harbor/UCLA Medical Center Torrance, CA

Steven D. Blatt, MD

SUNY Health Science Center at Syracuse Syracuse, NY

Ann S. Botash, MD

SUNY Health Science Center at Syracuse Syracuse, NY

Jocelyn Brown, MD, MPH

College of Physicians & Surgeons of Columbia University New York, NY

Mary Carrasco, MD

Children’s Hospital of Pittsburgh Pittsburgh, PA

Cindy Christian, MD

Children’s Hospital of Philadelphia Philadelphia, PA

Patrick Clyne, MD

Santa Clara Valley Medical Center San Jose, CA

Daniel L. Coury, MD Children’s Hospital Columbus, OH James Crawford, MD Children’s Hospital Oakland Oakland, CA

Nicholas Cunningham, MD, DrPH Columbia University

New York, NY

Michael D. DeBellis, MD

University of Pittsburgh Medical Center Pittsburgh, PA

Chris Derauf, MD

Kapi’olani Child Protection Center Honolulu, HI

John de Triquet, MD Children’s Hospital Norfolk, VA

Bernard P. Dreyer, MD

New York University School of Medicine New York, NY

Howard Dubowitz, MD University of Maryland Baltimore, MD

Kenneth W. Feldman, MD University of Washington Seattle, WA

For further information contact Dr Robert Reece via e-mail at: breece%[email protected]; Dr Lawrence Ricci at [email protected]; or Dr Robert Kirschner at [email protected].

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Martin A. Finkel, DO

University of Medicine and Dentistry of New Jersey Camden, NJ

Emalee G. Flaherty, MD Children’s Memorial Hospital Chicago, IL

Lori Frasier, MD

University of Missouri Hospitals & Clinics Columbia, MO

Lorraine Gari, MD Wolfson Children’s Hospital Jacksonville, FL

Jill Glick, MD

University of Chicago Children’s Hospital Chicago, IL

Penny Grant, MD

Broward County Child Protection Team Fort Lauderdale, FL

Gilles Fortin, MD

Clinique de Pediatrie Socio-Juridique Hopital Sainte-Justine

Montreal, Qubec, Canada

Scott Halpert, MD

Lane County Child Advocacy Center Eugene, OR

Ralph A. Hicks, MD Children’s Medical Center Dayton, OH

Dirk Huyer, MD

Hospital for Sick Children, University of Toronto Toronto, Ontario

Carol Jenny, MD

Hasbro Children’s Hospital Providence, RI

Mark Joffe, MD

Children’s Hospital of Philadelphia Philadelphia, PA

Steven W. Kairys, MD, MPH Dartmouth Medical School Lebanon, NH

Karen M. Kaplan, MD

Penn State Geisenger Health System Hershey, PA

Marilyn Kaufhold, MD Children’s Hospital—San Diego San Diego, CA

Kathi J. Kemper, MD, MPH Swedish Family Medicine Seattle, WA

Elliot J. Krane, MD Stanford University Stanford, CA

Henry Krous, MD

Children’s Hospital—San Diego San Diego, CA

Michelle Lorand, MD Cook County Hospital Chicago, IL

John McCann, MD

University of California, Davis Medical Center Sacramento, CA

Marcellina Mian, MD

Hospital for Sick Children, University of Toronto Toronto, Ontario

Kieran Moran, MD Sydney Children’s Hospital Sydney, Australia

Lucy M. Osborn, MD, MSPH

University of Utah Health Sciences Center Salt Lake City, UT

Vincent Palusci, MD DeVos Children’s Hospital Grand Rapids, MI

Mary Ann Radkowski, MD Children’s Memorial Hospital Chicago, IL

Mary E. Rimsza, MD Maricopa Medical Center Phoenix, AZ

Desmond Runyan, MD, DrPH University of North Carolina Chapel Hill, NC

Michael Ryan, MD New Children’s Hospital Sydney, Australia

Matthew D. Sadof, MD General Pediatrician

Temple University Health System Philadelphia, PA

Charles Schubert, MD

Children’s Hospital Medical Center Cincinnati, OH

Robert Sege, MD, PhD The Floating Hospital Boston, MA

Robert A. Shapiro, MD

Children’s Hospital Medical Center Cincinnati, OH

Benjamin Siegel, MD Boston Medical Center Boston, MA

Andrew Sirotnak, MD Denver, CO

Wilbur Smith, MD University of Iowa

Rebecca Socolar, MD University of North Carolina Chapel Hill, NC

Demetra Soter, MD Cook County Hospital Chicago, IL

Suzanne P. Starling, MD

Vanderbilt University Medical Center Nashville, TN

Carol Stashwick, MD, PhD Children’s Hospital at Dartmouth Lebanon, NH

R. Daryl Steiner, DO

Children’s Hospital Medical Center of Akron Akron, OH

John Stirling, MD

Clark County Child Abuse Intervention Center Vancouver, WA

Naomi Sugar, MD

University of Washington Seattle, WA

Thomas Truman, MD

Tallahassee Memorial Regional Medical Center Tallahassee, FL

David Turkewitz, MD York Hospital York, PA

Claudia Wang, MD UCLA Children’s Hospital Los Angeles, CA

J. M. Whitworth, MD Children’s Crisis Center Jacksonville, FL

Joseph A. Zenel, Jr, MD Doernbecher Children’s Hospital Portland, OR

Underreporting of Pertussis Deaths in the United

States: Need for Improved Surveillance

To the Editor.—

Thirteen persons with pertussis disease onset in 1994 and 1995 were reported to have died by state and local health departments to the national Supplemental Pertussis Surveillance System (SPSS), which is coordinated by the Centers for Disease Control and Prevention (CDC). By contacting all states and US territories to confirm the number of deaths during this time period, we determined that two of the cases were inaccurately listed as deaths and identified five additional pertussis deaths. Of the total 16 pertussis deaths (10 in 1994, 6 in 1995), 12 (75%) were confirmed by positive culture. All deaths occurred in children,3 months of age and only 1 had received any pertussis immunization. This distribution of the age and vaccination status of pertussis deaths is similar to that found among 23 pertussis deaths reported in 1992 and 1993.1

To assess the completeness of reporting to the SPSS, we used the Lincoln-Peterson Capture Recapture method,2,3_which

in-volved matching deaths reported to the SPSS with pertussis deaths reported to another independent surveillance system, in this case to death certificates listing pertussis as an underlying cause reported to the National Center for Health Statistics (NCHS). From 1989 to 1993, 45 deaths were reported to the SPSS and 46 to the NCHS; however, only 13 of these cases were reported to both systems. Assuming all deaths were accurately categorized as pertussis-related deaths, we estimated that a total of 153 (95% CI599 208) pertussis deaths occurred during this 5-year period, averaging 31 deaths per year. Of these, 75 were unreported to either system. Only 29% of the total esti-mated pertussis deaths were reported to the SPSS.

These results indicate that more than two thirds of all pertussis deaths were not accounted for in the national disease reporting system. It is estimated that approximately 10% of all pertussis cases are reported to the CDC.2_{Although underreporting is}

an-ticipated in a passive surveillance system such as the SPSS, there is clear need for more complete reporting of pertussis cases and deaths. Physician’s awareness of the possibility of pertussis as a differential diagnosis for acute cough illness, especially illness associated with paroxysms of coughing or prolonged cough last-ing.2 weeks is crucial to improved reporting. Suspecting pertus-sis soon after the onset of paroxysmal cough illness will result in timely collection of specimens and more sensitive diagnostic test-ing. Once the diagnosis has been made, the health care providers, clinic, or laboratory should report the case to the local and/or state health department.

The public health response to a report of a pertussis case should include antimicrobial prophylaxis of contacts to limit the spread of disease and vaccination of exposed children,7 years of age if needed. In addition, surveillance information should be collected and used to identify persons or areas in which additional efforts are required to reduce disease

inci-dence, and to target vaccination of unvaccinated or undervac-cinated children. Complete surveillance data is also necessary to monitor effectiveness of outbreak control strategies, to de-termine vaccination policies at the state or national level, and to evaluate effectiveness of vaccines. Improving completeness of pertussis reporting is especially important as acellular pertussis vaccines become more widely used among infants.4_{To monitor}

the impact of the change from whole-cell pertussis vaccines to acellular pertussis vaccines on the epidemiology of pertussis, data on vaccination status of cases and type and manufacturer of vaccines administered are essential to collect from all per-tussis cases.

Currently, the CDC is encouraging state health departments to increase completeness of epidemiologic, vaccination, and labora-tory data on pertussis cases and deaths.

Rina Shaikh, MPH Dalya Guris, MD, MPH

Peter M. Strebel, MBChB, MPH Melinda Wharton, MD, MPH

Centers for Disease Control and Prevention Atlanta, GA 30333

REFERENCES

1. Wortis N, Strebel PM, Wharton M, et al. Pertussis deaths: report of 23 cases in the United States, 1992 and 1993.Pediatrics.1995;97:607– 612 2. Sutter RW, Cochi SL. Pertussis hospitalizations and mortality in the United States, 1985–1988. Evaluation of the completeness of national reporting.JAMA.1992;267:386 –391

3. Cochi SL, Edmonds LE, Dyer K, et al. Congenital rubella syndrome in the United States, 1970 –1985: on the verge of elimination.Am J Epide-miol.1989;129:349 –361

4. Centers for Disease Control and Prevention. Pertussis vaccination: use of acellular pertussis vaccines among infants and young children— recommendations of the Advisory Committee on Immunization Prac-tices (ACIP).MMWR.1997;46(No.RR-7):1–25

Pulse Oximetry—So What?

To the Editor.—

In response to the call of Mower et al to add pulse oximetry to the standard panel of vital signs (“Pulse Oximetry as a Fifth Pediatric Vital Sign,”Pediatrics.1997;99:681– 686), I must object.

The authors have presented data that convincingly demon-strate that the use of pulse oximetry changed the frequency with which a variety of tests and interventions took place. With oxim-etry, more chest x-rays were obtained, more blood gas determi-nations drawn, and more children admitted. Diagnoses were changed or added in a number of cases.

Although clinical practice was altered by adding pulse oxime-try to the routine of evaluation, the most important question was begged: did the intervention of pulse oximetry benefit the chil-dren? The authors point out that moderate hypoxia may not induce tachypnea, so that oximetry would appear superior to respiratory rate in detecting hypoxia. I do not doubt this point. But have the authors demonstrated any benefit to the child in detect-ing hypoxia more exquisitely? What happened to the millions of children with asthma or viral pneumonia who experienced hyp-oxia without tachypnea over the last 30 years? Did our current system of observing the child clinically really fail to provide oxygen and other needed treatments to those who actually needed them?

And what of the possible harm done by lowering the thresh-old for obtaining chest x-rays, drawing arterial blood, and admitting to the hospital? By increasing our sensitivity in de-tecting hypoxia, we are at great risk of reducing our specificity in identifying truly significant disease. The proposal to add pulse oximetry to our routine assessment may help boost our ability to detect hypoxia, but it may also add a great amount of unnecessary testing, pain, and exposure to hospital pathogens to children who may recover from their eupneic hypoxia with-out any medical interventions.

I am willing to concede that the balance of benefit and risk may turn out to be in the oximeter’s favor, but until we know that, why

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DOI: 10.1542/peds.101.2.321

1998;101;321

Pediatrics

Zenel, Jr

Thomas Truman, David Turkewitz, Claudia Wang, J. M. Whitworth and Joseph A.

Suzanne P. Starling, Carol Stashwick, R. Daryl Steiner, John Stirling, Naomi Sugar,

Benjamin Siegel, Andrew Sirotnak, Wilbur Smith, Rebecca Socolar, Demetra Soter,

Ryan, Matthew D. Sadof, Charles Schubert, Robert Sege, Robert A. Shapiro,

Vincent Palusci, Mary Ann Radkowski, Mary E. Rimsza, Desmond Runyan, Michael

Michelle Lorand, John McCann, Marcellina Mian, Kieran Moran, Lucy M. Osborn,

Karen M. Kaplan, Marilyn Kaufhold, Kathi J. Kemper, Elliot J. Krane, Henry Krous,

Halpert, Ralph A. Hicks, Dirk Huyer, Carol Jenny, Mark Joffe, Steven W. Kairys,

Flaherty, Lori Frasier, Lorraine Gari, Jill Glick, Penny Grant, Gilles Fortin, Scott

P. Dreyer, Howard Dubowitz, Kenneth W. Feldman, Martin A. Finkel, Emalee G.

Nicholas Cunningham, Michael D. DeBellis, Chris Derauf, John de Triquet, Bernard

Mary Carrasco, Cindy Christian, Patrick Clyne, Daniel L. Coury, James Crawford,

Beltran-Coker, Carol D. Berkowitz, Steven D. Blatt, Ann S. Botash, Jocelyn Brown,

Randall Alexander, Mia Amaya, Judith Ann Bays, Kirsten Bechtel, Rebecca

David L. Chadwick, Robert H. Kirschner, Robert M. Reece, Lawrence R. Ricci,

A Forensic Pediatric Response

−−

Shaken Baby Syndrome

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1998;101;321

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Zenel, Jr

Thomas Truman, David Turkewitz, Claudia Wang, J. M. Whitworth and Joseph A.

Suzanne P. Starling, Carol Stashwick, R. Daryl Steiner, John Stirling, Naomi Sugar,

Benjamin Siegel, Andrew Sirotnak, Wilbur Smith, Rebecca Socolar, Demetra Soter,

Ryan, Matthew D. Sadof, Charles Schubert, Robert Sege, Robert A. Shapiro,

Vincent Palusci, Mary Ann Radkowski, Mary E. Rimsza, Desmond Runyan, Michael

Michelle Lorand, John McCann, Marcellina Mian, Kieran Moran, Lucy M. Osborn,

Karen M. Kaplan, Marilyn Kaufhold, Kathi J. Kemper, Elliot J. Krane, Henry Krous,

Halpert, Ralph A. Hicks, Dirk Huyer, Carol Jenny, Mark Joffe, Steven W. Kairys,

Flaherty, Lori Frasier, Lorraine Gari, Jill Glick, Penny Grant, Gilles Fortin, Scott

P. Dreyer, Howard Dubowitz, Kenneth W. Feldman, Martin A. Finkel, Emalee G.

Nicholas Cunningham, Michael D. DeBellis, Chris Derauf, John de Triquet, Bernard

Mary Carrasco, Cindy Christian, Patrick Clyne, Daniel L. Coury, James Crawford,

Beltran-Coker, Carol D. Berkowitz, Steven D. Blatt, Ann S. Botash, Jocelyn Brown,

Randall Alexander, Mia Amaya, Judith Ann Bays, Kirsten Bechtel, Rebecca

David L. Chadwick, Robert H. Kirschner, Robert M. Reece, Lawrence R. Ricci,

A Forensic Pediatric Response

−−

Shaken Baby Syndrome

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