Was the Baby Shaken? - Letters to the Editor - Letter to the Editor

Townsend Letter for Doctors and Patients,  Jan, 2002  

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Editor:

Child abuse laws have given rise to many accusations of "Shaken Baby Syndrome," which has become a popular diagnosis to explain infant deaths, and even for living infants who are brought to an emergency room following a fall. Much is made of the finding of pinpoint petechial hemorrhages in the retina at the back of the eye, but the existence and the extent of such hemorrhages are dependent on the capillary strength or fragility, the strength or weakness of the smallest blood vessels, which can be affected by many different conditions. In fact, an infant can die with extensive retinal hemorrhages, a blood clot under the capsule of the brain, extensive bruises, broken bones and sores that will not heal, due to Barlow's disease, without having been subjected to anything but the tenderest of loving care.

Barlow's disease is another name for infantile scurvy or vitamin C deficiency, which was a well-recognized condition among bottle-fed infants, both in Europe and in the United States in the first half of the 20th century It occurred not only among the poor who did not know or could not afford to buy orange juice as a supplement to the milk diet, but also among the infants of some affluent members of society who boiled the milk to destroy the germs of tuberculosis, so destroying all vitamin C. Other infants developed Barlow's disease due to the feeding of a commercial "malt soup," whose alkalinity destroyed vitamin C.

Today Barlow's disease is rare, but could perhaps still occur if people were to go overboard with heating the baby's bottle in a microwave oven, or if they do not know that natural apple juice is a very poor substitute for orange juice. One hundred grams of fresh orange juice (3-1/4 fluid ounces) contains about 49mg of vitamin C, but nowadays it is the fashion to give infants apple juice instead; unfortunately there is only 1 mg of vitamin C in the same amount of fresh apple juice, so unless the parent knows to buy apple juice with added vitamin C, there can be a risk of vitamin C deficiency.

People will rightly say that severe vitamin C deficiency is rare in the Western world today; not only is it rare, it is even more rarely diagnosed, as the bleeding gums which are so characteristic of adult scurvy are never seen in toothless infants. It is bacteria in the crevice between the tooth and the gum that cause local infection; infection causes local vitamin C depletion and vitamin C deficiency predisposes to infection, so a vicious cycle can develop, leading to the foul mouth and the bleeding gums of scurvy This does not occur in edentulous infants. Multiple bone fractures and sub-periosteal hemorrhages do occur in Barlow's disease, but all too often now the sub-periosteal hemorrhages, lifting the growing sheath right off the surface of the bone, are thought to be the result of the fractures, instead of being recognized as revealing their cause. Even this X-ray finding, formerly known as being characteristic of the healing phase of scurvy, is now often said to be evidence of child abuse. Of course vi tamin C deficiency is not the only cause of spontaneous bone fractures in infants; they also occur in osteogenesis imperfecta or fragilitas osseum; moreover, capillary fragility occurs in many other conditions ranging from measles to thrombocytopenic purpura.

Our recent knowledge of the role played by an increased blood histamine concentration, or histaminemia, as the leading cause of capillary fragility in vitamin C deficiency, enables us to understand the additive effect of all other causes of histaminemia. We now know that the bruising and bleeding of scurvy result from an increase in the blood histamine concentration, which causes the endothelial cells lining the inside of the blood vessels, to become separated from one another; there is no change in the blood clotting mechanism, but a profound disturbance of the endothelial architecture. It is now known that the blood histamine level begins to increase as soon as the plasma ascorbic acid or vitamin C concentration falls below the normal level of 1mg per 100ml, even though frank scurvy does not occur until it falls below one fifth of that value. Blood plasma vitamin C levels and whole blood histamine levels show a remarkable inverse relationship, both in guinea pigs and in humans, but many toxins and other fac tors, including vaccinations and inoculations also cause an increase in the blood histamine level.

We are all aware of the effects of increased tissue histamine concentrations, revealing themselves as nettle rash, hay fever or asthma, but an increased blood histamine level can be a silent killer. We now must appreciate that the degree of the histaminemia and the resultant capillary fragility can result from a concatenation of circumstances. We may have an infant with a borderline vitamin C depletion, which on its own would have been relatively innocuous, now becoming more severe as a result of infection or some other stress; even the common cold or coryza can halve the blood plasma vitamin C concentration in 24 hours. Furthermore, we now know that heavy metals like mercury copper, or even iron in excess can deplete vitamin C reserves, so we have to wonder about the effects of the mercurial antiseptic thimerosol used in some pediatric inoculants. Moreover, it has been shown that the toxins or toxoids of the usual inoculants cause increased blood histamine levels in animals. So we must consider the effects o f all the inoculants given together to an infant already ill or vitamin C depleted; the blood histamine level, the capillary fragility and the likelihood of petechial hemorrhages will be the result of all these factors added together.