In 1962 a new syndrome was “discovered” by Dr. C. Henry Kempe, a pediatrician. The paper was published in the Journal of the American Medical Association (JAMA), ostensibly after the usual review process. In the paper, there are four x-rays with an accompanying comment that parents often lie, but X-rays never do.
The new syndrome was “battered child syndrome,” and in years since, Kempe’s paper and the battered child syndrome has put thousands of Americans in prison for abusing their children.
I sent Kempe’s original JAMA paper to a radiologist experienced in diagnosing rickets, Dr. David Ayoub, and his interpretation of the x-rays indicated all of Kempe’s x-rays showed rickets, in various stages of healing, even showing the splayed distal femurs and bowlegs that are virtually pathognomonic of rickets. If Doctor Ayoub is correct, it is hard to overstate the injustices that Kempe et al has caused.
This month, another disturbing paper was published about bone pathology in sudden infant death syndrome (SIDS). The authors, Doctor Marta Cohen and colleagues, of the Sheffield Children’s Hospital in England, did x-rays and bone pathology examinations on 41 children who died of SIDS.
They found that only 25% of the SIDS babies had vitamin D levels greater than 30 ng/ml, while 12% had sub-optimal levels, 39% had moderate deficiency and 25% had levels below 10 ng/ml. However, the disturbing part of the study was the finding that bone pathology showed rickets in 69% of cases, but x-rays showed rickets in only 19% of cases. That is, x-rays missed rickets 50% of the time. The gold standard for the diagnosis of rickets is bone biopsy and bone histopathology, not x-rays.
The paper also showed that while prevalence of rickets increased with lower D levels, individually rickets was absent with 25(OH)D as low as 2.4 ng/ml and present as high as 52 ng/ml! This confirms what has been previously widely reported-that rickets is multifactorial and no 25(OH)D threshold levels can reliably predict the presence of rickets nor its exclusion. Low intake of calcium can cause rickets even when 25(OH)D levels are high.
It also found that radiologists only correctly identified 2 of 13 infantile rickets cases (15% sensitivity) and identified one case of rickets not supported by the pathology (false positive). Furthermore, the two pediatric radiologists were never unanimous in their diagnosis of rickets.
So, that not only means that a significant number of SIDS deaths may be related to vitamin D deficiency, it also means that radiologists miss rickets a lot of the time. My long standing theory is that too often radiologists diagnose “battered child syndrome” and another innocent parent goes to prison. Such was the case in the popularly covered death of baby Jayden in the UK, in which radiologists initially missed the diagnosis of rickets and wrongly accused the parents of abuse.
The Vitamin D Council has asked the editor of JAMA, Dr. Howard Bauchner, to properly review the 1962 Kempe et al paper by having it reviewed by older radiologists who are experienced in diagnosing rickets and who have practiced radiology in a country where rickets is endemic.
Below is my letter:
Dr. Howard Bauchner
Journal of the American Medical Association
Dear Dr. Bauchner:
In 1962, JAMA published a flawed and improperly reviewed paper that has led to the conviction of many innocent Americans. I am writing to ask JAMA to formally withdraw the paper.
In 1962, Kempe et al introduced a new syndrome to medicine, the “Battered Child Syndrome.” The authors presented four x-rays of allegedly battered children. The parents vehemently and repeatedly denied hitting their children.
Unlike any other crime in law, battered child syndrome is a crime in which an expert medical witness provides evidence of a crime, evidence of a motive and evidence of the perpetrator. When death occurs, battered child syndrome is, in essence, a medical diagnosis of murder. Recently, the Innocence Project is seeking to overturn many of these convictions as terrible miscarriages of justice.
Kempe et al made it clear that parents lie but x-rays do not. That is, the paper claims that x-rays in such cases are dispositive. Indeed, once an abnormal x-ray is presented as evidence of child abuse in the courtroom, and is accompanied by the child abuse interpretation of an expert medical witness, little is left for the defense but a plea bargain.
The Kempe et al paper contains 4 figures, all reproductions of radiographs. After reviewing the radiographs, I conclude, that almost all of the reproduced radiographs show rickets, some severe, a diagnosis not considered by the authors and apparently not considered by JAMA editors or reviewers. I have sent the Kempe et al paper to a knowledgeable radiologist, Dr. David Ayoub, who agrees that rickets is the skeletal pathology. The X-rays even show the characteristic distal femoral flares and bowlegs pathognomonic of rickets.
If true, the JAMA editorial failure in the Kempe et al paper is difficult to overstate. How many American families were needlessly destroyed when experts relied on this JAMA paper to erroneously diagnose “battered child syndrome”? How many innocent Americans were unjustly incarcerated due to expert testimony that relied on this paper?
I ask that the editors send the 4 figures in the paper, sans the text and sans the text in the captions, to several radiologists who are very experienced in diagnosing the many manifestations of rickets, for a blind review. If my fears are confirmed, I ask that the JAMA editors of today attempt to rectify the mistake of their predecessors by:
- Officially withdrawing the Kempe et al paper.
- Notifying the U.S. Supreme Court and all 50 state supreme courts of your findings.
- Locate all child physical abuse papers in JAMA that cited Kempe et al and notify the authors of your findings.
John J Cannell, MD
Vitamin D Council