DR Erfat Barnes sat in one of the few adult-size chairs in her office. On the other side of the room, green, yellow and red child-size plastic chairs waited for patients to fill them.
Barnes was surrounded by teddy bears, and a child’s drawing of colourful, square houses adorned a wall.
From her warm office, the Teddy Bear Clinic’s chief paediatrician at Charlotte Maxeke Hospital, recounted horrific cases of child abuse.
In some, she pointed out “evidence of (baby) shaking”, and described the “detective work” necessary to correctly identify a specific diagnosis introduced over the past several years into the South African medical field.
Shaken-baby syndrome is a highly controversial medical diagnosis describing a form of child abuse in which shaking an infant causes severe injury or death.
Also referred to as “abusive head trauma” or “non-accidental head injury”, the diagnosis first appeared in the 1940s and later evolved in the US and UK.
But a growing number of doctors and lawyers investigating the diagnosis argue it lacks merit.
Shaken-baby syndrome found its way to South Africa in recent years, and, aware of international debate, doctors are sifting through competing claims and literature to avoid misdiagnosis.
In some cases, there are no outward signs of abuse, so doctors relied for years on “the triad” – a combination of brain bleeding, brain swelling and bleeding in the eyes – as supposedly guaranteed signs of shaken-baby syndrome.
Heather Kirkwood is an American attorney who has dealt with these cases for the past decade. She has never found any evidence base for the diagnosis.
“Each of the triad elements have many other causes, and many of these cover all three of the triad elements,” she said.
The triad is still mentioned in South Africa, although doctors try to avoid diagnosing on the three symptoms alone. Instead, Barnes and others search for more signs of abuse such as broken bones and poor interaction between child and parent.
“The initial diagnosis is based on the triad, but once you’ve done that, you want to make sure you’re not dealing with rickets, for example,” Barnes said.
With a number of medical issues, such as the bone condition, rickets, mirroring symptoms of child abuse, Barnes sometimes calls for upwards of 20 tests to correctly diagnose abused children.
“We obviously don’t want to wrongfully accuse anyone, but at the same time, you cannot send a child back to a place where they are unsafe because these are the most vulnerable children.”
A former colleague of hers used US data, which is still debated, to estimate that doctors could expect to see about 500 cases of shaken-baby syndrome in South Africa a year.
Luke Lamprecht runs the Shaken and Abused Baby Initiative, an advocacy programme aimed at raising awareness of the diagnosis. He said: “In terms of recording and numbers, it’s very, very poor, and I think we still suffer from under-diagnosing rather than over-diagnosing.”
Dr Waney Squier is a British neuropathologist who is one of many doctors facing censorship or the threat of losing medical licences because of court appearances in which she and others testified against the diagnosis.
A few years ago, she gave a talk in Cape Town about shaken-baby syndrome. She noted that the attention of South African paediatricians was, at the time, with the outbreak of child rapes at the hands of men who believed sex with a virgin could cure HIV.
“I talked about shaken-baby syndrome, and they told me they weren’t really concerned with it,” Squier said.
The diagnosis has spread across most of the developed world, and specific countries, such as Sweden, can provide clues to its growth in a new country.
Over the past five years, Sweden has found itself an unlikely new battleground. As in South Africa, the shaken-baby syndrome diagnosis was imported there from overseas by paediatricians, brought by two doctors with connections to North America.
Once previously solid convictions came under fire, US and British experts rushed to Sweden to give lectures and lend expert opinions on legal proceedings. The country’s debate has not been kind to the diagnosis’ proponents. In 2014, the Swedish Supreme Court acquitted a man who had been convicted of shaking his three-month-old son.
The groundbreaking ruling was the first time an apex court called the entire diagnosis into question.
“It can be concluded that, in general terms, the scientific evidence for the diagnosis of violent shaking has turned out to be uncertain,” ruled the court, in its decision.
Then, a multi-year, government-sponsored study was published last year and found no strong evidence supporting the diagnosis.
Kirkwood said a significant portion of the diagnosis’ international spread could be attributed to a US-based organisation called the National Center on Shaken Baby Syndrome.
According to its website, the organisation has hosted its annual meetings in six countries, with stops in Sydney, Paris and Kyoto, among others.
“At the international (conferences) in particular, you see people from all around the world coming to be trained,” Kirkwood said.