A tragic birthday

<span class=”dropcap”>G</span>aining momentum with every win, a disturbing defense strategy is invading courtrooms across America. Its target: shaken baby syndrome — a devastating cascade of injuries that can lead to life-long brain damage in an infant, even death. A small but vocal group of defense witnesses are telling the courts that the science behind shaken baby syndrome — also known as abusive head trauma, or AHT — has been debunked. This attack on medical science is overturning convictions and setting legal precedent in the nation’s highest courts — even persuading the late Supreme Court Justice Ruth Ginsburg. But there’s a problem. Major medical associations and child abuse specialists say these claims just aren’t true. “Medical science, itself, is now on trial,” said Dr. Suzanne Haney, the chair of the American Academy of Pediatrics Council on Child Abuse and Neglect, in a <a target=”_blank” href=””>powerful op-ed published in May.</a> Child abuse specialists say these witnesses are confusing judges, juries, medical examiners and the media with theories for a child’s injuries that may hold little to no scientific validity. Their efforts are even keeping cases of alleged child abuse from coming to trial. We begin with the story of one of those cases. <span class=”scroll-element”></span> <span class=”dropcap”>A</span> tiny hand reached out and grabbed a huge fistful of first birthday cake. Bringing it to her mouth, little Rehma Sabir’s eyes widened as she realized her good fortune. “She went nuts on that cake,” remembers Anupendra Sharma, a family friend. “She was beaming. She would take a piece and offer it to the grandmothers. It was adorable.” As the only grandchild, Rehma’s birthday was a special occasion no family member wanted to miss. Rehma’s parents, Sameer Sabir and Nada Siddiqui, held her party on the weekend before her special day so relatives could fly from London and Toronto into Cambridge, Massachusetts. “It was a really happy weekend,” Sameer said. “Everything seemed right with the world.” Two days later on Rehma’s actual birthday — January 14, 2013 — all that changed. Rehma was still asleep when her nanny of six months, 34-year-old Aisling Brady McCarthy, arrived around 8 a.m. Nada recalls Rehma woke, ate her breakfast, then cheerfully played with her birthday presents while both women watched. The newly minted 1-year-old was active and curious, Nada said, putting blocks into the holes of a sorter and playing choo-choo with her new toy train. Rehma pretended to have a tea party, using two dainty fingers to sip from her teacup. When Nada headed to work around 9:30 a.m., Rehma burst into tears. Crying when left with her nanny had become commonplace for Rehma, Nada said, but she considered it simply age-appropriate separation anxiety. To make sure all was well, Nada texted Ash, as the family called her, at 10:14 a.m. Ash replied that Rehma was asleep. How odd, Nada thought. Rehma was always on the go, so napping at that time of day was highly unusual. Nada tried to shrug off her concern: After all, Rehma was likely tired from the weekend’s birthday festivities. Over the next six hours, several people entered and left the apartment, but only saw Rehma on a baby monitor, asleep in her crib. Sameer’s parents arrived at 11:30 a.m. and asked to see Rehma, but were told not to disturb her nap. After waiting for well over an hour, they left to have lunch and run errands. During their wait, at approximately 12:15 p.m., a friend of the family dropped off her nine-month-old son for Ash to watch. She too did not see Rehma awake, neither then nor when she picked up her son at 4 p.m. Around 4:30 p.m. Sameer’s parents returned, and were quite surprised to see Rehma on the baby monitor, still asleep. Ash told them Rehma woke around 1:20 p.m. and had eaten a bit before slumping in her high chair as if tired. She had then put Rehma back in her crib and the baby had slept ever since. Concerned, Rehma’s grandmother entered the baby’s room, rushed to the crib and tried to wake her. Just then, Nada returned home. “You know how people talk about how there’s a moment when your life changes and you always remember that moment?” Nada said. “I remember walking into the doorway of our apartment building and looking up and hearing Ash say, ‘Nada, something is wrong. We can’t wake Rehma up.’ Nada recalled running up the stairs to find Rehma in her grandmother’s arms. She was breathing, but her eyes were closed and her body was jerking. “And then, it was just a rush of memories. There were just policemen in the room and they were crouching by her … paramedics, fire department,” Nada said. “Someone said, ‘It’s her birthday.’ Someone said, ‘Oh, my God!’ ” <span class=”dropcap”>R</span>ehma was in a coma when she arrived at the emergency room at Boston Children’s Hospital. Doctors in the intensive care unit noticed injuries that were telltale signals of child abuse: bleeding inside Rehma’s brain and behind her eyes, as well as bruising on her skull and along her spine. Hospital X-rays found more red flags: healing fractures in Rehma’s left arm and leg, along with new compression fractures in her spine. “I remember that my first reaction when the doctor said that was, ‘How is that possible?’” Nada said. “I don’t understand how a little girl can have fractures that are healing … and no one ever picked up on it. “No doctor. Not me, her mother who was with her all the time. Not her nanny who was with her all the time,” Nada added. “She just showed no signs.” It’s possible to miss such injuries, explained Rehma’s pediatrician, Dr. Michael Yogman, because doctors try to avoid damaging radiation from X-rays during infancy. “That’s the surprising thing about babies,” Yogman said. “They can have fractures and not show any discomfort. Obviously, if she had shown some discomfort, we probably would have jumped at getting X-rays at that point.” As medical concerns began to mount, a call went out in the wee hours to child abuse pediatrician Dr. Alice Newton, asking her to review the case. Newton is one of a few hundred specialists in the country who undergo an additional three years of training beyond medical school to become <a target=”_blank” href=””>board certified in child abuse.</a> In that role, Newton has been at the epicenter of several high-profile Boston child abuse cases, earning accolades from child protection advocates <a target=”_blank” href=””>and ire from defense attorneys and parental rights groups.</a> Newton’s first stop was the radiology department to view scans of Rehma’s brain. Looking at the CT scan performed just after Rehma arrived at the hospital, she was worried by the severe swelling eliminating the typical hills and valleys that make up a brain’s architecture. Newton turned to the MRI of Rehma’s brain, taken about six hours after the CT scan, along with the results of a state-of-the-art high contrast <a target=”_blank” href=”″>scan</a> that shows changes at the cellular level. “Her brain stem was already swollen,” Newton said, pointing to the scans during an interview with CNN’s Chief Medical Correspondent Dr. Sanjay Gupta. “The brain was herniating or swelling so much that it was coming out of the cranial cavity.” Gesturing to some white areas of the scan, she added, “This is all brain tissue that is dead or dying, and that is going to lead to her death. “This is irreversible when we see this.” <span class=”dropcap”>S</span>haken baby syndrome is a subset of abusive head trauma, or AHT, defined by the US Centers for Disease Control and Prevention as an injury to the skull or brain of a child under 5 due to “<a target=”_blank” href=””>inflicted blunt impact and/or violent shaking</a>.” According to the nonprofit <a target=”_blank” href=””>National Center on Shaken Baby Syndrome</a>, approximately 1,300 children in the United States are reported to be victims of abusive head trauma each year. Because symptoms may be easily misdiagnosed and therefore unreported, child abuse specialists say the actual incidence of AHT is much higher. Approximately 25% of diagnosed cases of abusive head trauma are fatal, experts say. Some 80% of the survivors will suffer lifelong disabilities, which may contribute to an early death. When five-month-old Benjamin Dowling suffered abusive head trauma in 1984, his injuries were so severe that he lived with permanent brain damage until his death in 2019. Maintaining her innocence, the babysitter charged with the abuse pleaded no contest to attempted murder and aggravated battery. She was sentenced to 60 days in jail on the weekends and three years of probation. However, forensic experts recently ruled Benjamin’s death 35 years later was directly caused by the prior trauma. Based on that ruling, a Florida grand jury <a target=”_blank” href=””>indicted the now 59-year-old babysitter on new charges of first-degree murder</a>. She was arrested in July, pleaded not guilty, and is currently awaiting trial. Here’s what child abuse specialists believe happens when a baby is violently shaken: The force propels the infant’s brain back and forth inside the skull, tearing tiny bridging veins at the top while severing nerve fibers deep inside the brain. The resulting cell damage triggers inflammation and initiates a tragic cascade of swelling throughout the brain and brainstem, leading to seizures and abnormalities with heart rate, blood pressure and the ability to breathe. Babies who are shaken often have swollen brains; bleeding in the back of the eyes, called retinal hemorrhages; and bleeding under the dura, a membrane between the brain and the skull, called a subdural hemorrhage. Despite the devastation happening inside the skull, there may be no external physical signs of trauma. <span class=”dropcap”>N</span>o one knows the amount of force needed to shake a baby to death. The definitive study — a randomized trial in which researchers shake live babies of various ages — will obviously never happen. Biomechanical studies have attempted to recreate the injuries by shaking live lambs and piglets, mechanical recreations of babies, or “dummies,” and even dead babies. The results have been mixed. Critics of the science behind shaken baby syndrome, including Wisconsin Innocence Project co-founder Keith Findley, say basic physics show “pure shaking, that is, shaking alone” wouldn’t produce the brain and eye bleeding seen in AHT. “And if it did generate forces sufficient to create subdural hematomas and then retinal hemorrhages, it would almost certainly fracture the neck,” Findley added. “All of that force has to transfer biomechanically.” Child abuse specialists disagree. A baby’s neck isn’t likely to fracture during shaking because “loose musculature in infant necks” offers little resistance during shaking and “soft, cartilaginous cervical vertebrae don&#39;t break,” said retired child abuse pediatrician Dr. Robert Reece, editor of the book, “Child Abuse: Medical Diagnosis and Management.” In addition, specialists point to newer science using expensive autopsy and MRI techniques that found injury can occur at the hinge between the base of the skull and the spine where the brain stem is located. “When we started doing that, we found out, lo and behold, there is injury to that area, which explains why these children have disordered breathing or stop breathing,” said Penn State pediatric neurosurgeon Dr. Mark Dias, who conducted one of the studies. <span class=”dropcap”>P</span>olice began searching Sameer and Nada’s Cambridge apartment the next day. Behind Rehma’s changing table, detectives found a piece of drywall missing. A police report described it as “consistent with being damaged by forceful contact with the corner” of the table. The damage was not there before they left for work, Sameer and Nada told authorities. Next to the changing table, police found human blood on six baby wipes discarded in a diaper pail. More blood was found on a baby wipe in a kitchen garbage can, on a pillowcase and blanket in Rehma’s crib and on the onesie Rehma was wearing. DNA testing confirmed it was Rehma’s, according to the prosecution. None of the family had seen blood on Rehma or knew of any injury that would explain the discovery. An upstairs neighbor told police she had heard Rehma screaming and crying around the time Nada left for work. At 9:30 a.m., the neighbor said the crying became so “extreme” that she came downstairs and began knocking on the front door. She told police she could hear the baby “often gasping for its breath between cries.” The neighbor told police she then began “pounding” on the door, timing her knocks between cries. No one responded. The crying continued while the neighbor, who worked from home, went back upstairs to prepare for a 10 a.m. conference call. By the time her 20-minute call was over, she said, the crying had stopped. <span class=”dropcap”>A</span>t the hospital, Newton and her team of specialists were hard at work on their differential diagnosis. That’s a term doctors use to explain how they review and eliminate conditions that might cause the symptoms they see. In cases of suspected child abuse, the list of possibilities is long and includes a host of metabolic diseases, genetic syndromes, tumors, clotting disorders, infections and vitamin deficiencies. Potential causes are carefully crosschecked with a child’s medical record and a thorough interview of the family. If needed, appropriate tests are run. Rehma’s family had previously flagged one potential concern to doctors: her history of easy bruising. Rehma had sustained bruises on three occasions that were worrisome, Sameer said, so “we were fairly persistent with our pediatricians” to investigate any potential cause. When Rehma was 10 months, she had a full workup by a specialist in blood disorders at Boston Children’s Hospital. The hematologist found a small deficiency in a blood clotting protein called von Willebrand factor. But Rehma had Type O blood, which is often associated with a mild deficiency. Rehma’s lower levels, said the specialist, were not enough to consider her at risk for bleeding. “This baby did not have a bleeding disorder,” said Yogman, Rehma’s pediatrician, whose office ordered the tests. “She had some of the problems that we see every day in the first year of life — feeding issues, some reflux — but by and large she was a healthy little girl.” Newton and her team decided there was only one credible explanation for Rehma’s condition: The abuse had to have occurred that day, Newton maintained, because immediately after the injury, Rehma would not have appeared normal. Holding vigil in the ICU, Sameer and Nada were slowly losing hope that their baby girl would recover. “I was just sitting in the room watching the monitors,” Sameer said. “The nurse came in the room and checked her pupils. One of her pupils had dilated, which was a bad sign. And it all went south very quickly from there.&quot; Nearly 48 hours after she was found unresponsive in her crib, Rehma Sabir was declared brain dead. “Sameer asked me to come to the back of her room and we sat there,” Nada recalled, slowly and quietly. “And I remember he just took my hand and said, ‘She’s gone.’ “I didn’t fight, I didn’t do anything,” Nada continued. “And I remember leaving that room thinking that my life was over.” <span class=”dropcap”>A</span>s the only person caring for Rehma after her parents left that day, Aisling Brady McCarthy was at the center of the police investigation. In statements to the police on January 15 and 16, McCarthy said Rehma “was cranky as usual,” but ate her breakfast and then played with her tea cups and train. McCarthy said Rehma was “whiny,” after Nada went to work, so she put her down for a nap around 10:15 a.m. Rehma woke just after 1 p.m. and McCarthy said she placed her in her highchair. She said Rehma only ate two spoonfuls of food but held her bottle independently and had normal eye contact. After leaving Rehma briefly, McCarthy told police she returned to find Rehma with her head down. The baby had “heavy” eyes and looked “sleepy,” McCarthy said, so she took Rehma back to her crib, singing as they went. Rehma remained in her crib from approximately 1:30 p.m. until she was found unresponsive around 4:30 p.m. McCarthy said she checked on Rehma around 2:30 p.m. and again at 4 p.m., and the baby showed no signs of distress. According to the Commonwealth’s Statement of the Case, McCarthy “admitted she had sole care and custody of Rehma” all day; she also denied any “accidental or other trauma to Rehma” and had no explanations for her injuries. Because McCarthy was considered a flight risk — her visa had expired and she was in the United States illegally — prosecutors moved quickly to keep her from leaving for Ireland, her native country. McCarthy was soon indicted by a grand jury for murder and assault and battery and held on $500,000 bail. For Nada and Sameer, it was unthinkable that a woman they liked and trusted could have hurt their daughter. They pinned their hopes on the autopsy, hoping the results would provide an alternative answer. “For a very long time, we felt sorry for Ash and we did not have bad feelings towards her,” Nada said. “We struggled with it because she was our friend. “We kept thinking something is going to turn up. There will be some rare condition [Rehma] passed away from,” Nada said. “If we had to lose our daughter, we hoped it was to that and not to this horrifying scenario.” <span class=”layout-correction”></span> <span class=”dropcap”>A</span> few months later, Boston medical examiner Dr. Katherine Lindstrom released the autopsy report. She found blunt force injuries behind Rehma’s right ear, on her back and right buttock, and healing fractures in Rehma’s left arm, leg and upper back. She also found typical signs of abusive head trauma: detached retinas and widespread bleeding in both eyes; blood in the subdural layer of the brain, which is the tissue between the brain and skull; and swelling in Rehma’s brain and spine. She concluded Rehma’s death was caused by complications of blunt force trauma to the head. It was, she said, a homicide. Child abuse pediatrician Newton wasn’t surprised by the findings. “Rehma did have quite a terrible bruise, which I think was related to being thrown down on the side of her head and her ear,” Newton told Gupta as she pointed to Rehma’s CT scan. Reading the autopsy was excruciating for Nada and Sameer, confirming their worst fears. “Rehma didn’t pass away peacefully in her sleep,” Nada said through tears. “I try not to think about what she must have gone through. It just destroys my brain when I do that …” <span class=”dropcap”>T</span>he story of McCarthy’s arrest for Rehma’s death made international headlines. There was a media frenzy not unlike that of another Boston case, the historic 1997 “Nanny Trial” of 19-year-old British au pair Louise Woodward, broadcast live on Court TV. The attention took its toll on Nada and Sameer. “I just felt like we couldn’t catch a break,” Nada said. “We couldn’t be left alone just to be sad, to remember her.” The grieving couple said news crews camped out in their front yard, spurred on by defense team speculation that Rehma’s healing fractures occurred while the family traveled to visit relatives over the holidays. The defense also told the press that Rehma was not a victim of abuse but was a sickly, malnourished child. The family had videos of Rehma taken during their holiday travels that showed a lively, curious child who was full of energy – laughing, crawling and pulling herself up on furniture. But Nada and Sameer choose not to make them public. “The media just wanted a story. I don’t want to add to a story, she’s my daughter,” Nada said. “This had become about Ash, and shaken baby syndrome and a controversy. Everyone forgot this is my daughter.” <span class=”dropcap”>T</span>rial preparations limped along. One year passed, then another. Finally, a trial date was set for fall of 2015, nearly three years after Rehma’s death. Suddenly, just weeks before the trial was to begin, came a shocking development: Medical examiner Dr. Katherine Lindstrom had changed her mind on the cause and manner of Rehma’s death. It was no longer a homicide. The district attorney called Sameer and Nada on Friday, asking to meet Monday before the news was publicly announced. The couple spent the weekend hoping Lindstrom had spotted a disease or cause of death that everyone had missed. Please, they told each other, give us an understandable reason for Rehma’s death that will bring us peace. But that was not to be. “When I realized what her reasoning was,” Sameer said, “It was like being hit by a bus.” <span class=”section-end”></span>

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