Court Opinion

ID: 4663798
Source: CourtListenerOpinion
Date Created: 2021-03-01 18:12:52.602526+00
Date Added: 2024-06-11T08:02:31.400388
License: Public Domain

J-A01012-21

                            2021 PA Super 30

 IN THE INTEREST OF: M.R., A           :   IN THE SUPERIOR COURT OF
 MINOR                                 :        PENNSYLVANIA
                                       :
                                       :
 APPEAL OF: PHILADELPHIA               :
 DEPARTMENT OF HUMAN SERVICES          :
 ("DHS")                               :
                                       :
                                       :   No. 1400 EDA 2020

               Appeal from the Order Entered June 26, 2020
 In the Court of Common Pleas of Philadelphia County Juvenile Division at
                    No(s): CP-51-DP-0000952-2019

 IN THE INTEREST OF: M.R., A           :   IN THE SUPERIOR COURT OF
 MINOR                                 :        PENNSYLVANIA
                                       :
                                       :
 APPEAL OF: M.R., CHILD                :
                                       :
                                       :
                                       :
                                       :   No. 1401 EDA 2020

               Appeal from the Order Entered June 26, 2020
 In the Court of Common Pleas of Philadelphia County Juvenile Division at
                    No(s): CP-51-DP-0000952-2019

 IN THE INTEREST OF: J.R., A MINOR     :   IN THE SUPERIOR COURT OF
                                       :        PENNSYLVANIA
                                       :
 APPEAL OF: PHILADELPHIA               :
 DEPARTMENT OF HUMAN SERVICES          :
 ("DHS")                               :
                                       :
                                       :
                                       :   No. 1402 EDA 2020

               Appeal from the Order Entered June 26, 2020
 In the Court of Common Pleas of Philadelphia County Juvenile Division at
                    No(s): CP-51-DP-0000953-2019

 IN THE INTEREST OF: J.R., A MINOR     :   IN THE SUPERIOR COURT OF
                                       :        PENNSYLVANIA
                                       :
J-A01012-21

    APPEAL OF: J.R., CHILD                     :
                                               :
                                               :
                                               :
                                               :
                                               :   No. 1403 EDA 2020

                  Appeal from the Order Entered June 26, 2020
    In the Court of Common Pleas of Philadelphia County Juvenile Division at
                       No(s): CP-51-DP-0000953-2019

BEFORE: BENDER, P.J.E., OLSON, J., and KING, J.

OPINION BY BENDER, P.J.E.:                              FILED: MARCH 1, 2021

       The Philadelphia Department of Human Services (“DHS”) appeals from

the June 26, 2020 orders adjudicating dependent M.R., a child, and his twin

sister, J.R., a child (collectively, “Children”), but not finding child abuse as to

B.R. (“Mother”) and R.R. (“Father”) (collectively, “Parents”).          Children’s

guardians ad litem (“GAL”) also appeal from those same orders. At issue in

these appeals is whether the trial court abused its discretion by admitting the

testimony of Parents’ expert witness, Marvin Miller, M.D., who opined that

metabolic bone disease of infancy (“MBDI”) caused Children’s multiple

fractures, instead of abuse.1 Alternatively, DHS and GAL contend that, even

if Dr. Miller’s testimony was admissible, the trial court abused its discretion in

declining to find child abuse, given the overwhelming medical evidence

presented at the adjudicatory hearing that Children’s injuries were caused by

abuse.    After careful review, we conclude that the trial court improperly

____________________________________________

1Another name for MBDI is Temporary Brittle Bone Disease (“TBBD”). We
use both names interchangeably herein.

                                           -2-
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admitted Dr. Miller’s testimony and, therefore, we reverse its orders refusing

to make a finding of child abuse against Parents in each child’s case.

      The trial court summarized the procedural history and facts of this

matter as follows:
      Children were born on March 7, 2019. [DHS] first became aware
      of … Children and their family … when it received a [Child
      Protective Services (“CPS”)] report indicating that M.R. was
      diagnosed with multiple unexplained fractures. Subsequently, an
      additional CPS report was received when J.R. was subsequently
      diagnosed with several unexplained fractures. As a result of the
      CPS reports, an [Order of Protective Custody (“OPC”)] was
      obtained for both [C]hildren. A shelter care hearing was held on
      June 7, 2019[,] at which time … Children were placed into kinship
      care. This [c]ourt subsequently held a bifurcated adjudicatory and
      child abuse hearing on February 7, 2020[,] and June 26, 2020.

      At the February 7, 2020 adjudicatory hearing, Dr. Maria Henry
      testified that she is currently employed at [Children’s Hospital of
      Philadelphia (“CHOP”)] and serves as an attending physician on
      the [Suspected Child Abuse and Neglect (“SCAN”)] team, which
      evaluates children for child abuse. All counsel stipulated to Dr.
      Henry’s expertise in general pediatrics and pediatric child abuse.
      Dr. Henry indicated that [the] Child Protection Team was
      consulted on June 3, 2019[,] due to concerns of non-accidental
      trauma as the cause of … Children’s injuries. She stated that M.R.
      was initially admitted to the hospital on June 2, 2019[,] with
      scrotal swelling. While at the hospital, he was diagnosed [with] a
      fractured forearm and multiple rib fractures after doctors
      observed “fussiness[.]” As a result of [M.R.’s] multiple fractures,
      the genetics team was consulted to determine whether there was
      a genetic cause for the injuries. Dr. Henry testified that the
      genetics team found no underlying genetic conditions that would
      cause the injuries after performing a skeletal survey. Additionally,
      Dr. Henry stated that the endocrinologist team was also consulted
      to determine whether an underlying bone disorder was present.
      After examining M.R.’s [v]itamin D levels and [x]-rays, the team

                                     -3-
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       found no “rickets” or other underlying bone conditions.[2]
       Additionally, she stated that the reported fussiness was likely
       “paradoxical fussiness[,”] which can be indicative of a child’s pain
       due to an injury such as rib fractures.[] Dr. Henry further testified
       that as … Children are twins, J.R. was also examined for injuries.
       As a result, J.R. was diagnosed with multiple rib fractures. Dr.
       Henry testified that she underwent the same testing as M.R.[,]
       with similar results of no underlying genetic or bone disorders.
       Nemours[ Alfred I. DuPont] Hospital [for Children (“Nemours”)]
       also performed a skeletal survey after [P]arents sought a second
       medical opinion, which yielded the same results as the CHOP
       skeletal survey.

       Dr. Henry also took a family history during her investigation. She
       stated that Mother confirmed … Children were unable to roll.
       Additionally, she testified that Mother stated M.R. was “fussier
       than normal” the day prior to his hospitalization. She also
       reported that [P]arents denied any recent accidental trauma to …
       Children. Additionally, Dr. Henry noted that the family history did
       not contain any known bone diseases. Dr. Henry also stated that
       … [P]arents had … large family support, with numerous family
       members occasionally watching … Children.

       Dr. Henry concluded that the injuries to Children were the result
       of non-accidental trauma. Because all of the medical testing
       performed at CHOP determined … Children had no underlying
       genetic or bone disorders, she indicated that the injuries were
       caused by trauma. With respect to the nature of the injuries, Dr.
       Henry stated the amount of force necessary to cause the rib
____________________________________________

2  Dr. Henry explained that rickets is most commonly caused by vitamin D
deficiency and that “when children are not receiving sufficient vitamin D, that
can have an effect on the bones, and … there are typical[ly] radiographic signs
on the … bones when children’s bones are being affected by low vitamin D
levels.” N.T., 2/7/20, at 59. See also N.T., 6/26/20, at 91 (another CHOP
doctor, Dr. Sabah Servaes, testifying that “rickets is a systemic disorder where
there is a disorder and there’s vitamin D deficiency in infants that could be
due to multiple causes, and it results in a disorganized laying down of new
bone and causes some very characteristic findings on x-ray[s], for example,
we see [it in] very typical locations. And it’s an endocrine disorder or can be
considered an endocrine disorder. It’s a metabolic bone disease disorder, and
it can be treated and corrected.”).

                                           -4-
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        fractures is rarely seen in accidental injuries. As a result, Dr.
        Henry found that … Children’s fractures are most consistent with
        abuse to a degree of medical certainty.

        Dr. Cara Skraban also testified that she is currently employed at
        CHOP and serves as an attending physician in clinical genetics. All
        counsel stipulated to Dr. Skraban’s expertise in general pediatrics
        and clinical genetics. Dr. Skraban testified that she performed a
        consultation for … Children when they were hospitalized in June
        2019. As a part of the consultation, she examined … Children’s
        radiographs and performed genetic testing. She testified that the
        radiographs appeared to be normal, which indicated no physical
        signs of an underlying genetic condition or bone demineralization.
        Additionally, Dr. Skraban testified that … Children’s genetic testing
        resulted in no clinically significant markers for osteogenesis
        imperfecta.[3] Dr. Skraban found that … Children did not have an
        underlying bone disease, osteogenesis imperfecta[,] or other
        medical condition that would have caused their injuries. Dr.
        Skraban further testified regarding her review of the report
        generated by the clinical geneticist at Nemours who was consulted
        for … Children, Dr. [Michael] Bober. She stated that Dr. Bober
        confirmed CHOP’s findings after the subsequent skeletal survey
        and additional testing.

____________________________________________

3   Dr. Skraban described that:
        [O]steogenesis imperfecta is a genetic condition. It’s actually a
        family of genetic conditions in which the bones themselves aren’t
        properly formed in regards to the internal structure.

        So, osteogenesis imperfecta is due to abnormalities in the collagen
        of the individual. And, so, we think of collagen in our skin and in
        other areas, but it’s also really important in our bones to make
        sure that our bones are strong and prevent against fractures.

        And, so, the common cause of osteogenesis imperfecta is due to
        a difference in the gene, that … makes that collagen. And, so,
        what you end up having is an abnormal collagen in the bones that
        makes them weak and makes them fracture very easily.

N.T., 2/7/20, at 140-41.

                                           -5-
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       Anna Schuettge also testified that she is currently employed as a
       Nurse Practitioner at Karabots [Pediatric Care Center], a primary
       care practice connected with CHOP. Ms. Schuettge testified that
       she was part of … Children’s treating group of doctors prior to June
       2, 2019.[4] Ms. Schuettge stated that she administered an
       Edinburg test to Mother on May 6, 2019, in order to screen for
       signs of depression. She indicated that Mother’s score was 12,
       which resulted in suggestion of a safety plan and therapy for
       Mother. She also stated that Mother had reported a history of
       depression. Additionally, Ms. Schuett[ge] testified that she did
       not observe any physical injuries on … Children during their
       medical appointments.

       Jennie Niamonitos testified that she was the DHS investigative
       social worker assigned to Children’s case. She stated that …
       [P]arents would not speak with her regarding how the injuries
       occurred. Additionally, she further testified that Parents would
       not provide any possible kinship resources.

       Mother was also called to testify. She stated that she was the
       primary caretaker of … [C]hildren, but family members frequently
       visited. Mother acknowledged seeking a second opinion with
       Nemours and a third opinion with Dr. Miller. She indicated that
       she sent Dr. Miller … Children’s medical files.

       Prior to the June 26, 2020 adjudicatory hearing, a motion was
       made by DHS and [GAL] to exclude the expert testimony of Dr. …
       Miller. After considering the briefs submitted by the parties, this
       [c]ourt allowed [D]r. Miller to testify.

       Dr. Miller testified that he is employed at Dayton[] Children’s
       Hospital and serves as the Director of Medical Genetics.
       Additionally, he testified that he is a professor of pediatrics and
       OB/GYN at Wright State University Boonshoft School of Medicine.
       For the purposes of the adjudicatory hearing, Dr. Miller was
       certified as an expert in pediatric medical genetics[ and] bone
       health. Dr. Miller testified that he prepared a report for …
       Children’s case after being contacted by [P]arents. He testified
       that he reviewed … Children’s medical records, medical history,
       Mother’s delivery and pregnancy history, and diagnostic imaging
       studies in writing his report. He concluded that … [C]hildren had
____________________________________________

4 Ms. Schuettge testified that Parents had brought Children into Karabots
multiple times prior to June 2, 2019, for issues mainly related to Children’s
being “gassy” and fussy. See N.T., 2/7/20, at 166-67, 171-73, 190.

                                           -6-
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       [MBDI], which was a plausible alternative explanation for the
       fractures. He explained that he believed MBDI occurs primarily in
       the first three months after birth because the fetus could not move
       well in the womb. He testified that[,] during this time, the baby
       is more susceptible to fractures because of his [or her] weaker
       bones. After the baby turns three months of age, the bones
       increase in strength. Dr. Miller testified that this disorder was part
       of a study published in [t]he Journal of Pediatric Endocrinology
       and Metabolism, a peer[-]reviewed journal.[5]

       In forming this conclusion, Dr. Miller testified that there is no
       specific genetic testing for MBDI.        Instead, he stated that
       diagnosis depends on several other tests and tools such as …
       Children’s and Mother’s medical history. Specifically, Dr. Miller
       stated that he looks at several factors to determine whether MBDI
       is a likely diagnosis; however, all factors do not need to be
       present.

       Dr. Miller testified that several factors were present in … Children’s
       case[,] including the following: [m]aternal [v]itamin D deficiency,
       specific medications taken by … Mother, … Children’s low birth
       weight[,] and their status as twins. Specifically, Dr. Miller testified
       that Mother had a high likelihood of a [v]itamin D deficiency during
       her pregnancy because … Children are twins and she had
       previously had a gastric bypass surgery. Additionally, Dr. Miller
       stated … Children’s prescribed Zantac could have led to an
       increased risk of fractures, as indicated by medical studies.
       Because of the presence of several factors for MBDI, Dr. Miller
       concluded that … Children suffered from MBDI and the condition
       was a plausible explanation for their injuries.[6]
____________________________________________

5 See Miller M., Stolfi A., Ayoub D. Findings of metabolic bone disease in
infants with unexplained fractures in contested child abuse investigations: a
case series of 75 infants. J. PEDIATR. ENDCRINOL. METAB. 2019; 32:1103-20.
Hereinafter, we cite to this article as “Dr. Miller’s Journal Article.”

6 In Dr. Miller’s expert report, he stated that he also reviewed Children’s x-
rays and the report of radiologist, Dr. David Ayoub, with whom Dr. Miller
regularly consults, and they both noted findings of MBDI in Children, including
the following:
       [J.R.]

                                           -7-
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       Dr. Sabah Servaes testified as a rebuttal witness for DHS. Dr.
       Servaes testified that she is employed by CHOP as an attending
       pediatric radiologist.     Additionally, she testified that she is
       employed by the University of Pennsylvania Medical School as a
       professor in radiology. For the purposes of the adjudicatory
       hearing, Dr. Servaes was qualified as an expert in pediatric
       radiology. Dr. Servaes testified that she wrote an article to the
       editors of [t]he Journal of Pediatric Endocrinology and Metabolism
       criticizing Dr. Miller’s publication. Specifically, she opined both
       that the methodology was flawed and [that] … MBDI [is not] a
       recognized disorder [by child abuse teams in the field in which she
       works].2     Additionally, she testified that Children’s normal
       [v]itamin D levels at the time of their hospitalization would
       disprove Dr. Miller’s explanation for the injuries. Dr. Servaes also
       stated that [the] Child Protection Team declined to review
       Mother’s prenatal records. Dr. Servaes concluded that … Children
       did not suffer from [MBDI] based upon the testing and [x]-rays
       she reviewed.
          2The Journal of Pediatric Endocrinology and Metabolism did
          not retract Dr. Miller’s study as a result.

       Based on the foregoing testimony, this [c]ourt adjudicated …
       Children dependent based upon [42 Pa.C.S. §] 6302(1).
       Additionally, the trial court denied a finding [of] child abuse as to
       [P]arents or aggravated circumstances. On July 24, 2020, DHS
____________________________________________

       a. Widened ribs consistent with rachitic rosary
       b. Subperiosteal new bone formation
       c. Clubbed radius
       d. Picture framing of the vertebrae
       e. Growth arrest line
       f. Osteopenia
       [M.R.]

       a. Osteopenia
       b. Picture framing of the vertebrae
Parents’ Exhibit 3 (Report of Marvin E. Miller, M.D.) at 3. See also N.T.,
6/26/20, at 64 (Dr. Miller’s testifying that he regularly consults Dr. Ayoub,
and that he discussed the x-ray findings with Dr. Ayoub in preparing his expert
report in this case).

                                           -8-
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       filed a timely [n]otice of [a]ppeal along with a [concise s]tatement
       of [e]rrors….3
          3 On July 13, 2020, … DHS filed a timely Motion to
          Reconsider Admission of Parents’ Expert Witness and the
          Court’s Lack of Finding Child Abuse.[7]

                                           ***

       Subsequently, on July 24, 2020, … [GAL] filed a timely [n]otice of
       [a]ppeal along with a [concise s]tatement of [e]rrors….

Trial Court Opinion (“TCO”), 8/24/20, at 2-8 (internal citations omitted).

       On appeal, DHS and GAL raise virtually identical issues for our review.

DHS asks:
       1. Did the trial court abuse its discretion by admitting the
       testimony of Dr. … Miller, who opined that … Children’s injuries
       were caused by [MBDI] and not abuse, where the medical
       establishment has rejected MBDI as a fringe theory that does not
       exist outside the courtroom?

       2. Did the trial court abuse its discretion by declining to find that
       Parents were perpetrators of child abuse where … Children
       sustained numerous, unexplained fractures that were highly
       indicative of child abuse, testing ruled out possible medical or
       genetic causes, and … Children sustained no new injuries after
       being removed from Parents’ care; and where the sole evidence
       of a possible non-abusive cause was Dr. Miller’s novel and un-
       testable theory that … Children may have MBDI, but he admitted
       he would never find abuse unless the parent confessed, plus
       objective record facts such as … Children’s lab results directly
       refuted his claims?

____________________________________________

7 Our review of the docket indicates that the trial court did not rule on DHS’s
motion for reconsideration. Therefore, it is deemed denied. See Pa.R.C.P.
1930.2(b) (“A party aggrieved by the decision of the court may file a motion
for reconsideration in accordance with Pa.R.A.P 1701(b)(3). If the court does
not grant the motion for reconsideration within the time permitted, the time
for filing a notice of appeal will run as if the motion for reconsideration had
never been presented to the court.”); Pa.R.A.P. 1701(b)(3) (explaining the
requirements for the trial court’s granting reconsideration).

                                           -9-
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DHS’s Brief at 4. GAL poses the following questions for our review:
      1. Pa.R.E[.] 702(c) states that a witness who is qualified as an
      expert may testify if “the expert’s methodology is generally
      accepted in the relevant field.” Consequently, did the trial court
      err by denying DHS’s and … [GAL’s] Motion To Preclude the
      Testimony of Marvin Miller, M.D., where Dr. Miller’s methodology
      regarding his theory of [MBDI]/[TBBD]is not generally accepted in
      the medical field, and, in fact, is widely rejected?

      2. DHS must present clear and convincing evidence that Parents
      intentionally, knowingly[,] or recklessly caused bodily injury to a
      child through any recent act or failure to act. And, 23 Pa.C.S. §
      6381(d), provides that prima facie evidence of child abuse exists
      if a child has suffered abuse of such a nature as would ordinarily
      not be sustained or exist except by reason of the acts or omissions
      of the parent. Consequently, did the trial court err by failing to
      find child abuse by Parents where (1) DHS presented clear and
      convincing evidence through the testimony of three CHOP experts
      in pediatrics, genetics[,] and radiology that … [C]hildren’s multiple
      broken ribs and arm were the result of child abuse, (2) Parents
      were the only responsible caregivers for J.R. and M.R., and (3)
      Parents failed to rebut the evidence beyond Dr. Miller’s widely
      rejected theories?

GAL’s Brief at 5-6 (emphasis in original).

                                    Issue 1

      First, DHS and GAL challenge whether the trial court abused its

discretion by admitting the testimony of Dr. Miller, who opined that MBDI

caused Children’s fractures, not abuse. They argue that Dr. Miller’s testimony

is inadmissible because his methodology is not generally accepted in the

medical field, as required by Pennsylvania Rule of Evidence 702 and Frye v.

United States, 293 F. 1013 (D.C. Cir. 1923).

                             Frye and Rule 702

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      At the outset, we note that, “[w]hen reviewing a trial court’s grant or

denial of a Frye motion, an abuse of discretion standard applies.”        Walsh

Estate of Walsh v. BASF Corp., 234 A.3d 446, 456 (Pa. 2020) (citation

omitted).     “An abuse of discretion may not be found merely because an

appellate court might have reached a different conclusion, but requires a

result of manifest unreasonableness, or partiality, prejudice, bias, or ill-will,

or such lack of support so as to be clearly erroneous.” Grady v. Frito-Lay,

Inc., 839 A.2d 1038, 1046 (Pa. 2003) (citation omitted).

      Our Supreme Court has recently examined Rule 702 and Frye,

explaining:
      Rule 702, entitled “Testimony by experts,” which controls the
      admissibility of expert testimony on scientific knowledge, states:

         A witness who is qualified as an expert by knowledge, skill,
         experience, training, or education may testify in the form of
         an opinion or otherwise if: (a) the expert’s scientific,
         technical, or other specialized knowledge is beyond that
         possessed by the average layperson; (b) the expert’s
         scientific knowledge will help the trier of fact to understand
         the evidence or to determine a fact in issue; and (c) the
         expert’s methodology is generally accepted in the
         relevant field.

      Pa.R.E. 702 (emphasis added).

      The requirement that the expert’s methodology be generally
      accepted is commonly referred to as the Frye test.             First
      announced in Frye…, 293 F. at 1013, it was adopted by this Court
      in Pennsylvania in [Commonwealth v.] Topa[, 369 A.2d 1277
      (Pa. 1977)]. In Grady…, … 839 A.2d [at] 1047…, we clarified that
      the Frye rule “applies to an expert’s method, not his conclusions.”
      As artfully stated by former Chief Justice Cappy,

         The Frye standard is limited to an inquiry into whether the
         methodologies by which the scientist has reached her
         conclusions have been generally accepted in the scientific

                                     - 11 -
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        community…. It restricts the scientific evidence which may
        be admitted as it ensures that the proffered evidence results
        from scientific research which has been conducted in a
        fashion that is generally recognized as being sound, and it
        is not the fanciful creations of a renegade researcher. Yet,
        such a standard is not senselessly restrictive for it allows a
        scientist to testify as to new conclusions which have
        emerged during the course of properly conducted research.

     Blum [v. Merrell Dow Pharma., Inc.], 764 A.2d [1,] 9 [(Pa.
     2000)] (Cappy, C.J., dissenting) (emphasis in original). The
     proponent of the admission of expert scientific evidence bears the
     burden of establishing all of the elements supporting its
     admission, including the general acceptance of the methodology
     employed in the relevant scientific community. Grady, 839 A.2d
     at 1045; Betz [v. Pneumo Abex LLC], 44 A.3d [27,] 54 [(Pa.
     2012)]. While the methodologies employed by the expert must
     be generally accepted, the conclusions reached from those
     applications need not also be generally accepted. Trach v. Fellin,
     817 A.2d 1102, 1112 (Pa. Super. 2003) (en banc).

     The Court in Grady made clear that whether a methodology is
     generally accepted in the relevant scientific community is a
     determination that has to be made based on the testimony of the
     scientists in that community, not upon any scientific expertise of
     judges.

        One of the primary reasons we embraced the Frye test in
        Topa was its assurance that judges would be guided by
        scientists when assessing the reliability of a scientific
        method. See Topa, 369 A.2d at 1281 (quoting United
        States v. Addison, 498 F.2d 741, 744 (D.C. Cir. 1974)).
        Given the ever-increasing complexity of scientific advances,
        this assurance is at least as compelling today as it was in
        1977, when we decided that case. We believe now, as we
        did then, that requiring judges to pay deference to the
        conclusions of those who are in the best position to evaluate
        the merits of scientific theory and technique when ruling on
        the admissibility of scientific proof, as the Frye rule
        requires, is the better way of insuring that only reliable
        expert scientific evidence is admitted at trial.

     Grady, 839 A.2d at 1044-45; see also id. at 1045 (“This does
     not mean, however, that the proponents must prove that the
     scientific community has also generally accepted the expert’s

                                    - 12 -
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     conclusion. … This, in our view, is the sensible approach, for it
     imposes appropriate restrictions on the admission of scientific
     evidence, without stifling creativity and innovative thought.”).

                                     ***

     A careful review of our prior Frye decisions makes clear that it is
     the trial court’s proper function to ensure that the expert has
     applied a generally accepted scientific methodology to reach his
     or her scientific conclusions. To fulfill this function, the trial
     court must be guided by scientists in the relevant field,
     including the experts retained by the parties in the case
     and any other evidence of general acceptance presented by
     the parties (e.g., textbooks). Conversely, trial courts may not
     question the merits of the expert’s scientific theories,
     techniques[,] or conclusions, and it is no part of the trial court’s
     function to assess whether it considers those theories,
     techniques[,] and/or conclusions to be accurate or reliable based
     upon the available facts and data. As is plainly set forth in Rule
     702(c), the trial court’s role is strictly limited to determining
     whether “the expert’s methodology is generally accepted in the
     relevant field.” Pa.R.E. 702(c). The trial court may consider only
     whether the expert applied methodologies generally accepted in
     the relevant field, and may not go further to attempt to determine
     whether it agrees with the expert’s application of those
     methodologies or whether the expert’s conclusions have sufficient
     factual support. Those questions are for the jury to decide.

Walsh, 234 A.3d at 456-57, 458 (footnotes omitted; some emphasis added).

     Furthermore, this Court has observed that:
     “Scientific” methodology is based on

        generating hypotheses and testing them to see if they can
        be falsified; indeed, this methodology is what distinguishes
        science from other fields of human inquiry. … Stated
        differently, the scientific method is a method of research in
        which a problem is identified, relevant data are gathered, a
        hypothesis is formulated from these data, and the
        hypothesis is empirically tested. Within the meaning of the
        definition of the scientific method, empirical means provable
        or verifiable by experience or experiment. Key aspects of
        the scientific method include the ability to test or verify a
        scientific experiment by a parallel experiment or other

                                    - 13 -
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          standard of comparison (control) and to replicate the
          experiment to expose or reduce error.

Commonwealth v. Hopkins, 231 A.3d 855, 871 (Pa. Super. 2020) (quoting

Trach, 817 A.2d at 1113). “Courts accept a variety of sources as evidence

that the expert’s methodology is generally accepted, including judicial

opinions, scientific publications, studies, and statistics, expert testimony, or a

combination of the above.” Id. at 872 (citations omitted).

            Motions to Preclude and Testimony at the Hearing

       To address the admissibility of Dr. Miller’s testimony, we must delve

deeper into the record. Initially, we look to the motions to preclude Dr. Miller’s

testimony that DHS and GAL filed below. In GAL’s motion, it stated:
       1. Dr. Miller is not qualified to testify under [Rule] 702 because
       his theory of [TBBD], also known as [MBDI], is not generally
       accepted in the relevant field. To the contrary, it is widely rejected
       and practitioners consider it “grossly irresponsible” to rely on Dr.
       Miller’s theories.

       2. In the textbook, Diagnostic Imaging of Child Abuse, edited by
       Paul Kleinman, MD, FAAP,[8] Chapter 13 addresses Dr. Miller’s
       [TBBD], and concludes:

          What has occurred with the theory of TBBD is that it has
          taken on a Frankenstein-like existence in which, despite no
          data of reasonable quality supporting its existence, and
          compelling      data      undermining      its    proposed
          pathophysicologic mechanisms, it regenerates in an
          evermore tortured form. The primary explanation for the
          continued interest in the theory is the interface of the
          judicial system in child abuse pediatrics. Without judicial
          proceedings, TBBD would not have survived this long. There

____________________________________________

8 “FAAP” stands for Fellow of the American Academy of Pediatrics.               GAL
attached relevant portions of Chapter 13 to its motion as Exhibit A.

                                          - 14 -
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          is no medical or scientific debate regarding the existence of
          TBBD; the debate exists for the sake of the court room [sic].

       3. On January 16, 2020, the Society for Pediatric Radiology Child
       Abuse Committee wrote a criticism[, attached as Exhibit B,] of Dr.
       Miller’s theories:

          This letter is written on behalf of the Society for Pediatric
          Radiology (SPR) Child Abuse Committee.                We write
          collectively to respond to the recent article by Miller, Stolfi[,]
          and Ayoub to correct the record. Miller et al. opine that
          “infants who present with multiple unexplained fractures …
          are often diagnosed as victims of child abuse[,”] and that in
          these cases, unexplained fractures should instead be
          attributed to [MBDI].

          There is no legitimate medical evidence to support these
          authors’ conclusion. Their methods of evaluation deviate
          from standard practice guidelines and care, which are based
          on decades of evidence and supported by multidisciplinary
          consensus. Numerous published reports in well-regarded
          academic and public scientific journals have convincingly
          established that these authors and the authors they cite
          have engaged in a pattern of flawed and misleading
          scholarship that is demonstrably inconsistent with the
          relevant and voluminous evidence-based medical literature.
          This recent publication simply recycles flawed and
          inaccurate claims by Miller, Stolfi[,] and Ayoub: calling
          normal      bones     “rickets”;    characterizing      classical
          metaphyseal lesions as “rickets”; labeling healing bone
          fractures as “Looser zones”; and calling normal cupping of
          the distal ulna “rickets[.]”[9] … In this report, Miller and his
____________________________________________

9  To put this critique into context, Dr. Miller’s article states that “[t]he
radiographic abnormalities of MBDI … are those of healing rickets. Rickets is
a mineralization deficiency that can be related to inadequate vitamin D,
calcium and/or phosphate during pregnancy and early infancy.” See Dr.
Miller’s Journal Article at 1111. The article claims that these radiographic
abnormalities often go unappreciated or are dismissed by the reading
radiologist because, “while pediatric radiologists are familiar with the
radiographic findings of active rickets in which metaphyseal fraying is a
hallmark, they are unfamiliar with the radiographic findings of healing
rickets/MBDI in which metaphyseal fraying is absent.” Id. at 1112.

                                          - 15 -
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       coauthors run afoul of professional norms and standards of
       scientific inquiry. If their false and misleading arguments
       are repeated in court and communicated to the public, they
       could create a grave public health risk.        Parents and
       caregivers told that — regardless of the evidence — they
       could be falsely accused of child abuse will avoid seeking
       necessary or even lifesaving medical attention for their
       infants and children.

     4. Moreover, Diagnostic Imaging of Child Abuse explained that Dr.
     Miller’s “hypothesis” has “very notable shortcomings,” including:

       a. “poor level of evidence,”

       b. “profound amount of bias” in the studies because the
       infants “are haphazardly selected[”] and are “referred
       primarily by attorneys or parents accused of abusing them,”

       c. there is little to no follow-up,

       d. the investigators “have an explicit motivation for a
       particular finding,” and

       e. two fatal flaws — the outcome is subjective and the
       investigator knows the outcome in advance.1
          1In State v. Duncan, No. CRC94-04801, slip op. (Fl.
          Circ. Ct. 6th Dist. Dec. 11, 2018), a Florida court
          concluded in a similar case that neither Dr. Miller nor
          his counterpart, Dr. Ayoub[,] satisfied the Frye test.
          Rather, the court held that both Drs. Ayoub and Miller
          admitted that “their theory has not been generally
          accepted in the scientific community.” Dr. Ayoub
          further testified that “the medical community largely
          relies on Dr. Kleinman’s textbook Diagnostic Imaging
          of Child Abuse,[”] and that Dr. Kleinman is an
          authority in this field. Further, both Drs. Miller and
          Ayoub “testify exclusively for the defense.[”] The
          evidence also shows that neither is objective in their
          analysis of the evidence finding no case of child abuse
          where there is not a confession or witness to the
          abuse. (State v. Duncan is attached as Exhibit C.)

     5. Diagnostic Imaging of Child Abuse concludes: “The authors of
     the case reports find the proposition of TBBD unreasonable. Miller
     sees TBBD in many infants with fractures despite other more

                                    - 16 -
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       reasonable explanations, and finds no circumstances in which
       TBBD could be shown not to be present.”

       6. As DHS articulated, courts across the county routinely reject
       testimony from Dr. Miller because his theory is a hypothesis that
       is “not supported by conventional medical science.” In re Jett,
       No. 302732, 2011 Mich. App. LEXIS 1708 (Mich. App. Ct. Sept.
       29, 2011) (finding trial court erroneously admitted Dr. Miller’s
       testimony). See also In re JD & GD, No. 231322, 2002 Mich.
       App. LEXIS 3878 (Mich. App. Ct. June 7, 2002[)] (“Dr. Miller
       conceded that TBBD was not recognized in the [International
       Classification of Diseases, 9th Edition] and that most child abuse
       experts do not believe such a disease exists.”); State v. Swain,
       No. 01CA2591, 2002 Ohio App. LEXIS 327 (Ohio App. Ct. Jan. 23,
       2002) (Dr. Miller conceded he was “the only person in the United
       States writing about the topic as a recognizable disease…”); In
       the Interest of A.A.T., No. 04-16-344 CV, 2016 Tex. App. LEXIS
       13714 (Tex. App. Ct. Dec. 28, 2016) (finding trial court properly
       excluded testimony from Dr. Miller regarding [MBDI] or [TBBD]).

       [7.] Indeed, as recently as 2019, Dr. Miller acknowledged that
       “there was some dispute within his practice about him continuing
       to do testimony or consulting” related to [MBDI]. Lowery v.
       State, 2019 Tenn. Crim. App. LEXIS 359 (Tenn. Crim. App. June
       24, 2019[).]

GAL’s Motion to Preclude Parents’ Expert Witness Dr. Marvin Miller, 6/2/20, at

1-4 (some internal citations omitted; emphasis in original; some emphasis

omitted). In addition, DHS’s motion similarly discussed other jurisdictions’

criticisms of Dr. Miller’s theory, and noted the “lack of reliability and

acceptance of [MBDI/TBBD] as a legitimate medical diagnosis in children by

the medical community.” DHS’s Motion to Preclude Parents’ Expert Witness

Dr. Marvin Miller, 5/20/20, at 7.10
____________________________________________

10We deem the arguments raised below by GAL and DHS sufficient to preserve
this issue for our review. Thus, we disagree with Parents’ assertions that “DHS
and [GAL] failed to offer the trial court any analysis challenging the underlying

                                          - 17 -
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       In response, Parents claimed below that the issue is whether the

scientific community generally accepts the methodology used by Dr. Miller,

not whether that community generally accepts his conclusions. With respect

to Dr. Miller’s methodology, Parents contended that:
       The scientific methodology utilized by Dr. Miller is supported by
       the American Academy of Pediatricians [(“AAP”)]. In 2014, the
       AAP released a policy statement declaring[,] “Preexisting medical
       conditions and bone disease may make a child’s bones more
       vulnerable to fractures. These entities should be considered in the
       differential diagnosis of childhood fractures.”     In this policy
       statement, the AAP specifically identified preterm birth, [v]itamin
       D [d]eficiency, rickets, and demineralization from disuse as
       contributing factors to bone fragility.[11] One of the methods
       utilized by Dr. Miller is based on the widely accepted Utah
       Paradigm, a model for understanding bone strength and risk
       factors for metabolic bone disease. The Utah Paradigm is also
       used and accepted by the [AAP.12]

       Dr. Miller’s methodology and conclusions have been published in
       well-respected medical and scientific journals. Most recently, in
       July[] 2019, Dr. Miller’s work was published in the Journal of
       Pediatric Endocrinology and Metabolism. (See Exhibit A). This
       article was subject to blinded peer review by experts in pediatric
       endocrinology who are well versed in metabolic bone disorders.
       Peer-reviewed research is in fact the gold standard for general
       acceptance in the medical and/or scientific community. In 2018,
       doctors from Sweden published a peer[-]reviewed article entitled
       “Metabolic Bone Disease Risk Factors Strongly Contributing to

____________________________________________

data and methodology utilized by Dr. Miller in his research.” Mother’s Brief at
17; see also Father’s Brief at 14 (same).

11Parents did not attach this policy statement as an exhibit to their response,
or provide a citation to it.

12 Again, Parents do not attach as an exhibit, or provide a citation to, evidence
of the AAP’s using and accepting the Utah Paradigm.

                                          - 18 -
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       Long Bone and Rib Fractures During Early Infancy.”[13] This peer[-
       ]reviewed research identified similar risk factors that Dr. Miller
       identified as risk factors for [MBDI] such as “maternal obesity;
       mother of African, Asian or Latina descent; multiple births[;]
       infants born small for gestational age; and infant diagnosis of
       [v]itamin D deficiency.” (See Exhibit B). Furthermore, as part of
       Dr. Miller’s methodology in evaluating for [MBDI], one of the
       factors that he considers is the use of antacids by a mother during
       pregnancy as well as whether or not the subject infant has been
       placed on an antacid. In July 2019, the [AAP] published a study
       by Drs. Malchodi & Wagner, entitled “Early Acid Suppression
       Therapy Exposure and Fracture in Young Children.” (See Exhibit
       C). Among the various conclusions drawn by the authors is that
       infant use of antacids is associated with childhood fracture hazard
       so that the use of antacids in infants should be weighed carefully
       against possible fracture. The [AAP] is not a fringe organization
       espousing wild theories with unsubstantiated research. Dr. Miller
       is actually using research conducted by peers and supported by
       the AAP to buttress his own methodology.

Parents’ Response to DHS’s Motion to Exclude Parents’ Expert Witness,

6/2/20, at 4-6 (unnumbered).

       At the start of the hearing on June 26, 2020, the trial court asked

counsel if it needed to hear oral argument on the at-issue Frye motions, and

all parties agreed to rest on their filings. N.T., 6/26/20, at 8-9. The trial court

then denied DHS’s and GAL’s motions to preclude Dr. Miller from testifying,

stating that it would give the experts’ opinions “the weight [it] believes they

deserve.” Id. at 9; see also id. at 19 (the trial court’s stating, after Parents

offered Dr. Miller as an expert in pediatric medical genetics and bone health,

____________________________________________

13See Högberg U., Andersson J., Högberg G., Thiblin I. (2018) Metabolic bone
disease risk factors strongly contributing to long bone and rib fractures during
early infancy: A population register study. PLOS ONE 13(12):e0208033.
https://doi.org/10.1371/journal.pone.0208033.

                                          - 19 -
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that it is “going to accept him at this juncture, and [it] will give the appropriate

weight”).

      Subsequently, on direct examination, Dr. Miller testified to the following:
      [Mother’s attorney:] So, Dr. Miller, did you prepare a report in this
      case?

      [Dr. Miller:] I did.

      [Mother’s attorney:] And in preparing your report, what did you
      review? What documents did you review to prepare your report?

      [Dr. Miller:] Initially, I was sent by the parents the medical records
      of the twins…, and subsequently, I believe after you became
      involved, you provided me with … some of the medical history and
      delivery and pregnancy history and … the diagnostic imaging
      studies.

      [Mother’s attorney:] Okay. And after viewing all of the documents
      provided to you, did you arrive at a conclusion?

      [Dr. Miller:] I did.

      [Mother’s attorney:] And can you state the conclusion for the
      record?

      [Dr. Miller:] I thought the twins had [MBDI] and that was a
      plausible alternative explanation for the fractures.

      [Mother’s attorney:] Specifically, could you tell the [c]ourt how
      you got to that conclusion? What principles, scientific or technical,
      did you rely on to get to your conclusion?

      [Dr. Miller:] The information that I relied on includes both my own
      personal experience with this issue, which dates back to 1994, as
      well as to additional observations that I read in the medical
      literature and heard at various scientific meetings, which
      eventually led me to this entity which is called [MBDI].

            In 1994, I saw[,] as a medical geneticist[,] a young infant
      similar to …[C]hildren here, several months’ old[,] which [sic]
      presented with unexplained fractures….

                                      - 20 -
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           So at that time[,] the one medical disorder that child abuse
     pediatricians accepted as a plausible medical explanation was a
     genetic condition called osteogenesis imperfecta, or OI.

           At that time[,] there was no DNA test for that but a
     biochemical test.

           The problem with the biochem[ical] test was [that it was]
     85 percent accurate, [and had a ]15 percent false negative rate.
     That means if a hundred children with OI were tested and truly
     had OI as the explanation for fractures, 15 would have a normal
     test even though they had OI.

           When I explained this to the mother, she got very angry at
     me and asked me how I could present a test that could take
     children away from parents when the test was as inaccurate as I
     just described….

           So she tasked me with finding an alternative way to judge
     if somebody could have weak bones.

          Long story short, I found a bioengineer, Dr. Tom
     [Hangartner,] who had a very sophisticated and sensitive method
     for measuring bone density called CT, or computer topography,
     bone density. And we engaged in clinical research over the next
     20 years.

          One of the articles showed that many infants with
     unexplained fractures have … low CT bone density, and I
     emphasize the “CT” because [its] the most sensitive way of
     measuring bone density known to man. That’s a very important
     determinant of bone strength.

           So early in my explanation [sic] of this issue, it became
     apparent that, though the x-rays were read as normal, the
     children with unexplained [fractures] had low bone density.

            The other observations I made[ were that] many infants
     were confined inside the womb; that is, they didn’t move well.
     That has relevance to the present case because any time a baby
     doesn’t move well in the womb in [the] third trimester[,] … the
     fetus … has decreased bone loading. The bones will be diminished
     in strength at birth.

           I think it’s important that I give the [c]ourt an explanation
     of bone loading to give you a better idea of what I mean.

                                   - 21 -
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            The bone is a smart organ. Within it, there is a brain that
     tells the bone whether or not it’s an environment of low or high
     bone loading.

           If you take an astronaut, he has normal bone strength,
     normal bone loading. When you send that astronaut to outer
     space for three months, that astronaut will have unloaded his
     skeletal system; bones will be weaker. Even when that astronaut
     returns to [E]arth eight months later, his bones are weaker and
     [he] has a greater risk of fractures with typical forces.

           As he remains on [E]arth over the next bit of time, the bones
     get stronger because the sensor in the bones now realizes his
     bones are back on [E]arth and they have the increased bone
     strength.

           The other side of the coin is people with very, very strong
     bones, because the bone sensors sense the increased loading. An
     example is a gymnast. They constantly put load on arms and legs
     with tumbling and jumping.

           What I did and published in 1999 in Calcified Tissue
     International with Dr. [Hangartner] was the concept that bone
     loading from the third trimester is probably the most important
     determinate of bone strength in an infant when it [sic] is born.

           So that’s my contribution, my personal experience.

           But then I learned about other factors that play into fetal
     bone strength and young infant bone strength. Those factors
     include the following:

           Number one, whether or not the mother may or may not
     have diabetes during the pregnancy; number two, whether or not
     the baby may be premature; number three, whether or not the
     mother might have a vitamin D deficiency in the pregnancy.

           The next issue is whether or not the mother or infant may
     be taking drugs to interfere with the absorption of calcium and
     phosphate.

          Another issue is whether the infant is small for gestational
     age and did not grow well in utero.

          So a number of factors became apparent to me, not in my
     work but others, and so I put the idea that this bone strength of
     a young infant in the third trimester fetus is determined by

                                   - 22 -
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      multiple factors. Any time one or more is compromised, it could
      cause a bone fragility state. When born, that infant is at risk for
      fractures in the first six months of life. And those can occur with
      routine handling, can occur with circumcision, with putting on
      diapers or changing clothes.           It could occur with chest
      physiotherapy for treatment of bronchiolitis.

             So that’s the state of affairs that I arrived at, that multiple
      factors determine fetal and young infant bone strength. Anytime
      I see a situation where there’s several factors present, I think
      that’s a plausible medical explanation.

            That’s basically what my report says.

Id. at 20-28.

      Specifically, when asked to summarize the risk factors he considered in

reaching his conclusion regarding Children’s injuries in particular, Dr. Miller

stated:
      So, number one, the risk factors for [MBDI] include the following:
      [m]aternal vitamin D deficiency likely during the pregnancy;
      maternal calcium and phosphate deficiency during the pregnancy
      because of the medications their mother was taking; most
      importantly, the decreased fetal bone loading from the
      intrauterine confinement; the intrauterine growth retardation, the
      fact that both infants were small; and, again, what you asked me
      about the Zantac medication [taken] by both infants which, again,
      can cause an increased risk o[f] fractures.

Id. at 31-32.

      On cross-examination, Dr. Miller testified that genetic tests cannot

detect MBDI, and that “[t]he diagnosis of [MBDI] is strongly inferred by

reading of the x-rays.” Id. at 38. Further, he agreed that as long as one of

the above-stated risk factors is present, a baby could have MBDI, see id. at

48, and reiterated that “x-rays are often the telling study that will allow us to

jump on that diagnosis.” Id. at 49. Dr. Miller explained that, regarding x-ray

                                     - 23 -
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findings, “what I typically do is make a PowerPoint of the imaging studies that

I think are relevant. I send them to [Dr. Ayoub, a radiologist with whom Dr.

Miller regularly consults]. I have my own opinions based on what he’s taught

me, and then he sends me back the mocked-up PowerPoint presentation.” Id.

at 64.

         Moreover, when challenged on cross-examination about when Dr. Miller

would find that child abuse caused unexplained fractures instead of MBDI, Dr.

Miller answered that it would require “a noncoerced confession; an impartial

eyewitness; and third, a videotape.                You have those, then you can

unequivocally say there was abuse if you have one of those types of

affirmation.”    Id. at 59.     Later, when asked on re-direct examination why

Children did not have any bruising consistent with some kind of infliction of

injury, Dr. Miller opined:
         We are led to believe these rib fractures are caused by tight
         gripping and shaking of the infant. There should be grip marks, if
         the child was looked at [by healthcare providers] so completely
         and so many times over that period of time [between birth and
         M.R.’s June 2, 2019 hospital admission].

         And … I can’t emphasize this enough and it’s in my report…[,]
         whenever you have four or more rib fractures, the Garcia article
         of 1990[,14 cited in Dr. Miller’s study,] states unequivocally you
         will always see severe internal lung damage that compromises the
         child’s ability to breath and [the child] will have respiratory
         distress.

         Both twins have more than four rib fractures. Neither ever had
         severe lung trauma or respiratory distress.         That’s a very
         compelling reason, along with the lack of bruising, that makes me
____________________________________________

14 See Garcia V.F., Gotschall C.S., Eichelberger M.R., Bowman, L.M. Rib
fractures in children: a marker of severe trauma. J TRAUMA 1990; 30:695-700.

                                          - 24 -
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      very comfortable saying that this is highly unlikely [to be] child
      abuse.

Id. at 73-74.

      Following Dr. Miller’s testimony, DHS called Dr. Servaes as a rebuttal

witness. With respect to Dr. Miller’s study published in the Journal of Pediatric

Endocrinology and Metabolism, she explained that she, along with another

pediatric radiologist, a geneticist, and an attorney, prepared a letter refuting

that study on behalf of the Society for Pediatric Radiology (“SPR”) Child Abuse

Committee after the article
      was brought to our attention[,] … primarily because of it[s] flawed
      methodology and inaccurate conclusions and suppositions that are
      within it[. T]he descriptions of the cases are not accurately
      portrayed; … the images are not reflective of what’s described;
      and even the literature that’s utilized to substantiate their
      arguments is not used in an appropriate fashion.

      So we find the methodology is flawed and the conclusions are
      erroneous and that the use of that article both in terms of treating
      patients as well as in a court of law is problematic.

Id. at 83. Dr. Servaes explained that SPR is a national, professional society

representing pediatric radiologists, and is “tasked with the responsibility of

trying to oversee the way we practice imaging” for diagnosing child abuse.

Id. at 87.   She said that SPR has “had activities ranging from publishing

studies or consensus documents or volunteering to help to determine which

studies help us to decide what … the best imaging is to do and how to do

imaging appropriately in trying to make this decision.” Id. She added that

SPR wrote the letter because MBDI is a “sort of fantastic diagnosis that can’t

be tested by [a] laboratory and has a disappearance over time.” Id. at 90.

                                     - 25 -
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      Dr. Servaes also criticized Dr. Miller’s use of the Garcia article to support

the proposition that, when children have four or more rib fractures, they will

always have significant respiratory issues. Id. at 84. Dr. Servaes said it was

inappropriate for Dr. Miller to draw that conclusion from that study because

many children in that study were the victims of automobile accidents, and had

sustained significant injuries that landed them in the intensive care unit. Id.

at 85-86.    Therefore, Dr. Servaes said it is not appropriate to draw the

conclusion from that study, that every time a child has four or more rib

fractures, he or she will experience respiratory distress. Id. at 85.

      Additionally, Dr. Servaes disputed Dr. Miller’s finding of rickets only at

specific ribs, explaining that “rickets is a systemic disease that affects the

entire body, the bones throughout the skeleton in a very symmetric fashion[,]”

and therefore rickets would not occur at only certain ribs. Id. at 91. She also

testified to the following:
      [DHS:] So would you disagree with Dr. Miller’s opinion that
      [C]hildren[’s] having risk factors for vitamin D deficiency in the
      womb would somehow, therefore, give a heightened level of
      potentiality to have bone fragility?

      [Dr. Servaes:] So it’s important to think about risk factors and
      take that into consideration, but the evidence is what the x-rays
      look like and what the laboratory values are and the pattern. You
      have to take the entire picture, not just single aspects and decide,
      because this one thing is present, the conclusion is drawn. You
      have to look at the entire picture.

      [DHS:] So, for example, in this case, the fact that they did the
      studies in terms of finding out what … [C]hildren’s levels of vitamin
      D, alkaline phosphate, calcium, did those scans [sic] and pulled a
      history and also did genetic testing that was indicated, putting all

                                      - 26 -
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        those pieces together is how, in the medical community, one
        would arrive at [a] proper diagnosis?

        [Dr. Servaes:] That’s correct. So because there was a risk of
        vitamin D deficiency[,] having tested … [C]hildren when they
        came to the hospital, that helps to disprove that that is a cause of
        their fractures.

Id. at 94-95.

        Finally, with respect to Dr. Miller’s use of x-rays, Dr. Servaes testified

that:
        [O]ne of the issues that came to my mind as Dr. Miller was
        speaking was that he shared the radiographs with PowerPoint.
        That’s not a sufficient way to view the x-rays. You do not get the
        appropriate level of anatomic detail.

        In radiology[,] imaging is what we do, and we use very high-
        resolution monitors to look at x-rays, and x-ray in particular is
        very sensitive the quality of the image.

        And we do our imaging studies in a very precise way so that we
        could see the detail of the entire feature of the bone. We have to
        look at where the bone is growing. Particularly in children, that is
        important. And in cases where … there is a concern about child
        abuse and looking at the bones, it’s very important that we have
        standards that describe precisely how to obtain those x-rays.

        And so the quality is degraded by putting it into a PowerPoint and
        [it] compresses the image and you lose some of the quality as …
        you can’t depict it as well as if you looked at it on a diagnostic
        monitor….

        For someone to provide expert opinion about these x-rays based
        upon PowerPoint images is not adequate diagnostic information,
        and I disagree with the conclusions that they’ve drawn and many
        of the findings that are described in the reports such as … talking
        about the widened ribs consistent [with] rachitic rosary; that’s not
        present. The clubbed radius is not a finding there. The picture
        framing of the vertebrae is not there. The growth arrest lines are
        present in one of the children; that’s a very nonspecific finding.
        The bones are not osteopenic in either child…. The subperiosteal
        new bone formation is a finding that’s present. It’s not … reflective
        of metabolic bone disease but of healing fractures because these

                                       - 27 -
J-A01012-21

      are an asymmetric and irregular pattern. It doesn’t represent a
      systemic disease.

Id. at 97-99.

      On cross-examination, Dr. Servaes acknowledged that when she and

several other authors sent the letter to the Journal of Pediatric Endocrinology

and Metabolism, the journal did not retract the publication of Dr. Miller’s

article.   Id. at 112.   However, when asked if the Journal of Pediatric

Endocrinology and Metabolism was an established journal, Dr. Servaes

responded that “my definition of ‘established’ … might not fit in this case

because my … understanding is that that is a journal in which you pay to

publish….” Id. at 118. Dr. Servaes also recognized that other physicians have

studied MBDI, noting:
      [Mother’s attorney:] And you talked about how Dr. Miller is the
      only doctor out there making this diagnosis of [MBDI]; is that fair
      to say?

      [Dr. Servaes:] No, he’s not. I think there’s a few other physicians
      who join him.

      [Mother’s attorney:] So you are aware of the study done in 2018
      … by a conglomerate of Swedish doctors who also did the same
      kind of testing … done by Dr. Miller and his cohorts regarding
      brittle bone disease?

      [Dr. Servaes:] I know -- I am not sure if I know the specific study
      you are talking about.

                                     ***

      [Mother’s attorney:] I will reference the peer review article that
      appeared in the journal that was published as a study done in
      Sweden in 2018. The lead author is [Ulf Högberg]?

      [Dr. Servaes:] Yes.

      [Mother’s attorney:] Are you aware of that article?

                                    - 28 -
J-A01012-21

      [Dr. Servaes:] Yes.

      [Mother’s attorney:] Are you aware in that article that was
      published there was 47 references to other studies that they used
      to get to their conclusions? Are you aware of that?

      [Dr. Servaes:] Okay. Yes.

Id. at 113-14.

                             Trial Court Opinion

      In light of the foregoing, especially the testimony adduced at the

adjudicatory hearings, the trial court gave the following explanation in its

Pa.R.A.P. 1925(a) opinion for admitting Dr. Miller’s testimony:
      Dr. Miller’s testimony clearly meets the … requirements under
      [Rule] 702. Dr. Miller’s educational and employment qualifications
      [and employment] as the Director of Medical Genetics at Dayton
      Children’s Hospital helped this [c]ourt determine the central fact
      at issue: whether there was an underlying cause other than child
      abuse for … Children’s injuries. As a geneticist who issued a report
      on this case, Dr. Miller had the requisite knowledge, skill[,] and
      training in order to render a medical opinion on this case.
      Additionally, Dr. Miller’s report was generated on diagnostic
      testing and medical records made available to all of the experts
      testifying in this matter; therefore, his conclusions were based
      upon sufficient data.

      Dr. Miller’s methodology was also sufficient as to qualify him as
      an expert witness. Although the expert witnesses disagreed with
      Dr. Miller’s conclusions, Dr. Miller’s study regarding MBDI was
      published in [t]he Journal of Pediatric Endocrinology and
      Metabolism. (N.T.[,] 6/26/20[,] at 83). The journal is peer-
      reviewed, so selection for publication in the journal demonstrates
      an acceptance of his theory within the medical community. (Id.
      at 112). Further, upon criticism from Dr. [Servaes] and her peers,
      the journal declined to retract the study, which further supports
      the acceptance of Dr. Miller’s methodology by his peers in the
      medical community.          (Id.).     Additionally, Dr. Servaes
      acknowledged that other doctors have joined Dr. Miller’s theory
      and similar studies have been published.            (Id. at 113).
      Furthermore, in making his report, Dr. Miller examined medical
      records, diagnostic imaging[,] and the medical histories of both …

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       Children and Mother. (Id. at 21). Notably, these diagnostic tests
       and tools were also utilized by DHS’[s] expert witnesses in making
       their reports. (N.T.[,] 2/7/20[,] at 49, 58, 60, 138-[3]9, 142-
       [4]4). Although there is not a specific genetic test for MBDI, Dr.
       Miller relies on other medical diagnostic tools, such as medical
       histories and maternal health histories. (N.T.[,] 6/26/20[,] at 67).
       Dr. Miller used these reports and his professional knowledge to
       form his report regarding … Children. (Id. at 21). Specifically, he
       used medical histories and the same diagnostic testing to form his
       opinion with a different result. Therefore, the testimony of Dr.
       Miller clearly satisfies the standard required by [Rule] 702.

TCO at 10-11.

                                        Analysis

       Both DHS and GAL attack the trial court’s above-stated rationale. They

argue that Dr. Miller has not applied a generally accepted scientific

methodology to reach his conclusion that MBDI caused Children’s fractures.

We agree.

       To begin, the trial court emphasized in its analysis that the Journal of

Pediatric Endocrinology and Metabolism published Dr. Miller’s study and that

other, similar studies have been published.15         While we recognize that

scientific publications and studies are ways in which an expert’s methodology

can be shown to be generally accepted in the relevant field, see Hopkins,

supra, we concur with DHS that “the mere fact of publication is not enough

to establish general acceptance, especially where the medical establishment’s

reaction to those publications has been opprobrium and concern over the

____________________________________________

15Though the trial court mentions “studies,” Parents only specifically refer to
one similar study in their briefs; that is, the study by Högberg, cited supra,
which Dr. Servaes acknowledged at the hearing. See Mother’s Brief at 24-
25; Father’s Brief at 13.

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misuse of TBBD/MBDI in the courtroom.” DHS’s Brief at 22. Both the Society

of Pediatric Radiology and the Diagnostic Imaging of Child Abuse textbook

have pointed out flaws in Dr. Miller’s scientific methodology, such as, inter

alia, the bias involved and Dr. Miller’s refusal to acknowledge more reasonable

explanations for a child’s injuries, like abuse. As DHS observes:
      The value of the peer[-]review process is not simply in an article’s
      being green-lit for publication by a journal’s editorial board or
      reviewers. Rather, the purpose of publication is to stimulate
      scientific discourse. Publication allows other scientists to test the
      theory by examining and critiquing a study’s methodology, or by
      attempting to replicate or falsify its results. It is this broader
      dialogue of publication and response that generates a scientific
      consensus about the theory’s reliability. See Daubert v. Merrell
      Dow Pharm., Inc., 509 U.S. 579, 593 (1993) (“Publication
      (which is but one element of peer review) is not a sine qua non of
      admissibility; it does not necessarily correlate with reliability…[.]
      But submission to the scrutiny of the scientific community is a
      component of ‘good science,’ in part because it increases the
      likelihood that substantive flaws in methodology will be
      detected.”).

DHS’s Brief at 30-31. In addition, the fact that other doctors have published

a similar study does not automatically make Dr. Miller’s methodology

generally accepted in the scientific community. That study may contain the

same flaws as Dr. Miller’s research. DHS astutely notes:
      Parents point to just one source used to assess general
      acceptance: whether any peer-reviewed, published research
      exists on the topic. But they ignore all of the other sources,
      including: how the field has reacted to peer-reviewed research
      supporting the expert’s theory; the views of professional
      organizations in the field; whether the technique is taught in
      textbooks; the testimony of other experts; and how other courts
      have treated the methodology.

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DHS’s Reply Brief at 1-2 (citation omitted). Thus, we disagree with the trial

court that publication proves that doctors and scientists in the medical field

generally accept Dr. Miller’s scientific methodology as a means for arriving at

the conclusion that MBDI caused Children’s injuries, especially when

considering the plethora of other sources discrediting his methodology.

      Furthermore, we reject the trial court’s determination that Dr. Miller

used the same scientific methodology as the CHOP and Nemours doctors, in

that he examined medical records, diagnostic imaging, and the medical

histories of both Children and Mother to reach his conclusion of MBDI. DHS

discerns:
      Here, Dr. Miller’s method of interpreting the [x]-rays was itself not
      generally accepted. Dr. Servaes, a pediatric radiologist, explained
      that Dr. Miller did not use a generally accepted method to interpret
      the radiographs because he and his consulting radiologist, Dr.
      Ayoub, viewed them in a compressed version on PowerPoint
      instead of using the proper imaging equipment.

      Dr. Servaes also explained that Dr. Miller had not interpreted the
      x-rays correctly, as he had labeled normal, healthy features as
      evidence of “rickets” or other bone defects. Her testimony is
      consistent with the findings of the entire CHOP SCAN team and
      Parents’ geneticist Dr. Bober … that … Children’s bones were well-
      formed and there was no evidence of rickets. Indeed, Dr. Miller’s
      “methodology” of discovering non-existent bone defects in x-rays
      is not unique to this litigation: the Society for Pediatric Radiology’s
      response to Dr. Miller’s published article specifically criticized Dr.
      Miller and Dr. Ayoub for this tactic, including their habit of “calling
      normal bones ‘rickets[.’”]

      The trial court also pointed to Dr. Miller’s claimed reliance on
      “diagnostic testing” and “medical histories[.”] In reality, his
      opinion was not based on any diagnostic testing, as that testing
      had ruled out any medical risk factors for bone fragility such as
      vitamin D deficiency. As for … Children’s medical history, it is

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       unclear how that alone could support any diagnosis, as Parents
       provided no explanation for … Children’s injuries.

DHS’s Brief at 35-36 (emphasis in original).

       Indeed, Dr. Miller emphasized that “[t]he diagnosis of [MBDI] is strongly

inferred by reading of the x-rays[,]” and that “x-rays are often the telling

study that will allow us to jump on th[e] diagnosis” of MBDI. N.T., 6/26/20,

at 38, 49. However, as DHS argues, Dr. Miller’s method of interpreting the x-

rays was itself not generally accepted by the medical community, given the

testimony of Dr. Servaes regarding the use of PowerPoint to view x-rays, the

findings of other doctors at CHOP and Nemours that Children’s bones were

normal, and the Society for Pediatric Radiology’s critique of Dr. Miller’s

published article that he mischaracterized normal bones as rickets. Further,

Dr. Servaes testified that, in making a proper diagnosis, it is “important to

think about risk factors and take that into consideration, but the evidence is

what the x-rays look like and what the laboratory values are and the pattern.

You have to take the entire picture, not just single aspects and decide,

because this one thing is present, the conclusion is drawn. You have to look

at the entire picture.”       Id. at 94.16     Here, unlike the other doctors who
____________________________________________

16 Other doctors at the hearing also spoke to the importance of looking at the
‘entire picture’ and Children’s lab tests in making a diagnosis. See also N.T.,
2/7/20, at 84 (Dr. Henry’s testifying that “[s]o, in regards to the cause, these
children’s fractures are most consistent with physical abuse. And I want to
sort of explain the reason. … [W]e have a negative evaluation, or a normal
evaluation[,] by our colleagues in bone health. The genetic testing that has
been performed to date has been negative. We have a third skeletal survey
that does not show additional injuries. And we know that rib fractures in and

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evaluated Children, Dr. Miller did not consider the ‘entire picture,’ in particular

the results of Children’s lab tests, in making his diagnosis of MBDI. Instead,

Dr. Miller essentially ignored these tests and drew conclusions based on a

purported risk factor being present. See N.T., 6/26/20, at 48 (Dr. Miller’s

testifying that, as long as one risk factor is present in an infant, that infant

could have MBDI). Thus, the trial court abused its discretion in ascertaining

that Dr. Miller applied a generally accepted scientific methodology simply

because he claimed to have used medical records, diagnostic imaging, and

the medical histories of both Children and Mother. Accordingly, as Parents did

not meet their burden of showing that the medical community generally

accepts the scientific methodology used by Dr. Miller in reaching his conclusion

that MBDI caused Children’s fractures, we hold that the trial court should not

have admitted Dr. Miller’s testimony.

____________________________________________

of themselves are highly specific for abuse. So, these findings are all
consistent with trauma as the cause. We don’t have a plausible … accidental
mechanism, and for that reason, these findings are most consistent with
abuse.”); id. at 147-48 (Dr. Skraban’s testifying that there was not a medical
cause for Children’s injuries as “the calcium, and the phosphorus, and the
vitamin D [levels] were looked at, both from a nutritional perspective, but
[there are] also genetic causes of rickets, for example, of which you … would
expect the same underlying differences … in those things, in the calcium,
phosphorus, and alkaline phosphatase. And, so, it’s not only helpful from a
nutritional perspective, but it’s also helpful from a genetics perspective to see
that all of those levels were normal. And, so, of the other common genetic
conditions that would cause fractures in infancy, having those normal levels
… was reassuring.”); id. at 149-51 (Dr. Skraban’s testifying that Dr. Bober at
Nemours reviewed Children’s lab tests and x-rays to rule out any underlying
metabolic bone disease or genetic condition as a cause of their injuries).

                                          - 34 -
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      The exclusion of Dr. Miller’s testimony affects the trial court’s finding on

child abuse. In not finding child abuse as to Parents, the trial court provided:
      The petitioning party in a dependency action must demonstrate
      the existence of child abuse by clear and convincing evidence. 23
      Pa.C.S.[] § 6381(d); [s]ee In re L.Z., 111 A.3d [1164,] 1179[
      (Pa. 2015)]. However, the identity of the abuser need only be
      established by prima facie evidence. (Id.). The Child Protective
      Services Law provides for the following evidentiary presumption:

         Evidence that a child has suffered child abuse of such a
         nature as would ordinarily not be sustained or exist except
         by reason of the acts or omissions of the parent or other
         person responsible for the welfare of the child shall be prima
         facie evidence of child abuse by the parent or other person
         responsible for the welfare of the child.

      23 Pa.C.S.[] § 6381(d). In the application of Section 6381(d),
      “evidence that a child has suffered injury that would not ordinarily
      be sustained but for the acts or omissions of the parent or
      responsible person is sufficient to establish that the parent or
      responsible person perpetrated that abuse unless the parent or
      responsible person rebuts the presumption.” See In re L.Z., 111
      A.3d at 1185.

      Here, DHS failed to establish a prima facie case of child abuse
      because they failed to demonstrate that … Children were victims
      of child abuse. Although the medical experts offered by DHS
      concluded that … Children’s injuries resulted from child abuse, Dr.
      Miller’s theory contradicted this testimony. (N.T.[,] 2/7/20[,] at
      84, 86-[8]7; N.T.[,] 6/26/20[,] at 21). Dr. Miller’s testimony
      presented an alternative medical explanation for the injuries …
      Children suffered other than child abuse. His testimony that …
      Children suffered from MBDI demonstrates an alternative and
      accidental cause for … Children’s injuries. Because, according to
      Dr. Miller’s expert testimony, MBDI could have plausibly caused
      the multiple rib fractures, DHS failed to establish clear and
      convincing evidence that … Children were victims of child abuse.
      (N.T.[,] 6/26/20[,] at 26). Therefore, absent clear and convincing
      evidence that child abuse occurred, there is no prima facie
      evidence Parents were the perpetrators of child abuse. For the
      foregoing reasons, this [c]ourt properly declined to make a child
      abuse finding as to Parents.

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TCO at 12-13.

      As the trial court abused its discretion in admitting Dr. Miller’s testimony

pursuant to Rule 702 and Frye, its explanation for not finding child abuse

against Parents falters. Without Dr. Miller’s testimony, it is evident that DHS

has demonstrated child abuse by clear and convincing evidence; all of the

remaining evidence in the case overwhelmingly points to abuse as the cause

of Children’s injuries.

      “The term ‘child abuse’ shall mean intentionally, knowingly or recklessly

doing any of the following: (1) Causing bodily injury to a child through any

recent act or failure to act.” 23 Pa.C.S. § 6303(b.1)(1). ‘Bodily injury’ is

defined as “[i]mpairment of physical condition or substantial pain.” 23 Pa.C.S.

§ 6303(a).    “The requisite standard of proof for a finding of child abuse

pursuant to Section 6303(b.1) is clear and convincing evidence.” Interest of

A.C., 237 A.3d 553, 558 (Pa. Super. 2020) (citation omitted). “Clear and

convincing evidence is ‘evidence that is so clear, direct, weighty, and

convincing as to enable the trier of fact to come to a clear conviction, without

hesitancy, of the truth of the precise facts in issue.’” Id. (citation omitted).

Moreover, “[t]he standard of review in dependency cases requires an appellate

court to accept the findings of fact and credibility determinations of the trial

court if they are supported by the record, but does not require the appellate

court to accept the lower court’s inferences or conclusions of law. Accordingly,

we review for an abuse of discretion.” Id. at 557 (citations omitted).

      As GAL aptly states:

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       The trial court’s [o]pinion confirms the existence of clear and
       convincing evidence … that Parents intentionally, knowingly[,] or
       recklessly caused bodily injury to … [C]hildren through their
       actions or failure to act; [the trial court] wrote:

             Dr. Henry testified that (1) … [C]hildren had no underlying
              genetic conditions or underlying bone conditions that could
              have caused the injuries, (2) that … [C]hildren showed
              paradoxical fussiness that can be indicative of pain from rib
              fractures, (3) that Mother denied any accidental trauma, (4)
              that there was no family history of bone disease, (5) the
              amount of force required for rib fractures is rarely seen in
              accidental injuries, and (6) … [C]hildren’s fractures were
              most consistent with abuse. [TCO at 3-4.]

             Dr. Skraban concluded that [(1)] the [x]-rays were normal
              with no sign of an underlying genetic condition or bone
              demineralization, (2) Dr. Bober confirmed CHOP’s findings,
              and (3) … [C]hildren did not have osteogenesis imperfecta.
              [Id. at 4].

       The trial court further stated that Mother testified “she was … the
       primary caretaker of … [C]hildren, but family members frequently
       visited.” [Id. at 5; see also N.T., 2/7/20, at 221-24.] As such,
       there is prima facie evidence that Parents were responsible for …
       [C]hildren.[17]

GAL’s Brief at 45-46 (internal citation omitted). We agree that DHS presented

clear and convincing evidence to establish child abuse by Parents. Thus, we

reverse the trial court’s orders, and direct it to make a finding of child abuse

as to Parents for each child.18

       Orders reversed. Case remanded. Jurisdiction relinquished.

____________________________________________

17See also N.T., 2/7/20, at 222 (Mother’s testifying that Children were in her
care throughout the day until Father came home from work).

18Given our disposition, we need not address the remaining issues raised by
DHS and GAL.

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Judgment Entered.

Joseph D. Seletyn, Esq.
Prothonotary

Date: 3/1/21

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