Court Opinion

ID: 9897556
Source: CourtListenerOpinion
Date Created: 2023-11-14 19:16:06.094773+00
Date Added: 2024-06-11T09:16:30.307547
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RECORD IMPOUNDED

               NOT FOR PUBLICATION WITHOUT THE
              APPROVAL OF THE APPELLATE DIVISION

                                 SUPERIOR COURT OF NEW JERSEY
                                 APPELLATE DIVISION
                                 DOCKET NO. A-2069-21
                                            A-2936-21

STATE OF NEW JERSEY,

     Plaintiff-Appellant,

v.

DARRYL NIEVES,

     Defendant-Respondent.        APPROVED FOR PUBLICATION
_________________________               September 13, 2023

STATE OF NEW JERSEY,                  APPELLATE DIVISION

     Plaintiff-Appellant,

v.

MICHAEL CIFELLI,

     Defendant-Respondent.
_________________________

           Argued May 15, 2023 – Decided September 13, 2023.

           Before Judges Gooden Brown, DeAlmeida and
           Mitterhoff.

           On appeal from the Superior Court of New Jersey,
           Law Division, Middlesex County, Indictment No. 17-
           06-0785 and an interlocutory order of the Superior
           Court of New Jersey, Law Division, Middlesex
           County, Indictment No. 17-11-1303.
David M. Liston, Assistant Prosecutor, argued the
cause for appellant (Yolanda Ciccone, Middlesex
County Prosecutor, attorney; David M. Liston, of
counsel and on the briefs).

Cody Tyler Mason, Deputy Public Defender, argued
the cause for respondent Darryl Nieves (Joseph E.
Krakora, Public Defender, attorney; Cody Tyler
Mason, of counsel and on the brief).

Philip Nettl argued the cause for respondent Michael
Cifelli (Benedict and Altman, attorneys; Joseph
Benedict and Philip Nettl, on the brief).

Carter E. Greenbaum (Paul, Weiss, Rifkind, Wharton
& Garrison LLP) of the New York and California
bars, admitted pro hac vice, argued the cause for
amicus curiae Medical Physicians (Steven C. Herzog
(Paul, Weiss, Rifkind, Wharton & Garrison LLP),
Carter E. Greenbaum, Tania Brief (Innocence Project,
Inc.) of the New York bar, admitted pro hac vice,
Audra J. Soloway (Paul, Weiss, Rifkind, Wharton &
Garrison LLP) of the New York bar, admitted pro hac
vice, David Cole (Paul, Weiss, Rifkind, Wharton &
Garrison LLP) of the District of Columbia and
Massachusetts bars, admitted pro hac vice, Robyn
Bernstein (Paul, Weiss, Rifkind, Wharton & Garrison
LLP) of the New York bar, admitted pro hac vice, and
Michael Bass (Paul, Weiss, Rifkind, Wharton &
Garrison LLP) of the New York bar, admitted pro hac
vice, attorneys; Steven C. Herzog, of counsel and on
the brief; Tanya Brief, Audra J. Soloway, David Cole,
Robyn Bernstein, Kirsten Dedrickson, and Michael
Bass, on the brief).

Nakul Y. Shah argued the cause for amici curiae The
Innocence Network and Center for Integrity in
Forensic Sciences (Riker Danzig LLP, attorneys;

                                                        A-2069-21
                         2
            Lance J. Kalik, of counsel and on the brief; Nakul Y.
            Shah, on the brief).

            Ethan Kisch argued the cause for amici curiae
            Biomechanical Engineers Lindsay "Dutch" Johnson,
            Ph.D., Ken Monson, Ph.D., and Kirk Thibault, Ph.D.,
            D-IBFES (Gibbons PC, attorneys; Lawrence S.
            Lustberg and Ethan Kisch, on the brief).

      The opinion of the court was delivered by

GOODEN BROWN, J.A.D.

      In these appeals, we consider the scientific reliability of expert

testimony that shaking alone can cause the injuries associated with shaken

baby syndrome (SBS), also known as abusive head trauma (AHT). The State

sought to admit the testimony to prove aggravated assault and child

endangerment charges against defendants Darryl Nieves and Michael Cifelli,

fathers of infant sons who exhibited associated symptoms while in their

respective fathers' care. Following a Frye1 hearing, Judge Pedro J. Jimenez, Jr.

1
   Frye v. United States, 293 F. 1013 (D.C. Cir. 1923). Recently, in State v.
Olenowski, 253 N.J. 133, 153 (2023), our Supreme Court held that New Jersey
courts will no longer apply the Frye standard for admissibility, and will instead
rely upon a "Daubert-type standard in criminal cases." See Daubert v. Merrell
Dow Pharms., Inc., 509 U.S. 579 (1993). Under Daubert, general acceptance
in the scientific community can still "have a bearing on the inquiry," as it does
under the Frye standard, but "is not a necessary precondition" to admissibility.
Daubert, 509 U.S. at 594, 597. Because the holding in Olenowski is not
retroactive, id. at 154, our review of the trial court's decision is governed by
the Frye standard, and we take no position on the outcome under a "Daubert-
type" analysis. Id. at 153.

                                                                          A-2069-21
                                       3
concluded that expert testimony of shaking-only SBS/AHT was not

scientifically reliable, barred admission of the evidence at Nieves's trial, and

dismissed the indictment against Nieves. Over the State's objection, Judge

Benjamin S. Bucca, Jr. adopted the decision barring the testimony, ruling that

the parties had previously agreed to be bound by Judge Jimenez's decision in

the Nieves matter in the prosecution of Cifelli.

      We granted the State leave to appeal orders relating to both defendants

and now consolidate the appeals for purposes of this opinion.           The State

challenges Judge Jimenez's decision dismissing Nieves's indictment based on

the purported inadmissible evidence, arguing it established SBS/AHT's general

acceptance within the medical community through expert testimony and

supporting authoritative scientific studies.       The State also appeals Judge

Bucca's order entered in the Cifelli matter, arguing it never agreed to be bound

by the decision in the Nieves matter and, in any event, the decision was wrong.

      We affirm both judges' decisions. The evidence supports the finding that

there is a real dispute in the larger medical and scientific community about the

validity of shaking only SBS/AHT theory, despite its seeming acceptance in

the pediatric medical community.       Where the underlying theory integrates

multiple scientific disciplines, as here, the proponent must establish cross -

disciplinary validation to establish reliability. The State failed to do that here.

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                                        4
Indeed, all the experts at the hearing agreed that, at the very least, there was

controversy surrounding the theory that the biomechanical principles

underlying SBS/AHT actually supported the conclusion that shaking only can

cause the injuries associated with SBS/AHT.

                                      I.

                                  A. Nieves

      In early February 2017, within a two-week period, Nieves's son, D.J.,2

had three medical episodes where his body became limp and he appeared to

lose consciousness. D.J. was eleven months old at the time and Nieves was

caring for D.J. on all three occasions. The third incident—during which D.J.

had a seizure—resulted in the infant's hospitalization and triggered a child

abuse investigation against Nieves.

      D.J.'s medical history showed that he was born premature in March

2016, at twenty-five weeks of gestation, due to complications related to

preeclampsia, a potentially dangerous pregnancy condition involving high

blood pressure that can cause damage to the mother's organs and even death.

Upon his birth, D.J. remained at Saint Peter's University Hospital (Saint

Peter's) through October 2016, but for two temporary stays at the Children's

2
   We use initials to protect the privacy of the child-victim pursuant to Rule
1:38-3(c)(9).

                                                                         A-2069-21
                                           5
Hospital of Philadelphia (CHOP) in May and July 2016, when he underwent

cardiac surgery.   Following his discharge, D.J. lived with his mother and

Nieves, who acted as his primary caregiver.

      Based upon D.J.'s history and presenting symptoms when he was

admitted to Saint Peter's in February 2017 following his third episode of

limpness, Dr. Gladibel Medina, a child abuse pediatrician, diagnosed D.J. with

SBS/AHT, with shaking only,3 "within a reasonable degree of medical

certainty." As a result, on June 30, 2017, Nieves was indicted by a Middlesex

County grand jury and charged with second-degree aggravated assault,

N.J.S.A. 2C:12-1(b)(1), and second-degree endangering the welfare of a child,

N.J.S.A. 2C:24-4(a)(2).

      On July 2, 2018, Nieves moved for a Frye hearing to challenge the

scientific reliability of the SBS/AHT hypothesis and preclude Medina's related

testimony at his trial. Nieves argued that SBS/AHT was no longer accepted in

the scientific community. Although Judge Jimenez initially denied the hearing

request, we granted Nieves's motion for leave to appeal the denial and

3
   AHT is the current terminology used to describe the theory. Because the
parties and the experts refer to both terms, we refer to them as SBS/AHT in
this opinion. Although there is a distinction between SBS/AHT with shaking
only versus SBS/AHT with impact, unless otherwise stated, SBS/AHT as used
in this opinion refers to shaking only as that is the primary dispute on appeal.

                                                                         A-2069-21
                                       6
remanded for a Frye hearing, which the judge conducted on five diverse dates

between September 24 and October 15, 2020.

      Following the hearing, on January 7, 2022, Judge Jimenez issued an

order and accompanying seventy-five-page written decision granting Nieves's

motion and prohibiting expert SBS/AHT testimony at trial. On January 28,

2022, the judge denied the State's motion for reconsideration. Finding that the

State was unable to prove causation without Medina's SBS/AHT testimony, the

judge granted Nieves's dismissal motion and dismissed the indictment without

prejudice. A memorializing judgment of dismissal was entered on February

11, 2022.

                                    B. Cifelli

      In late December 2016 and early January 2017, Cifelli's ten-week-old

son, J.C., went to the hospital twice.       The first visit occurred after J.C.

exhibited excessive vomiting, fatigue, and a fever.        The symptoms were

attributed to a "G.I. illness" and "viral infection." The second visit was due to

J.C.'s vomiting and seizure-like activity and resulted in the infant's

hospitalization. Cifelli was caring for J.C. both times. The second incident

triggered a child abuse investigation against Cifelli.

      During J.C.'s hospitalization following the second incident, his

symptoms included: fluid around the brain, which required surgery to drain

                                                                          A-2069-21
                                        7
the fluids; old and new brain bleeds; intraretinal and submacular retinal

hemorrhages, meaning blood in multiple layers of J.C.'s eyes; an apparent

macular hole in his right eye, which was later diagnosed as "foveal

vitreoretinal traction"—marked by the gel-like substance between the lens of

the eye and the retina pulling away from the retina; and a sudden increase in

J.C.'s head circumference. Based upon J.C.'s medical history, which showed

that J.C. was born premature in November 2016, and presenting symptoms,

Medina diagnosed him with SBS/AHT with or without impact, finding that

there was no other medical diagnosis that could explain his symptoms.

      On November 1, 2017, Cifelli was indicted by a Middlesex County

grand jury and charged with second-degree aggravated assault, N.J.S.A.

2C:12-1(b)(1); and second-degree endangering the welfare of a child, N.J.S.A.

2C:24-4(a)(2).4 Relying on the dismissal of a related Title 9 complaint filed by

the Division of Child Protection and Permanency (DCPP) alleging child abuse

and neglect, Cifelli moved to dismiss the indictment. 5 Judge Bucca denied the

4
   Subsequently, on October 20, 2021, a second indictment was returned
against defendant and J.C.'s mother, Alexandria Newton, charging them with
additional acts of child endangerment against both J.C. and his sibling . That
indictment is not the subject of this appeal.
5
   The Family Part's dismissal of the Title 9 complaint did not involve a
determination about the scientific reliability of the SBS/AHT hypothesis, but

                                                                         A-2069-21
                                       8
motion.   Thereafter, Cifelli moved for a Frye hearing to challenge the

admissibility of Medina's SBS/AHT testimony, which the judge initially

denied, finding that SBS/AHT was generally accepted by the scientific

community and therefore reliable.

      However, after we granted Nieves's motion for leave to appeal Judge

Jimenez's denial of a Frye hearing and remanded the matter for a hearing,

Cifelli moved for reconsideration of the denial in his case.      Although no

written order was issued on Cifelli's reconsideration motion, the parties agreed

to hold the matter in abeyance pending the outcome of the Frye hearing in the

Nieves matter. Once Judge Jimenez issued his decision in the Nieves matter

barring expert SBS/AHT testimony, Cifelli moved to dismiss his indictment,

citing the parties' purported agreement to be bound by the Frye ruling in the

Nieves matter. The State opposed the application, asserting that while it had

agreed to await the outcome of the Frye ruling in the Nieves matter, it never

agreed to be bound by the ruling.          On March 29, 2022, following oral

argument, Judge Bucca ruled that both sides had agreed to be bound by the

ruling and, pursuant to that agreement, adopted Judge Jimenez's Frye ruling in

___________________
rather the sufficiency of the evidence that J.C.'s injuries were attributable to
SBS/AHT, as opposed to a different pathology.

                                                                         A-2069-21
                                       9
the Nieves matter.     However, Judge Bucca did not dismiss the indictment

against Cifelli.6

                                C. Frye Hearing

      The State's sole witness at the Frye hearing was Medina, a child abuse

pediatrician and medical director at the Dorothy B. Hersh Regional Child

Protection Center at Saint Peter's, who evaluated D.J. at DCPP's request.

Medina testified as an expert in pediatrics and child abuse pediatrics. Nieves

presented three expert witnesses: (1) Dr. Joseph Scheller, who testified as an

expert in the fields of pediatric neurology and neuroimaging; 7 (2) Dr. Julie

Mack, who testified as an expert in the fields of radiology and pediatric

radiology; and (3) Dr. Chris Alan Van Ee, who testified as an expert in

biomechanics.       The parties also introduced into evidence and discussed

numerous scientific studies and articles during the hearing.

      Medina recounted D.J.'s three "episode[s] of alteration in awareness"

while Nieves was caring for him. Although D.J. was eleven months old at the

time of these episodes, developmentally, he was "at a level of a [three] to

6
   At the time, there was a pending motion to join the additional charges
against Cifelli and J.C.'s mother to this case.
7
  The judge qualified Scheller as an expert in neuroimaging over the State's
objection. The State argued Scheller was not a radiologist and was not board
certified by the American Academy of Medicine in this subspecialty.

                                                                       A-2069-21
                                       10
[four] month[]" old, and was not ambulatory. According to Medina, the first

episode occurred on or about February 3, 2017, when D.J. "became

unresponsive" during a diaper change, and Nieves "blew in his mouth" to

revive him. Nieves notified D.J.'s mother, who was home at the time, and they

called 911.

      D.J. "was better" by the time paramedics arrived and the parents elected

to follow-up with D.J.'s pediatrician, rather than having D.J. transported by

ambulance to the hospital. The pediatrician thought D.J.'s symptoms were

triggered by acid reflux and directed the parents to exercise "reflux

precautions," such as keeping the infant's head elevated "to avoid vomiting."

His parents reported that D.J. was "a little bit more irritable and cranky" in the

following days and vomited or had reflux "twice a day."

      Medina testified that the second incident occurred on February 8, 2017,

also during a diaper change. During that episode, D.J. again "went limp."

Nieves administered "oxygen via nasal cannula" to D.J., which revived him.

The third incident occurred on February 10, 2017.         Medina testified t hat,

according to the parents, when Nieves picked D.J. up from a seated upright

position for a diaper change, D.J. "all of a sudden went limp." D.J. had what

Medina described as a "seizure-like episode," and experienced both "limpness"

and "stiffening."    Nieves notified D.J.'s mother, and they called for an

                                                                           A-2069-21
                                       11
ambulance. Because of the presenting symptoms, D.J. was admitted at Saint

Peter's and remained there for approximately three weeks.

      When D.J. arrived at St. Peter's, he did not have any external physical

injuries, such as broken limbs, bruising, or neck injuries. During his stay, he

was examined by several specialists, including a neuroradiologist, pediatric

ophthalmologist, geneticist, hematologist, and neurologist. A neuroradiologist

conducted an MRI and determined that D.J. had "subdural bleeding at different

stages of evolution."    A pediatric ophthalmologist identified "[m]ultiple,

severe preretinal, intraretinal, and subretinal hemorrhages in both eyes." A

neurosurgeon and neurologist tested and cleared D.J. of seizure disorders and

any underlying "metabolic" or "genetic" conditions that could cause his

symptoms.

      Based on these and other findings, the hospital notified DCPP, and

Medina was selected to conduct a comprehensive evaluation of D.J. based on

"suspicion of abuse." After considering information provided by D.J.'s parents

as well as his medical history and examination results, in April 2016, Medina

opined that D.J. was subjected to child physical abuse and specifically

diagnosed D.J. with SBS/AHT, with or without impact. Medina's evaluation

included considering alternate diagnoses for D.J.'s symptoms, known as a

differential diagnosis. See Creanga v. Jardal, 185 N.J. 345, 357-58 (2005)

                                                                        A-2069-21
                                      12
(accepting the use of a properly conducted differential diagnosis in the medical

community).

      Medina testified that, according to the Centers for Disease Control and

Prevention (CDC), SBS/AHT is defined as "an inflicted injury of the skull . . .

in an infant or a child under five years caused by violent shaking, blunt head

impact or a combination of both." Medina explained that SBS/AHT results

from "the movement of the brain inside the skull," which causes "acceleration

and deceleration" and "creates rotational forces" inside the head. According to

Medina, these forces create "tension" in the "bridging veins" 8 of the head,

causing the veins to tear or leak, "producing blood in the intracranial cavity."

      Medina was adamant that SBS/AHT was not a biomechanical finding, 9

but a "clinical diagnosis." Medina explained that AHT was previously known

as "shaken baby syndrome," but in 2009, the American Academy of Pediatrics

broadened the term to "abusive head trauma," or AHT. She added that the

renaming was not meant as a rejection of shaking as a mechanism of injury,

8
   Mack and Scheller described bridging veins as large veins located in
between the brain and the skull, which transport blood to larger blood vessels,
which then deliver the blood to the heart.
9
    Scheller and Van Ee explained that biomechanics is the study of the
"mechanics of injury" by means of measuring force. For example, a
biomechanical test will inflict different types of force against crash test
dummies to measure the levels of force and determine where impact occurs on
the body.

                                                                           A-2069-21
                                       13
but because AHT more accurately reflected all mechanisms of intracranial

injury.

      Medina identified specific symptoms associated with SBS/AHT,

including: subdural hematomas, retinal hemorrhages, seizures, lethargy, scalp

swelling, neck injury, fractures or external bodily injury, injury to nerve tissue,

injury to the spinal cord, and bruising. She testified that a "triad of symptoms"

was "used to support a diagnosis and a finding" of SBS/AHT. She specified

that the triad consisted of: (1) "subdural hemorrhages"; (2) "severe retinal

hemorrhages"; and (3) "encephalopathy." She testified that "the triad itself

[was] not diagnostic, but the combination of findings, in the absence of

pathology, [was] what gives the final diagnosis."

      Medina defined a subdural hemorrhage as "bleeding under the dural

membrane." She explained that technically "[s]ubdural space does not exist,"

but is "created when there's blood vessel damage, leakage of blood from blood

vessels, and collection of blood in that area."        She said that a subdural

hemorrhage is mostly caused by "trauma," but a finding of a subdural

hemorrhage alone did not support "a diagnosis of abuse," as it could be "found

with other abnormalities."

      Turning to retinal hemorrhages, Medina explained that the retina has

three primary layers—the preretinal, intraretinal, and subretinal layers—and

                                                                            A-2069-21
                                        14
the retina has blood vessels that "occupy the back of the eye" and "extend to

the front of the eye." She said that shaking created "acceleration/deceleration

rotational forces" which caused the jelly-like substance within the eye—the

vitreous—to "pull against the retina causing rupture of the retinal vessels."

Medina stated that retinal hemorrhages can also be caused by "disease, illness,

accidental trauma, or inflicted injury," but "retinal hemorrhages that are

observed in inflicted injury" involved a specific "pattern." Such hemorrhages

were severe and multilayered—visible on more than one of the preretinal,

intraretinal, and subretinal layers—and presented at the front and back of the

eye.

       Medina explained that the encephalopathy or neurological symptoms

referred to "the outward presentation or demonstration of something that has

gone wrong intracranially."      She stated that "encephalopathy" was "the

external presentation of intracranial trauma," and included "unresponsiveness,

apnea, seizures, [and] altered mental status."

       Medina testified that a child abuse investigation was triggered by the

presence of certain symptoms, viewed in conjunction with the child's medical

history, the stated reason for the hospital visit, any inconsistencies between the

stated reason for the visit and the infant's presentation of symptoms , whether

the type of injury was "developmentally possible" based on the infant's age,

                                                                           A-2069-21
                                       15
and any changes in the infant's demeanor and behavior. Once a child abuse

evaluation was triggered, a child abuse pediatrician worked with various

pediatric specialists, reviewing the child's "medical history," "physical

findings," "laboratory tests," and "imaging studies" to rule out alternate

medical explanations for the child's symptoms. Medina stated that this process

of diagnosing SBS/AHT was widely accepted in the medical community.

      Medina attributed D.J's subdural hemorrhage detected in his MRI to the

"tearing of the bridging veins in [his] brain."      Medina said the pediatric

ophthalmologist's finding of "[m]ultiple, severe preretinal, intraretinal, and

subretinal hemorrhages in both eyes" was consistent with the pattern

associated with SBS/AHT. Further, intraretinal hemorrhages usually resolved

within two weeks following trauma and D.J.'s results indicated a recent event.

      Acknowledging his premature birth and the associated medical and

developmental issues, Medina found that D.J.'s past neurosonograms showed

"normal" brain structure and subarachnoid spaces, and "did not reveal any

subdural hemorrhage[s]." Similarly, although D.J. had "mild retinopathy" at

his premature birth—meaning "abnormally growing blood vessels in the back

of his eye"—he was "found to have healthy mature . . . retinas without any

abnormalities" or "hemorrhages" at six months old.

                                                                         A-2069-21
                                      16
      Medina also considered whether D.J. experienced any "volume loss" in

his head, as changes in head circumference "could predispose him to having

subdural collections."      Reviewing his head circumference growth rates,

Medina found that from birth through January 2017, D.J. had "steady" head

growth within the twenty-fifth and fiftieth percentile range. However, when

he was admitted to Saint Peter's in February 2017, his head circumference

made a "significant jump"—measuring between the fiftieth and seventy-fifth

percentile range—which, Medina stated, could be attributed to "the subdural

collection in his brain."

      As part of her differential diagnosis, without further explanation, Medina

ruled out other causes for D.J.'s retinal hemorrhaging, including seizures,

cardiopulmonary resuscitation (CPR), vaccination status, coughing, or reflux.

Medina also rejected D.J.'s parents' account that his symptoms could have been

attributed to his four-year-old half-brother jumping in the crib with D.J.

Medina explained that the incident occurred a month prior, and D.J.'s "retinal

hemorrhages [were] acute."

      Medina made the diagnosis of "abusive head trauma, as occurs with a

shaking event with or without impact" because there "was no explanation for

[D.J.'s] presentation in terms of other potential accidental trauma," and

"[e]verything else was ruled out by the treating providers." Medina opined

                                                                         A-2069-21
                                      17
that D.J.'s diagnosis was either shaking with "impact into a soft surface,

because he [did not] have any external signs of trauma," or shaking alone.

      In contrast, Van Ee questioned the idea that vigorous shaking could

"rip[] a bridging vein" without also injuring the neck. He testified that "the

neck is very weak and vulnerable to injury" and, from a biomechanical

perspective, it would be "the first place to look for injury." Mack disagreed

that subdural collections are always the result of trauma, or attributable to torn

bridging veins. She also noted that torn bridging veins would constitute a

"surgical emergency" due to the large amount of blood flow through those

veins, and distinguished D.J.'s brain scans from those of children who had

suffered from ruptured bridging veins.

      Instead, Mack identified benign enlargement of the subarachnoid spaces

(BESS) as a possible diagnosis for D.J. She defined BESS as an "anatomic

variation" where a child has fluid around the brain in the subarachnoid or

subdural space. Although Medina ruled out BESS as a potential cause of D.J.'s

symptoms, Mack opined that D.J. had BESS because his neuroimaging showed

that D.J.'s "subarachnoid space was slowly expanding"; the subarachnoid space

mainly seemed to have fluid, not blood; and there was no sign of injury. Mack

testified that a BESS diagnosis would account for D.J.'s increased head

                                                                           A-2069-21
                                         18
circumference,   the   subdural   fluid    collections,   and   even   his   retinal

hemorrhages.

      Scheller testified that D.J.'s scans indicating a "large fluid collection"

and only a "tiny sliver of recent blood clotting" evidenced that D.J. had a

"subdural hygroma," which he described as a "plumbing problem," where fluid

collects in the brain. According to Scheller, subdural hygroma would account

for D.J.'s retinal hemorrhages, his seizures, and his increased head

circumference.   Scheller attributed D.J.'s hygroma to his premature birth,

noting that this was a common finding in premature babies, but acknowledged

that subdural hygroma could also result from minor trauma. Although Scheller

agreed that shaking a baby was not "a good thing," he posited that the problem

was that nobody knew "for sure" what type of harm it actually caused. Thus,

he criticized a SBS/AHT diagnosis due to "the lack of . . . scientific data" to

support the injuries associated with shaking only SBS/AHT.

      The experts' testimony referenced various scientific studies and articles

introduced at the hearing. The articles showed the evolution of SBS/AHT,

evaluated the various studies done to test the theory, and commented on the

reliability of the theory. Medina acknowledged that the "foundation" of the

SBS/AHT hypothesis—that head injuries can be caused by a whiplash or

shaking event—stemmed from a 1968 biomechanical concussion study by

                                                                             A-2069-21
                                          19
A.K. Ommaya. A.K. Ommaya et al., Whiplash Injury & Brain Damage: An

Experimental Study, 204 J. Am. Med. Assoc. 285 (1968). Ommaya's testing

involved strapping monkeys into a chair with wheels, accelerating them to a

speed of thirty miles per hour, and then braking to create a whiplash event to

mimic a rear-end collision. Id. at 286. The study concluded that a whiplash

event at thirty-miles-per-hour could cause "rotational displacement of the

head" and, "without direct impact to the head," could cause concussions,

"subarachnoid and subdural hemorrhage" and "cerebral contusions."         Id. at

285-86.

      A study by A.N. Guthkelch built upon Ommaya's research and connected

subdural hematomas from whiplash injuries to SBS/AHT. A.N. Guthkelch,

Infantile Subdural Haematoma & its       Relationship to Whiplash Injuries , 2

British Med. J. 430 (1971). 10 Although the study was not offered into evidence

at the hearing, the experts referenced Guthkelch's findings in their testimony

and the study was provided in the record.

      Guthkelch stated that subdural hematomas in infants were most

commonly caused by the rupture of the bridging veins in the head, which could

be caused by impact or non-impact events.       Id. at 430. Citing Ommaya's

10
   The words hematoma and hemorrhage are sometimes spelled differently in
the articles cited. Because these alternate spellings are correct, they have not
been corrected when quoting the articles.

                                                                         A-2069-21
                                      20
study, Guthkelch posited that shaking an infant could cause subdural

hematomas. Ibid. In so doing, he noted that "the relatively large head and

puny neck muscles of the infant must render it particularly vulnerable to

whiplash injury." Ibid. Reviewing a study of twenty-three "proved or strongly

suspected paternal assault" cases on children, Guthkelch noted that of thirteen

children with subdural bleeding, seven had no skull fractures and five had no

external injuries to the head. Id. at 430-31. Guthkelch concluded that "all

cases of infantile subdural haematoma are best assumed to be traumatic unless

proved otherwise," and that where there are subdural hematomas and no

significant external injury, one should consider whether it is from shaking. Id.

at 431.

      Ommaya's study was also relied upon by John Caffey, who first coined

the term "shaken baby syndrome" in his 1974 study involving confessed

SBS/AHT cases.      John Caffey, The Whiplash Shaken Infant Syndrome:

Manual Shaking by the Extremities with Whiplash-Induced Intracranial &

Intraocular Bleedings, Linked with Residual Permanent Brain Damage and

Mental Retardation, 54 Pediatrics 396 (1974). Although the article was not

offered into evidence, Caffey's findings were discussed by all the experts and

the study was provided in the record. Caffey reviewed confession cases where

the perpetrators admitted to shaking. Id. at 397-99. He noted that shaken

                                                                         A-2069-21
                                      21
babies often lacked external signs of trauma but suffered from "massive

traumatic intracranial and intraocular bleeding."     Id. at 399.   Caffey thus

considered how shaking alone caused these injuries, noting that "[t]he normal

infantile brain and its blood vessels are highly vulnerable to whiplash stresses"

because the infant head was "relatively heavier," and the neck muscles were

weaker. Id. at 401.

      According to Caffey, these structural features "maximized" the

"whiplash stresses" from shaking an infant. Ibid. Additionally, Caffey stated

that an infant's brain and the blood vessels therein—the bridging veins—were

"relatively larger and more stretchable," which could result in "excessive

tearing" and stretching. Ibid. Caffey agreed that a "single manual shake of an

infant may be less forceful and pathogenic than the single whiplash in an

automobile accident," but said repeated shaking "may be much more harmful

to the brain and the intracranial blood vessels and also to the veins in the

eyes." Ibid. Caffey did not elaborate on how he reached this conclusion but

suggested that "[c]urrent evidence, though manifestly incomplete and largely

circumstantial, warrants a nationwide educational campaign" on SBS/AHT.

Id. at 403.

      Van Ee explained that Caffey interpreted Ommaya's study as supporting

"this idea that shaking could cause injuries to children." Van Ee disagreed

                                                                          A-2069-21
                                       22
with this interpretation, however, because the level of force measured in

Ommaya's study was "not something that a human can generate in shaking."

Rather, according to Van Ee, a shaking event would be more akin to a "low

speed rear-end sort of accident," in terms of acceleration forces. Van Ee stated

that Ommaya similarly criticized Caffey's reliance on his 1968 study,

referencing a 2002 article by Ommaya, which was not offered at trial but was

included in the record on appeal.     A.K. Ommaya et al., Biomechanics &

Neuropathology of Adult & Paediatric Head Injury, 16 Brit. J. of Neurosurgery

220 (2002).

      In the article, Ommaya noted that "Caffey, Gulthkelch and others" had

relied upon his prior study to support their findings about SBS/AHT, without

necessarily realizing that his prior study involved acceleration levels "for

motor vehicle crashes at [thirty] mph." Id. at 221. He stated that it was

"improbable that the high speed and severity of the single whiplash" event

from his study "could be achieved by a single manual shake or even a short

series of manual shaking of an infant in one episode." Ibid.

      Considering the acceleration forces with SBS/AHT with shaking only,

Ommaya said that the "values are well below thresholds for cerebral contusion,

[subdural hematomas], subarachnoid haemorrhage, deep brain haemorrhages

and cortical contusions." Id. at 226. While Ommaya stated that prolonged,

                                                                         A-2069-21
                                      23
severe shaking could cause trauma to the infant brain, including cerebral and

cervical spinal cord trauma, he noted that this type of injury could also cause

physical injuries, such as soft tissue bruising or skeletal fractures, and would

cause neck injuries. Id. at 222, 225. As for retinal hemorrhaging, Ommaya

stated that "smaller masses require higher levels of force to cause damage" as

compared to higher masses, and that "the levels of force required for retinal

bleeding by shaking to damage the eye directly is biomechanically

improbable." Id. at 233.

      Ommaya also questioned the methodology involved in a differential

diagnosis of SBS/AHT, stating that it relied upon various assumptions which

were "ambiguous or incorrect," such as:        shaking can "directly" disrupt

bridging veins, causing subdural hematomas; shaking can cause retinal

hemorrhages; short falls cannot cause subdural hematomas; trivial trauma

cannot cause subdural hematomas which can re-bleed; and there was no lucid

interval between injury and manifestation of symptoms. Id. at 227.

      Nevertheless, Medina pointed to other studies that continued to rely on

Ommaya's 1968 study, by utilizing different animal models, computerized

models, anthropomorphic dolls, and crash dummies.        For example, Medina

testified about a 1987 study by Ann-Christine Duhaime, which built off the

Ommaya study to determine whether vigorous shaking of an infant could

                                                                         A-2069-21
                                      24
indeed reach the injury thresholds for intracranial trauma.        Ann-Christine

Duhaime et al., The Shaken Baby Syndrome:          A Clinical, Pathological, &

Biomechanical Study, 66 J. Neurosurgery 409 (1987).

      Duhaime conducted her own biomechanical test using biofidelic dolls

representing a one-month-old baby, designed with three different neck

structures. Id. at 411-12. The dolls were implanted with an accelerometer to

measure the results of shaking and impact.       Id. at 411.     As described by

Scheller, Duhaime sought to create forces "powerful enough to create a

subdural hematoma." Medina explained, however, that Duhaime could not

replicate the same level of force with shaking alone, although she found that

shaking with impact did generate the requisite level of force.

      Based on her results, Duhaime concluded that shaking alone could not

cause fatality, the "most severe acute form" of SBS/AHT.             Id. at 414.

Moreover, Duhaime stated that "the angular acceleration and velocity

associated with shaking" fell "well below the injury range," whereas incidents

involving impact fell in the injury range for concussions, subdural hematomas,

and diffuse axonal injury ranges.    Ibid. Based upon her testing, Duhaime

concluded that "shaking alone does not produce the shaken baby syndrome."

Id. at 409. However, as Medina, Van Ee, and Scheller recognized, Duhaime's

conclusion was not that shaking alone can never cause injury, but that fatality

                                                                          A-2069-21
                                       25
from SBS/AHT was not usually caused by shaking alone.                Nonetheless,

Medina acknowledged that since Duhaime's study, there has been debate about

whether shaking alone can reach the threshold for injuries needed to support an

SBS/AHT diagnosis.

      A subsequent study by C.Z. Corey and M.D. Jones attempted to replicate

Duhaime's study by using a different type of doll. C.Z. Corey & M.D. Jones,

Can Shaking Alone Cause Fatal Brain Injury?, 43 Med. Sci. & L. 317.

Specifically, Corey and Jones replicated the doll used by Duhaime, but

allowed the "standard head" to be removed and fitted with "a modified head

with a more realistic neck insertion point." Id. at 321. They also switched out

the doll's neck, using three different neck structures.      Ibid.    They then

measured the "impact tolerance limits" of shaking using the different types of

dolls, which resulted in "both chin-to-chest and back of head (occiput)-to-back

impacts,"—meaning the doll's chin hit its chest, and the back of its head then

hit its back. Id. at 325, 332. The tolerance limits surpassed those found in the

Duhaime study. Id. at 332. Based on their diverse findings, Cory and Jones

cautioned that future studies should "simulate an infant as accurately as

possible." Id. at 329.

      Cory and Jones questioned whether such "end-point" impacts were

"anatomically possible" in real infants, and noted that other studies also had

                                                                           A-2069-21
                                      26
models which resulted in end-point impacts, which in turn affected the

acceleration of the dummy's head and produced "increased tensile neck

forces." Id. at 325-26. The study posited that if such end-point impacts were

possible from shaking alone, then when determining injury thresholds, one

should look to "impact tolerance limits," as opposed to only "the currently

applied angular acceleration (shaking) data." Id. at 327-28.

      While the injury thresholds in Cory's and Jones's study were greater than

those found by Duhaime, Van Ee distinguished the study's findings because it

involved impact—when the chin hit the chest and the head hit the back of the

spine—which then caused great levels of acceleration.          Moreover, Van Ee

noted that although those impact levels reached "the threshold for concussion,"

they did not "reach the levels for subdural or diffuse axonal injury."

      At the hearing, the experts also referenced a biomechanical study

conducted by Michael T. Prange, who compared "rotational velocities"

between "shaking, shaking with impact, and falls" on different surfaces.

Michael T. Prange et al., Anthropomorphic Simulations of Falls, Shakes &

Inflicted Impacts on Infants, 99 J. Neurosurgery 143 (2003). Prange's testing

involved the use of an anthropomorphic doll to match a one-and-one-half-

month-old baby. Id. at 144. As explained by Van Ee, the study "tr[ied] to

understand . . . what's the head acceleration that's happening under these

                                                                         A-2069-21
                                       27
situations," and looked at the properties of the neck and skull stiffness "to

envelope the responses" between the two to determine "the response of a real

infant." Van Ee explained that, according to the study, "both the one-foot falls

onto concrete and carpet have greater exposure, have greater head angular

acceleration than what is achieved during shaking."

      Prange noted some flaws in his study, including differences in skull

formation, neck strength, and neck motion in real infants, such that the test

overestimated the level of angular acceleration and rotational motions. Id. at

147-48. Prange also noted that while subdural hematomas were "produced by,

and correlated to, the angular velocity or angular accelerations of the head,"

and the anthropomorphic testing data was "useful to evaluate the rotational

responses of the head," he cautioned that the tests could not predict whether

the forces were "sufficient to cause injury," due to a lack of "[r]egional tissue

thresholds specific to the infant." Id. at 148.

      Nevertheless, Prange calculated the likelihood of injury using "a more

qualitative approach," which correlated the "measured accelerations and

changes in velocity" with the documented injury thresholds from other studies

involving cadavers, animals, and human test subjects. Ibid. He found that the

angular velocity and angular accelerations associated with shaking were lower

than any of this recorded data. Ibid. Thus, Prange stated there was no data

                                                                          A-2069-21
                                        28
demonstrating that the angular velocity and angular acceleration associated

with shaking could cause subdural hematomas. Ibid. As explained by Van Ee,

Prange concluded "we still don't have any data that says shaking can give rise

to the injuries associated with it" and that "the term shaking should not be used

in legal settings" because "there's not a scientific basis from biomechanics to

support this idea."

       Van Ee also testified about a 2017 study by Carole A. Jenny, which

involved a crash test dummy representing a five-pound newborn. Carole A.

Jenny et al., Biomechanical Response of the Infant Head to Shaking:           An

Experimental Investigation, 34 J. Neurotrauma 1 (2017).           Jenny's study

resulted in peak angular acceleration and angular velocity levels higher than

those recorded by Duhaime and Prange, likely due to "differences in the

surrogates used to represent an infant," and possibly also due to "differences in

the delivery of shaking by volunteers." Id. at 4-5. Jenny noted that the Cory

and Jones's study approached her recorded peak angular acceleration levels.

Id. at 6.

       Without clearly stating how the recorded outcomes correlated with

injury thresholds, Jenny's article addressed the various limitations in

extrapolating the data to calculate the likelihood of injury. Id. at 8. These

limitations included the lack of "validated infant brain injury thresholds"; the

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                                       29
risk of calculating "misleading" levels when attempting to scale injury

thresholds for adult cadavers or primates; the lack of animal models involving

repeated shaking, which, she said, "have been shown to cause greater injury at

lower peak rotational velocities than do single impulse loads"; the fact that

longer duration of events may produce injury at lower levels of acceleration;

the lack of data on the biomechanical properties of the infant neck; and the

complicated "pathophysiology" and vulnerability of an infant brain that cannot

be replicated through the use of surrogate models.            Ibid.   Thus, Jenny

concluded that attempts to predict injury thresholds would not be reliable

"given the limitations inherent in these thresholds." Ibid.

      Van Ee testified that Jenny's outcomes did not reach the injury

thresholds. Van Ee also noted that Jenny had done an earlier study in the

2000s that measured levels of acceleration associated with falls.         Jenny's

earlier study was not introduced into evidence and involved greater

acceleration levels than those reached "during a shake." As a result, Van Ee

explained that Jenny's later study suggested that "the biomechanical data did

not support the clinical thinking" about SBS/AHT.

      Finally, the parties referred to two biomechanical studies by John W.

Finnie, who tested lambs by shaking them and dissecting them to examine

their injuries. Finnie chose lambs as the test subjects because they had some

                                                                           A-2069-21
                                       30
similarities with human infants' brain structures and neck muscles. John W.

Finnie et al., Neuropathological Changes in a Lamb Model of Non-Accidental

Head Injury (the Shaken Baby Syndrome), 19 J. Clinical Neuroscience 1159

(2010).

      In the first study, Finnie tested seven lambs by having them "vigorously

shaken with enough force to snap the head back and forth onto the chest,

similar to the actions believed to occur in the SBS." John W. Finnie et al.,

Diffuse Neuronal Perikaryal Amyloid Precursor Protein Immunoreactivity in

an Ovine Model of Non-Accidental Head Injury (the Shaken Baby Syndrome),

17 J. Clinical Neuroscience 237 (2010). The results showed a small subdural

hemorrhage in two lambs, and "minimal" retinal hemorrhaging in two lambs.

Id. at 239.

      In the second study, Finnie tested nine lambs through "vigorous[]"

shaking.      Finnie, Neuropathological Changes in a Lamb Model of Non-

Accidental Head Injury (the Shaken Baby Syndrome), 19 J. Clinical

Neuroscience at 1159. The notable findings from the second study were as

follows: (1) three of the "lower body weight" lambs died after the last episode

of shaking; (2) subdural hemorrhaging was only found "macroscopically"; (3)

microscopic subarachnoid hemorrhaging was "infrequent[]" and more common

                                                                        A-2069-21
                                      31
in the lower body weight group; and (4) no retinal hemorrhages were detected.

Id. at 1160-63.

      Finnie stated that the death of several lambs supported the view that non -

accidental head injury can result from shaking only. Id. at 1164. That said,

Finnie concluded that "[t]he pathological and biomechanical aspects" of

SBS/AHT "remain[ed] controversial."          Ibid.   Finnie cautioned against a

diagnosis of non-accidental head injury "unless there is other corroborating

evidence of abuse or a convincing admission by the perpetrator." Ibid. Finnie

stressed the following findings: (1) the mechanisms of brain injury can vary;

(2) a reliable history of past abuse is "usually lacking"; (3) there is no specific

pathognomy for accidental injury versus inflicted injury; and (4) there are

usually no external symptoms, which, he said, was not determinative in and of

itself. Ibid.

      Van Ee conducted his own study measuring levels of acceleration for

different types of injury. Van Ee organized incidents into groups, such as car

crashes and a one-foot fall on a linoleum floor. Van Ee explained that the

purpose of the study was to look at head acceleration levels associated with

different events. According to Van Ee, because SBS/AHT hypothesized that

head acceleration caused injury, then all things that involved a higher level of

acceleration than SBS/AHT should also cause that injury.          Van Ee found,

                                                                            A-2069-21
                                        32
however, that this was not the case. Van Ee's biomechanical studies did not

show that "shaking can actually give the injuries that are associated with it,"

thus undermining the biomechanical hypothesis of SBS/AHT. Thus, while

Van Ee agreed that shaking could cause injury, even death, he questioned

whether such vigorous shaking could only result in the triad.

      Van Ee also pointed out that biomechanical tests did not actually

measure injury and instead measured levels of acceleration, which could then

be compared to "injury reference values" to make "meaningful inferences"

about what type of injuries can result from certain levels of acceleration. Van

Ee similarly acknowledged the limitations of translating injury thresholds to

humans from testing on non-humans, but noted that these models and tests

were the same models and tests used to design bicycle helmets, child car seats,

and playground flooring. Van Ee stated that if that science was viewed as

reliable for those purposes, then "that same science should be valid when you

apply it to another environment."

      Scheller testified that he had not found any biomechanical studies that

demonstrated that shaking alone could "create the amount of force that is

thought to be needed . . . to make a baby suffer a subdural hematoma."

Medina contended that the value of biomechanical studies was limited because

the results varied based on factors such as the type of doll that was used or the

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                                       33
shaking pattern. Pointing to comments by Angell Shi from a 2019 study,

Medina noted the limitations in scaling data from biomechanical testing to

reflect infant injury threshold values. Angell Shi et al., Retinal Findings in

Young Children with Increased Intracranial Pressure From Nontraumatic

Causes, 143 Pediatrics 1 (2019).

      Medina pointedly testified that infant brains "are significantly different

than adult brains," because of different water content and weaker neck

muscles. Thus, according to Medina, the biomechanical data had to be scaled

from primates to adult human brains and then to infant brains.          Medina

explained that there was limited information about infant brains, and no model

could accurately simulate it, so "no one really knows the injury thresholds that

are required to cause injury [in] terms of biomechanics."

      The State presented other studies discussing SBS/AHT.        The studies

largely fell into two groups: (1) articles which discussed the acceptance of

SBS/AHT in the medical and scientific communities; and (2) confession

studies, which examined findings of SBS/AHT in cases where the perpetrator

had confessed to shaking the baby. Both sets of studies relied on clinical data,

as opposed to biomechanical testing, to support the SBS/AHT hypothesis. 11

11
   The parties submitted numerous articles on appeal that were not presen ted
to the trial judge. In State v. Rochat, 470 N.J. Super. 392, 436 (App. Div.

                                                                         A-2069-21
                                      34
      To support the confession studies, generically, Medina described

confessions as "the strongest evidence."    In contrast, Scheller and Van Ee

disputed the accuracy of confession studies, questioning the confessions based

on when they were made, what exactly the person confessed to, and whether

the event actually involved shaking only.

      Medina testified about a confession study by Matthieu Vinchon, which

compared forty-five cases of confessed "inflicted head injury" with thirty-nine

cases of witnessed "accidental trauma" to determine whether these cases

involved the triad of symptoms associated with SBS/AHT. Matthieu Vinchon,

Confessed Abuse Versus Witnessed Accidents in Infants: Comparison of

Clinical, Radiological, & Ophthalmological Data in Corroborated Cases, 26

Child’s Nervous Sys. 637 (2010).        Vinchon relied only on "confessions

obtained from the judiciary," concluding that this set of data would be the most

trustworthy. Id. at 642.

      Vinchon's study found that the "inflicted" cases had a higher number of

subdural hematomas than the accidental trauma cases, and a significantly
___________________
2022) (quoting State v. Harvey, 151 N.J. 117, 167 (1997)), we agreed that an
appellate court should review "posttrial publications" to "account for the rapid
pace of new technology" and to determine if there have been any changes in
general acceptance "between the time of trial and the time of appellate
review." However, several of the studies were available at the time of the
hearing. Nevertheless, we have considered them because the parties did not
object to the additional submissions.

                                                                         A-2069-21
                                      35
higher number of retinal hemorrhages (severe retinal hemorrhages in fifty-six

percent of the inflicted cases, as opposed to only six retinal hemorrhages –

mostly mild – in the accidental trauma cases). Id. at 639-40. Given these

statistics, Vinchon determined that severe retinal hemorrhages, "in the absence

of facial trauma [were] specific of [inflicted head injury]" and the presence of

such hemorrhages carried a "very high predictive value" for inflicted head

trauma.12 Id. at 644.

      Vinchon made less firm findings about the rest of the triad, stating that

the study showed "minimal" clinical manifestations of encephalopathy, and

that while subdural hematomas were a "cardinal feature" in inflicted trauma,

they also presented with other types of injuries and diseases. Id. at 643. He

concluded that the "association" of subdural hematomas with "severe" retinal

hemorrhages and the absence of signs of impact constituted "virtual certainty

of abuse." Ibid.

      Medina also referred to a confession study by Catherine Adamsbaum

that looked at twenty-nine confessed cases of SBS/AHT, and compared them

12
    "'Positive predictive value' is the proportion of patients who have positive
test results and actually have the disease or condition." Sandeep Narang, A
Daubert Analysis of Abusive Head Trauma/Shaken Baby Syndrome, 11 Hous.
H. Health L. & Pol'y 505, 538 (2011). It thus "reflects the probability that a
positive test reflects the underlying condition being tested." Ibid. Specificity
reflects "the chance that someone without the disease will actually have a
negative test." Ibid.

                                                                         A-2069-21
                                      36
to eighty-three cases where there was a diagnosis without confession.

Catherine Adamsbaum et al., Abusive Head Trauma:           Judicial Admissions

Highlight Violent & Repetitive Shaking, 126 Pediatrics 546 (2010). All the

cases involved subdural hematomas, as that was a criteria for inclusion in the

study.     Id. at 547.   The study concluded that approximately eighty-eight

percent of all patients had retinal hemorrhages, with about eighty-two percent

in the confessed cases and about ninety percent in the diagnosed cases. Id. at

548-49. Adamsbaum stated the study confirmed "the role of shaking in the

etiology of these injuries." Id. at 553. She acknowledged, however, that the

"main limitation of the study is that perpetrator admissions are not scientific,"

and that confessions may be flawed, incomplete, or inaccurate. Ibid.

         The Vinchon and Adamsbaum studies were examined in depth in a 2016

study by the Swedish Agency for Health Technology Assessment and

Assessment of Social Services, which was referred to by the experts as the

"SBU." Göran Elinder et al, Traumatic Shaking: The Role of the Triad in

Medical Investigations of Suspected Traumatic Shaking, Report No. 255E

(2016).     The SBU selected these two studies because they were the only

studies about SBS/AHT that were of "moderate quality" sufficient to warrant

review. Id. at 20-22, 27. The SBU concluded that both studies "demonstrate

that traumatic shaking can cause subdural hematoma and retinal hemorrhages."

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                                       37
Id. at 23.     However, it noted that both studies had "methodological

limitations." Id. at 27.

      For instance, the Adamsbaum study required the presence of subdural

hematomas as "a criterion for inclusion" in the study, and Vinchon failed to

respond to the SBU's request for details surrounding the confessions. Id. at

27-28. The SBU also commented on the general unreliability of confession

studies, noting the problem with circular reasoning, and the uncertainty in

dating the age of a subdural hematoma. Id. at 29-30. The study concluded that

there was limited scientific evidence that the triad could be associated with

shaking, and that there was insufficient scientific evidence to assess the

accuracy of the triad's role in identifying traumatic shaking. Id. at 5, 67. It

also included a statement from the Swedish National Council on Medical

Ethics, which opined that it was "ethically problematic for medical

professionals to establish with certainty that certain specific injuries in infants

are automatically evidence that they were caused by shaking." Id. at 67.

      A subsequent article by Geoffrey David Debelle served as a critique of

the SBU. Geoffrey David Debelle et al., Abusive Head Trauma & the Triad: A

Critique on Behalf of RCPCH of "Traumatic Shaking: The Role of the Triad

in Medical Investigations of Suspected Traumatic Shaking," 103 Archives of

Disease in Childhood 1 (2018). Debelle rejected the premise that the presence

                                                                            A-2069-21
                                        38
of the triad directly resulted in a SBS/AHT diagnosis, explaining that

SBS/AHT was diagnosed when the triad was presented, but after a practitioner

had reviewed the child's history and engaged in a differential diagnosis to rule

out all potential causes for the presenting symptoms. Id. at 2.

      Suzanne P. Starling examined inflicted traumatic brain injury cases with

perpetrator admissions against a comparison group where there was no

admission, to determine the time interval between the trauma and the onset of

symptoms. Suzanne P. Starling et al., Analysis of Perpetrator Admissions to

Inflicted Traumatic Brain Injury in Children, 158 Archives Pediatrics &

Adolescent Med. 454 (2004). Of the sixty-nine children from the admitted

trauma group, thirty-two involved SBS/AHT with shaking only, and of that

group, ninety-one percent had subdural hematomas, and eighty-four percent

had retinal hemorrhages. Id. at 456. Starling also noted that the shaking-only

cases "were 2.39 times more likely to have retinal hemorrhages" than the

impact only cases, which, she said, suggested that shaking was "more likely to

cause retinal hemorrhages than impact." Id. at 457. Starling explained that in

the confessed group, most perpetrators said they detected symptoms

"immediately" after the shaking and/or impact. Id. at 456-57. According to

Starling, this data "confirm[ed] recent studies showing immediate onset of

symptoms in children who sustain primary head injury." Id. at 457.

                                                                         A-2069-21
                                       39
      To vouch for the studies evidencing acceptance of SBS/AHT in the

medical community, Medina commented that SBS/AHT was "accepted by all

the pediatric subspecialities involving intracranial injury, which are general

pediatrics,    pediatric   ophthalmology,    pediatric     neurology,   pediatric

neurosurgery, pediatric radiology, [and] pediatric neuroradiology." She also

cited a number of national and international organizations that have recognized

the theory, including the American Academy of Pediatrics, the American

Academy       of   Ophthalmology,   the    American      Academy   of   Pediatric

Ophthalmology and Strabismus, the Royal College of Ophthalmology, the

Royal College of Pediatrics and Child Health, the Norwegian, Japan and

Swedish Pediatric Societies, the American and European Societies for

Radiology and Neuroradiology, the Latin American Society for Pediatric

Regulatory, the American Professional Society for the Abuse of Children, the

CDC, and the World Health Organization.

      To further support the acceptance of SBS/AHT in the medical

community, Medina referred to a "Consensus Statement" by numerous

pediatric and radiological organizations in support of the diagnosis of

SBS/AHT.       Aribinda Kumar Choudhary et al., Consensus Statement on

Abusive Head Trauma in Infants & Young Children, 48 Pediatric Radiology

1048 (2018).       The Consensus Statement by Choudhary explained that

                                                                          A-2069-21
                                      40
SBS/AHT was a "medical diagnosis" made by a team of medical professionals

after consideration of all the facts and evidence. Id. at 1049.

      The Choudhary Statement expounded that the significance of the triad

had been mischaracterized, in that the presence of the triad did not

automatically trigger an SBS/AHT diagnosis, but that such a diagnosis was

based on all of the historical, clinical, and laboratory findings. Id. at 1051.

The Statement explained that a diagnosis "signifies that accidental and disease

processes cannot plausibly explain the etiology of the infant/child’s i njuries,"

and was meant as a medical conclusion, not a finding of intent of the

perpetrator. Id. at 1050. The Statement also considered and cautioned against

the use of alternate theories associated with the symptoms of SBS/AHT,

including BESS, and concluded by noting that a consensus statement generally

reflected "general physician acceptance" of the theory, in this case of

SBS/AHT. Id. at 1056-57, 1059.13

      In response to the Choudhary Statement, Papetti stated that "[t]he

SBS/AHT      diagnosis    is   premised     on    certain   biomechanical      and

pathophysiological assumptions and beliefs, nearly all of which have been

13
    Amici curiae Medical Physicians assert, however, that the Consensus
Statement did not reflect a true consensus by members of the organization ,
claiming that there was insufficient time given for members to vote, and that
other members had voiced their objection.

                                                                            A-2069-21
                                       41
shown to be unreliable." Randy Papetti et al., Outside the Echo Chamber: A

Response to the "Consensus Statement on Abusive Head Trauma in Infants and

Young Children", 59 Santa Clara L. Rev. 299, 303 (2019).          Among other

things, Papetti concluded that shaking creates low acceleration-deceleration

forces which do not reach the injury thresholds; considered different causes for

the triad, such as short falls; noted the absence of neck injury in SBS/AHT

cases; and questioned whether the type of intracranial bleeding found in

SBS/AHT cases was actually due to bridging vein rupture, as opposed to

leakage, given the small amount of bleeding documented. Id. at 312-13, 318,

321-22.

      In an article about the significance of bridging vein rupture and

intracranial trauma, Caroline Rambaud stated that intracranial bleeding may be

minimal because "the bleeding is venous, and therefore slow," and because

brain swelling can impact bleeding. Caroline Rambaud, Bridging Veins &

Autopsy Findings in Abusive Head Trauma, 45 Pediatric Radiology 1126,

1127 (2015). The article also noted that bridging veins are weaker in the

subdural portion of the brain, as compared to the subarachnoid portion , due to

structural differences in the veins, and thus tore more easily. Id. at 1128. The

article recommended conducting autopsies to ascertain the type of bridging

vein rupture to help confirm whether the "mechanism behind the bleeding

                                                                         A-2069-21
                                      42
[was] traumatic," meaning involving "acceleration/deceleration and rotational

and shearing forces." Id. at 1127, 1129.

      During the hearing, the experts also referred to numerous articles citing

the special significance of retinal hemorrhages to a SBS/AHT diagnosis. For

example, Medina referred to a statement by the American Academy of

Ophthalmology, explaining that "[t]he most common ocular manifestation of a

shaking injury, present in approximately 85% of cases, is retinal

hemorrhages."    Alex V. Levin et al., Abusive Head Trauma/Shaken Baby

Syndrome, (Statement by the American Academy of Ophthalmology), at 1

(2015).

      The Statement noted that retinal hemorrhages can be found in the

different layers of the retina, and "tend to be concentrated in or near the

posterior pole, but frequently are so extensive that they occupy nearly the

entire fundus." Id. at 2. The statement cited the vitreoretinal traction theory to

explain how such retinal hemorrhages are caused. Id. at 3. The theory posited

that the "repetitive acceleration-deceleration forces with or without head

impact" from shaking caused hemorrhaging, noting that "[t]he well-formed

vitreous of infants and young children is very firmly attached to retinal blood

vessels, the peripheral retina and the macula." Ibid.

                                                                           A-2069-21
                                       43
      Despite the vitreoretinal traction theory's acceptance by pediatric

ophthalmologists and the child abuse community, Scheller disagreed that a

specific pattern of hemorrhages was only associated with SBS/AHT, stating it

was never corroborated in laboratory studies involving animals and mechanical

models and noting that the reporting doctors were trained to treat and diagnose

such issues, not to determine their cause. He concluded that the concept of a

specific pattern of retinal hemorrhages had "no foundation in science or in . . .

well done research."

      Following the hearing, Judge Jimenez issued an order and lengthy

written decision barring evidence concerning SBS/AHT. After summarizing

the testimony at the hearing, the judge applied the governing princip les and

concluded that SBS/AHT evidence was not reliable. First, the judge found that

a SBS/AHT diagnosis required expert testimony pursuant to N.J.R.E. 702,

inasmuch as it was "outside the knowledge of the average juror." Next, the

judge explained that to determine whether a particular methodology is

"sufficiently established" to support admissibility, there must be a clear testing

method.

      However, according to the judge, with SBS/AHT, there was no test "that

could support a finding that humans can produce the requisite physical force

necessary to produce the symptoms in an infant associated with [SBS/]AHT."

                                                                           A-2069-21
                                       44
The judge noted that, in a sense, a SBS/AHT diagnosis was not made based

upon the same type of clinical findings as other diagnoses. Instead, "[i]t [was]

made by way of a process of elimination involving medical testing to assess

and/or eliminate possible causes of the triad of injuries associated with

[SBS/]AHT," with SBS/AHT as the "final option" once all other possibilities

were eliminated. Thus, the judge found that SBS/AHT was "more conjecture

than a diagnosis because it [was] an option embraced once a diagnostician runs

out of diagnostic options."

      The judge pointed out that, starting with the Ommaya study in 1968,

studies have attempted to determine the injury threshold—meaning the level of

force—necessary to generate intracranial trauma in the test surrogates, be it

animals, computerized models, or various anthropomorphic devices, such as

crash test dummies. The judge explained that not only were these findings "so

diverse that no consensus [could] be reached concerning the injury threshold

for intracranial injury in infants," the studies also were not validated in terms

of how they represented injury to real infant brains, "given how different [an

infant brain was] from any other models tested."

      The judge concluded that "no study has ever validated the hypothesis

that shaking a child can cause the triad of symptoms associated with

[SBS/]AHT," and likened the theory to "junk science," given the lack of

                                                                          A-2069-21
                                       45
testing. Thus, the judge found that "[SBS/]AHT is a flawed diagnosis because

it originates from a theory based upon speculation and extrapolation instead of

being anchored in facts developed through reliable testing."

      The judge also found that the theory, in and of itself, was prejudicial

because it "evoke[d] a sense of horror that affect[ed] the sensibilities of any

competent juror," undermining the jurors' ability to fairly weigh the evidence.

Given the prejudicial nature of the evidence, the judge concluded that

SBS/AHT testimony was not admissible "unless it [was] coupled with physical

evidence that an accused subjected the infant-victim to some impact of

physical trauma that would support holding the accused criminally liable."

                                     II.

      These ensuing appeals followed. In the Nieves appeal, the State raises

the following points for our consideration:

            POINT I

            THE TRIAL COURT MISAPPLIED N.J.R.E. 702
            AND THE FRYE TEST IN BARRING EXPERT
            TESTIMONY ON ABUSIVE HEAD TRAUMA
            (AHT) AS UNRELIABLE; THE STATE PROVIDED
            AMPLE EVIDENCE OF THE DIAGNOSIS'S
            GENERAL ACCEPTANCE IN THE RELEVANT
            SCIENTIFIC COMMUNITY.

                  A. The State Established AHT's General
                  Acceptance as A Diagnosis Through
                  Expert Testimony.

                                                                        A-2069-21
                                       46
                 B. The State Established AHT's General
                 Acceptance as A Diagnosis Through
                 Authoritative Scientific And Legal
                 Writings.

                 C. The State Established AHT's General
                 Acceptance as A Diagnosis Through
                 Judicial Opinions.

                 D. The Reasons Cited by The Trial Court
                 Do Not Justify Exclusion of Dr. Medina's
                 Testimony.

            POINT II

            THE TRIAL COURT'S ORDER DISMISSING THE
            INDICTMENT MUST BE REVERSED BECAUSE IT
            WAS BASED ON THE COURT'S ERRONEOUS
            EXCLUSION OF EXPERT TESTIMONY ON AHT
            AND   BECAUSE   THERE   IS  SUFFICIENT
            EVIDENCE OF DEFENDANT'S GUILT WITHOUT
            THE EXCLUDED TESTIMONY.

      In the Cifelli appeal, the State raises the following points for our

consideration:

            POINT I

            THE TRIAL COURT'S ORDER BARRING
            TESTIMONY ON ABUSIVE HEAD TRAUMA
            (AHT) MUST BE REVERSED BECAUSE IT
            RESTED  ON   AN  IMPERMISSIBLE AND
            ERRONEOUS BASIS.

            POINT II

            JUDGE JIMENEZ MISAPPLIED N.J.R.E. 702 AND
            THE FRYE TEST IN BARRING EXPERT
            TESTIMONY ON ABUSIVE HEAD TRAUMA

                                                                    A-2069-21
                                    47
           (AHT) AS UNRELIABLE IN STATE V. NIEVES,
           WHERE THE STATE PROVIDED AMPLE
           EVIDENCE OF THE DIAGNOSIS'S GENERAL
           ACCEPTANCE IN THE RELEVANT SCIENTIFIC
           COMMUNITY, AND JUDGE BUCCA ERRED BY
           ADOPTING JUDGE JIMENEZ'S FINDINGS IN
           STATE V. NIEVES.

                 A. The State Established AHT's General
                 Acceptance as A Diagnosis Through
                 Expert Testimony.

                 B. The State Established AHT's General
                 Acceptance as A Diagnosis Through
                 Authoritative Scientific Legal Writings.

                 C. The State Established AHT's General
                 Acceptance as A Diagnosis Through
                 Judicial Opinions.

                 D. The Reasons Cited by Judge Jimenez
                 Do Not Justify Exclusion of Dr. Medina's
                 Testimony.

     In the Nieves appeal, we granted motions to appear as amici curiae and

participate in oral argument in support of Nieves's position to the following

individuals and entities: (1) Lindsay "Dutch" Johnson, Ph.D., Ken Monson,

Ph.D., and Kirk Thibault, Ph.D., D-IBFES, three biomechanical engineers; (2)

the Innocence Network and the Center for Integrity in Forensic Sciences; and

(3) Dr. Jacob Andersson, Prof. Anders Eriksson, Dr. Patrick Hamel, Dr. Ulf

Hogberg, Dr. Lawrence Hutchins, Prof. Niels Lynoe, Dr. David Ramsay, Dr.

                                                                      A-2069-21
                                     48
Cyrille Rossant, Dr. Guillaume Sebire, Dr. Dale Vaslow, and Dr. Knut Wester,

a group of eleven medical physicians.

                                     III.

      We first review the State's challenge to Judge Jimenez's ruling on the

reliability and admissibility of SBS/AHT testimony. Whether expert scientific

evidence is sufficiently reliable under the Frye test to be admissible under

N.J.R.E. 702 is a legal question that we review de novo. Rochat, 470 N.J.

Super. at 436.    In our review, we "independently scrutinize the record,

including the comprehensive and amplified declarations of the experts, the

scientific validation studies and peer-reviewed publications, and judicial

opinions." State v. Pickett, 466 N.J. Super. 270, 303 (App. Div. 2021).

      Pursuant to N.J.R.E. 702, "[i]f scientific, technical, or other specialized

knowledge will assist the trier of fact to understand the evidence or to

determine a fact in issue, a witness qualified as an expert by knowledge, skill,

experience, training, or education may testify thereto in the form of an opinion

or otherwise." To satisfy the rule, the proponent of expert evidence must

establish that: (1) the subject matter of the testimony is "beyond the ken of the

average juror"; (2) the field of inquiry is "at a state of the art such that an

expert's testimony could be sufficiently reliable"; and (3) the witness has

                                                                          A-2069-21
                                        49
"sufficient expertise" to offer the testimony. State v. J.L.G., 234 N.J. 265, 280

(2018) (quoting State v. Kelly, 97 N.J. 178, 208 (1984)).

      The issue challenged in these appeals is the second query—whether

SBS/AHT is a reliable scientific theory.      Our assessment of the scientific

reliability of the SBS/AHT theory is governed by the Frye standard. Under

that standard, "[s]cientific test results are admissible in a criminal trial only

when the technique is shown to be generally accepted as reliable within the

relevant scientific community." State v. Cassidy, 235 N.J. 482, 491-92 (2018).

"That is to say, the test must have a 'sufficient scientific basis to produce

uniform and reasonably reliable results and will contribute materially to the

ascertainment of the truth.'" State v. Pittman, 419 N.J. Super. 584, 592 (App.

Div. 2011) (quoting State v. Chun, 194 N.J. 54, 91 (2008)).

            "Proof of general acceptance within a scientific
            community can be elusive," and "[s]atisfying the test
            involves more than simply counting how many
            scientists accept the reliability of the proffered
            [technique]." General acceptance "entails the strict
            application of the scientific method, which requires an
            extraordinarily high level of proof based on
            prolonged, controlled, consistent, and validated
            experience."

            [Cassidy, 235 N.J. at 492 (alterations in original)
            (citation omitted) (quoting State v. Harvey, 151 N.J.
            117, 171 (1997)).]

                                                                          A-2069-21
                                       50
      "The proponent of the technique has the burden to 'clearly establish'

general acceptance."    Ibid.   (quoting State v. Johnson, 42 N.J. 146, 171

(1964)). "[T]here are three ways to establish general acceptance under Frye:

expert testimony, authoritative scientific and legal writings, and judicial

opinions."   J.L.G., 234 N.J. at 281.    Establishing general acceptance of a

scientific theory through judicial opinions may include decisions from other

jurisdictions, but it is "unusual for an appellate court to rely exclusively on

judicial notice." State v. Doriguzzi, 334 N.J. Super. 530, 539 (App. Div. 2000)

(citing Ferlise v. Eiler, 202 N.J. Super. 330, 335 (App. Div. 1985)).           In

Doriguzzi, 334 N.J. Super. at 540, we expressed caution on relying solely on

judicial opinions, in part due to the different standards and considerations

other jurisdictions employ, but also the need to have "reliable scientific data"

when determining a novel issue. Ibid.

      To support admissibility, the State cites two New Jersey cases where

SBS/AHT testimony was deemed admissible.            In State v. Compton, we

determined that SBS/AHT evidence was admissible because: (1) the State's

expert testified that the theory "was generally accepted both as descriptive of a

condition and as a diagnosis"; (2) "the condition has been adequately analyzed

and recognized in medical research and literature"; and (3) other jurisdictions

                                                                          A-2069-21
                                        51
have explicitly or implicitly recognized the theory. 304 N.J. Super. 477, 485-

86 (App. Div. 1997).

      In Compton, we cited State v. Galloway, 133 N.J. 631, 637-38 (1993),

where the defendant was convicted of murder based on SBS/AHT evidence

after admitting to shaking a three-month-old infant hard several times.

Compton 304 N.J. Super. at 486.       We noted that our Supreme Court had

"recognized the condition implicitly, by acknowledging expert testimony

describing the syndrome in connection with a particular case at bar, or treating

it as an accepted medical condition without further comment." Ibid. (citing

Galloway, 133 N.J. at 638).       However, given the age of Compton and

Galloway, and the change in the scientific community's view about SBS/AHT

evidence, continued adherence to these cases is neither prudent nor pragmatic.

See J.L.G., 234 N.J. at 281-83 (revisiting the admissibility of CSAAS

testimony despite finding it admissible twenty-five years earlier); State v.

Moore, 188 N.J. 182, 207-08 (2006) (holding that hypnotically refreshed

testimony "cannot meet the general acceptance standard of admissibility"

despite being deemed admissible twenty-five years earlier).

      There is a dearth of recent New Jersey cases challenging the

admissibility of SBS/AHT testimony. See State v. Blakney, 389 N.J. Super.

302, 312, 316 (App. Div. 2006), rev'd on other grounds, 189 N.J. 88 (2006)

                                                                         A-2069-21
                                      52
(noting no objection to the admission of SBS/AHT testimony where the

victim-infant's treating pediatrician and an expert in forensic pathology both

attributed the victim-infant's injuries to SBS/AHT).         We acknowledge,

however, that "[g]eneral acceptance within the relevant scientific community

consists of more than just counting up how many cases go in a certain

direction." Doriguzzi, 334 N.J. Super. at 546.

      As to out-of-state judicial support, the State relies on a number of

SBS/AHT cases, of which only a limited number expressly determined the

admissibility of SBS/AHT evidence under Frye.        Others either determined

admissibility under a different standard or did not actually decide the question

of admissibility of SBS/AHT as a theory. See State v. Stewart, 923 N.W.2d

668, 676 (Minn. Ct. App. 2019) (finding that SBS/AHT was "reliable" as a

theory and therefore admissible based on the State's representation that this

was an "accepted" diagnosis); Sissoko v. State, 182 A.3d 874, 898, 906 (Md.

Ct. Spec. App. 2018) (applying the "Frye-Reed" standard to determine that a

diagnosis of SBS/AHT, absent external findings, remained a generally

accepted diagnosis in the medical community); State v. West, 551 S.W.3d 506,

516-17 (Mo. Ct. App. 2018) (determining there was no error in admitting

expert testimony as the dispute about SBS/AHT could be examined during

cross-examination); In re Morris, 355 P.3d 355, 360-61 (Wash. Ct. App. 2015)

                                                                         A-2069-21
                                      53
(discussing the admissibility of SBS/AHT testimony in the context of an

ineffective assistance of counsel challenge and determining that the testimony

was admissible based on articles from various medical organizations

supporting the theory); State v. McClary, 541 A.2d 96, 102 (Conn. 1988)

(upholding the admissibility of SBS/AHT testimony under Frye from thirty-

five years ago with no experts disputing the theory); People v. Flores-Estrada,

51 N.Y.S.3d 863, 864-65 (N.Y. Sup. Ct. 2017) (relying on submitted scientific

evidence and prior caselaw to decline to hold a Frye hearing to determine the

admissibility of SBS/AHT testimony and explaining that any dispute about the

theory can be adduced through cross-examination and the presentation of

defense experts).

      In contrast, Nieves cites a number of out-of-state cases to support his

position that SBS/AHT is no longer generally accepted, but none of the cases

involved the courts' express consideration of the admissibility of SBS/AHT

evidence under Frye.    Two of the cases involved vacating the defendants'

convictions where the change in view of SBS/AHT evidence constituted

"newly discovered evidence." See State v. Edmunds, 746 N.W. 2d 590, 599

(Wisc. Ct. App. 2008) (citing the newly discovered evidence as a "shift in

mainstream medical opinion" about whether shaking alone can cause death,

whether babies can experience a "lucid interval" following intracranial trauma,

                                                                        A-2069-21
                                      54
and whether "other causes may mimic the symptoms" associated with

SBS/AHT); People v. Bailey, 999 N.Y.S.2d 713, 723-27 (N.Y. Cnty. Ct. 2014)

(vacating conviction and remanding for a new trial based on a "significant

change in medical science" about SBS/AHT, particularly in connection with

biomechanical studies that questioned causation, and studies about how short

falls can cause injuries associated with SBS/AHT), aff’d, 41 N.Y.S.3d 625

(N.Y. App. Div. 2016).

      "Reliance upon other courts' opinions can be problematic . . . '[u]nless

the question of general acceptance has been thoroughly and thoughtfully

litigated in the previous cases . . . ." Doriguzzi, 334 N.J. at 545 (quoting

People v. Kirk, 681 N.E.2d 1073, 1077 (Ill. App. Ct. 1997)). Although "[a]

long line of decisions uniformly in favor of a legal proposition suggests that a

legal proposition is generally accepted[,] . . . . [w]e are mindful, however, that

in science, the repetition of authority does not automatically establish

reliability for purposes of a Frye hearing." Pickett, 466 N.J. Super. at 307.

Indeed, some of the cases cited by the State confirmed the reliability of

SBS/AHT based on a prior court's acceptance of SBS/AHT, a type of

circularity that is inappropriate given Nieves's position that the medical and

scientific community's view about SBS/AHT has evolved over time,

warranting a new review of the issue.

                                                                           A-2069-21
                                        55
      To establish general acceptance of a scientific theory, "the party

proffering the evidence need not show infallibility of the technique nor

unanimity of its acceptance in the scientific community." Cassidy, 235 N.J. at

492. Rather, the party must demonstrate that the "test and the interpretation of

its results are non-experimental, demonstrable techniques that the relevant

scientific community widely, but perhaps not unanimously, accepts as

reliable."   State v. Ghigliotty, 463 N.J. Super. 355, 383 (App. Div. 2020)

(quoting Harvey, 151 N.J. at 171).

      To be sure, "[g]eneral acceptance is not an end in itself," but a way to

evaluate whether there is "a sufficient level of reliability" lying beneath the

expert testimony to "allow consideration . . . by the factfinder." Doriguzzi,

334 N.J. Super. at 546.     Critically, where, as here, the underlying theory

"integrates multiple scientific disciplines," then "there might be more than one

scientific community to consider," and the proponent must establish "cross -

disciplinary validation to determine reliability." Pickett, 466 N.J. Super. at

302, 323. Still,

             "[w]hat constitutes reasonable reliability depends in
             part on the context of the proceedings involved."
             Admissibility of the evidence

                   entails a weighing of reliability against
                   prejudice in light of the context in which
                   the evidence is offered. Expert evidence
                   that poses too great a danger of prejudice

                                                                         A-2069-21
                                      56
                  in some situations, and for some purposes,
                  may be admissible in other circumstances
                  where it will be more helpful and less
                  prejudicial.

            [In re Commitment of R.S., 339 N.J. Super. 507, 539
            (App. Div. 2001) (citation omitted) (quoting State v.
            Cavallo, 88 N.J. 508, 520 (1982)).]

      SBS/AHT is a multidisciplinary diagnosis based on the theory that

vigorously shaking an infant—with or without impact—creates such great

rotational acceleration and deceleration forces that result in a constellation of

symptoms that may not manifest externally.        Whether SBS/AHT theory is

generally accepted within the medical and scientific community requires

evaluation of two considerations: (1) whether the theory is generally accepted

by the biomechanical community and supported by biomechanical testing; and

(2) whether the theory is generally accepted by the pediatric medical

community and supported by the clinical data connecting the constellation of

symptoms with SBS/AHT.

      Although the State has demonstrated general acceptance in the pediatric

community, we agree with Judge Jimenez that the State has not demonstrated

general acceptance of the SBS/AHT hypothesis to justify its admission in a

criminal trial. On the contrary, the evidence amply demonstrates that there is

no general acceptance from the biomechanical community, and biomechanical

testing has never proven the premise of SBS/AHT, despite the hypothesis

                                                                          A-2069-21
                                       57
being grounded in biomechanical principles. Although Medina was dismissive

of the dispute within the biomechanical community, all the experts at the

hearing agreed that, at the very least, there was "controversy" surrounding

whether the biomechanical theory behind SBS/AHT actually supported the

conclusion that shaking alone can cause the injuries associated with SBS/AHT.

Indeed, the State failed to submit any biomechanical study that was able to

confirm the theories set forth by Caffey and Guthkelch, that shaking alone can

create acceleration and deceleration forces sufficient to cause intracranial

trauma.14

      Although unanimity of view is not a prerequisite to satisfying the

general acceptance and reliability standard, Ghigliotty, 463 N.J. Super. at 383,

the dispute runs deeper than diversity in view and goes to the very foundation

of the SBS/AHT hypothesis. One cannot conclude that SBS/AHT is "state of

the art," J.L.G. 234 N.J. at 280 (quoting Kelly, 97 N.J. at 208), when the very

basis of the theory has never been proven. Without a biomechanical study

supporting SBS/AHT, it remains a hypothesis without "uniform and reasonably

14
    Significantly, amicus curiae Medical Physicians cited a recent article by
Guthkelch—which was not provided to the trial court or on appeal—wherein
Guthkelch acknowledged that biomechanical tests could not reach the injury
thresholds from shaking alone. A.N. Guthkelch, Problems of Infant Retino-
Dural, Hemorrhage with Minimal External Injury, 12 House. J. Health L. &
Pol'y 201, 202-03 (2012).

                                                                         A-2069-21
                                      58
reliable results" from which to ascertain the truth. Pittman, 419 N.J. Super. at

592 (quoting State v. Hurd, 86 N.J. 525, 536 (1981), abrogated on other

grounds by State v. Moore, 188 N.J. 182 (2006)). It also fails to show that

"the interpretation of its results are non-experimental, demonstrable

techniques," which can be accepted as reliable. Ghigliotty, 463 N.J. Super. at

383 (quoting Harvey, 151 N.J. at 171).       It therefore does not satisfy the

"extraordinarily high level of proof" necessary to constitute general

acceptance.   Cassidy, 235 N.J. at 492 (quoting Harvey, 151 N.J. at 171).

Because biomechanical theory is the foundation of the SBS/AHT hypothesis,

the lack of biomechanical support renders the theory scientifically unreliable,

notwithstanding its support in the pediatric community. We therefore affirm

Judge Jimenez's decision precluding the testimony at trial.

                                     IV.

      We next turn to the State's challenge to Judge Jimenez's dismissal of

Nieves's indictment. Following the Frye ruling, Nieves moved to dismiss the

indictment, arguing that the only evidence against him was Medina's testimony

that D.J.'s symptoms were due to SBS/AHT. The State opposed the motion,

contending that while Medina could no longer testify about the symptoms

associated with SBS/AHT, she could testify "as to the symptoms presented by

D.J., the undisputed fact that shaking with impact [could] cause those

                                                                         A-2069-21
                                      59
symptoms," and that she ruled out any possible causes for D.J.'s symptoms.

The judge granted Nieves' motion and dismissed the indictment without

prejudice on the ground that there was "insufficient evidence to prove

causation." The judge reasoned that because Medina would not be able to

explain causation or "the source of the trauma," the jury would have "to

speculate" about what happened.

      We review a trial court's decision on a motion to dismiss an indictment

for abuse of discretion. State v. Bell, 241 N.J. 552, 561 (2020) (citing State v.

Twiggs, 233 N.J. 513, 544 (2018)). Under that deferential standard, "the trial

court's 'decision should be reversed on appeal only [if] it clearly appears that

the exercise of discretion was mistaken.'"       Ibid.   (alteration in original)

(quoting State v. Abbati, 99 N.J. 418, 436 (1985)).       "The absence of any

evidence to support the charges would render the indictment 'palpably

defective' and subject to dismissal." State v. Morrison, 188 N.J. 2, 12 (2006)

(citing State v. Hogan, 144 N.J. 216, 228-29 (1996)). "A trial court, however,

should not disturb an indictment if there is some evidence establishing each

element of the crime to make out a prima facie case." Ibid.

      Contrary to the State's contention, without SBS/AHT testimony, there

was insufficient evidence to support the indictment against Nieves.          The

elements of aggravated assault pursuant to N.J.S.A. 2C:12-1(b)(1) required

                                                                          A-2069-21
                                       60
proof of an attempt "to cause serious bodily injury to another," or proof that

defendant caused such injury "purposely or knowingly or under circumstances

manifesting extreme indifference to the value of human life recklessly cause[d]

such injury." The elements of endangering the welfare of a child pursuant to

N.J.S.A. 2C:24-4(a)(2) required proof that defendant: (1) had "a legal duty for

the care of a child," and (2) harmed the child, such that the child would qualify

as an "abused or neglected" child under the law.

      Without SBS/AHT testimony, the State cannot demonstrate a necessary

element of both offenses – that Nieves caused D.J. harm. Although the State

could present testimony that D.J. was in Nieves's care when D.J. had his

episodes of limpness, and that he was found to have retinal hemorrhages and

subdural hematomas, the State would not be able to explain how Nieves

harmed D.J., leaving the question for the jury to determine. Although a jury

may draw a reasonable inference from the facts presented, "the State's right to

the benefit of reasonable inferences should not be used to shift or lighten the

burden of proof, or become a bootstrap to reduce the State's burden of

establishing the essential elements of the offense charged beyond a reasonable

doubt." State v. Brown, 80 N.J. 587, 592 (1979). "Speculation, moreover,

cannot be disguised as a rational inference." State v. Lodzinski, 249 N.J. 116,

144-45 (2021). "An accused 'may not be condemned upon surmise, conjecture

                                                                          A-2069-21
                                       61
or suspicion.'" Id. at 145 (quoting State v. LaFera, 42 N.J. 97, 119 (1964)).

Requiring the jury to infer that Nieves harmed D.J. would require the jury to

make such a leap.

                                     V.

      In the Cifelli appeal, the State argues that it never agreed to be bound by

Judge Jimenez's Frye ruling in Nieves, and Judge Bucca thus erred in adopting

that decision as the basis to bar SBS/AHT testimony in the Cifelli case without

making his own findings. The divergent positions of the parties regarding the

impact of Judge Jimenez's Frye ruling on the Cifelli matter and their agreement

in that regard were manifested in certifications submitted by the respective

attorneys reflecting their respective recollection of the events leading up to the

agreement.15 Defense counsel maintained that the parties would be bound by

Judge Jimenez's Frye ruling while the State denied any agreement to be bound

by Judge Jimenez's decision.

      Following oral argument conducted on March 29, 2022, Judge Bucca

entered an order dated March 31, 2022, finding that the parties "agreed to be

bound by the ruling on the admissibility of abusive head trauma testimony" in

the Nieves matter.    Pursuant to the agreement, the judge granted Cifelli's

15
   At least four different prosecuting attorneys were assigned to the Cifelli
matter during the relevant time period.

                                                                           A-2069-21
                                       62
motion to bar SBS/AHT testimony, "with th[e] court incorporating the

findings" made by Judge Jimenez in the Nieves matter.

      In his supporting oral decision, Judge Bucca recounted the procedural

overlap between both cases and stated "there [was] no doubt in th[e c]ourt's

mind that it was agreed between the parties that the decision by Judge Jimenez

as to the admissibility of the expert testimony on abusive head trauma wou ld

be binding . . . on the Cifelli case." The judge explained that his "recollection

[was] clear" due to the unique characteristics of the dual proceedings. The

judge noted that "[i]n hindsight, it would have been better that we

memorialized this agreement by way of an order," but the lack of an order

"should not undermine th[e c]ourt's clear recollection as to the understanding

between the parties."

      Because our disposition in the Nieves appeal resolves the admissibility

of SBS/AHT testimony under Frye, regardless of the propriety of a trial court's

decision to be bound by another court's ruling in these circumstances, 16 we

deem Judge Bucca's decision to defer to Judge Jimenez's Frye ruling moot.

"An issue is 'moot when our decision sought in a matter, when rendered, can

16
   Cf. State v. Gibson, 219 N.J. 227, 240-41, 248 (2014) (cautioning against a
common practice in municipal courts of incorporating testimony from the
suppression hearing into the trial record and warning "that 'the interest in
judicial economy cannot override a defendant's right to a fair trial.'" (quoting
State v. Brown, 170 N.J. 138, 160 (2001))).

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have no practical effect on the existing controversy.'" Redd v. Bowman, 223

N.J. 87, 104 (2015) (quoting Deutshe Bank Nat'l Tr. Co. v. Mitchell, 422 N.J.

Super. 214, 221-22 (App. Div. 2011)). In other words, "a case is moot if the

disputed issue has been resolved[.]" Enron (Thrace) Expl. & Prod. v. Clapp,

378 N.J. Super. 8, 13 (App. Div. 2005) (quoting Caput Martuum v. S. & S.,

366 N.J. Super. 323, 330 (App. Div. 2004)).

       Because we have resolved the scientific reliability and admissibility of

SBS/AHT testimony, our holding must be accorded conclusive weight. See,

e.g., State v. Rose, 206 N.J. 141, 183 (2011) ("[T]he legal findings and

determinations of a high court's considered analysis must be accorded

conclusive weight by lower courts."); Caldwell v. Rochelle Park Twp., 135

N.J. Super. 66, 76 (Law Div. 1975) ("[A] trial court is bound to follow the

rulings of an appellate court in this State, which decisions are binding when

the same issues are presented."). Based on our decision, we need not address

the remaining arguments.

     Affirmed.

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