Abstract
Thank you for your comments. We agree that the issue of shaken baby syndrome is a highly critical one that requires a thoughtful approach. However, we respectfully disagree with your points.
We did not engage in a circular argument of using the presence of cervical nerve root injuries to define our “trauma” cases at the outset. We did not present detailed histories for all 35 cases because this would not be practical for a manuscript. However, as we stated in the manuscript, our descriptive case series includes numerous infants who were known to have experienced severe hyperflexion and hyperextension forces (e.g. in motor vehicle collisions or abusive trauma) by history or circumstances. The series also includes a group of infants who died of apparently natural causes or who asphyxiated in unsafe sleep environments. The conspicuous presence of cervical nerve root pathology in the former group and the absence of those injuries in the latter group is compelling.
You suggested that nerve root hemorrhages may have occurred because of a hypoxic/ischemic event rather than a hyperflexion/hyperextension neck injury. There is no evidence to suggest that anoxic encephalopathy can cause intraneural and perineural cervical nerve hemorrhages, and in fact our data would seem to refute that hypothesis: many cases with nerve root pathology did not have a post-injury survival period, and did not have anoxic encephalopathy. Furthermore, several cases with anoxic encephalopathy did not have nerve root pathology. The infant in case 14 (who also had a subdural hemorrhage) may have been the victim of an assault. The totality of available information did not permit case classification as such, hence the cautious label of undetermined cause and manner.