I read with interest the article on neonatal shaken baby syndrome.¹ Although a fascinating account of the sequence of events in this saga, it is factually incorrect in several respects. As the perinatal pathologist involved in the Birmingham series, I raised the possibility that the brain damage was due to the effects of physiotherapy prior to the publication of our report. My co-authors felt that the suggestion was too speculative to be included. It is, however, of note that the physiotherapy regime was changed at this time as a precaution and as I remember I encountered only one further case until my retirement in 2000. At the time I presented the pathological data at several scientific meetings both in the UK and abroad, suggesting physiotherapy was relevant and also that the method used in Birmingham appeared to be unique in allowing free movement of the baby’s head during treatment of the chest.

Some years later I received a telephone call from Dr David Becroft, the perinatal pathologist concerned with the New Zealand cases that pathologically appeared very similar to our own. They had no explanation for their cases at this time and I indicated that I had always been of the opinion that physiotherapy was responsible. As I understand it this resulted in changes in the physiotherapy regime in New Zealand and the disappearance of the lesion.

In retrospect, I should have insisted that my hypothesis, however speculative, was included in our original paper or expressed the view in the correspondence columns at the time because it might have prevented or at least reduced the number of affected cases in New Zealand. Certainly today I would not have been so reticent. In the event it is gratifying that detailed clinical analysis of the cases confirmed my original opinion.

As to the pathology of the condition, detailed unpublished studies of the affected brains in our series suggest the lesion is more akin to that of hydranencephaly than infantile shaken baby syndrome and leads me to raise the possibility that hydranencephaly may be the result of intra-uterine brain trauma.