In cases of child deaths, the differentiation between natural and unnatural death is essential. However, in some cases this differentiation is rather difficult as children tend to injure themselves and are often involved in accidents. Therefore, with every atypical injury to a child, abuse or neglect must be considered and a forensic specialist should be consulted if there is any doubt. This article will provide an overview of findings, risk factors and prevention of sudden infant death as well as typical signs of child abuse.


Image: “Sickies.” by Monica H. License: CC BY 2.0

Sudden Infant Death

Sudden infant death or, in Latin, mors subtil infinitum is defined as the unexpected or inexplicable death of a baby or an infant while they are asleep. The prerequisite is that despite an autopsy, no other cause could be determined, meaning it is a diagnosis of exclusion.

Apparent life-threatening event, or ALTE, which was previously referred to as “near SIDS” is to be considered a precursor to sudden infant death. It constitutes the sudden and simultaneous respiratory standstill with blue discoloration, paleness of the skin, limb muscles and bradycardia. This condition can be successfully remedied with rescue measures.

Epidemiology of Sudden Infant Death

In Western industrialized nations, sudden infant death syndrome is the most common cause of death in infants following the newborn period. The ratio between boys and girls is 60 % vs. 40 %. Approximately 80 % of fatalities occur before the sixth month of life, peaking between the second and fourth month. 6 % of sudden infant death cases, however, occur during the second year of life. Two thirds of all fatalities occur during the winter months.

Sudden Infant Death Risk Factors

It has been determined that in 99 % of affected children, at least one risk factor could be proven. Risk factors are:

  • prone position while sleeping
  • overheating babies who sweat excessively
  • covered head
  • sleeping in the parents’ bed
  • passive smoking (smoking during pregnancy increases the SIDS risk sevenfold)
  • low socioeconomic family status
  • young mothers, single mothers
  • mother’s drug use or polytoxicomania (during pregnancy or while breastfeeding)
  • apparent life-threatening event (ALTE)
  • a sibling has died from sudden infant death
  • premature birth before the 33rd week or low birth weight.

Measures to Prevent Sudden Infant Death Syndrome

The most important preventative measure is the avoidance of risk factors. Under no circumstances, babies should be passively smoking. The temperature in the baby’s room should be between 61 and 64º Fahrenheit (16-18°C). Furthermore, the baby should sleep in supine position on a firm mattress in a sleeping bag instead of under a blanket and he/she should not be sleeping in his/her parents’ bed.

There must not be any stuffed animals, blankets, comfort blankets or similar items that can cover the child’s face in the baby’s bed. Breastfeeding until the sixth month of life also drastically reduces the risk of sudden infant death syndrome.

In the Netherlands, the number of sudden infant deaths was reduced tenfold by publicizing these preventative measures via television. In Germany, the number of fatalities was lowered threefold as well, since it was recommended that babies sleep in supine position.

Note: Supine position, smoke-free, correct bedding!

Hypotheses Explaining Sudden Infant Death Syndrome

There are countless theories to explain sudden infant death. The most probable one is multifactorial genesis in particularly vulnerable babies, in which internal and external factors work together. The reason for the frequency peak between the second and fourth month of life is the fact that this period is a critical period in the baby’s development.

In 80 % of the cases, there is an initial hypoxia followed by progressing bradycardia and gasping for air. After several minutes, there are prolonged periods of apnea without adequate arousal reaction, causing the child to suffocate.

Reflective breath holding
This theory suggests that the baby holds his/her breath reflectively like divers would if his/her mouth and nose area is covered by liquid. This leads to insufficient oxygen circulation and increased sweating of the child.

Insufficient blood flow to the brainstem
Some babies are predisposed to having blood flow to the brainstem reduced by simply turning their head to the side. In a study published in 2010, the blood flow through the basilar artery (arteria basilaris) was measured in different lying positions via Doppler sonography, and the parents of the affected babies were educated accordingly. This lead to a significant risk reduction for sudden infant death within this study group.

Botulinum toxin poisoning


Image: “Six-week-old infant with botulism” by Openi. License: CC BY 2.0

A German group of researchers succeeded in detecting botulinum toxin in nine of 57 examined SIDS cases. It is assumed that chlostridium botulinum is contained in honey which can increase due to the baby’s gastric acid being not acidic enough yet and the fact that the intestinal flora has not fully matured yet. The botulinum toxin that has developed subsequently leads to respiratory paralysis meaning that during the autopsy no cause of death can be determined. Therefore, it is recommended not to feed honey to children under the age of two.

Disturbances of serotonin levels
In trials with transgenic mice, it was shown that the overexpression of serotonin receptor more frequently leads to bradycardia and hypothermia, resulting in death. In the brains of suddenly deceased children, biochemical disturbances of serotonin-producing cells of the raphe nuclei were found as well, meaning that disruptions of the serotonin homeostasis may be the cause of sudden infant death.

Gases formed by Scopulariopsis brevicaulis
Scopulariopsis brevicaulis is a mold fungus that can break down arsenic pigmented paint (mostly green) in the presence of carbohydrates. During this breakdown process, the poisonous gas trimethylarsine is produced. A prominent victim was Napoleon whose room was painted green and in whose hair and finger nails significant concentrations of arsenic were detected. In a controversial study from 1990, Scopulariopsis brevicaulis was found in the mattresses of all 45 babies who had passed away due to sudden infant death.

Common Post-mortem and Autopsy Findings in Cases of Sudden Infant Death

Typically, the deceased child is in good condition and well fed. There are no external injuries or petechiae. Lips and nail beds are cyanotic. As the baby is usually found in prone position, livor mortis can be found on the front of the body. If the baby was lying face down, there is typically no livor mortis on the face.

Moist bed sheets hint toward sweating. Foamy, bubbly secretion can be found in the airways and it is possible that vomit can be found in the mouth area. Furthermore, during autopsy, subepicardial and thymic petechiae, also referred to as asphyxiation petechiae, can frequently be found.

In addition to that, the right side of the heart is often filled with liquid blood while there is no blood in the spleen. It is also possible that a pulmonary edema is present, along with blood-rich dystelectasis or atelectasis. In most cases, the deceased baby’s bladder is empty and signs of an acute infection can be found in the upper airways.

During the histological examination, the presence of interstitial and intra-alveolar pulmonary edema as well as peribronchial lymphocytic monocytic infiltrate is striking. Furthermore, lipid depletion of the adrenal glands and unspecific hepatitis can be found. More uncommon findings are myocarditis and anomalies of the cardiac conduction system.

Differential Diagnosis with Regard to Sudden Infant Death Syndrome

For differential diagnosis, both natural and unnatural causes of death have to be considered. Natural deaths in babies can occur as a result of infections, metabolic disorders, malformations such as bronchopulmonary dysplasia, Reye syndrome as well as hyperthermia of internal etiology. These causes of death must be distinguished from unnatural deaths such as asphyxia, trauma caused by shaking, intoxication, neglect and hyperthermia of external genesis.

Child Abuse and Neglect

Definition of Child Abuse

There is no uniform definition of child abuse. The German Bundestag defines it as non-accidental, conscious or unconscious violent physical and/or emotional injuries occurring in families or other institutions, meaning in cohabitation. This can lead to injuries and/or developmental inhibition and even death. Therefore, the well-being and the rights of the child are compromised or threatened.

If child abuse is strongly suspected, this represents a justifiable emergency. Therefore, a physician may breach patient-doctor confidentiality as the best interest of the injured party—in this case the child—prevails.

Child abuse is closely connected to domestic violence. Domestic violence and child abuse overlap in between 30 and 60 % of the cases. Mothers of abused children are affected by violence in approximately 50 % of the cases as well.

Types of Child Abuse

As children are often defenseless, there are many different methods of abuse. Those are beating with or without tools, kicking, pulling hair, throwing or tossing, shaking, choking, thermal force such as burning, scalding, submerging in cold water, locking away, darkness, tying up, standing for hours, taking on painful positions, forcing to eat feces or vomit, hunger or thirst as well as sexual abuse.


Image: “Lesion located on the tongue with a pedicled base” (5-year-old, sexually abused boy) by Openi. License: CC BY 2.0

Findings in Cases of Child Abuse

General findings in cases of child abuse are a compromised general condition (also referred to as psychosocial short stature), a great number of frequently occurring injuries, as well as the atypical location of the injuries along with untreated injuries. Frequently, there is a discrepancy between the findings and the statements made by the child or the guardian. In many cases, pediatricians or the treating clinics are changed and examination records are missing.

Note: Falls from a height of between three and five foot (100-150 cm), i.e., from the changing table, typically do not result in life-threatening injuries in babies and infants.

Typical localization of abrasions and hematoma:

Typical for falls Typical for abuse
Palms Back
Knee and shins Buttocks
Elbows Forearms
Nose, forehead, back of the head Eyes, lips, ears

Typical findings in thermal injuries:

 Accidental  Third-party cause
Irregular injury pattern  Uniform depth
Irregular margins Sharply demarcated, stocking or glove pattern burns due to immersion burns
Splash pattern  Missing trailing-off pattern

Trauma caused by shaking
Trauma caused by shaking, or shaken baby syndrome, is one of the most common causes of death in child abuse cases. In the USA, it is one of the causes of permanent mental disability. In 20-25 %, it ends in death as a result of cerebral edema.

Typically, the triad of subdural hematoma, retinal bleeding and swelling in the brain can be found. In 85 % of the cases, the aforementioned retinal bleeding can be seen. As far as differential diagnosis are concerned, other causes to be considered can be ruled out by simultaneous fractures of long hollow bones and histological findings of diffuse axonal damage.


Image: “Subdural hematoma on MRI” by Hellerhoff. License: CC BY-SA 3.0

Other common findings are finger marks on the baby’s shoulders, arms and thorax. When presenting at the clinic, symptoms are lethargy, vomiting and cramps caused by the increasing pressure in the brain. The diagnosis is made via babygram (an X-ray of the entire body of the infant), skull CT and ophthalmic examination.


Image: “Retinal hemorrhage” by Openi. License: CC BY 2.5

Whiplash shaken infant syndrome
In cases of children being shaken repeatedly, chronic subdural hematomas and metaphyseal fractures of the long hollow bones, caused by acceleration and deceleration mechanisms, can be found.

Battered child syndrome
Battered child syndrome is the term for X-ray findings in children who are battered. Classical findings are periosteal reactions such as collar formation on the long hollow bones, epiphyseal detachments and simultaneous rib fractures (in part with callus formation).


Image: “Fractures of ribs in an infant” by National Institute of Health. License: Public domain

Behavior patterns in abused children

  • Anxiety, jumpiness
  • Compliance, even apathy
  • Depression and tension
  • Seeking help and clinging behavior, overly friendly toward strangers
  • Provoking behavior
  • Observing behavior, alertness

Munchhausen Syndrome by Proxy

Munchhausen by proxy syndrome, or factitious disorder, constitutes exaggerating, fabricating or causing symptoms in third parties, mostly children, in order to force medical attention. This artificial disorder usually affects one parent, whereby the mother is affected in significantly more cases.

As opposed to Munchhausen syndrome, Munchhausen by proxy syndrome was not included in the DSM-IV catalog in order to not exonerate individuals who abuse children, as the mortality rate in victims is up to 35 %.

According to Rosenberg, four diagnostic criteria must be met to confirm the diagnosis:

  1. The child’s illnesses are simulated, caused or maintained by a reference person.
  2. The child is repeatedly presented to physicians and subjected to medical diagnostics and treatment.
  3. The true cause of the child’s symptoms is not given when presenting the child.
  4. The child’s symptoms and medical conditions vanish once he/she has been separated from the individual causing them.

Among the simulated symptoms are usually illnesses that are difficult to verify, such as epileptic seizures. Children are also intentionally poisoned or almost suffocated and subsequently presented to the emergency room in order to be praised as the savior.

It is typical that the affected individuals have medical knowledge or even work in the medical field. Therefore, they do not draw attention due to implausible statements, but rather after frequently presenting the child or, in cases where the perpetrator is a nurse, the children getting sick frequently or even dying during their shift. The cause of this disorder is attention seeking.

Child Murder

False statements in cases of child murder frequently constitute falls, accidents or alleged stillbirth. While the first two can be identified via the aforementioned information concerning child abuse, the differentiation between stillbirth and postnatal murder is often difficult, as only little force is needed.

Signs that a newborn was alive:

  • Positive lung float test according to Schreyer (caution: the lung float test is falsely positive with decay, meaning that the liver float test is usually positive as well, with frozen lungs and after reanimation attempts; it is falsely negative in births in liquids)
  • positive float test of segments of the gastrointestinal tract
  • Navel damarcation

Signs that a baby is newborn:

  • Vernix caseosa in skin folds in the groin area and the arm pits
  • Dried blood in hair and on the skin
  • Possible birth trauma (cephalohematoma, dd: caput succedaneum)

Popular Exam Questions Regarding Sudden Infant Death Syndrome and Child Abuse

The answers are below the references.

1. Which of the following is not a risk factor for sudden infant death syndrome?

  1. Passive smoking
  2. Male gender
  3. Sleeping in parents’ bed
  4. Sleeping without a blanket
  5. Premature birth before the 33rd week

2. A six-year-old boy is presented to the emergency room by his mother. She states that her son and his little sister had spent the day with their father and that she noticed a circular red mark with some bleeding in the neck area of the boy when giving the children a bath. When questioned, the boy reacts scared and tells his mother and the pediatrician that his two-year-old sister had thrown a block at him. Which of the following applies to this case?

  1. The mother suffers from Munchhausen by proxy syndrome.
  2. The boy most likely suffers from a personality disorder and has inflicted the injury himself.
  3. There is the urgent suspicion that the father is guilty of child abuse.
  4. The boy’s statement is plausible in light of the injury pattern.
  5. The fact that the boy is scared in his mother’s presence is an indicator that she is the one who injured him.

3. What is not a typical finding of shaken baby syndrome?

  1. Retinal bleeding
  2. Subdural hematoma
  3. Cerebral edema
  4. Finger marks in the head and facial area
  5. Diffuse axonal damage


S1-Leitlinie Plötzlicher Kindstod der Deutschen Gesellschaft für Schlafforschung und Schlafmedizin (DGSM). In: AWMF online (Stand: 31.01.2012 , gültig bis 31.01.2017)

Deeg, K.-H., Reisig, A.: „Dopplersonografisches Screening der Blutströmung in der Arteria basilaris während Kopfrotation reduziert das Risiko für den plötzlichen Kindstod. “ Ultraschall Med 31, 2010

Kinney, H. C. et al.: Serotonergic brainstem abnormalities in Northern Plains Indians with the sudden infant death syndrome. In: J Neuropathol Exp Journ, 2003

Paterson, D. S. et al.: Multiple serotonergic brainstem abnormalities in sudden infant death syndrome. In: JAMA, 2006

Bohnel, H. et al.:Is there a link between infant botulism and sudden infant death? Bacteriological results obtained in central Germany. Eur J Pediatr. 2001

Helfer, M. E., Kempe, R. S., Krugman, R. D.: Das mißhandelte Kind. Körperliche und psychische Gewalt; Sexueller Mißbrauch; Gedeihstörungen; Münchhausen-by-proxy-Syndrom; Vernachlässigung, 2002 – Suhrkamp

Herrmann, B., Dettmeyer, R., Banaschak, S., Thyen, U.: Kindesmisshandlung, 2. Auflage (2010) – Springer Verlag

Deegener, G., Körner W. (Hrsg.): Kindesmisshandlung und Vernachlässigung (2005) – Hogrefe

Dettmeyer, R. B., Schütz, H. F., Verhoff, M. A.: Rechtsmedizin, 2. Auflage (2014) – Springer Verlag

Correct answers: 1D, 2C, 3D

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