Physical Abuse: Signs and Symptoms

Download the Checklist for Use in Suspected Cases of Physical Child Abuse (Note: checklists and supplements are large files and may take time to download. You need Adobe Acrobat to view these files.)

The following was adapted from the Massachusetts Department of Social Services Investigation Training manual, “Evidence and Indicators of Maltreatment.”(1)

Distinguishing Abuse from Nonintentional Injury
Behavioral and Emotional Indicators
Special Topics: Munchausen Syndrome by Proxy
Special Topics: Abuse vs. SIDS

Physical Abuse: Injuries

Signs of Possible Inflicted Injury:
- Unsuspected fractures “accidentally” discovered in the course of an examination (sometimes a routine examination).
- Injuries inconsistent with, or out of proportion to the history provided or with the child’s age/developmental stage.
- Multiple fractures, often symmetrical, or fractures at different stages of healing; any fractures in nonambulatory children are suspicious.
- Skeletal trauma combined with other types of injuries, such as burns.
- Subdural hematoma.
- Failure to thrive - the child may appear malnourished, chronically underweight, or be losing weight.
Bruises and Welts
- Caused by pinching or hitting the child with a hand or with an object.
- Bruises go through an evolution of color: initially - red, violet, black, or blue; later - brown, green, or yellow. The color is affected by the depth and location of the bruises as well as surrounding light and skin color. Estimating the age of a bruise by its color cannot be done with much precision:

- A bruise with any yellow is usually older than 18 hours
- Red, blue, and purple/black may occur anytime from 1 hour of bruising to resolution
- Red can be present no matter what the age of the bruise
- Bruises of identical age and cause on the same person may not appear as the same color and may not change at the same rate

- Bruise sites: neither the ears or buttocks are injured frequently in accidents; bruises on knees, shins, foreheads, and elbows may be either intentional or nonintentional.
- Pinch bruises: often symmetrical pattern (i.e. on each earlobe).
- Loop or belt marks: caused by whipping the child with a looped cord (i.e. an electrical cord) or belt; no disease or accident looks like a loop or belt mark.
- Ligature bruises: may be caused by ropes tied around the child’s ankles or neck, resulting in a bruise or a burn.
- Slap marks: fingers may leave bruises on the face.
- Loose tissue with little bony structure underneath (i.e. eyelids, genitals) bruise most easily and retain bruises longest.
- Genital bruises: be suspicious if a caretaker delays seeking treatment for a child with a genital injury. Injury may be caused by pinching a boy’s penis to punish him for touching himself or using a string or rubber band around the penis (causing grooves) to prevent the child from wetting the bed. Bruises in the inner thigh or genital area may indicate sexual abuse.
- Note that Mongolian spots (birthmarks) may be mistaken for abuse - these are usually grayish-blue, clearly defined spots on the buttocks, back, or extremities, and are most common in African American and American Indian babies.
- Occur on soft tissue areas such as abdomen, throat, buttocks, and thighs.
- Injuries to buttocks, lower back, or thighs can be caused by whipping.
- Some areas of the body are normally protected by being inside or covered by other body parts (i.e. medial aspects of extremities); it would be difficult to fall and injure these areas.
- Lacerations of the ear, nose, or throat do not tend to occur accidentally and should arouse suspicion.
- A torn frenulum of the upper lip, especially in an infant, is very concerning for abuse in the absence of a plausible history.
- Determine if bite marks are human or animal: torn flesh is usually a dog bite; compressed flesh is usually a human bite.
- If the wound is fresh, swab for possible recovery of the offender’s saliva for DNA evidence.
- Human bites appear as distinctive oval to horseshoe-shaped marks in which tooth impressions appear as bruises facing each other.
- If the distance between the canines is >3cm, the bite is most likely from a human adult. Adult bite marks are a sign of serious danger to a child - uncontrolled aggression.
- Victim’s teeth should be examined and measured to exclude the possibility of a self-inflicted bite.
- A forensic odontologist or pathologist should evaluate the size, countour, and color(s) of the bite marks, as well as make molds of a suspected abuser’s teeth and possibly of the bite itself since each individual has a characteristic bite pattern.
Download the Checklist for Use in Suspected Cases of Deliberate Burn Injuries of Children

- Burns from hot water are the most common whether abusive or nonintentional.
- Accidental burns tend to be asymmetrical in distribution.
- A burn covering >20% of the body is severe regardless of the child’s age; a burn covering >65% of the body can be fatal, even if it is a first degree burn.
- Medical conditions mistaken for burns include scalded skin syndrome (caused by staph), impetigo, and severe diaper rash.
- Immersion burns: have a “water line” or sharp demarcation border; document the absence of splash marks - symmetric burns with sharp edges are very suspicious.
- Doughnut hole burns: caused when a child is forced into a bathtub; parts of the body, usually the buttocks, rest on the bottom of the tub and thus will not burn, creating a patch of unburned skin in the center of the burn (like a doughnut hole).
- Dunking burns: caused by dunking the child into scalding water (often as punishment for wetting the bed); hands and feet are not burned since the child is held and dunked; sharp demarcations - often called “parallel lines” - since the child is held but not forced to the bottom of a tub or pot on the stove (so no doughnut burn); document the absence of splash marks.
- Stocking or glove burns: caused by immersing the child’s hands or feet in hot water or holding the hands or feet under very hot running water; usually shows sharp demarcation.
- Splash burns: caused by the offender throwing hot liquid at the child. Nonintentional splash burns are usually on the head or top of the chest and run downward (may be caused by a child reaching upward to grab a pot handle). Liquids thrown at a child hit at a horizontal angle, so the burns will be concentrated on the child’s face or chest, and will run toward the back of the body. Splash burns on the back or buttocks are highly suspicious.
- Cigarette burns: usually appear on the trunk, external genitalia, or extremities - often the palms of the hands or soles of the feet; usually symmetrical in shape (impetigo blisters are irregular and can be ruled out by testing for signs of strep); often multiple burns in various stages of healing.
- Chemical burns: caused by household products. Some parents or caretakers force children to drink lye derivatives (toilet bowl cleaner, detergents, or oils), causing chemical burns of the mouth and throat, vomiting, and esophageal damage.

Fractures and Dislocations

Download the Skeletal Injuries Supplement

- Fractures are usually inflicted in nonambulatory children; 90% of all abusive fractures in children 2 years or younger include the ribs.
- Metaphyseal fractures: a chip of the metaphysis is pulled off by a ligament; can only occur from a jerking force applied to the extremities (for example, by shaking or swinging a child by the arms or legs).
- Spiral fracture: diagonal fracture usually caused by the twisting of an extremity; common in children due to more pliant bones - can occur very easily in small children by twisting their own leg or ankle in an accidental injury. Thus, spiral fractures are not necessarily indicative of abuse.
- Pelvic fractures: double vertical fractures through superior and inferior pubic rami and sacroiliac joint dislocation on the contralateral side; do not normally result from accidental injuries.
- Periosteal elevation: injury to this highly vascular tissue occurs when an infant’s extremities are twisted or shaken, causing the periosteum to be separated from the bone and blood to collect in the new space; if symmetric, it may be a normal variant.
- Rib fractures: can be caused by a caretaker squeezing the baby forcefully; victims may present with signs of respiratory distress, though are usually asymptomatic.

Internal Injuries
- Injuries to internal organs are caused by blows to the abdomen or squeezing; significant violent force is required to cause a life-threatening abdominal injury.
- Only a small percentage of children receive internal injuries from abuse; for those who do, the mortality rate is 40-50%.
- Signs and symptoms include: abdominal, chest, flank, or back pain; visible bruising of the chest or abdomen; distended, swollen abdomen; tense abdominal muscles; labored breathing or dyspnea; pleuritic pain; nausea or vomiting. However, many children exhibit minimal symptoms after abdominal trauma.
Neurological Damage: Skull Fracture, Brain or Spinal Cord Damage, and Intracranial Hemorrhage
- Serious life-threatening cranial injuries, with the exception of epidural hematomas, do not result from a child falling from a short height such as a bed or crib.
- Skull fractures: more likely in young children - any pressure from cerebritis or or hemorrhage can separate fontanelles; brain injury is more likely due to increased subdural space in young children.
- Subdural hematoma: ruptured vessels in subdural space.
- Subgaleal hematoma: the scalp separates from the skull; often a sign of skull fracture and reason to image the skull; may be caused by jerking or twisting a child’s hair - especially in girls with pigtails - and may be evident by a bald spot. (Alopecia may be caused by neglect if the child lies on his or her back for long periods of time.)
Shaken Baby Syndrome
- A child has been held around the upper thorax, under the arms, and shaken back and forth with great force or held upside down by the feet and shaken up and down.
- Many infants die, especially if there is a delay in getting treatment; those who survive often have permanent brain damage and may be paralyzed, developmentally delayed, or develop cerebral palsy.
- There is often an absence of externally visible injuries, but retinal hemorrhage is pathognomonic; subdural hematoma and metaphyseal lesions are common.
Other Physical Injury
- Asphyxiation, suffocation, and drowning may be due to abuse.
- Blinding and eye injuries: blows to the eyes can result in a dislocated lens and, later, to cataracts; blows to the front or back of the head can result in bilateral black eyes (“raccoon eyes”) and/or massive swelling of the eyelids. Subconjuctival hemorrhage is caused by direct trauma (i.e. a blow to the face), but can be caused by birthing trauma; unrelated to retinal hemorrhage.
- Injuries to teeth, jaws, mouth, and lips: a strong blow is required to completely dislodge a tooth from its socket; injuries to the maxilla are rarely seen in accidents. Forced feeding of infants may cause bruised lips or a torn frenulum, which is pathognomonic of abuse.
- Damage to ears and hearing: blows to the ears or pinching and twisting of the ears can result in bruised pinna.
- Hair pulling: may see irregular patches of missing hair with broken hair visible, but no completely bald areas; be sure to distinguish from alopecia.
- 17% mortality rate, but more are nonintentional.
- Salt poisoning: forcing a child to swallow salt (often as a punishment for bedwetting); causes hypernatremia, which can lead to dehydration, vomiting, and seizures.
- Water poisoning: forcing a child to ingest water (often as a punishment for involuntary urination); causes hyponatremia, which can lead to convulsions, confusion, lethargy, and coma.
- Laxatives: cause diarrhea, which can lead to severe dehydration, fever, and bloody stools.
- Sedatives: symptoms include lethargy and coma.
- Pepper: ingesting black pepper can damage the mucous membranes of the oropharynx and stomach and may clog the throat and lungs, which can lead to apnea.


Distinguishing Physical Abuse from Nonintentional Injury

Possible Nonintentional Injuries/Illnesses that may Resemble Abuse:

Is it Nonintentional?
Steps to Confirm
Is it a Medical Condition?
Steps to Confirm
Bruise Nonintentional falls - Check for location of bruises; bruises on knees, shins, forehead, or elbows are usually nonintentional.
- In the case of black eyes, check for bruises on the forehead; bruises to the forehead often drain through soft tissues to give appearance of black eyes 24-72 hours afterwards, usually confirmed with history and bruise that is not tender.
- Check to see whether bruises on a single surface are clustered; usually one bruise on a single surface is accidental.
- Correlate nonintentional incident with developmental age and motor skills of child.
- Check for discrepancies between the bruise and history provided by the caretaker.

- Hemophilia
- Leukemia
- Idiopathic Thrombocytopenic Purpura (ITP)
- Mongolian spots
- Maculae cerulae
- Salmon patches
- Hemangiomas (“strawberry marks”)

- Check clotting function: PT, PTT, bleeding time, platelet count, CBC.
- Check for history of prolonged bleeding; check for family history of bleeding disorders.
- Histopathologic examination.
- Find out whether or not spots were present at birth.
- Are spots flat, nontender, and/or more blue/green than true bruises? (Think of Mongolian spots.)
- Bruise coloring should evolve over days.
Bite Mark - Bitten by an animal
- Bitten by a toddler
- Check to see whether flesh is torn or just compressed; torn flesh is usually a dog bite, and compressed flesh is usually a human bite.
- Measure the distance between the center of the canines (the 3rd tooth on each side); if it is greater than 3cm, the bite is most likely from a human adult.
- Check for discrepancies between the injury and history provided by the caretaker.
None None
Hair Loss None None - Trichotillomania
- Tinea capitis (ringworm)
- Idiopathic (i.e. alopecia areata)
- Nutritional deficiencies
- Check to see if loss of hair is in a localized spot.
- Varying bald spots may be indicative of abuse.
- Is the presumed diagnosis appropriate for the child’s age?
- Check for scaly skin.
- Fungal culture of scalp.
- Check history.


- Spilling of hot liquid

- Check location of splash burns; nonintentional burns are most likely to occur on the front of the head, neck, trunk, and arms. It is usually possible to estimate the direction from which the liquid came and the position of the body.
- Check for discrepancies between the burn and history provided by the caretaker.
None None
- Brushing against a cigarette - Check location of burns; usually nonintentional if found on child’s face, arms, or trunk.
- Check shape of burn; usually nonintentional if burn is more elongated than round, with a higher degree of intensity on one side.
- Check for discrepancies between the burn and history provided by the caretaker.
- Impetigo
- Insect bites

- Culture for strep infection.
- Examine lesions: impetigo lesions have various shapes and sizes; cigarette burns are symmetrical.
- Insect bites usually itch, are round, and not painful.

- Falling into a hot bath - Check for clear lines of demarcation; nonintentional burns have no clear line demarcating the burned and unburned skin.
- Check deepness of burn; nonintentional burns are not as deep as forced burns because an unrestrained child will rarely be unable to remove himself from the burning environment.
- Check to see whether or not the perineum and feet are burned, but not the hands; it is impossible for a child to unintentionally fall into a tub without hands going into the water.
- Check for doughnut hole and parallel lines; these may be indicative of abuse.
- Check for discrepancies between the burn and history provided by the caretaker.
- Staph Scalded Skin Syndrome (SSSS)
- Toxic Epidermal Necrolysis (TEN)
- Severe diaper rash
- Ask about symptoms of fever, malaise, and sore throat.
- Check for mouth and nose crusting.
- Ask about onset of medical condition.
- Coming into contact with a burning object - Check location of the burn; some areas of the body are clearly more difficult for a child to self-inflict a burn.
- Check pattern of the burn; an irregular burn will be left when a young child reflexively moves away from a burning object.
- Check deepness of burn; nonintentional burns are usually deep on one edge of the burn.
- Check margins of the burn; nonintentional burns usually do not have crisp overall margins.
- Check for discrepancies between the burn and history provided by the caretaker.
- Varicella (chickenpox) - Check history

- Birthing trauma (fractured clavicles most common)
- Little league elbow
- Nursemaid’s elbow
- Fractures from passive exercises for therapeutic reasons
- Accidental trauma

- Determine cause of fracture.
- Check for discrepancies between the fracture and history provided by the caretaker.
- Congenital syphilis
- Infantile cortical hyperostosis
- Leukemia
- Menkes’ kinky hair syndrome
- Osteogenesis imperfecta
- Osteomyelitis
- Rickets, scurvy

- Radiographic imaging and analysis by pediatric radiologist, if possible.
- It is critical to tell radiologist that child abuse is suspected.
- X-ray is fine for screening; a bone scan can be used to reveal older, healing fractures caused by abuse.
- Bone scan is also useful for revealing acute rib fractures which will not be apparent on plain film.

Head Injury - Birth trauma causing effusion, cephalohematoma, diffuse cerebral edema, infarction, cerebral contusions, or posttraumatic hypopituitarism
- Insect bite on head (usually forehead)

- Check onset of injury; injuries from birth traumas should become apparent shortly after birth.
- Check for discrepancies between the injury and history provided by the caretaker: subdural hematomas found in an infant or toddler without adequate explanation may be indicative of abuse.

- Infectious meningitis causing subdural effusion - Check compatibility between the history and physical findings.
- Consider the child’s developmental maturity in assessing neurological function.
Eye Injury - Chemical burns
- Nonintentional foreign body to the eye
- Check for discrepancies between the injury and history provided by the caretaker. - Conjunctival hemorrhage during birth
- Allergic conditions

- Conjunctival hemorrhage during birth usually disappears by one month.
- Check history.

Ear Injury Injury from inserting cotton swab - Check whether or not laceration is of the external auditory meatus; this injury can only occur by inserting a pointed object into the ear.
- Check for discrepancies between the injury and history provided by the caretaker.
None None
Nasal Injury Injury from inserting a foreign body into the nose - Check whether or not foreign bodies are found in more than one site; if found only in the nose, this is common the normally-developing child.
- Check for discrepancies between the injury and history provided by the caretaker.
None None
Tooth Injury - Nonintentional falls
- Striking the mouth with a hard instrument accidentally
- Check to see whether or not any teeth are loosened; any loosening of the teeth should be immediately examined by a dentist to determine the severity.
- Check for discrepancies between the injury and history provided by the caretaker.
None None
Poisoning - Giving toxic doses of vitamins and minerals to cure an illness
- Feeding a baby improperly diluted formula
- Nonintentional ingestion of medicines, household cleaners, etc.
- Check with caretaker about cause of poisoning; nonintentional poisoning may be a form of neglect that can be treated with education and support.
- Check for discrepancies between the condition and history provided by the caretaker.
- Endocrine -Endocrine workup.

Common Folk Medicine Practices Which Cause Injury That May Resemble Abuse:

Country/Region/Ethnic Group
Circular burns, about 6-8cm in diameter; often multiple. Can result from “cupping,” in which a cup of ignited alcohol is placed over an affected part of the body. As the heated area cools, the skin is sucked up into the cup, producing redness and burns. Mexico

Subdural Hematomas

A remedy for “fallen fontanelle” has been recognized as a cause of subdural hematomas. This practice, called Caida de Mollera (which means “fallen fontanelle”), is founded on the belief that a depression in the top of an infant’s skull occurs when the fontanelle has “fallen,” and can only be retrieved by vigorously sucking the depression back out. Mexico
Light linear bruising with petechiae, usually between ribs on both the front and back; also may be seen on the neck, both sides of the spine, or along the inner arms. These bruises, although they resemble strap marks, may actually be the result of the folk-medicine practice of Cao Gio (coining). In this practice, used to relieve symptoms such as fever, chills, headaches, and vomiting,the skin is massaged with oil and stroked with the edge of a coin until bruising occurs. It is believed that coining forces the “bad wind ” or noxious substance from the body. Normally, this practice should not cause undue concern about child abuse. Vietnam
Hmong people
Light bruising petechiae, or abrasion on both sides of the spine, behind both knees, in the bend of both arms, and on the chest from just above the nipple to the clavicle. These bruises may be the result of the folk-medicine practice of Tzowsa (spooning). This employs a similar method to coining, but a spoon is used. If a raised area appears, cupping treatment is applied. It is believed that this treatment alleviates pain. Hmong people
Intense, isolated, non-symmetrical bruises anywhere on the body. Often found between the eyes on the forehead, along the trachea, in a necklace pattern around the base of the neck, bilaterally on the upper chest, upper arms, or along the spine. These bruises may be the result of the folk-medicine practice of Bat Gio (pinching), in which Pinching Tiger Balm, a mentholated ointment may be massaged into the area before it is pinched. It is very commonly used to exude the “bad wind” for localized pain, lack of appetite, head exhaustion, dizziness, fainting, blurred vision, cough, fever, or any other minor illness. Southeast Asia
2nd and 3rd degree burns on the foot and ankle. In this practice, an analgesic balm such as “Icy Hot” may be applied to a child’s foot, which is then held under running water. This home treatment, based on a hot-cold theory of disease held in many Latin American cultures, is performed in an effort to cure the child’s sprained ankle. Because there is a clear line of demarcation, it may resemble and immersion burn. Latin America
Burns or scars, usually 0.5-1cm in diameter (like cigarette burns), located randomly around the lower rib cage or in a definite pattern around the umbilicus. These burns may be part of a folk medical therapy in which pieces of burning string are lowered onto the child’s skin, in order to cure abdominal pain or fever. Southeast Asia


Physical Abuse: Behavioral and Emotional Indicators

The following factors may influence the intensity and type of reaction a child has to the experience of maltreatment (although some important issues related to any one child’s experience may not be included in this list):
Identity of perpetrator
Child’s age
Child’s developmental status, including whether or not the child has any developmental disabilities
History of prior, or concurrent maltreatment, trauma or stress
Relationship with alleged perpetrator
Duration (time span) of the abuse
Circumstances/context of the abuse (i.e. has the child been afraid, embarrassed, etc?)
Type and intensity of abuse or neglect
Family, social and community support
Child’s coping strategies, and generality personal characteristics (i.e. temperament)

A child’s reactions may involve behaviors that can be observed by other people, or may simply involve the child’s innermost thoughts and/or subjective emotional feelings. Some of the reactions to maltreatment can be similar across age groups, while other reactions may be more common in younger or in older children. In general, it can be difficult to differentiate children who have been abused or neglected from children who have experienced other kinds of stressful experiences. It is important to remember that research in the area of child abuse suggests that many abused children do not exhibit any obvious reactions to maltreatment. Therefore, if a child is not exhibiting concerning behaviors, but you have reason to suspect child abuse, it is strongly recommended that you consult a professional with expertise in the area of child maltreatment for guidance.

The following list includes general signs and symptoms that may sometimes be observed in maltreated children. When reviewing this list, it is very important to remember that fears and behavioral difficulties are commonly associated with normal child development. Many of the following are concerning only when behavioral changes are extreme or occur suddenly. If you have concerns, it is often helpful to consult a professional with expertise in this area.

Behavioral Indicators:
- Running away from home frequently
- Staying at school beyond class time
- Threatening self-harm or suicide
- Assaulting others
- Trying to deny or hide signs of abuse
- Verbalizing a poor self-image
- Thumb sucking or nail biting
- Poor relationships with other children
- Verbal abuse of other children
- Irrational fears
- Overly compliant behavior
- Being inattentive or absent from school frequently
- Indiscriminate friendliness with strangers
- Fearfulness when other children cry and are approached by an adult
- Hypervigilance
- Rocking or uncontrollable crying
- Excessive daydreaming
- Unawareness of others
- Perfectionism
- Eating problems
- Compulsive behavior
- Never looking to caretaker(s) for comfort
- Passivity, maintaining a “low profile”
- Regression or delayed development
- Constant overactivity
- Sleep disturbances
- Doesn’t expect needs to be met
- Aggressiveness
- Unusual interpretations and perceptions of others - maltreated children, especially children exposed to physical violence, may interpret innocuous or neutral interactions/situations as hostile and respond with unwarranted aggression

Emotional Indicators:

- Extremely low self-esteem
- Feeling unwanted and deserving of abuse
- Irrational fears
- Blaming, placing responsibility on others
- Constant anger or temper tantrums
- Fear of family members
- Out-of-control feelings
- Constant worrying and tenseness
- Fear of leaving school
- Attribution of own feelings to others
- Depression


Special Topics: Munchausen Syndrome by Proxy

The following was adapted from the U.S. Department of Justice guide, “Child Neglect and Munchausen Syndrome by Proxy.”(2)

Munchausen syndrome by proxy (MSBP) is a form of child abuse wherein a parent or caretaker (usually the mother) intentionally fabricates illness in her child and repeatedly presents the child for medical care, disclaiming knowledge as to the cause of the problem. Child victims of MSBP are at risk for serious injury.

Diagnostic Criteria: MSBP occurs when there is:

Illness in a child that is simulated (faked) or produced by a parent or other caretaker, or both.
Presentation of the child for medical assessment and care, usually persistently, often resulting in multiple medical procedures.
Denial of knowledge by the parent or caretaker as to the cause of the child’s illness.
Subsiding of acute symptoms and signs when the child is separated from the parent or caretaker.

Typically, but not always, the mother spends a good deal of time on the hospital ward with the child and exhibits a remarkable familiarity with medical terminology. She may be “confidentially friendly” with the hospital staff and other patients, although she may show frustration with her child’s chronic illness and anger at the medical staff’s inadequate vigor in pursuing her child’s problems. She may insist that she is the “only one” from whom the child will eat, drink, or swallow medications.

If more than one child in a family dies of SIDS or of any other ill-defined disease, MSBP - that is, homicide - along with some genetic, metabolic, environmental, and toxicological causes of death, must be considered as more likely explanations.

Common Presentation of Munchausen Syndrome by Proxy and the Usual Methods of Deception:

Presentation: Mechanism:
Apnea Suffocation, drugs, poisoning, lying
Seizures Lying, drugs, poisons, asphyxiation
Bleeding Adding blood to urine, vomit, etc.; opening IV line
Fevers, sepsis Injecting feces, saliva, or contaminated water into child
Vomiting Poisoning with drugs that cause vomiting; lying
Diarrhea Poisoning with laxatives, salt, mineral oil


Special Topics: Abuse vs. SIDS

The following was adapted from the U.S. Department of Justice guide, “Recognizing When a Child’s Injury is Caused by Abuse.”(3)

Sudden infant death syndrome (SIDS) is the “sudden death of an infant under one year which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, including performance of a complete autopsy, examination of the death scene, and review of the clinical history.” SIDS is unexpected, usually occurring in apparently healthy infants ages 1 month to 1 year. Most deaths from SIDS occur by the end of the sixth month, with the greatest number taking place between the ages of 2-4 months.

Note the following key points:

SIDS is a diagnosis of exclusion following a thorough autopsy, death scene investigation, and comprehensive review of the child and his or her family’s case history.
SIDS is a definite medical entity and is the major cause of death in infants after the first month of life, with most deaths occurring between the ages of 2-4 months.
SIDS victims appear to be healthy prior to death.
SIDS currently cannot be predicted or prevented.
SIDS deaths appear to cause no pain or suffering; death occurs very rapidly, usually during sleep.
SIDS is not child abuse.
SIDS is not caused by external suffocation.
SIDS is not caused by vomiting and choking or by minor illnesses such as colds or infections.
SIDS is not caused by the DPT vaccine or other immunizations.
SIDS is not contagious.
SIDS is not the cause of every unexplained infant death.

Criteria for Distinguishing SIDS from Fatal Child Abuse and Other Medical Conditions:

Consistent with SIDS Less Consistent with SIDS Concerning for Child Abuse
Circumstances Surrounding Death An apparently healthy infant fed and put to bed. Found lifeless (silent death). EMS resuscitation unsuccessful. Infant found not breathing. EMS transports to hospital. Infant lives hours to days. History of substance abuse or family illness. History is not typical of SIDS or there is a discrepant or unclear history. Prolonged interval between bedtime and death.
Age of Child

Peak: 2-4 months (90% <7 months)
Range: 1-12 months

8-12 months >12 months

Physical Examination and Lab Studies at Time of Death

Bloody, watery, frothy, or mucous nasal discharge. Postmortem lividity in dependent areas (portions of the body that are lower - due to gravity, the blood settles). Sometimes there are marks on pressure points (places where a blood vessel runs near a bone). No skin trauma. Apparently well-cared-for baby. Organomegaly of the viscera. Diagnostic signs of a disease process (by PE, laboratory tests, imaging studies). Skin injuries. Traumatic injuries to body parts: mucous membranes of the eyelids, fundi, scalp, inside of the mouth, ears, neck, trunk, anus or genitals, and extremities. Evidence of malnutrition, neglect, or fractures may be present.
History of Pregnancy, Delivery, and Infancy Prenatal care ranged from minimal to maximal. Frequently, mothers used cigarettes during pregnancy. Some victims were premature or had low birth weight. Newborns showed minor defects with regard to their feeding and general temperament. Less height and weight gain after birth. Being a twin or triplet. Possible history of spitting, GE reflux, thrush, pneumonia, illnesses requiring hospitalization, tachypnea or tachycardia, cyanosis. Usually no signs of difficulty before death. Prenatal care was minimal to maximal (therefore, it has no significance in distinguishing SIDS from non-SIDS deaths). Child has history of recurrent illnesses and/or multiple hospitalizations (“sickly” or “weak” baby). Previous specific diagnosis of organ system disease. Little or no prenatal care. Mother arrived late at hospital for delivery, or birth occurred outside of hospital. Little or no well-baby care. No immunizations. Mother used cigarettes, drugs, and/or alcohol during and after pregnancy. Child described as hard to care for or to “discipline.” Deviant feeding practices were used.
Death Scene Investigation Crib or bed in good repair. No dangerous bedclothes, toys, plastic sheets, pacifier strings, or pillows stuffed with pellets. No cords, bands, or other possible means of entanglement. An accurate description was provided of the child’s position, including whether there was head or neck entrapment. Normal room temperature. No toxins or insecticides present. Good ventilation, furnace equipment. Defective crib or bed or inappropriate sheets, pillows, or sleeping clothes. Presence of dangerous toys, plastic sheets, pacifier cords, pellet-stuffed pillows. Evidence that child did not sleep alone. Poor ventilation and heat control. Presence of toxins or insecticides. Unsanitary conditions. Chaotic, unsanitary, and crowded living conditions. Evidence of drug or alcohol use by caretakers. Signs of a struggle in crib or other equipment. Bloodstained bedclothes. Evidence of hostility, discord, or violence between caretakers. Admission of harm, or accusations by caretakers.
Previous Infant Death in Family No previous unexplained or unexpected infant deaths. One or more previous unexplained or unexpected infant deaths. One or more previous unexplained or unexpected infant deaths.
Autopsy Findings No adequate cause of death at postmortem. Normal skeletal survey, toxicological findings, chemistry studies (blood sugar may be high, normal, or low), microscopic examination, and metabolic screen. Presence of changes in certain organs thought to be more commonly seen in SIDS than in non-SIDS deaths. Occasionally, subtle changes in liver, including fatty change and blood forming in the liver. Subtle changes in liver, adrenal glands, or myocardium. Traumatic cause of death (intracranial or visceral bleeding). External bruises, abrasions, burns. Evidence of malnutrition, fractures, or scalp bruises. Abnormal body chemistry values: Na, Cl, K, BUN, sugar, liver and pancreatic enzymes, and CPK. Abnormal toxicological findings.
Previous Involvement of DSS or Law Enforcement No Yes Yes



(1) Massachusetts Department of Social Services. Investigation Training: Evidence and Indicators of Maltreatment. March 2002.
(2) U.S. Department of Justice. Portable Guides to Investigating Child Abuse: Child Neglect and Munchausen Syndrome by Proxy. September 1996.
(3) U.S. Department of Justice. Portable Guides to Investigating Child Abuse: Recognizing When a Child’s Injury or Illness is Caused by Abuse. June 1996.

(4) Kendall-Tackett KA, Williams LM, Finklehor D. Impact of sexual abuse on children: a review and synthesis of recent empirical studies. Psychol Bull, 1993; 113:164-80.
(5) Friedrich WN, Fisher J, Broughton D, Houston M, Shafran CR. Normative sexual behavior in children: a contemporary sample. Pediatrics, 1998; 101(4):E9.
(6) Cavanaugh Johnson T. Understanding the sexual behaviors of young children. Siecus Report, August/September.

Adams Classification Table Specific References:
(i) Berenson A, Heger A, Andrews S. Appearance of the hymen in newborns. Pediatrics, 1991; 87:458-465.
(ii) Berenson AB, Heger AH, et al. Appearance of the hymen in prepubertal girls. Pediatrics, 1992; 89:387-394.
(iii) McCann J, Wells R, Simon M, Voris J. Genital findings in prepubertal girls selected for non-abuse: A descriptive study. Pediatrics, 1990; 86:428-439.
(iv) Heger AH, Ticson L, Guerraq L, et al. Appearance of the genitalia in girls selected for nonabuse: Review of hymenal morphology and non-specific findings. J Pediatr Adolesc Gynecol 2002;15:27-35.
(v) Berenson AB, Chacko MR, Wiemann CM, Mishaw CO, Friedrich WN, Grady JJ. A case-control study of anatomic changes resulting from sexual abuse. Am J Obstet Gynecol, 2000;182:820-834.
(vi) McCann, J, Voris J, Simon M, Wells R. Perianal findings in prepubertal children selected for non-abuse: A descriptive study. Child Abuse & Neglect, 1989; 13:179-193.
(vii) Centers for Disease Control and Prevention (CDC) Guidelines, MMWR, Vol. 51, May 10, 2002.
(viii) McCann J, Voris J, Simon M. Genital injuries resulting from sexual abuse, A longitudinal study. Pediatrics, 1992; 89:307-317.
(ix) McCann J, Voris J. Perianal injuries resulting from sexual abuse: A longitudinal study. Pediatrics, 1993; 91:390-397.
(x) Emans SJ, Woods ER, Allred EN, Grace E. Hymenal findings in adolescent women: Impact of tampon use and consensual sexual activity. J Pediatr,1994; 125:153-160.
(xi) Berenson AB, Grady JJ. A longitudinal study of hymenal development from 3 to 9 years of age. J Pediatr 2002;140:600-607.

Last Updated: February 7, 2004
Contact Us