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Objective: To examine the circumstances of homicides of children in New South Wales from 1991 to 2005. Design and setting: Retrospective analysis of all identified child homicides in NSW from 1991 to 2005, based on data on offenders and victims obtained from crime statistics, documents located by systematic searches of legal databases and media reports, and medicolegal reports of offenders who committed child homicides during psychotic illness. Main outcome measures: Demographic characteristics of homicides and a history of prior psychiatric treatment among offenders with psychosis. Results: We located documents describing 165 homicides by 157 offenders. Fifty-nine deaths were a consequence of child abuse, including those of five children who died from methadone overdoses. Both the offenders and the victims in fatal child abuse were significantly younger than in other forms of child homicide. The courts found that 27 child homicides had been committed by 26 offenders during the acute phase of psychotic illness, and 15 of these offenders had never been treated with antipsychotic medication. Conclusions: Earlier identification and treatment of psychotic illness in mothers, and changes in the way methadone is provided to opiate-dependent parents, might result in a small overall reduction in the number of child deaths. More lives could be saved by measures that reduce the incidence of child abuse, including the prohibition of corporal punishment of children.