Child Death Review Research Articles

Child Fatalities Resulting From Caregiver Behavior: A Public Health Approach to Child Maltreatment Classification.

Limited research describes approaches for applying a public health lens to fatal child maltreatment classification. Specialized terminology and tools could help improve consistency in classifying deaths resulting from caregiver behavior. A six-criterion classification tool was developed via expert panel review of over 100 child deaths by the Alaska Division of Public Health's Child Death Review (CDR) program. Next, accuracy and acceptability were assessed by inviting staff from other CDRs using a national listserv to classify 21 brief case scenarios with the tool. Among the 47 respondents, sensitivity was 0.87, specificity 0.77, and accuracy 0.84. Variability by tool criterion ranged from 97% to 74% accurate. Most respondents (66%) reported the tool as being helpful for classifying deaths and moderate reliability was found. Study participants found it difficult to consistently apply specific criteria which resulted in a modification of the tool to improve the potential for universal adoption.

Massachusetts Pediatric Injury Equity Review (MassPIER): A Process to Address Injury Inequities.

Significant inequities in pediatric injury outcomes exist. We aim to develop a process to assist child death review (CDR) teams in identifying upstream factors that lead to inequitable outcomes in pediatric injuries. We spent 6 months (November 2021-April 2022) working with 3 CDR teams in Massachusetts to understand their tools and processes for CDR. During that time, we began to iteratively develop a pediatric injury equity review process and tools. Between May and October 2022, acceptability and adaptability of the resulting Massachusetts Pediatric Injury Equity Review (MassPIER) process and tools were evaluated through focus groups and a Research Electronic Data Capture survey of participants. We compared the prevention recommendations of the CDR teams before the implementation of MassPIER with those generated using MassPIER. A χ2 and Fisher's exact test assessed whether the 2 sets of recommendations differed with regard to equity. A 7-step process was developed, along with 2 tools for use during the MassPIER process. From an acceptability and adaptability standpoint, 100% of participants strongly agreed or agreed that the MassPIER process was simple to follow and adaptable to any type of injury. Ninety-five percent of participants agreed or strongly agreed that the approach could be replicated by other teams. Furthermore, the MassPIER process increased the likelihood of generating equity-focused recommendations in general (P < .05), and particularly recommendations focusing on economic inequities (P < .05). MassPIER is effective in facilitating equity-focused discussion and recommendation development. It is acceptable to team members, and adaptable to other types of injury.

Characteristics of Children Ages 1-17 Who Died of COVID-19 in 2020-2022 in the United States.

This study describes characteristics of children ages 1 to 17 years who died of coronavirus disease 2019 (COVID-19) in 2020 to 2022 and whose deaths were reviewed by child death review (CDR) teams across the United States. We used data in the National Fatality Review-Case Reporting System to examine children who died of COVID-19. Deaths were determined because of COVID-19 from death certificates or CDR determinations. A total of 183 children 1 to 17 years old who died of COVID-19 were reported in the National Fatality Review-Case Reporting System. One-third (33%) were 15- to 17-year-olds, and 26% were 1- to 4-year-olds. Fifty-six percent were reported as male, 54% white, 24% Black, and 18% Hispanic ethnicity. Physicians declared cause of death in at least 82% of deaths. More than two-thirds (68%) had a medical condition (excluding COVID-19) at time of death. The most common conditions were nervous system disorders (19%), congenital disorders (14%), obesity (12%), respiratory disorders (12%), and neurodevelopmental disorders (10%). Of children with an underlying condition, 35% had 3 or more conditions. Less than half (42%) had contact with a health care provider within a month of their death; and three-fourths died within 14 days of exposure. This study describes the demographics, death investigation findings, and medical conditions of children who died of COVID-19. The results highlight the short timeline between COVID-19 exposure and death. Pandemic planning that prioritizes prevention efforts and timely access to effective medical care may result in saving children's lives.

National Fatality Review Case Reporting System: Twenty Years of Data Collection.

The National Fatality Review Case Reporting System (NFR-CRS) is a web-based data collection tool for child death review and fetal and infant mortality review teams. The NFR-CRS captures information from the multidisciplinary review, including the social and community risk factors that may have impacted the death. The NFR-CRS is a nimble data system that has evolved throughout the past 20 years. The most recent enhancements include a life stressors section focused on collecting contextual information such as racism and poverty, revised cause of death sections to better align data collected with risk factors identified in the research, and enhanced data visualizations. The NFR-CRS has improved data quality since the launch of a data quality initiative in 2015. As a result of the data quality initiative, the completeness, consistency, accuracy, and timeliness of the NFR-CRS data have improved. Limitations for the NFR-CRS include the fact that data entered are not population-based, data fields have evolved over time, and there are high percentages of missing and unknown data. Despite its limitations, the NFR-CRS remains a valuable research tool, especially when paired with other data sources.

Improving Consistency in Classifying Child Maltreatment for Sudden Unexpected Infant Deaths.

Develop guidelines for child death review teams that will improve the consistency in classifying child maltreatment (CM) and distinguish between classification of exposure to hazards and neglect for sleep-related sudden unexpected infant deaths (SUID). Sleep-related SUID (n = 25 797) were identified from the National Fatality Review-Case Reporting System between 2004 and 2018. Key variables considered when classifying CM among sleep-related SUID were identified. Logistic regression was used to assess the strength of associations and identify factors that distinguished between exposure to hazards and neglect. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. Guidelines were developed based on these findings. Among the 13 034 sleep-related SUID with CM identified, hazards in the infant sleep environment were strongly associated with classification of both exposure to hazards and neglect, as were supervisor impairment and child welfare substantiation of the death. Comparing neglect to exposure to hazards, there was no association with sleep environment hazards with ORs ranging from 0.8 to 1.3 (95% CI 0.4-3.0), but sleep-related SUID were approximately twice as likely to be classified as neglect when the supervisor was impaired (OR 2.3, 95% CI 2.0-2.7) or child welfare action was taken (OR 1.8, 95% CI 1.5-2.0). The guidelines recommend classification of exposure to hazards for sleep environment hazards with elevation to neglect if the supervisor was impaired or child welfare substantiated the death. Among sleep-related SUID, classification of exposure to hazards is based on presence of sleep environment hazards, whereas neglect is based on supervisor impairment and child welfare action.

Using Sudden Unexpected Infant Death-Case Registry Data to Drive Prevention.

Sudden unexpected infant death (SUID) is a major contributor to infant death and a persistent public health issue. After an initial decline after the 1994 "Back to Sleep" campaign, SUID numbers plateaued. Currently, ∼10 infants die suddenly and unexpectedly each day in the United States. In 2019, we established a surveillance system for SUID in Cook County, Illinois, partnering our academic medical center, the Cook County Medical Examiner's Office, and child death review to create the Cook County SUID Case Registry. Our data show that, in Cook County, including the city of Chicago, ∼1 infant dies unexpectedly during sleep every week. Of these SUID, ∼25% were because of suffocation/possible suffocation. SUID peaks at 30 to 60 days old. SUID rates are 15 times higher in non-Hispanic Black infants and 3 times higher in Hispanic infants, compared with white infants. Nearly all involved 1 or more unsafe sleep factors. SUID are concentrated in community areas experiencing high hardship. Through our Community Partnership Approaches for Safe Sleep-Chicago team, we have developed collaborative prevention approaches in affected communities, allowing for conversations with families and those who support them to better understand barriers to safe sleep that they experience. These partnerships and our data allow for tailoring of informed prevention approaches to address upstream factors driving disproportionate infant mortality in historically disinvested communities, as well as optimizing the immediate risks posed by the infant sleep environment. Data from our system show the number of SUID declining modestly since our prevention work began.

Understanding Natural Disaster or Weather-Related Drowning Deaths Among Children.

Drowning is the leading cause of death during flood disasters. Little is known about these deaths. Child death review teams review details of child deaths to understand circumstances and risk factors to inform prevention. Using data entered in 2005 to 2021 for children ages 0 to 17 years from the National Fatality Review-Case Reporting System, we identified 130 drowning deaths directly attributed to natural disaster or weather incidents, and 14 deaths indirectly attributed to these incidents. Frequencies, proportions, and χ2 statistics were used to describe selected measures and compare with other drowning deaths. Children who drowned as a direct result of a natural disaster- or weather-related incident were more likely to be aged >4 years (81% vs 40%, P < .001) and located in a rural or frontier setting (63% vs 30%, P < .001). They were more likely to be supervised at the time of the incident (61% vs 38%, P < .001), and it was more likely for additional children (35% vs 5%, P < .001) or adults (33% vs 3%, P < .001) to have perished. The indirect deaths were commonly a result of damage to protective barriers. The characteristics of natural disaster- or weather-related drowning deaths among children differ from other drowning deaths. Natural disaster- or weather-related drowning may warrant tailored drowning prevention strategies. Improved surveillance of all water-related deaths may be a proactive action leading to the development of these prevention strategies, whereas poststorm remediation of protective barriers can be used as a reactive prevention after a storm has passed.

Characteristics and Circumstances of Suicide Among Children Aged 6 to 9 Years: 2006-2021.

Limited research exists on suicide among children aged 5 to 9 years. The objective of this study was to examine characteristics of suicide in children younger than 10 years. Data are from the National Fatality Review-Case Reporting System (NFR-CRS) for years 2006 through 2021 for children aged 6 to 9 years who died by suicide. No suicide deaths were reported in NFR-CRS for children aged ≤ 5 years. Descriptive analyses by demographics and circumstances were conducted. A thematic analysis of prevention recommendations made by child death review teams was performed. From 2006 to 2021, NFR-CRS identified 78 suicide decedents aged 6 to 9 years. The largest share were aged 9 years (72%), male (74%), non-Hispanic Black (42%), and died by hanging (86%) at home (91%). School-related problems (39%), history of child maltreatment (36%), history of mental health services (30%), argument with parents (23%), and familial discord (19%) were common circumstances. Key suicide prevention themes included education for caregivers and school staff, improved behavioral health services, and implementation of school policies and programs. Results provide a more complete picture of suicide among younger children, improving understanding of their unique characteristics. It is recommended that program planners consider both age-appropriateness and the impacts of social (eg, racism) and structural inequities in their approaches to prevention, encompassing both community and school-based strategies. For pediatricians, results emphasize the importance of lethal means counseling, safety planning, and educating parents and caregivers on the distinct warning signs of suicide for younger children.

Unexplained Infant Deaths Without Unsafe Sleep Factors: 2011 to 2020.

To describe sudden unexpected infant deaths (SUIDs) occurring in safe sleep environments and explore differences in selected characteristics. We examined SUID from 22 jurisdictions from 2011 to 2020 and classified them as unexplained, no unsafe sleep factors (U-NUSF). Data were derived from the Sudden Unexpected Infant Death and Sudden Death in the Young Case Registry, a population-based Centers for Disease Control and Prevention surveillance system built on the National Center for Fatality Review and Prevention's child death review program. SUID classified as U-NUSF included infants who were (1) awake, under supervision, and witnessed to become unresponsive or (2) found unresponsive in a safe sleep environment after sleep (unwitnessed). We calculated frequencies and percentages for demographics, birth and environmental characteristics, medical history, and death investigation findings. Most of the 117 U-NUSF SUID occurred before 4 months of age. Witnessed deaths most commonly occurred at <1 month of age (28%), whereas unwitnessed deaths most commonly occurred at ages 2 to 3 months (44%) Among all U-NUSF, 69% occurred in the infant's home (62% witnessed, 77% unwitnessed). All unwitnessed deaths occurred in a crib; most witnessed deaths occurred while being held (54%) or in a car seat traveling (18%). Most infants (84%) had no history of abuse or neglect. Abnormal autopsy findings were reported in 46% of deaths (49% witnessed, 42% unwitnessed). Characterizing these deaths is key to advancing our knowledge of SUID etiology. Our study revealed a heterogeneous group of infants, suggesting physiologic, genetic, or environmental etiologies.

Medical examiner service in children’s deaths: a survey of current practice in paediatric intensive care units in England and Wales

IntroductionA statutory system of medical examiners (ME) was introduced in England and Wales in September 2024. The next of kin will be given the opportunity to speak to the ME...

A study on awareness and perception about perinatal death auditing among health care workers in two districts of Karnataka State, India

ABSTRACT Background: To start perinatal death auditing, doctors should have good knowledge about it. Objectives: To know the awareness and perceptions of doctors about different aspects of perinatal death auditing like 1) different types of contributors; 2) high-risk approach; 3) consequences; 4) documentary requirements; and 5) existing system of mortality meeting/child death reviews. Methodology: The perinatal death auditing project was implemented in two districts of Karnataka state. As a part of the pre-intervention survey, awareness and perceptions of doctors and a few health care administrators were explored. They were requested to participate in the study. Those who consented were approached in their hospitals and interviewed. Trained medical social workers conducted the interviews. Awareness was scored from 0 to 3 with 0 being no knowledge and 3 being good knowledge. Perceptions were scored from 0 to 3 with 0 being no negative perceptions and 3 being fear of legal consequences. The responses were documented, scored, and described. Results: Though 22 doctors were eligible, only 16 consented to participate in the study. Knowledge of doctors about different contributors was inadequate. They were apprehensive about legal consequences. They knew that documentation could protect them and be useful in a court of law. They were not clear about the conduct of mortality meeting/existing system of child death reviews. Conclusion: Knowledge was inadequate. They were apprehensive about legal consequences. Training of doctors and allaying apprehensions are required for starting perinatal death auditing.

Comparing types of child fatality review in the U.S.

Child fatality review programs consist of multidisciplinary teams of professionals, agencies and community members with an interest in caring for and protecting children. While the purpose of all child fatality reviews is to conduct a comprehensive, multidisciplinary review of child fatalities to better understand how and why children die, there are distinct types of reviews in the United States that each use findings to take action to prevent other fatalities and improve the health and safety of children in different ways. Each brings a unique perspective, incorporating different stakeholders and methodologies and playing different roles in identifying patterns, gaps in services, and potential areas for improvement within the broader context of child health and safety. Three major types of review now consistently used across the U.S. include Child Death Review, Fetal Infant Mortality Review, and Citizen Review Panels. These differ in their history of development, statutory authority, financial support, nature of cases reviewed, processes, and reporting to stakeholders. This article is an introduction to the major different types of community-based death review to help practitioners understand and participate more productively in these processes to prevent further fatalities.

Understanding three approaches to reporting sudden unexpected infant death in the USA

IntroductionIn the USA each year, there are approximately 3400 sudden unexpected infant (<1 year of age) deaths (SUID) which occur without an obvious cause before an investigation. SUID includes the...

Pediatric vehicular heatstroke: An analysis of 296 cases from the National Fatality Review Case Reporting System

Objectives To explore the National Fatality Review Case Reporting System (NFR-CRS) as a new data source to (1) characterize pediatric vehicular heatstroke (PVH) deaths among children <15 years of age reviewed by Child Death Review teams, and (2) identify factors independently associated with common PVH scenarios and incident locations. Methods Data for 2005–2019 were used to characterize 296 PVH deaths. Frequencies and percentages were calculated to describe child, supervisor, and incident characteristics. Multiple logistic regression with and without imputation were carried out to identify factors associated with the two outcomes of interest: PVH scenario (left in vehicle vs. gained access) and incident place (supervisor workplace vs. other locations). Odds ratios and 95% confidence intervals (OR, 95% CI) were calculated. Results Most children had been left unattended in vehicles (N = 225, 76.0%) and 13.5% (N = 40) had gained access independently. Children were most often male (N = 168, 56.8%), non-Hispanic White (N = 131, 44.3%), and <2 years of age (N = 172, 58.1%). Disability or chronic illness was noted for 4.7% (N = 14), 13.9% (N = 41) had a history of maltreatment, and 6.1% (N = 18) an open CPS case at the time of incident. Children left unattended were more likely to be <2 years of age (adjusted imputed OR 26.7, CI 7.3–97.2) and less likely to have an open CPS case (0.2, 0.0–0.4) and for the incident to occur at home (0.2, 0.1–0.9) compared to children who gained access. PVH deaths occurring at the supervisor’s workplace were more likely to be <2 years of age (6.2, 2.4–15.8), to have occurred on a weekday (5.9, 1.7–20.9), and to have been supervised by their parent at the incident time (2.7, 1.1–6.7) compared to other locations. Conclusions The results align with previous PVH findings and added new information on child race/ethnicity, CPS action, disability/chronic illness, and maltreatment. With the exception of parents being more likely to be the supervisor in incidents occurring at home, which was expected, neither supervisor characteristics nor child race/ethnicity or sex were independently significant in multiple regression, suggesting that PVH is pervasive and that education campaigns should be similarly broad.

Utility of Expert Panel to Identify Preventable Perinatal Deaths: Results from Audit Based Interventional Study in Two Districts of Karnataka State, India

Background: India has child death review which misses the information from private hospitals and community. Community based perinatal death auditing is required to identify preventable perinatal deaths. The objectives are to know utility of expert panel in an audit-based approach to identify 1). preventable perinatal deaths, 2) Risk factors in cases of perinatal deaths Methodology: Perinatal death auditing was conducted in two districts of Karnataka state. As a part of audit system, an expert panel consisting of paediatricians and obstetricians was formed for each district. The panel met every month and received information about perinatal deaths occurring in the hospitals (government and private) apart from the community in these districts. The panel considered available information about survival chances and care provided to decide if a perinatal death was preventable, possibly preventable or not preventable. Results: Proportion Of identified preventable and possibly preventable perinatal deaths in Koppal District (60%, 20%) was higher than Dakshina Kannada district (34.4%, 30.2%). The proportion preventable intranatal and neonatal risks in Koppal District (79%, 66%) was higher than Dakshina Kannada District (47%, 19%). Conclusion: Expert panel is useful to identify preventable perinatal deaths. The pattern of risk identified has implications for improvements in quality of care provided to high-risk cases.

Characteristics of Fatal Poisonings Among Infants and Young Children in the United States.

Fatal poisoning is a preventable cause of death among young children. Understanding factors surrounding these deaths will inform future prevention efforts. Our objective was to describe the characteristics of fatal pediatric poisonings using child death review data. We acquired data from 40 states participating in the National Fatality Review-Case Reporting System on deaths attributed to poisonings among children aged ≤5 years from 2005 to 2018. We analyzed select demographic, supervisor, death investigation, and substance-related variables using descriptive statistics. During the study period, 731 poisoning-related fatalities were reported by child death reviews to the National Fatality Review-Case Reporting System. Over two-fifths (42.1%, 308 of 731) occurred among infants aged <1 year, and most fatalities (65.1%, 444 of 682) occurred in the child's home. One-sixth of children (97 of 581) had an open child protective services case at time of death. Nearly one-third (32.2%, 203 of 631) of children were supervised by an individual other than the biological parent. Opioids (47.3%, 346 of 731) were the most common substance contributing to death, followed by over-the-counter pain, cold, and allergy medications (14.8%, 108 of 731). Opioids accounted for 24.1% (7 of 29) of the substances contributing to deaths in 2005 compared with 52.2% (24 of 46) in 2018. Opioids were the most common substances contributing to fatal poisonings among young children. Over-the-counter medications continue to account for pediatric fatalities even after regulatory changes. These data highlight the importance of tailored prevention measures to further reduce fatal child poisonings.

Medical records as screening tools for child death review in Japan.

Although many child death review (CDR) systems have been developed in Japan, the optimal system is still being identified. The aim of this study is to identify the etiologies of child deaths and to propose a screening method for initiating the CDR process in Japan. Clinical medical records (CMRs) in hospitals and autopsy records were surveyed for cases of deaths of children aged less than 15 years between 2014 and 2016 in Aichi Prefecture, Japan. The data were analyzed in three steps, and the findings were compared with the vital statistics. Of the 695 children whose death certificates were submitted to Aichi Prefecture, 590 could be traced to pediatric care hospitals. The distribution of causes of death was slightly different from the vital statistics, with 11.5% dying of extrinsic causes and 19.7% dying of unknown causes. Maltreatment was suspected in 64 cases, which was much higher than that in government statistics. Overall, 158 (26.8%) deaths were considered preventable. The number of unnatural deaths, which might be screened in, was calculated as 172 (29.2%) in the vital statistics, whereas the survey of CMRs revealed that 241 (40.8%) to 282 (47.8%) should be screened in. Surveying CMRs in hospitals may be a suitable method to detect and screen deaths to start the CDR process in Japan.

Barriers, facilitators, and implementation strategies for the initiation of Child Death Review system in Japan: a modified Delphi method study

Background:To further curb preventable child deaths, some countries have implemented Child Death Review (CDR). CDR is a comprehensive multidisciplinary process that investigates, reviews, and registers all child deaths to consider prevention strategies. This study deciphered the barriers, facilitators, and implementation strategies in Japan.Methods:This study used a three-round modified Delphi method. The expert panel consisted of local government officers and health professionals responsible for the CDR pilot project in Japan. As a modification, the initial list of barriers, facilitators, and implementation strategies to address each barrier and facilitator was prepared based on project reports and interviews with local government officers. Throughout the three rounds, the panel evaluated predefined barriers and facilitators, suggested and evaluated additional items, and appraised the potential effectiveness of the implementation strategies on barriers and facilitators which they were meant to address. The importance of barriers and facilitators, and the potential effectiveness of implementation strategies were evaluated using 5-point Likert scale. The priority of the combinations of barriers, facilitators, and implementation strategies were determined considering their importance and effectiveness.Results:A total of 31 experts participated in the panel. Response rates were 96.8%, 80.6%, and 90.3% for the first, second, and third rounds, respectively. A total of 13 barriers, eight facilitators, and 72 implementation strategies corresponding to the barriers and facilitators reached consensus. At the national government level, a barrier-strategy combination of “lack of legislation (barrier)” and “legislation for CDR (strategy),” and a facilitator-strategy combination of “good multi-agency collaboration (facilitator)” and “official notices from the national government (strategy)” were at the highest priority. At the local government level, combinations of “lack of legislation (barrier)” and “constant budget allocations (strategy),” “lack of legislation (barrier)” and “citizens’ acceptance (strategy),” and “good multi-agency collaboration (facilitator)” and “appointment of a full-time staff (strategy)” were at the highest priority.Conclusion:This study demonstrated that legislation is the key to better implementation of CDR in Japan. Legislation can address various barriers such as personal information collection, multi-agency collaboration, high workload, and budget instability. Without legislation, careful strategies must be taken to solve difficulties caused by its absence.Trial registrations:None.

Availability of death review of children using death certificates and forensic autopsy results

The Model Project for Child Death Review (CDR) was initiated in Japan, but parental consent is required for detailed investigations. We proposed an alternative method to review child deaths using death certificates and forensic autopsy results when parental consent is not provided. We extracted and reviewed death certificates for the deceased younger than 18 years from among all certificates submitted in Shiga Prefecture between 2015 and 2017. In addition, we analyzed autopsy records in cases that underwent forensic autopsy. The prevalence of each cause of death was compared among age groups. The situation and circumstances of unnatural deaths were analyzed in detail. Of 131 certificates, unnatural deaths accounted for 29.7 %. The prevalence of each cause of death significantly differed among age groups. Malignant disease and suicide were most common in school-aged children and congenital disease was most common in infants. Suicide was the leading cause of unnatural death, followed by suffocation, which was most common in infants. Situations where suffocation was reported included co-sleeping with the mother and breastfeeding. Despite parental consent not being obtained, the trends of regional child deaths and the circumstances of accidental deaths were clarified by the present method. However, the results of detailed investigation were lacking. This study provided basic information for implementing detailed methods and procedures for CDR at the governmental level. To perform optimal CDR, legislation for collecting detailed information without parental consent is required.

The Need for Improved Collaboration between Schools and Child Death Review Teams.

Schools are essential public health partners for safeguarding students' health. Child Death Review (CDR) is one public health activity where collaboration with schools is integral for developing strategies to prevent child death but the degree of collaboration is unknown. This study assessed school participation in CDR and the prevalence of school problems in reviewed child death cases, comparing non-suicide and suicide-related deaths. Using the National Fatality Review-Case Reporting System, we created a dataset of school-aged children (5 to 20 years) whose death was reviewed from 2005 to 2017 and used frequencies, proportions, and chi-squared statistics on selected measures. Educational representatives infrequently participated in CDRs (24.9%). School records were rarely accessed for reviewed deaths (5.2%). Less than half (41.2%) of reviewed deaths had any school information and of these, 35.5% of children were indicated as having problems in school. Compared with non-suicide deaths, a larger proportion of suicide deaths had school representatives attend CDRs (28.4% vs 24.1%, P < .0001), and access to educational records (4.2% vs 9.2%, P < .0001). Efforts are needed to address potential barriers to systems integration, including state policies and federal educational privacy laws. School participation in CDRs is lacking for both suicide and non-suicide deaths.