Child Death Review Research Articles

Child Death Review: Past, Present, and Future.

This article describes the current state of child death reviews (CDR) in the United States. The CDR process has evolved over almost 40 years from informal local meetings to a coordinated effort involving all 50 states. Child death review programs across the country vary in the level of financial and administrative support, legislation, and review processes. While there is still a long way to go in standardizing the practice between states, great strides have been made in data collection, education, and prevention initiatives.

Unintentional non-traffic injury and fatal events: Threats to children in and around vehicles

ABSTRACTObjective: There have been substantial reductions in motor vehicle crash–related child fatalities due to advances in legislation, public safety campaigns, and engineering. Less is known about non-traffic injuries and fatalities to children in and around motor vehicles. The objective of this study was to describe the frequency of various non-traffic incidents, injuries, and fatalities to children using a unique surveillance system and database.Methods: Instances of non-traffic injuries and fatalities in the United States to children 0–14 years were tracked from January 1990 to December 2014 using a compilation of sources including media reports, individual accounts from families of affected children, medical examiner reports, police reports, child death review teams, coroner reports, medical professionals, legal professionals, and other various modes of publication.Results: Over the 25-year period, there were at least 11,759 events resulting in 3,396 deaths. The median age of the affected child was 3.7 years. The incident types included 3,115 children unattended in hot vehicles resulting in 729 deaths, 2,251 backovers resulting in 1,232 deaths, 1,439 frontovers resulting in 692 deaths, 777 vehicles knocked into motion resulting in 227 deaths, 415 underage drivers resulting in 203 deaths, 172 power window incidents resulting in 61 deaths, 134 falls resulting in 54 deaths, 79 fires resulting in 41 deaths, and 3,377 other incidents resulting in 157 deaths.Conclusions: Non-traffic injuries and fatalities present an important threat to the safety and lives of very young children. Future efforts should consider complementary surveillance mechanisms to systematically and comprehensively capture all non-traffic incidents. Continued education, engineering modifications, advocacy, and legislation can help continue to prevent these incidents and must be incorporated in overall child vehicle safety initiatives.

An exploratory analysis of the notable activities of U.S. child death review teams

ABSTRACTChild death review teams (CDRTs) focus on the prevention of child deaths, but a comprehensive understanding of their activities is lacking. This exploratory study addressed this gap through a qualitative analysis of reported CDRT activities using the “spectrum of prevention” framework. We collected state-level CDRT reports published 2006–2015, recorded their activities (n = 193), and coded them using the “spectrum of prevention” framework. The highest percentage (64.2%) of activities was categorized under “fostering coalitions and networks.” We recommend that CDRTs increase their reporting of activities so others can better understand their potential impact on preventing child deaths.

Procedures in child deaths in The Netherlands: a comparison with child death review

AimChild Death Review (CDR) is a method in which every child death is systematically and multidisciplinary examined to (1) improve death statistics, (2) identify factors that give direction for prevention, (3) translate the results into possible interventions, and (4) support families. The aim of this study was to determine to what extent procedures of organizations involved in the (health) care for children in The Netherlands cover these four objectives of CDR.Subject and methodsOrganizations in the Eastern part of The Netherlands and Dutch umbrella organizations involved in child (health) care were asked to provide their protocols, guidelines or other working agreements that describe their activities and responsibilities in case of a child’s death. Eighteen documents and nine interview reports were made available. For the analyses we used scorecards for each CDR objective.ResultsThe procedures of Perined, the National Cot Death Study Group, Dutch Cot Death Foundation and Child Protection Service cover the largest part of the objectives of CDR. Organizations pay most attention to the translation of results into possible interventions. Family support gets the least attention in protocols, guidelines and other working agreements.ConclusionDutch organizations separately cover parts of CDR. When the procedures of organizations are combined, all CDR objectives are covered in the response to only specific groups of child deaths, i.e., perinatal deaths, Sudden Unexpected Deaths in Infants and fatal child abuse cases. Further research into the conditions that are needed for an optimal implementation of CDR in The Netherlands is necessary. This research should also evaluate the recently implemented NODOK procedure (Further Examination of the Causes of death in Children), directed to investigate unexplained deaths in minors 0–18 years old.

The Interface Among Poverty, Air Mattress Industry Trends, Policy, and Infant Safety.

Infants can suffocate on air mattresses, even when the mattress is fully inflated. The interfacing issues of poverty, the bedbug epidemic, and changes in the design and marketing of air mattresses may be increasing consumer use of air mattresses as primary sleep environments and thus increasing the potential for infant death. Despite recent changes to improve air mattress safety labeling, the National Child Death Review Case Reporting System found that between 2004 and 2015 across 24 states, an air mattress was the incident sleep place for 108 infants whose deaths were either during sleep or in a sleep environment. At the same time, design components such as inflatable headboards and memory foam pillow tops potentially increase the hazard to infants, and marketing changes represent air mattresses as a preferred low-cost primary sleep environment. Analysis of current data surveillance systems, published position statements, and consumer materials from national organizations and federal agencies reveal opportunities for changing policy to better protect infants from this hazard.

Classification of maltreatment-related mortality by Child Death Review teams: How reliable are they?

Accurate estimation of the incidence of maltreatment-related child mortality depends on reliable child fatality review. We examined the inter-rater reliability of maltreatment designation for two Alaskan Child Death Review (CDR) panels. Two different multidisciplinary CDR panels each reviewed a series of 101 infant and child deaths (ages 0–4 years) in Alaska. Both panels independently reviewed identical medical, autopsy, law enforcement, child welfare, and administrative records for each death utilizing the same maltreatment criteria. Percent agreement for maltreatment was 64.7% with a weighted Kappa of 0.61 (95% CI 0.51, 0.70). Across maltreatment subtypes, agreement was highest for abuse (69.3%) and lowest for negligence (60.4%). Discordance was higher if the mother was unmarried or a smoker, if residence was rural, or if there was a family history of child protective services report(s). Incidence estimates did not depend on which panel's data were used. There is substantial room for improvement in the reliability of CDR panel assessment of maltreatment related mortality. Standardized decision guidance for CDR panels may improve the reliability of their data.

Injury Prevention and State Law as Strategies for the Reduction of Child Maltreatment Fatalities

This review focuses on one state’s multidisciplinary legislative efforts to decrease the incidence of child maltreatment, including fatalities and near-fatalities. Such efforts have encompassed primary and secondary prevention modalities, including early support to parents, training, and education about recognition and reporting of child maltreatment for professionals who interact with children, review of all child deaths, and multidisciplinary in-depth case review of the most serious child maltreatment cases. Although reliable trends can be difficult to determine based upon the complexity of the problem and multiple confounding variables, there are a number of indicators that suggest these cumulative efforts are beginning to have a favorable impact on the most serious child maltreatment cases, although heightened awareness has likely contributed to an increase in the total number of reported cases. Multidisciplinary collaborative efforts including governmental, academic, and non-profit entities may affect meaningful change in legislation and other interventions to decrease the incidence of the most serious cases of child maltreatment.

The Sudden Death in the Young Case Registry: Collaborating to Understand and Reduce Mortality.

Knowledge gaps persist about the incidence of and risk factors for sudden death in the young (SDY). The SDY Case Registry is a collaborative effort between the National Institutes of Health, the Centers for Disease Control and Prevention, and the Michigan Public Health Institute. Its goals are to: (1) describe the incidence of SDY in the United States by using population-based surveillance; (2) compile data from SDY cases to create a resource of information and DNA samples for research; (3) encourage standardized approaches to investigation, autopsy, and categorization of SDY cases; (4) develop partnerships between local, state, and federal stakeholders toward a common goal of understanding and preventing SDY; and (5) support families who have lost loved ones to SDY by providing resources on bereavement and medical evaluation of surviving family members. Built on existing Child Death Review programs and as an expansion of the Sudden Unexpected Infant Death Case Registry, the SDY Case Registry achieves its goals by identifying SDY cases, providing guidance to medical examiners/coroners in conducting comprehensive autopsies, evaluating cases through child death review and an advanced review by clinical specialists, and classifying cases according to a standardized algorithm. The SDY Case Registry also includes a process to obtain informed consent from next-of-kin to save DNA for research, banking, and, in some cases, diagnostic genetic testing. The SDY Case Registry will provide valuable incidence data and will enhance understanding of the characteristics of SDY cases to inform the development of targeted prevention efforts.

Rigour and Rapport: a qualitative study of parents\u2019 and professionals\u2019 experiences of joint agency infant death investigation

BackgroundIn many countries there are now detailed Child Death Review (CDR) processes following unexpected child deaths. CDR can lead to a fuller understanding of the causes for each child’s death but this potentially intrusive process may increase the distress of bereaved families. In England, a joint agency approach (JAA) is used where police, healthcare and social services investigate sudden child deaths together and a key part of this is the joint home visit (JHV) where specialist police and paediatricians visit the home with the parents to view the scene of death. This study aimed to learn of bereaved parents’ experiences of JAA investigation following Sudden Unexpected Death in Infancy (SUDI).MethodsThis was a qualitative study of joint agency investigation of SUDI by specialist police, healthcare and social services including case note analysis, parental questionnaires, and in-depth interviews with parents and professionals. Families were recruited at the conclusion of the JAA. Data were analysed using a Framework Approach.Results21/113 eligible families and 26 professionals participated giving theoretical saturation of data. There was an inherent conflict for professionals trying to both investigate deaths thoroughly as well as support families. Bereaved parents appreciated the JAA especially for the information it provided about the cause of death but were frustrated with long delays waiting to obtain this. Many parents wanted more emotional support to be routinely provided. Most parents found the JHV helpful but a small minority of mothers found this intensely distressing. In comparison to JHVs, when police visited death scenes without paediatricians, information was missed and parents found these visits more upsetting. There were issues with uniformed non-specialist police traumatising parents by starting criminal investigations and preventing parents from accessing their home or collecting vital possessions.ConclusionsOverall most parents feel supported by professionals during the JAA; however there is scope for improvement. Paediatricians should ensure that parents are kept updated with the progress of the investigations. Some parents require more emotional support and professionals should assist them in accessing this.

Developing an understanding of fatal child abuse and neglect: Results from the South African child death review pilot study

Fatal child abuse is the severest consequence of violence against children. Yet, little is known about this phenomenon, as routine data do not describe it. Child death review (CDR) teams have been established to systematically review deaths from birth to adolescence as a public health response to better identify child abuse deaths, to develop policy and to improve the child protection response. This article describes the incidence of fatal child abuse and injury patterns associated with such deaths. CDR teams reviewed all child fatalities from 1 January to 31 December 2014 at two pilot sites in South Africa (SA). Data were collected on demographics, causes and circumstances of the death, and family social context. We assessed the feasibility of CDR teams in the SA setting to strengthen the identification of child abuse deaths and influence practice. A total of 707 cases were reviewed. Over half (52.4%) of the deaths were due to natural causes. A third were caused by murder, with nearly half (44%) of all murders attributed to fatal child abuse. The burden of fatal child abuse and neglect was found among the <1-year age group. Abandonment at birth was most common, followed by blunt force injuries and strangulation/asphyxiation deaths. CDR teams are effective in better identifying deaths due to child abuse and neglect via a multidisciplinary approach and regular case reviews.

Developing an understanding of fatal child abuse and neglect: Results from the South African child death review pilot study

Fatal child abuse is the severest consequence of violence against children. Yet, little is known about this phenomenon, as routine data do not describe it. Child death review (CDR) teams have been established to systematically review deaths from birth to adolescence as a public health response to better identify child abuse deaths, to develop policy and to improve the child protection response. This article describes the incidence of fatal child abuse and injury patterns associated with such deaths. CDR teams reviewed all child fatalities from 1 January to 31 December 2014 at two pilot sites in South Africa (SA). Data were collected on demographics, causes and circumstances of the death, and family social context. We assessed the feasibility of CDR teams in the SA setting to strengthen the identification of child abuse deaths and influence practice. A total of 707 cases were reviewed. Over half (52.4%) of the deaths were due to natural causes. A third were caused by murder, with nearly half (44%) of all murders attributed to fatal child abuse. The burden of fatal child abuse and neglect was found among the <1-year age group. Abandonment at birth was most common, followed by blunt force injuries and strangulation/asphyxiation deaths. CDR teams are effective in better identifying deaths due to child abuse and neglect via a multidisciplinary approach and regular case reviews.

Developing an understanding of fatal child abuse and neglect: Results from the South African child death review pilot study

Developing an understanding of fatal child abuse and neglect: Results from the South African child death review pilot study

Unintentional asphyxia, SIDS, and medically explained deaths: a descriptive study of outcomes of child death review (CDR) investigations following sudden unexpected death in infancy.

A comprehensive child death review (CDR) program was introduced in England and Wales in 2008, but as yet data have only been analyzed at a local level, limiting the learning from deaths. The aim of this study is to describe the profile of causes and risk factors for sudden unexpected death in infancy (SUDI) as determined by the new CDR program. This was a descriptive outcome study using data from child death overview panel Form C for SUDI cases dying during 2010-2012 in the West Midlands region of England. The main outcome measures were: cause of death, risk factors and potential preventability of death, and determination of deaths probably due to unintentional asphyxia. Data were obtained for 65/70 (93%) SUDI cases. 20/65 (31%) deaths were initially categorized as due to medical causes; 21/65 (32%) as SIDS; and 24/65 (37%) as undetermined. Reanalysis suggested that 2/21 SIDS and 7/24 undetermined deaths were probably due to unintentional asphyxia, with 6 of these involving co-sleeping and excessive parental alcohol consumption. Deaths classified as "undetermined" had significantly higher total family and environmental risk factor scores (mean 2.6, 95% CI 2.0-3.3) compared to those classified as SIDS (mean 1.6, 95% CI 1.2-1.9), or medical causes for death (mean 1.1, 95% CI 0.8-1.3). 9/20 (47%) of medical deaths, 19/21 (90%) SIDS, and 23/24 (96%) undetermined deaths were considered to be potentially preventable. There were inadequacies in medical provision identified in 5/20 (25%) of medically explained deaths. The CDR program results in detailed information about risk factors for SUDI cases but failed to recognize deaths probably due to unintentional asphyxia. The misclassification of probable unintentional asphyxial deaths and SIDS as "undetermined deaths" is likely to limit learning from these deaths and inhibit prevention strategies. Many SUDI occurred in families with mental illness, substance misuse and chaotic lifestyles and most in unsafe sleep environments. This knowledge could be used to better target safe sleep advice for vulnerable families and prevent SUDI in the future.

Child deaths in South Africa: Lessons from the child death review pilot.

South Africa (SA) has not met the child mortality target for the Millennium Development Goals, despite having invested substantially in programmes and policies to achieve these targets. The scale-up of the prevention of mother-to-child transmission programmes reduced HIV transmission from mother to child, but this has not been sustained owing to limitations in community-based child health services.Child mortality has declined, but has now plateaued.Children continue to die from preventable and treatable causes of death.Current data sources are incomplete, and do not provide information on deaths occurring out of health facilities.The child death review (CDR) pilot explores the pattern of child deaths and informs prevention strategies to improve child survival in SA. In this editorial we draw on the conclusions of the CDR pilot,where multiagency teams were established to investigate non-natural and unexpected deaths referred to two mortuary sites in order to strengthen child health and protection response systems and to prevent child deaths.

The South African child death review pilot: A multiagency approach to strengthen healthcare and protection for children.

Child mortality trends in South Africa (SA) show a decrease, but remain high and appear to have plateaued. To attain the new sustainable development goals, we need a better understanding of causes of death and the associated factors. To describe the SA child death review (CDR) pilot, the pattern of child deaths reviewed and the factors associated with these deaths. CDR teams were established at two pilot sites, Salt River mortuary (Western Cape Province) and Phoenix mortuary (KwaZulu-Natal Province). All child deaths were reviewed by a multidisciplinary team at the pilot sites for the period 1 January 2014 - 31 December 2014. The CDR pilot reviewed 711 cases. Over half (53.3%) were natural deaths, as opposed to 42.6% non-natural deaths. Most infant deaths (83.9%) were due to natural causes, while 91.7% of deaths in the 15 - 17-year-old age group were due to injuries. The leading cause of deaths reviewed (30.8%) was respiratory tract infection (RTI), mainly among infants (51.6%). Homicide was the second most common cause of death and affected children of all ages, with the highest burden (52.8%) in the 15 - 17-year age group. Child abuse and neglect accounted for 11.3% of deaths. RTI was shown to be more likely after the neonatal period (odds ratio (OR) 2.92; p&lt;0.000) and in preterm infants (OR 1.98; p=0.005). CDR teams have been effective in improving identification of the causes of out-of-hospital deaths, as well as by identifying remediable factors critical to reducing child deaths further.

Implementation of Child Death Review in the Netherlands: results of a pilot study.

BackgroundChild mortality in the Netherlands declined gradually in the past decades. In total 1130 children and youth aged 0 to 19 years died in 2014 (i.e. 29.4 per 100,000 live births). A better understanding of the background and the circumstances surrounding the death of children as well as the manner and cause of death may lead to preventive measures. Child Death Review (CDR) is a method to systematically analyze child deaths by a multidisciplinary team to identify avoidable factors that may have contributed to the death and to give directions for prevention. CDR could be an addition to further reduce avoidable child deaths in the Netherlands. The purpose of this study is to explore the strengths, weaknesses, opportunities and threats (SWOT) of the pilot-implementation of CDR in a Dutch region. The results are translated in recommendations for future implementation of the CDR method in the Netherlands.MethodsChildren who lived in the pilot region and died aged 29 days after birth until 2 years were, after parental consent, included for reviewing by a regional CDR team. Eighteen logs and seven transcribed records of CDR meetings concerning 6 deceased children were analyzed using Atlas ti. The SWOT framework was used to identify important themes.ResultsThe most important strengths identified were the expertise of and cooperation within the CDR team and the available materials. An important weakness was the poor cooperation of some professional groups. The fact that parents and professionals endorse the objective of CDR was an important opportunity. The lack of statutory basis was a threat.ConclusionsMany obstacles need to be taken away before large-scale implementation of CDR in the Netherlands becomes possible. The most important precondition for implementation is the acceptance among professionals and the statutory basis of the CDR method.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1500-9) contains supplementary material, which is available to authorized users.

Death Scene Investigation and Autopsy Practices in Sudden Unexpected Infant Deaths

To describe and compare sudden unexpected infant death (SUID) investigations among states participating in the SUID Case Registry from 2010 through2012. We analyzed observational data from 770 SUID cases identified and entered into the National Child Death Review Case Reporting System. We examined data on autopsy and death scene investigation (DSI) components, including key information about the infant sleep environment. We calculated the percentage of components that were complete, incomplete, and missing/unknown. Most cases (98%) had a DSI. The DSI components most frequently reported as done were the narrative description of the circumstances (90%; range, 85%-99%), and witness interviews (88%, range, 85%-98%). Critical information about 10 infant sleep environment components was available for 85% of cases for all states combined. All 770 cases had an autopsy performed. The autopsy components most frequently reported as done were histology, microbiology, and other pathology (98%; range, 94%-100%) and toxicology (97%; range, 94%-100%). This study serves as a baseline to understand the scope of infant death investigations in selected states. Standardized and comprehensive DSI and autopsy practices across jurisdictions and states may increase knowledge about SUID etiology and also lead to an improved understanding of the cause-specific SUID risk and protective factors. Additionally, these results demonstrate practices in the field showing what is feasible in these select states. We encourage pediatricians, forensic pathologists, and other medicolegal experts to use these findings to inform system changes and improvements in DSI and autopsy practices and SUID prevention efforts.

Stakeholders' opinions on the implementation of Child Death Review in the Netherlands.

BackgroundThe death of a child is an enormous tragedy for both the family and others involved. A child’s death appeals to everyone’s responsibility to take measures to prevent similar deaths in the future. Child Death Review (CDR) is an interagency approach in which a child’s death is systematically analyzed by a multidisciplinary team. The aim of CDR is to identify avoidable factors that give direction to prevention and to improve death statistics. CDR is not yet implemented in the Netherlands. The purpose of this study is to determine Dutch stakeholders’ opinions regarding the facilitating and impeding factors in the implementation of CDR in the Netherlands.MethodsFour focus groups were conducted: three with professionals who are involved in children’s deaths and one with parents who have lost a child under the age of 2 years. The recorded discussions were transcribed and analyzed using Atlas ti. The facilitating and impeding factors were measured using the measurement instrument for determinants of innovations (MIDI). The MIDI identifies facilitating and impeding determinants associated with the innovation, user, organization and social-political context.ResultsImprovement of the quality of (health) care and obtaining a clear explanation for the child’s death (user and innovation) were identified as benefits of CDR. The emotional burden for professionals and parents and the time implications were considered to be drawbacks of CDR (user and innovation). The multidisciplinary approach (innovation), parental consent and the use of anonimyzed data (user) were considered as facilitators to implementation. Insufficient information (innovation), potential legal consequences for professionals and organizations (user), insufficient ratification by organizations (organization) and confidentiality (social-political context) were identified as impeding implementation.ConclusionsThe determinants identified as facilitating and the recommendations provided to overcome the barriers can be used as input for the strategy for implementation of CDR. A pilot study is necessary to determine to what extent the chosen implementation strategy is effective.Electronic supplementary materialThe online version of this article (doi:10.1186/s13104-016-1966-x) contains supplementary material, which is available to authorized users.

Paediatric suicide in the USA: analysis of the National Child Death Case Reporting System

ImportanceSuicide is a leading cause of death among youths. The relationship between mental health, psychosocial factors and youth suicidality needs further analysis.ObjectiveTo describe paediatric suicide in the USA and the...

Crib Bumpers Continue to Cause Infant Deaths: A Need for a New Preventive Approach

To assess whether clutter (comforters, blankets, pillows, toys) caused bumper deaths and provide an analysis of bumper-related incidents/injuries and their causal mechanisms. Bumper-related deaths (January 1, 1985, to October 31, 2012) and incidents/injuries (January 1, 1990, to October 31, 2012) were identified from the US Consumer Product Safety Commission (CPSC) databases and classified by mechanism. Statistical analyses include mean age, 95% CIs, χ(2) test for trend, and ANOVA with a paired-comparisons information-criterion post hoc test for age differences among injury mechanisms. There were 3 times more bumper deaths reported in the last 7 years than the 3 previous time periods (χ(2)(3) = 13.5, P ≤ .01). This could be attributable to increased reporting by the states, diagnostic shift, or both, or possibly a true increase in deaths. Bumpers caused 48 suffocations, 67% by a bumper alone, not clutter, and 33% by wedgings between a bumper and another object. The number of CPSC-reported deaths was compared with those from the National Center for the Review and Prevention of Child Deaths, 2008-2011; the latter reported substantially more deaths than CPSC, increasing the total to 77 deaths. Injury mechanisms showed significant differences by age (F4,120 = 3.2, P < .001) and were caused by design, construction, and quality control problems. Eleven injuries were apparent life-threatening events. The effectiveness of public health recommendations, industry voluntary standard requirements, and the benefits of crib bumper use were not supported by the data. Study limitations include an undercount of CPSC-reported deaths, lack of denominator information, and voluntary incident reports.