Investigation
and
on Child
Committee
Review
Abuse
and
of Unexpected
Neglect
and
A significant
proportion
of infant and child deaths
are preventable.
Of the 55 861 deaths
of children
aged 14 and younger
in the United
States in 1989,
more than three fourths
occurred
in children
under
the age of 2 years.1 Approximately
one third of the
latter
were
unexpected,
including
those due to sudden infant
death
syndrome
(SIDS)
or trauma,
or
deaths
that were otherwise
unexplained.
Child abuse
deaths occur in greatest
numbers
among
infants, followed by those in toddlers
and preschool
children.2
Children
younger
than
6 years
of age
are
most
vul-
nerable
to abuse because
of their small size, incomplete verbal
skills,
and often
limited
contact
with
adults other than their primary
caretakers.3
With few exceptions,
throughout
the United
States
there
is no uniform
system
for the investigation
of
infant
and child deaths.
Many jurisdictions
lack appropriately
trained pathologists,
interagency
collaboration
that would
facilitate
sharing
of information
about the family, and a survefflance
system
to evaluate data regarding
infant deaths. As a result, progress
in the understanding
of SIDS is inhibited,
cases of
child abuse
and neglect
may be missed,
familial
genetic diseases
go undiagnosed,
public health threats
may be unrecognized,
and inadequate
medical
care
may be undetected.
Lack of adequate
infant
and
child death
investigation
is an impediment
to preventing
ifiness,
injury
and death of other children
at
risk.
Adequate
pation
death
of numerous
examiner’coroner,
investigation
requires
individuals
public
health
including
officials,
the
partici-
medical
the
pa-
tient’s physician,
the pathologist,
and personnel
from
agencies
involved
with child welfare
and social services and law enforcement.
Collaboration
between
agencies
enhances
the ability to determine
accurately
the cause and circumstances
of death.
Information
about the death of one child may lead to preventive
strategies
to protect
the life of another.
ADEQUATE
DEATH
INVESTIGATION
An adequate
death investigation
indudes
a complete autopsy,
investigation
of the circumstances
of
death, review
of the child’s medical
and family
history, and review
of information
from relevant
agencies and health care providers.
A complete
autopsy
consists
of an external
and internal
examination
of
the body, microscopic
examination,
and toxicologic,
statement has been approved by the Council
on Child and Adolescent
Health and the Council
on Pediatric
Practice.
The recommendations
in this policy statement
do not indicate an exdusive
course
of treatment
or serve as a standard
of medical care. Variations,
taking
into account individual
circumstances,
may be appropriate.
This
734
PEDIATRICS
Infant
Committee
and
Child
on Community
Deaths
Health
Services
microbiologic,
and other appropriate
studies.
When
possible,
the autopsy
should
be performed
by a forensic and/or
pediatric
pathologist,
using
a standard
infant and child death autopsy
protocol.4
Investigation of the circumstances
of death should
include
a
scene
investigation
and interview
with
caretakers
and responders
by trained
death
investigators
who
are sensitive
to issues of family grief. By current national
standards,
the diagnosis
of SIDS cannot
be
made without
a complete
autopsy
with appropriate
ancillary
studies
and scene investigation.5
Interagency
cooperation
and review
of all relevant
records
are necessary
parts of a death investigation.
Relevant
records
include,
but are not limited
to, all
medical
records including
those from birth on, social
services
tective
and
including
reports
those
Services,
emergency
and
law enforcement
reports.
INFANT
AND
CHILD
Thorough
retrospective
one approach
to ensure
tion. A centralized
data
functioning
of infant
would
allow
for the
deaths.
Several
models
operational
at both
state
from Children’s
Proparamedic
records,
DEATH
REVIEW
review
of child deaths
is
quality
in death investigabase could aid in the proper
and child death
review
and
identification
of preventable
have been established
and are
and
local
levels.6
The
Ameri-
can Academy
of Pediatrics
(AAP) also has developed
a model bifi on child death investigation.
Infant and
child death review requires
the participation
of many
agencies.
An appropriately
constituted
child death
review
team should
evaluate
the death investigation
process,
reexamine
difficult
or controversial
cases,
and monitor
death statistics
and certificates.
Benefits
of such death review
include
(1) quality
assurance
of
death investigation
at locallevels,
(2) identification
of
barriers
to death
investigation,
(3) enhanced
interagency
cooperation,
(4) improved
allocation
of limited resources,
(5) enhanced
awareness
and education on the management
and prevention
of infant
and child death, (6) better epidemiologic
data on the
causes of death,
and (7) improved
accuracy
of death
certificates.
RECOMMENDATIONS
Recommendations
gation are as follows:
regarding
child
death
investi-
1. Pediatricians
should
advocate
proper death certification
for children,
recognizing
that such certification
is not
possible
in sudden,
unexpected
deaths
in the absence
of comprehensive
death investigation
including
autopsy.
Vol. 92 No. 5 November
1993 from by guest on July 31, 2017
Downloaded
2. Pediatricians
and AAP chapters
should
support
state
legislation
that requires
autopsies
of all
deaths
of children
younger
than 6 years that result
from trauma;
that are unexpected,
including
SIDS;
and that are suspicious,
obscure,
or otherwise
unexplained.
It should
never be assumed
that the
death of a child with a chronic
impairment
occurred
as a result
of that impairment.
3. Pediatricians
and AAP chapters
should
support
state legislation
and other
efforts
that establish
comprehensive
child death investigation
and review systems
at the local and state levels.
4. Pediatricians
should
be involved
in the training
of
death
scene
investigators
so that
appropriate
knowledge
of issues
such as SIDS, child abuse,
child development,
and pediatric
disease
is used
in the determination
of cause of death.
5. Pediatricians
should
accept
the responsibffity
to
be involved
with the death review
process.
6. The AAP supports
public
policy
initiatives
directed at preventing
childhood
deaths,
based on
information
acquired
both locally
and at the state
level from adequate
death investigations,
accurate
death certifications,
and systematic
death reviews.
Cortturr
ON CimD
ABUSE
AND
1993
NEGLECT,
TO
Liaison
Representatives
B. Benoit, MD, American
Academy
of
Child and Adolescent
Psychiatry
Kenneth
E. Powell, MD, MPH, Centers for Disease
Control
Marilyn
D. Rosman,
PhD,
American
Medical
Association
Section
Robert
Co&nmii
1994
Liaison
H. Kirschner,
ON
Coiiirin-v
MD, Section
HEALTH
on Pathology
SERVICES,
1993
Rudolph
E. Jackson,
Alan Kohrt, MD
Arthur
Lisbin, MD
ro
MD
Carolyn J. McKay, MD
Philip F. Merk, MD
R. Larry Meuli, MD
Donna O’Hare, MD
Michael
Weitzman,
MD
Harry L. Wilson, MD
Liaison
Representatives
Janet S. Schultz,
RN, National
Nurses
& Practitioners
Assoc
of Pediatric
Anne E. Dyson, MD, AAP Partnership
for
Children
Jennie McLaurin,
MD, Migrant
Clinicians
Network
Paul Melinkovich,
MD, Project Advisory
Committee
on Community-Based
Programs
Yvonne Russell, MD
Bruce E. Schratz,
MD, American
Academy
of
Family Physicians
James F. Steiner, DDS, American
Academy
of
Pediatric
Dentistry
REFERENCES
1994
Richard D. Krugman,
MD, Chair
Judith Ann Bays, MD
David L. Chadwick,
MD
Mireffle
B. Kanda,
MD
Carolyn J. Levitt, MD
Margaret
T. McHugh,
MD, MPH
Marshall
Renee Jenkins, MD, Chair
Stanley I. Fisch, MD
1. Centers
for Disease
Control/National
Center
for Health
Statistics.
Advance report of final mortality
statistics,
1989. Monthly
Vital Statistics
Report. January
7, 1992;40(S):2
2. Ewigman
B, Kivlahan
C, Land G. The MISSOUrI
child fatality study:
underreporting
of maltreatment
fatalities among children
younger than
5 years of age, 1983 through
1986. Pediatrics.
1993:91:330-337
3. MCC1ain
PW, Sacks JJ, Froehike
RG, Ewigman
BG. Estimates
of fatal
child abuse and neglect, United States, 1979 through
1988.
Pediatrics.
1993:91:338-343
4. Task Force for the Study of Non-Accidental
Injuries and Child Deaths
convened by the illinois Dept of Children
and Family
Services and the
Office of the Medical
Examiner-Cook
County.
Protocol for Child Death
Autopsies.
Chicago, IL: illinois Dept of Children
and Family Services;
1987
5. Willinger
M, James LS, Catz C. Defining
the sudden infant death syndrome
(SIDS): deliberations
of an expert panel convened
by the National Institute
of Child Health and Human
Development.
Pediatr
Pathol. 1991;11:677-684
6. Durfee MJ, Gellert
GA, Tilton-Durfee
D. Origins and clinical relevance
of child death review teams. JAMA.
1992267:3172-3175
Downloaded from by guest on July
31, 2017
AMERICAN
ACADEMY
OF PEDIATRICS
735
Investigation and Review of Unexpected Infant and Child Deaths
Pediatrics 1993;92;734
Updated Information &
Services
including high resolution figures, can be found at:
/content/92/5/734
Citations
This article has been cited by 2 HighWire-hosted articles:
/content/92/5/734#related-urls
Permissions & Licensing
Information about reproducing this article in parts (figures, tables)
or in its entirety can be found online at:
/site/misc/Permissions.xhtml
Reprints
Information about ordering reprints can be found online:
/site/misc/reprints.xhtml
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright © 1993 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.
Downloaded from by guest on July 31, 2017
Investigation and Review of Unexpected Infant and Child Deaths
Pediatrics 1993;92;734
The online version of this article, along with updated information and services, is located on
the World Wide Web at:
/content/92/5/734
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright © 1993 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from by guest on July 31, 2017