Objective. To investigate underascertainment of unexpected infant deaths at the national level as a result of probable classification as attributable to unknown cause.
Methods. Using linked birth and death certificates for all US birth cohorts from 1983–1991 and 1995–1996, we identified 53 470 sudden infant death syndrome (SIDS) fatalities, 9071 unintentional injury deaths, 3473 injury deaths classified with intentional or suspicious intent, and 8097 deaths with unknown underlying cause. For these deaths, we compared relative risks (RRs) for maternal and infant variables available on birth certificates known to be predictive of SIDS, unintentional injury, and homicides. Variables available on death certificates were compared for unlinked and linked records. Factors related to state and national management of cases pending final cause determination are reviewed.
Results. For deaths from unknown cause, rates were consistently high among the same risk groups that have been shown to be at increased risk for SIDS, unintentional injury, and homicides. For most risk factors, RRs for deaths attributable to unknown causes were somewhat lower than for RRs for intentional/suspicious injury deaths but higher than for SIDS or unintentional injury, indicating combined contributions from all causes. For example, age at death from unknown cause includes RRs that more strongly resemble patterns of intentional/suspicious injuries than SIDS or unintentional injury. Deaths from unknown cause were more likely to occur during the first week of life for unattended births occurring outside clinical settings or when birth certificates were not found, similar to intentional/suspicious injury deaths.
Conclusions. Risk profiles indicate that deaths of unknown cause are likely to represent a mixture of unexpected deaths. The process for determination of cause of unexpected death affects national underascertainment of SIDS and injury deaths. Better coordination among child fatality review teams and local, state, and national officials should reduce underascertainment and improve documentation of circumstances surrounding deaths for prevention efforts.
The American Academy of Pediatrics (AAP) has called for improved comprehensive death investigation of sudden, unexpected deaths to provide proper death certification for children.1 They emphasize the continuing need for careful, timely review of deaths attributable to sudden infant death syndrome (SIDS) and trauma through appropriately constituted review teams. Many states or local jurisdictions are performing in-depth multiple record reviews.2,3 State studies based on these reviews have documented underascertainment of fatal child abuse and neglect in young children as reported by medical examiners, ranging from 60% to 100%.4–6 Similar levels of underascertainment have been projected to the national level.4,7
These state studies tracked possible sources of underascertainment by reviews of vital statistics, medical examiner or coroner records, law enforcement files, and social service registries. Discrepancies among state-level data sources may include 1) inability to report, such as when there is disagreement on designating the death as a homicide; 2) failure of involved agencies to categorize or code information properly; and/or 3) inadequate gathering of case information.6 Intensified state efforts to complete these reviews have resulted in more interagency coordination and time spent on final determination of cause of death for most sudden, unexpected child fatalities. However, these efforts may have delayed reporting to state vital statistics offices on final determination of pending cases.
States provide annual statistical files to the National Center for Health Statistics (NCHS) based on death certificates to produce annual national mortality rates by cause and intent.8,9 The need for a timely national file means that some deaths that are under investigation at the time the death certificate is filed are marked pending in state files submitted for national vital statistics. NCHS requests that amendments to show the cause in these pending records be filed, but if the case is not amended when the national file is closed, then these certificates are coded to the International Classification of Diseases, Ninth Revision (ICD-9) code 799 for cause unknown.9,10 Therefore, state records may include the final determination for reviewed cases that are shown to be attributable to unknown cause in national files. State studies of factors associated with underascertainment have focused on reviews for child abuse and neglect. However, SIDS and traumatic injury cases all are recommended for examination by child fatality review teams as unexpected causes of death.
Since 1983, SIDS rates have dropped almost 50%,11,12 with the majority of the decline probably attributable to changes in sleep position and increased use of nonprone sleep positions after AAP recommendations in the early 1990s.13 Classification of possible SIDS cases to unknown cause may have increased with more death scene investigations or fatality reviews that use more precise definitions of SIDS.13 Combined with increased state activities to review all sudden, unexpected child fatalities, increased numbers of US deaths with unknown cause may result in national underascertainment of SIDS or unintentional, intentional, or undetermined intent injury classifications.
Risk factors for both natural and traumatic infant deaths are similar across most causes of infant death.11,13–17 For unexpected deaths that require postmortem reviews, relative risks (RRs) are heightened for injury deaths classified as either intentional or undetermined intent compared with unintentional injury or SIDS.14–19 Risk factors consistently include maternal age or low education, lack of prenatal care, premature birth, and being a second or later born infant. Also, males have higher risk of SIDS.
Underascertainment or misclassification of unexpected infant deaths reported through vital statistics systems may occur for various reasons. Death of an infant who is born outside a clinical setting and/or without a trained attendant may occur in association with a hidden pregnancy. Under these circumstances, birth certificates are less likely to be filed or available for subsequent linkage and can be found only in total mortality files from death certificates, limiting available risk factor information on these deaths.
Differing trends within causes of unexpected deaths and review of those deaths have occurred during the past 15 years.3,13,14 Before recent declines in SIDS rates concurrent with more systematic review based on improved case definitions, death to unattended births and other deaths difficult to classify may also have been classified as SIDS.13 Decreasing trends in SIDS deaths and unintentional injury deaths13,14 and increases in rates of intentional deaths should have affected the case mix of deaths of unknown cause if delays in reviews have resulted in more cases of unknown cause.
This study is the first to investigate potential sources of national underascertainment of unexpected deaths. We analyzed whether infant deaths reported to NCHS with unknown cause have risk factor profiles that more closely resemble SIDS, unintentional injury, or intentional injury deaths. Using a linked birth/infant death database, we compared rates between 1983–1991 and 1995–1996 to assess changes in numbers, rates, and RRs of fatalities reported with unknown cause that may be associated with underreporting of unexpected deaths. Unlinked mortality files are included to account thoroughly for both total magnitude and differences for all unexpected deaths reported in annual mortality statistics by cause but can be analyzed only for the limited risk factor information on the death certificate. The unlinked data are more likely to include deaths of unknown cause for which no birth certificate was found, including for infants who were born without trained attendants and found dead in the first few days of life. Trend analysis is included to compare relative distributions of risk factors, accounting for actual changes in cause-specific death rates and changes resulting from effects of delayed reporting as a result of increased child fatality reviews.
The US-linked birth/infant death data sets were analyzed for the 1983–1991 and 1995–1996 birth cohorts. Linked files are not available for 1992–1994 birth cohorts. Methods of data linkage and file characteristics are reported elsewhere.20–22 Approximately 98% of infant deaths are linked to corresponding birth certificates each year. Some death certificates could not be linked because corresponding birth certificates were not found. In 1989, NCHS began releasing individual record data on unlinked certificates attached to this data set. The final 1983–1997 NCHS mortality file was used to show complete trends.11 The 1997 birth cohort linked file was not available during this analysis.
Causes of death are certified on death certificates by physicians, medical examiners, or coroners23 and are coded according to specifications of the ICD-9 with underlying cause of death selected under rules established by the World Health Organization.10 SIDS is defined as the sudden death of an infant that is unexpected by history and for which a thorough postmortem examination fails to demonstrate an adequate cause of death (ICD code 798.0). SIDS is considered natural, whereas injury deaths are termed traumatic. Traumatic causes describe mechanisms such as suffocation, strangulation, or blunt force from external forces (ICD E-codes).
For traumatic deaths, the certifiers assign official determination of unintentional, intentional, or undetermined intent. Criteria for assignment of undetermined intent specify that it be assigned only when, after a thorough investigation, it cannot be determined whether the injuries are accidental or homicidal.10,23 Studies of deaths classified as undetermined show that they are often considered suspicious because circumstances are similar to intentional deaths while intent will remain unclear.24,25 They include approximately 4% of all injury deaths in each year of this study. Intentional and undetermined intent injury deaths are combined in this analysis as intentional/suspicious like other studies to address similar underlying issues and risk factors.7,18,19,26,27
Unintentional injury deaths are classified under codes E800 to E949 (excluding medical misadventures); intentional injury deaths are classified under codes E960 to E969 (homicide and injury purposely inflicted by other persons). Undetermined intent deaths are classified under codes E980 to E989. Deaths from unknown cause are classified by code 799, including both natural and traumatic deaths but specifically excluding all deaths that can be attributed to extreme prematurity, fetal growth retardation, congenital malformations, and SIDS. When final determination of cause remains unknown, cases are classified with code 799 or left blank. Pending cases that have not been amended by the time the national data file is closed at NCHS are converted to code 799.
Factors were limited to certificate variables previously identified for SIDS, injury, and homicide deaths: mother’s age, race, education, and marital status; trimester of pregnancy that prenatal care began; and gestational age, gender, and live birth order.13–19 Missing data on fathers for fatalities (eg, missing age = 33%, race = 30% in 1983–1991) required omission of father’s risk factors except for whether such data were present. We were unable to examine Hispanic origin because before 1988, the majority of states did not report the variable.28 Gestational age and birth weight are highly correlated, so only gestational age at birth was kept because of implications for prenatal timing of interventions. Birth in a hospital, clinic/office/birthing center, place of residence, or somewhere else and with a trained birth attendant (doctor, nurse midwife, or other midwife) are included for 1989–1991 and 1995–1996, but this detail level is unavailable from all states before 1989.
The number of deaths and live births represent complete counts that are not subject to sampling error.21 Data are grouped for the 1983–1991 period to provide stable numbers for rates and RRs because annual random variations in subcategories with small numbers may produce wide variations in RRs that are not meaningful. Data for 1995–1996 are included to address recent changes but may include some unstable risk categories as a result of small numbers, as does the unlinked data in 1989–1991 and 1995–1996. Therefore, data for unlinked files show percentages only. Denominators for rates are per 100 000 live births. Significance tests are based on t tests for trend and Poisson tests of differences. RRs are based on the ratio of the death rate in higher risk categories of a factor compared with the safest category as shown.
SIDS rates were higher than trauma or deaths from unknown causes, even after decreasing almost 50% from 146/100 000 to 77/100 000 between 1983 and 1997 (Fig 1). SIDS rates in 1995–1997 are approximately 4 times higher than unintentional injury or unknown cause rates and 9 times higher than intentional/suspicious rates. Total death rates from unintentional injury and unknown cause remained in a similar range (approximately 20/100 000 live births). Unintentional injury rates decreased approximately 25% (from 25/100 000 in 1983 to 19/100 000 in 1997), although rates for some causes have increased (eg, mechanical suffocation; data not shown).11 Between 1983 and 1995, deaths classified with unknown causes increased almost 50%, with most of the increase occurring in the late 1980s. Rates ranged from 16/100 000 to 24/100 000 from 1983–1995 (trend test, P = .01) and stabilized at 19/100 000 in 1996–1997.
Intentional injuries increased >55% (from 5/100 000 to 8/100 000; trend test, P = .001), whereas suspicious injury deaths (classified as undetermined intent and representing approximately 4% of all injury fatalities) did not change. Combined, suspicious and intentional injury deaths increased 41% overall (from 7/100 000 to 10/100 000; trend test, P < .001).
Mortality rates by cause, restricted to linked fatalities only, are highest for expected risk factor categories, eg, low maternal education, maternal age <17 or 17 to 19 years, single mother, no/late prenatal care, gestational age <28 weeks, higher birth order, and being black or American Indian (Table 1). These categories tend to have the lowest proportion of births within each factor. Boys have higher SIDS rates than girls when compared with other causes, consistent with known SIDS risk factors. Rates tend to be high when information on a category within a risk factor from the birth certificate, such as timing of prenatal care or gestational age, is reported as unknown. Rates are higher when there is no information about the father.
The RR of death for high-risk infants within each variable is greatest among intentional/suspicious injury deaths compared with other causes, except for gestational age <28 weeks, high birth order, and male gender (Table 2). Boys are at 50% greater risk of SIDS compared with girls; 40% greater for unknown causes; and approximately 10% to 20% greater for unintentional and intentional/suspicious injuries. Deaths of unknown cause have RRs similar to SIDS and unintentional injury deaths for many high-risk categories compared with the reference categories shown on Table 2, but RRs for unknown cause and intentional/suspicious injuries are higher when mothers are unmarried, mothers received no prenatal care, gestational age is <28 weeks or unknown, race is black, or information on father is unknown.
Approximately 99% of all births occurred in clinical settings and were attended by trained birth attendants (doctors, nurse-midwives, or other midwives; Table 3). The percentage of deaths to births that did not occur in clinical settings or with a trained attendant cannot be completely ascertained because some death certificates do not have a corresponding birth certificate. However, on the basis of linked certificates, being born at a place of residence or an unknown place and with no trained birth attendant (or attendant unknown) were associated with higher mortality rates. A higher proportion of deaths from intentional/suspicious injury or with unknown cause occurred for births delivered in residences or other or unknown places or when no trained birth attendant was noted. SIDS rates decreased among all categories of birth place and attendant factors between the 2 time periods; rates for deaths of unknown cause decreased more when births occurred in nonclinical settings or with no trained attendant than in clinical settings with trained attendants.
RRs of intentional/suspicious injury deaths among infants who were born at a place of residence or unknown place are 11 times higher than for infants who were born in a clinical setting (hospitals, birthing centers, doctor offices) and 3 to 4 times greater when cause is unknown. RRs for unattended intentional/suspicious injuries are approximately 6 times greater than for attended births and approximately 2 to 3 times greater than when cause was unknown. RRs for unintentional injury when birth was unattended were 1.9 times attended. RRs for unattended SIDS births compared with attended births decreased to 1.0 in 1995–1996.
In linked certificate data, 0.7% of all deaths in both time periods were to infants who were born in nonclinical settings without trained attendants (801 in 1989–1991 and 414 in 1995–1996; data not shown). One fourth of these deaths were from unexpected or unknown causes in both time periods. When limited to deaths of these infants, the age at death differs among the unexpected or unknown causes. The majority of deaths happened during the first day or week of life except for SIDS. Approximately 90% of the 86 intentional/suspicious injury deaths reported in both time periods in linked files occurred during the first week, with almost three fourths of those during the first day. Approximately 70% of the 55 deaths of unknown cause in both time periods occurred during the first week. Approximately half of the 35 unintentional injury deaths in the 2 time periods occurred during the first week, almost all during the first day. Infants who died from unknown cause were more likely to have missing data on gestational age or a gestational age of <28 weeks if the birth was unattended. Delivery circumstances are unavailable in unlinked files where cases of unknown cause or injury deaths of undetermined intent may more likely to be found.
The unlinked files represent approximately 2% of all infant deaths, while 2.3% of unexpected deaths are unlinked (Table 4). Among unexpected deaths, no birth certificate was obtained for 4.0% of deaths of unknown cause, 5.0% of intentional/suspicious injuries, 3.0% of unintentional injuries, and 1.5% of SIDS. Table 4 compares age at death in linked certificates with deaths in unlinked files during 1989–1991 and 1995–1996. Except for SIDS in 1989–1991, total numbers of unlinked certificates for each cause were very small, making comparisons between the time periods potentially unstable. Proportions of deaths during the first week of life are approximately 4 times greater in the unlinked file than in the linked file. Deaths during the first day of life or before the first week are more likely to be missing birth certificates for intentional/suspicious injury deaths, deaths from unknown cause, and unintentional injury deaths than are SIDS. The majority of intentional/suspicious injury deaths occurred during the first week of life among unlinked certificates compared with 6% to 7% for linked certificates. Among unlinked deaths from unknown causes, 43% and 48% of deaths occurred during the first week of life in 1989–1991 and 1995–1996, respectively, compared with 11% to 12% of linked certificates. SIDS is highly unlikely during the first week or month of life. Neither the linked nor the unlinked deaths from unknown cause were as likely to be reported during the 1- to 4-month time period as was SIDS.
In unlinked files, deaths are more likely to occur during the first day or week for traumatic deaths and those of unknown cause compared with SIDS (Table 4). The proportions who die from traumatic and unknown causes in the first day and week among infants who were born with no trained attendants in nonclinical settings in the linked file (Table 3) are higher but show a pattern similar to unlinked deaths by cause. It seems that many infants for whom no birth certificate was found may have been born with no trained attendants and in nonclinical settings. This is reinforced by the relative proportions of deaths in the first day or week between unlinked and linked files: within the unlinked file, proportions of deaths during the first day are 5 to 14 times greater than the distribution in the linked file among the 4 causes shown (Table 4). Proportions of deaths during 1 to 6 days in the unlinked file are 2 to 7 times greater than in the linked file, except for SIDS.
Other Information on Deaths of Unknown Cause
We reviewed additional/contributing conditions from multiple cause of death files for cases with underlying cause shown as ICD code 799 (data not shown). Fewer than 10% of the records had any additional conditions mentioned. Of these, the most frequent additional conditions were code 799.0, asphyxia (excluding newborn code 768 for intrauterine hypoxia or birth asphyxia); code 799.1, cardiorespiratory failure (excluding newborn syndrome codes 769 and 770.8); code 798.0, SIDS; and codes 765.0/765.1 for extreme prematurity, other prematurity, or small for size (excluding code 764, slow fetal growth/fetal malnutrition).
Performance of an autopsy may indicate that all possible diagnoses such as SIDS or shaken infant syndrome were carefully examined before assigning cause and/or designating cause as unknown, with possible delays in pending certificates at both the state and national levels. Since 1994, national data have not shown whether an autopsy was performed. On the basis of linked file data, the proportion of unexpected deaths for which an autopsy was performed seems to have increased between 1983 and 1991 (data not shown). In 1989–1991, 98% of intentional/suspicious injury deaths had an autopsy performed as did 94% of SIDS, 87% of unknown cause deaths, and 72% of unintentional injury deaths.
Our ability to accurately track the decline in SIDS rates or changes in traumatic death rates at the national level is diminished by the magnitude of deaths with unknown cause. The case mix of >8000 deaths assigned to unknown cause during the 11 years reviewed for this study is not available to reallocate these deaths to SIDS, traumatic deaths, or any other causes at the national level. However, death certification requirements and comparisons of risk profiles suggest contributions from all causes of unexpected death.
Distributions of age at death probably are the best indicators of the case mix of unexpected deaths allocated to unknown cause because the patterns are relatively distinctive and usually associated with developmental stages of the infant.14,18,29 Unintentional injury deaths are infrequent in the first month of life, with the majority occurring at ≥5 months of age.14 Intentional and suspicious deaths are most likely to occur during the first week and month, whereas SIDS occurs most frequently between 1 and 4 months. With decreases in SIDS associated with sleep position in recent years, the AAP suggests that the proportion of reported SIDS cases that actually are attributable to infanticide may be increasing.29 Our data showed that SIDS deaths in the first week of life declined very slightly between 1989 and 1991 and 1995 and 1996 (to none in the unlinked file in the latter period), with a shift of deaths at ≥5 months to higher proportions found primarily in the unlinked file without birth certificates. Approximately 75% of SIDS occurred between 1 and 4 months in 1995–1996, and approximately 18% occurred between 5 and 11 months. Deaths from unknown cause that occurred between 1 and 4 months during 1995–1996, the expected timing of most SIDS, represented 54% and 31% in the linked and unlinked files, respectively. The proportions of the deaths classified with unknown cause that occur in the first week of life (13% in the linked file and 38% in the unlinked file in 1995–1996) are inconsistent with expected timing of SIDS.29 On the basis of expected timing of SIDS and contributions of unintentional injury deaths at 1 to 4 months or later, probably no more than half of the deaths of unknown causes might be SIDS cases.
Higher death rates for unknown causes since 1988 may be partly a result of closer scrutiny of possible SIDS cases, including more autopsies, with fewer ambiguous cases assigned a SIDS designation.30 Conversely, because most of the increase in the rates for deaths of unknown cause occurred before the dramatic decrease in SIDS rates after an intervention initiated in the early 1990s,13 only a minor portion of the decrease in SIDS could be attributable to reassignment to unknown causes.
The magnitude of the RRs of death from unknown cause for most risk factors tended to fall between levels for intentional/suspicious injury deaths and SIDS or unintentional injuries, suggesting influences from all sudden, unexpected causes. RRs of death attributable to unknown cause were most similar to risks for intentional/suspicious injury when mothers were unmarried, mothers received no prenatal care, gestational age is <28 weeks or unknown, race is black, or information on father is unknown. Particularly striking is the high proportion of deaths from unknown cause in the unlinked file that occurred during the first week of life, like the majority of unlinked intentional/suspicious injury deaths. Although numbers are small in the unlinked file, the pattern is similar to deaths in the linked file for births delivered in nonclinical settings without trained birth attendants. It is apparent that ignoring potential intentional or suspicious deaths classified with either unknown cause or SIDS leads to an underestimation of the magnitude of the public health problem of injury, abuse, neglect, or abandonment of infants.
Relation to Previous Studies
Our findings clarify and add information to results of earlier studies of underascertainment of child abuse or neglect based on careful review of substantiated multiple record sources.2–6,31 Ewigman et al5 estimated that child abuse and neglect may have been involved in 7% to 27% of injury deaths reported in 1983–1986 as unintentional and in at least 5% of deaths classified as SIDS in Missouri. A retrospective California study of infant/toddler traumatic deaths used final coroner reports to show that homicide estimates would increase 18% if cases that were classified as undetermined or left unspecified were examined more carefully.24 On the basis of state reviews in Missouri and North Carolina, 2 studies estimated underascertainment of deaths from child abuse and neglect between 60% and 100% at the national level.4,5 During 1983–1997, 4486 infants were officially reported as intentionally killed and 793 died from injuries with undetermined but suspicious intent—a total of almost 1 a day.12 Because our national study shows more than twice as many deaths classified with unknown cause compared with intentional/suspicious traumatic deaths, approximately 30% to 50% of the deaths with unknown causes would have to result from child abuse and neglect (intentional or not) for our findings to concur with estimates by others of underascertainment of 60% to 100% at the national level.4–6
Potential Biases and Limitations
Assignment of unknown or intentional/suspicious causes by certifiers is possibly biased toward the higher risk factor profiles shown in this analysis.32,33 Such profiles may increase investigations or cause the certifiers to question intent for lower socioeconomic groups more often than in cases that occur in middle- or upper-class families. Studies that find this bias suggest the effect would be to understate fatalities attributable to intentional/suspicious injury or from unknown causes rather than SIDS or unintentional injury.32,33
Another bias may be indicated by the relatively high proportion of infants who were born at <28 weeks in cases of unknown cause. These infants may actually be at higher risk of unexpected death among all causes13,29 or could include some cases in which infants are born prematurely and unexpectedly outside clinical settings and/or without pre- and postnatal care. This may result in ambiguity among certifiers about whether a small fetus was actually a live birth with a subsequent death in the first few days of life and/or the underlying cause of death was prematurity.24 Our data do not include adequate information on prematurity among unattended cases because of missing data or lack of birth certificates. However, those cases with birth certificates showed that infants who died from unknown cause were more likely to have missing data on gestational age or a gestational age of <28 weeks if the birth was unattended.
Other limitations result from reliance on birth and death certificates. Factors identified from certificates do not describe circumstances of death that might be available from child fatality reviews. For example, death certificates are not intended to provide relationship of perpetrators in cases of abuse or homicide. Most birth certificate information is available only for mothers, yet state studies and police data show a majority of male perpetrators after the first week of life, frequently a boyfriend or a relative who is caring for a child.34–37 Better information on family structure or social support is needed.32 These social measures may be markers for lack of readily available caregiving and parenting resources, but we also need to describe interactions among family structure, social support, alcohol, drug abuse, and other contributors.
Addition of information on national files about whether determination of cause is pending or an autopsy was done would improve assessment of changing trends of SIDS cases or deaths of unknown cause. An autopsy indicates that the death was, indeed, unexpected and recommended procedures for ascertaining cause of death were initiated. Autopsies may also be an indication that cases were under investigation when the certificate was originally filed, with final determination of cause and/or intent still pending. Child fatality review of unexpected deaths should improve the quality of certificate data sources. Physicians, medical examiners, and coroners should be encouraged to file amended death certificates promptly in cases in which cause of death was initially unknown or was changed after further investigation. States should query pending cases in a timely manner. National files can be corrected only if states amend the record before the data year is closed for final processing. Reduced national and state underascertainment of specific causes of death for infants and children will result from more complete and timely information from local levels.
Wider dissemination of information about fatality circumstances from child death review investigations should also facilitate better interventions.18,29 One interagency effort is under way to address the interplay among medical, criminal, and child protective concerns of review teams while expanding and supporting a network of review teams among states.38 Efforts include guidelines for development and maintenance of teams with standard procedures.
The AAP and others propose continual functioning of multiagency review teams to accelerate progress in understanding SIDS, reduce the number of fatal cases of child abuse and neglect, increase the awareness of familial genetic diseases, focus attention on public health threats, and detect and remediate inadequate medical care.1,29,39 States, medical providers, social services agencies, and child fatality review teams need better support to organize improved information systems to facilitate prevention programs with appropriately targeted interventions.2,18,29 As stated in AAP recommendations on investigation and review of unexpected infant and child deaths, lack of adequate investigations allows flawed systems to continue and are an impediment to preventing illness, injury, and the deaths of other children at risk.1
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Hauser M, Vance J, Albright E. Gene medicine. JAMA. 2001;286:2333
Noted by JFL, MD
- Received March 22, 2001.
- Accepted September 14, 2001.
- Reprint requests to (M.D.O.) Maternal and Child Health Bureau, US Health Resources and Services Administration, 5600 Fishers Ln, Room 18-41, Rockville, MD 20857. E-mail:
- ↵American Academy of Pediatrics, Committee on Child Abuse and Neglect and Committee on Community Health Services. Investigation and review of unexpected infant and child deaths. Pediatrics.1999;104 :1158– 1160
- ↵American Academy of Pediatrics, Division of State Government Affairs. 1999 State Legislation Report. Elk Grove Village, IL: American Academy of Pediatrics;1999
- ↵Ewigman B, Kivlahan C, Land G. The Missouri child fatality study: underreporting of maltreatment fatalities among children younger than five years of age, 1983 through 1986. Pediatrics.1986;91 :330– 337
- ↵California Department of Justice State Child Death Review Board. Child Deaths in California, 1992–1995. Sacramento: CA: California Department of Justice;1997
- ↵McClain PW, Sacks JJ, Froehlke RG, Ewigman BG. Estimates of fatal child abuse and neglect, United States, 1979–1988. Pediatrics.1993;91 :338– 343
- ↵Rosenberg HM, Kochanek KD. The death certificate as a source of injury data. In: Proceedings of the International Collaborative Effort on Injury Statistics, I. Hyattsville, MD: National Center for Health Statistics; 1995;8:1–17. DHHS Publ. No. (PHS) 95-1252
- ↵National Center for Health Statistics. Technical appendix. In: Vital Statistics of the United States, 1992, II, Mortality, Part A. Washington, DC: Public Health Service;1996
- ↵World Health Organization. World Health Classification: Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death, Ninth Revision. Geneva, Switzerland: World Health Organization;1977
- ↵Hoyert DL, Kochanek KD, Murphy SL. Deaths: United States, Final Data for 1997. National Vital Statistics Report. Hyattsville, MD: National Center for Health Statistics;1999;47(No. 19) :88
- ↵National Center for Health Statistics. Mortality Public Use Data Files and Documentation, 1983–97. Hyattsville, MD: Public Health Service;1997
- ↵Brenner RA, Overpeck MD, Trumble AC, DerSimonian R, Berendes H. Deaths due to injuries in infants, United States, 1983–1991. Pediatrics.1999;103 :968– 971
- Scholer SJ, Hickson GB, Ray WA. Sociodemographic factors identify US infants at high risk of injury morbidity. Pediatrics.1999;103 :1183– 1188
- Touhy PG, Counsell AM, Geddis DC. Sociodemographic factors associated with sleeping position and location. Arch Dis Child.1993;69 :664– 666
- ↵Ponsonby AL, Dwyer T, Kasl SV, Couper D, Cochrane JA. Correlates of prone infant sleeping position by period of birth. Arch Dis Child.1994;72 :204– 208
- ↵Overpeck MD, Brenner RA, Trumble AC, Smith GS, MacDorman MF, Berendes HW. Infant injury deaths with unknown intent: what else do we know? Inj Prev.1999;5 :272– 275
- ↵National Center for Health Statistics. Birth Cohort Linked Birth/Infant Death Data Sets: Public Use Data File Documentation for 1983 to 1991. Hyattsville, MD: US Public Health Service; 1988–1999
- ↵National Center for Health Statistics. 1995 and 1996 Birth Cohort Linked Birth/Infant Death Data Sets. NCHS CD-ROM, Series 20, No. 12a, 1998; and NCHS CD-ROM, Series 20, No. 14a,1999
- ↵Mathews TJ, Curtin SC, MacDorman MF. Infant Mortality Statistics From the 1998 Period Linked Birth/Infant Death Data Set. National Vital Statistics Reports. Hyattsville, MD: National Center for Health Statistics;2000;48 (No. 12)
- ↵National Center for Health Statistics. Medical Examiners’ and Coroners’ Handbook on Death Registration and Fetal Death Reporting. Hyattsville, MD: National Center for Health Statistics;1987. DHHS Publ. No. (PHS) 87-1110
- ↵National Center for Health Statistics. Vital Statistics of the United States, I, Natality. Washington, DC: Public Health Service;1997
- ↵American Academy of Pediatrics, Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Changing concepts of sudden infant death syndrome: implications for infant sleeping environment and sleep position. Pediatrics.2000;105 :650– 656
- ↵Meadows R. Unnatural sudden infant death. Arch Dis Child.1999;80 :7– 14
- Department of Health and Human Services, National Center on Child Abuse and Neglect. Child Maltreatment 1995: Reports From States to the National Child Abuse and Neglect Data System. Washington, DC: Government Printing Office;1997:2– 9
- ↵Bureau of Justice Statistics. Homicide Trends in the U.S. Washington, DC: National Criminal Justice;2000. Publ. No. 179767. Available at: www.ojp.usdoj.gov/bjs/homicide
- ↵National Center for Child Fatality Review. “How To” Guide for Child Fatality Review Teams. Available at: www.ican-ncfr.org
- ↵Chukwudi OS, Forjuoh SN, West P, Brooks C. Child death reviews: a gold mine for injury prevention and control. Inj Prev.1999;5 :276– 279
- Copyright © 2002 by the American Academy of Pediatrics