AAP Voices Blog

Why Every Pediatrician Should Care About Child Fatality Review

When I was up for promotion to professor, one of the review committee members asked what work I did felt the most meaningful to me. Without hesitation, I said, “Child fatality review.”

He looked at me a bit quizzically, with a mixture of confusion and trepidation. I then explained, “I know it sounds terrible, but for every child’s death we prevent, we allow another child to live.” 

In essence, child fatality review is the ultimate quality assurance program for all the systems that serve children; medical, child protective, public health and safety, education, and mental health. Every year, 3,500 babies die of sleep-related deaths, including accidental suffocation and strangulation in bed. These tragedies are where Child Fatality Review (CFR) teams come in. 
 
Picture a room with a pediatrician, a medical examiner, a social worker, a police officer, a public health official, and a child welfare representative, all looking at the same case from different angles. That's who composes the child fatality review team. Instead of just noting a clinical cause of death, they reconstruct the events that lead to the death. This includes asking questions such as; was the family already known to child protective services? Was there a history of unsafe sleep practices? Did a doctor see something at an earlier visit that, in hindsight, mattered?
That fuller picture is what makes review data so different from a death certificate or a single autopsy report. It turns one tragedy and one data point into many data points that pediatricians can actually use.
 
Medical professionals can use this data to improve the quality of care they give patients, much how we did at my home institution, Yale New Haven Hospital in Connecticut. Sleep-related death, often due to unsafe sleep practices such as sleeping with another person or sleeping in a crib or bassinet that is cluttered with items, is the leading cause of post-neonatal death in the state. Based on our CFR data, which the Center for Disease Control has corroborated, our rates of sleep-related death have not changed since 2018 (61.4 infants per 100,000 live births) despite a myriad of statewide interventions. This included 2015 legislation mandating all birthing hospitals provide parents with safe sleep guidance that corresponds to AAP guidelines at newborn hospital discharge.
 
The rate of sleep-related death of infants born at Yale New Haven Hospital, the largest birthing hospital in the state, (140 infants per 100,000 births) was 2.3 times that of the state in 2019. The hospital is the largest with a birthing center in the state, with about 6,000 births a year. A multidisciplinary team of nurses, physicians, social workers, parents, and administrators was convened to examine why this was happening and ways to reduce this alarming trend. 

Using child fatality review data, we aimed to reduce the rate of sleep-related deaths by 50%. We developed numerous interventions, and after each intervention, evaluated our yearly sleep-related death rate using the same data. Some of these interventions included standardized education and safety planning for parents; competency-based education for providers; establishing a clinical pathway for providers so they could help parents make a safety plan when bedsharing was unavoidable; and conducting “Crib audits” so that when an infant in the nursery was found sleeping unsafely, real-time education could be provided. 

Because of this multidisciplinary, collaborative effort, we reduced our sleep-related death rate 10-fold, with results dropping the hospitals rates below that of the state as a whole. We plan to continue these efforts at the three other birthing hospitals within our system, which would account for a third of all births in Connecticut. Dr. Scott Krugman, MD, FAAP, has pioneered this approach at other hospitals in Baltimore, Maryland. 
 
Child fatality review data takes individual tragedies and turns them into aggregate data for collective action. For pediatricians, engaging with CFR data can help protect children by sharpening clinical instincts, strengthening the guidance given at every visit, and, over time, saves lives. Unsafe sleep deaths can be avoided with the proper prevention interventions and education.

Without CFR data, we miss out on crucial information that pertains directly to our patient populations that we can use to tailor our approach and make the biggest impact possible.
 

When the cost of a missed warning sign is irreversible, learning from cases of babies lost to Sudden Unexpected Infant Death is one of medicine's most powerful tools for ensuring better outcomes, and that more babies live to see their first birthday. 

*The views expressed in this article are those of the author, and not necessarily those of the American Academy of Pediatrics.