Certified cause of death in children and young adults with cerebral palsy.

The status of 732 children suffering from cerebral palsy from the South East Thames region (births from 1970-9) was ascertained at the end of 1989, and copies of death certificates of the 73 children who have died, aged 4 weeks to nearly 16 years, were obtained. Infantile cerebral palsy (ICD Code 343-) was coded as the underlying cause of death in only 16 (22%) cases. On 28 (38%) certificates there was no mention of any form of cerebral palsy, the proportion in which it was not mentioned increasing with age. In 20 (28%) cases the coded underlying cause of death was respiratory, hence in published national statistics the number of deaths from respiratory causes is inflated. A postmortem examination was known to have been performed in 23 cases, but the recorded information was in some cases limited to a ''terminal event''. The importance of good data on the death certificate, and the significance of published national statistics, need to be communicated to all those involved in the certification process if cerebral palsy and other chronic conditions, which raise the relative risk of death, are not to be under-represented.     

Neonatal mortality in France: usefulness of a neonatal death certificate]

A neonatal death certificate was introduced in France in 1997. It provides detailed data on the causes of death and the characteristics of newborn, birth and parents. Our aim was to describe the new results of this certificate. METHOD: All deaths in 1999 in the first 27 days of life were included (N=2036). Certificates were analysed using the usual process, especially following the International Classification of Diseases. RESULTS: The neonatal death certificate was used for 87% of deaths. The proportion of documented items was 96% for gestational age and birthweight, 87% for maternal age and parity and 70% for maternal occupation. Almost three quarters of the deaths occurred in the first 6 days (36.9% in the first 24 hours and 35.1% between one and six days). 30.5% of the died infants were born before 27 weeks of gestation and 36.5% between 27 and 36 weeks. A shift in medical care was observed at 26 weeks, with an increase in caesarean sections before labour and newborn referrals. In all, 63.3% of neonatal deaths were due to perinatal conditions, and 27.9% to congenital anomalies. The proportion of deaths explained by congenital anomalies was higher for longer gestational age: 14% of deaths between 25 and 28 weeks of gestation vs 38 to 43% between 33 and 42 weeks. CONCLUSION: The neonatal death certificate was well accepted; however the data on detailed causes of death and parent's characteristics were insufficient. Analysis of the circumstances and the causes of death is facilitated with the neonatal death certificate and it will be developped in the future.     

Pilot study of revised stillbirth and neonatal death certificates.

Draft revised stillbirth and early infant death certificates were sent with a short questionnaire to certifying doctors for 206 stillbirths and 198 neonatal deaths for which death certificates had been received in the Office of Population Censuses and Surveys over a three week period in 1982. The new certificates complied with the recommendations of the World Health Organisation and asked for details of the cause of death, including separate sections for maternal and fetal conditions. Replies were received for 163 stillbirths and 151 neonatal deaths. Questionnaires were examined clerically and answers and comments analysed. Draft certificates were processed by computer to examine any differences between the causes of death given on the new forms and information given on the original certificates. This testing suggested that revised certificates are acceptable. Extension of the early infant death certificate to cover all neonatal deaths does not seem to create problems and should provide information on the association between maternal conditions and deaths occurring in the second to fourth weeks of life. If the full potential of the new certificates is to be realised, attention needs to be given to the detailed layout of the forms and clearer notes of guidance. Certifiers need to be encouraged to give appropriate details of any obstetric problems.     

Apolipoprotein E e4 and its prevalence in early childhood death due to sudden infant death syndrome or to recognised causes

BACKGROUND:: Specific genetic polymorphisms have been shown to be more common in unexplained infant death. The APOE genotype exhibits opposite effects at the extremes of age with protective effects of e4 on perinatal mortality but detrimental effects as age progresses. OBJECTIVE:: To determine whether the APOE e4 allele is associated with early childhood (1 week-2 years) unexplained death ('sudden infant death syndrome', SIDS) or with recognised causes (non-SIDS) and to compare these cohorts with published perinatal and adult data. METHODS:: DNA was extracted from spleen tissue of children dying in South East Scotland between 1990 and 2002. APOE alleles (e2, e3, e4) were determined using PCR. Comparisons of allele frequencies between groups were made. RESULTS:: There were 167 SIDS cases and 117 non-SIDS cases. Allele distributions of SIDS cases were similar to healthy newborns. Allele distributions of non-SIDS cases were more similar to adults than to healthy newborns. The percentage of children with at least one e4 allele was significantly lower in non-SIDS compared to SIDS (p=0.016). Non-SIDS cases had a higher frequency of e3 compared to SIDS cases (p=0.01) and to healthy newborns (0.005). CONCLUSIONS:: Children dying from identified causes have different APOE allele distributions from SIDS cases, but are similar to adults. Children dying from SIDS have an allele distribution comparable to healthy newborns. The prevalence of e4 in SIDS is not of an order to contribute significantly to the age-related decline in e4.     

Sudden infant death in France during the winter of 1986

From the statistics of the medical causes of deaths and the results of a retrospective survey carried out among the physicians who certified the deaths, an analysis of post-neonatal mortality during winter of 1986 was undertaken in order to know if the relative part of the sudden infant death syndrome (SIDS) had increased during that winter. It appeared that the deaths attributed to SIDS can be distinguished from deaths of other causes for several factors (place of death, former status of the baby). However, the low number of post mortem examinations performed does not allow in all the declared cases to assess SIDS as internationally defined. However, it is shown that sudden mortality was not higher during this special winter and that immunizations were not more frequently related to this cause than to other causes of death.     

A new hierarchical classification of causes of infant deaths in England and Wales.

In 1986 The Office of Population Censuses and Surveys (OPCS) introduced new certificates for stillbirths and neonatal deaths. This allowed certifiers more flexibility in the completion of the certificate, and the number and ordering of the causes given. Tabulations have been published of the fetal and maternal causes of death mentioned on the certificates for every year from 1986 to 1991 in annual reference volumes. It has not been possible either to derive a single cause group for each death, however, or to compare the information available on neonatal deaths with that on postneonatal deaths, which are still derived from the standard death certificate. The aim of the work described here was to adapt previous classifications to derive a single cause grouping for stillbirths and infant deaths which would provide the maximum information about preventability and yet meet the national and international responsibilities of OPCS. The methods used and the tests carried out on the validity and consistency of the chosen classification are described.     

Annual summary of vital statistics: 2008

The number of births in the United States decreased between 2007 and 2008 (preliminary estimate: 4 251 095). Birth rates declined among all women aged 15 to 39 years; the decrease among teenagers reverses the increases seen in the previous 2 years. The total fertility rate decreased 2% in 2008 to 2085.5 births per 1000 women. The proportion of all births to unmarried women increased to 40.6% in 2008, up from 39.7% in 2007. The 2008 preterm birth rate was 12.3%, a decline of 3% from 2007. In 2008, 32.3% of all births occurred by cesarean delivery, up nearly 2% from 2007. Twin and triplet birth rates were unchanged. The infant mortality rate was 6.59 infant deaths per 1000 live births in 2008 (significantly lower than the rate of 6.75 in 2007). Life expectancy at birth was 77.8 years in 2008. Crude death rates for children aged 1 to 19 years decreased by 5.5% between 2007 and 2008. Unintentional injuries and homicide were, respectively, the first and second leading causes of death in this age group. These 2 causes of death jointly accounted for 51.2% of all deaths of children and adolescents in 2008. This annual article is a long-standing feature in Pediatrics and provides a summary of the most current vital statistics data for the United States. We also include a special feature this year on the differences in cesarean-delivery rates according to race and Hispanic origin.     

Lack of precision in neonatal death classifications based on the underlying causes of death stated on death certificates

Large-scale analyses of causes of neonatal deaths are usually based on death-certificate information. A new computer-based method has been introduced to define the cause of stillbirths and neonatal deaths in large amounts of material and to classify them according to two different models [Wigglesworth and Neonatal and Intrauterine death Classification according to (a)Etiology (NICE)]. The method is based on a combination of detailed information from health care registries and the death-certificate information. The present study aimed to compare these two classification models with a previously published method based solely on death certificate information [International Collaborative Effort (ICE)]. The study population comprised 2378 neonatal deaths in Sweden between 1987 and 1992. Cross-tabulation was made between the ICE classification and the other two classification models. In addition, case examples are presented in detail, exemplifying how classification errors arose. The ICE classification gives a rather low precision, notably for two important causes of death: asphyxia and immaturity. Among 328 infants dying from asphyxia according to computerized Wigglesworth classification, ICE classified 59% as asphyxia and 22% were labelled immaturity. When ICE classified the deaths as due to asphyxia, this was verified in only 50%. Among 792 infants dying from immaturity according to computerized Wigglesworth classification, 64% were classified as such by ICE. The findings cast doubts on the results of studies based exclusively on death-certificate information. Whenever possible in the analysis of neonatal deaths, death-certificate information should be supplemented with more detailed data. The computer-based method introduced here makes such analyses possible for large databases.     

Sudden newborn infant death in maternity. Anatomo-clinical study of 31 cases]

PATIENTS AND METHODS. All cases of sudden and unexpected death occurring in maternity were studied over a period of 6 years (1985-1991). Anamnestic data, results of clinical examination of the body and findings of bacterial screening of body fluids or tissues were collected. The results at necropsy were also collected following the protocol used, with parental consent, in all cases of sudden infant death syndrome. RESULTS. There were 31 cases of sudden and unexpected death. Of these, 48% occurred before the 24th hour of life, 68% before the 36th hour and 84% before the 72nd hour. The majority of death occurred at night (55% between midnight and 6 AM, 90% between 9 PM and 9 AM). Analysis of the data provided a precise cause of death in 25 cases (81%), and a probable cause in 4 cases (13%). The major causes were perinatal anoxia, generally associated with massive amniotic inhalation (16 cases), and maternal-fetal infection (9 cases). No cause was found in 2 cases. Despite the fact that the death occurred unexpectedly, half of the newborns showed warning signs, some hours before the event. These signs were either not detected or ignored. CONCLUSION. The incidence of sudden death in neonates is 0.15 to 0.36/1,000 live births. Its causes are generally correlated with common neonatal diseases. Its occurrence at night and the existence of warning signs raise questions concerning the care of neonates in maternity.     

Errors in the certification of neonatal death

OBJECTIVE: To examine the precision of the perinatal death certificate (PDC) and ascertain the possible sources of error in the certification of neonatal deaths. METHODS: The 'Main' and 'Other' causes of death recorded on the PDC were obtained from the Registry of Births, Deaths and Marriages and compared with those from a clinicopathological summary (CPS) completed after all pending laboratory results and/or autopsy information were available. RESULTS: There were 179 neonatal deaths during the 7 year period under review. The PDC and CPS main causes of death were concordant in 103 of 179 infants (58%) and discordant in the remaining 76 infants (42%). The PDC main cause of death was incorrectly classified in 61 of 76 infants (80%) with discordant findings and was incompletely classified in the remaining 15 infants (20%). The following discordancies were recorded for the 61 infants with an incorrect classification: (i) transposition of the 'Main' and 'Other' causes of death, resulting in a sequencing discordancy in 14 infants (23%); (ii) recording a non-pathological condition as the main cause of death in 40 infants (66%); and (iii) recording an incorrect pathological condition as the main cause of death in seven infants (11%). Eight of the 61 (13%) incorrect classifications and four of the 15 (27%) incomplete classifications were associated with laboratory and/or autopsy data being unavailable when the PDC was completed. CONCLUSIONS: The concordancy between the PDC and CPS would have increased from 58 to 91% if the 'Main' and 'Other' causes of death had been sequenced correctly, if the main cause of death had been ascribed to a pathological disease rather than a non-pathological condition and if corrective information from pending laboratory tests and/or autopsy examination had been made available to the Registry of Births, Deaths and Marriages.     

Annual summary of vital statistics: 2005

The general fertility rate in 2005 was 66.7 births per 1000 women aged 15 to 44 years, the highest level since 1993. The birth rate for teen mothers (aged 15 to 19 years) declined by 2% between 2004 and 2005, falling to 40.4 births per 1000 women, the lowest ever recorded in the 65 years for which there are consistent data. The birth rates for women > or = 30 years of age rose in 2005 to levels not seen in almost 40 years. Childbearing by unmarried women also increased to historic record levels for the United States in 2005. The cesarean-delivery rate rose by 4% in 2005 to 30.2% of all births, another record high. The preterm birth rate continued to rise (to 12.7% in 2005), as did the rate for low birth weight births (8.2%). The infant mortality rate was 6.79 infant deaths per 1000 live births in 2004, not statistically different from the rate in 2003. Pronounced differences in infant mortality rates by race and Hispanic origin continue, with non-Hispanic black newborns more than twice as likely as non-Hispanic white and Hispanic infants to die within 1 year of birth. The expectation of life at birth reached a record high in 2004 of 77.8 years for all gender and race groups combined. Death rates in the United States continued to decline, with death rates decreasing for 9 of the 15 leading causes. The crude death rate for children aged 1 to 19 years did not decrease significantly between 2003 and 2004. Of the 10 leading causes of death for 2004 in this age group, only the rates for influenza and pneumonia showed a significant decrease. The death rates increased for intentional self-harm (suicide), whereas rates for other causes did not change significantly for children. A large proportion of childhood deaths continue to occur as a result of preventable injuries.     

Changes in the neonatal and infant mortality rate and the causes of death in Korea

Neonatal mortality rate (NMR) or infant mortality rate (IMR) are the rate of deaths per 1,000 live births at which babies of either less than four weeks or of one year of age die, respectively. The NMR and IMR are commonly accepted as a measure of the general health and wellbeing of a population. Korea's NMR and IMR fell significantly between 1993 and 2009 from 6.6 and 9.9 to 1.7 and 3.2, respectively. Common causes of infantile death in 2008 had decreased compared with those in 1996 such as other disorders originating in the perinatal period, congenital malformation of the heart, bacterial sepsis of newborns, disorders related to length of gestation and fetal growth, intra-uterine hypoxia, birth asphyxia. However, some other causes are on the increase, such as respiratory distress of newborn, other respiratory conditions originating in the perinatal period, other congenital malformation, diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism. In this study, we provide basic data about changes of NMR and IMR and the causes of neonatal and infantile death from 1983 to 2009 in Korea.     

Infant mortality: a practical approach to the analysis of the leading causes of death and risk factors

The analysis of infant mortality data provides an opportunity for developing preventive strategies to improve this indicator of a population's health. All infant deaths in North Carolina during a 5-year period (1980 through 1984) were analyzed using the International Classification of Diseases, 9th revision (ICD-9), and a system for linked birth and death records that allows the analysis of birth certificate information on deaths. Causes of death were aggregated based on common etiology such as prematurity or obstetric-related conditions rather than the more traditional organ system taxonomy of the ICD-9 codes. Analyses were carried out separately for very low birth weight (less than or equal to 1500 g), moderately low birth weight (1501 through 2500 g), and normal birth weight (greater than 2500 g) babies. Maternal characteristics identified from the birth certificate were also compared with the different causes of death. Prematurity-related conditions accounted for 37.5% of all deaths, ranking far above the 17.4% for congenital anomalies and 12.9% for sudden infant death syndrome. For normal birth weight babies, sudden infant death syndrome ranked first, followed by congenital anomalies and nonperinatal infections. For the moderately low birth weight babies, congenital anomalies ranked first, with sudden infant death syndrome second and prematurity-related conditions third. For the very low birth weight babies, prematurity-related conditions accounted for nearly 70% of the deaths, with obstetric conditions and congenital anomalies ranking second and third, respectively. Maternal risk factors identified an overrepresentation of nonwhite, unmarried, and young teenage mothers and mothers with less than adequate prenatal care.(ABSTRACT TRUNCATED AT 250 WORDS)     

A new hierarchical classification of causes of infant deaths in England and Wales

In 1986 The Office of Population Censuses and Surveys (OPCS) introduced new certificates for stillbirths and neonatal deaths. This allowed certifiers more flexibility in the completion of the certificate, and the number and ordering of the causes given. Tabulations have been published of the fetal and maternal causes of death mentioned on the certificates for every year from 1986 to 1991 in annual reference volumes. It has not been possible either to derive a single cause group for each death, however, or to compare the information available on neonatal deaths with that on postneonatal deaths, which are still derived from the standard death certificate. The aim of the work described here was to adapt previous classifications to derive a single cause grouping for stillbirths and infant deaths which would provide the maximum information about preventability and yet meet the national and international responsibilities of OPCS. The methods used and the tests carried out on the validity and consistency of the chosen classification are described.     

Relationship of neonatologists' end-of-life decisions to their personal fear of death

OBJECTIVE: To study the relationship of Australian and New Zealand (ANZ) neonatologists' personal fear of death to their forgoing life-sustaining treatment and hastening death in newborns destined for severe disability and newborns for whom further treatment is considered non-beneficial or overly burdensome. DESIGN: A self-report questionnaire survey of ANZ neonatologists. SETTING: Neonatologists registered in the 2004 ANZ Directory of Neonatal Intensive Care Units. PARTICIPANTS: 78 of 138 (56%) neonatologists who responded to the study questionnaire. MAIN OUTCOME MEASURES: Between-group differences in the Multidimensional Fear of Death Scale. RESULTS: In newborns for whom further treatment was deemed futile, 73 neonatologists reported their attitude to hastening death as follows: 23 preferred to hasten death by withdrawing minimal treatment, 35 preferred to hasten death with analgesia-sedation, and 15 reported that hastening death was unacceptable. Analysis of variance showed a statistically significant difference between the three groups regarding fear of the dying process (F = 3.78, p = 0.028), fear of premature death (F = 3.28, p = 0.044) and fear of being destroyed (F = 3.20, p = 0.047). Post hoc comparisons showed that neonatologists who reported that hastening death was unacceptable compared with neonatologists who preferred to hasten death with analgesia-sedation had significantly less fear of the dying process and fear of premature death, and significantly more fear of being destroyed. CONCLUSIONS: ANZ neonatologists' personal fear of death and their attitude to hastening death when further treatment is considered futile are significantly related. Neonatologists' fear of death may influence their end-of-life decisions.     

Quality of perinatal death registration

The quality of national perinatal mortality statistics was evaluated from a survey in nine maternity hospitals in Hainaut, Belgium (total births: 7862). The overall completeness of perinatal death registration was 86%. Under-registration was especially frequent in low birth weight babies. In 69% of cases, the birth weight value reported on death certificates was in exact agreement with the value in hospital records. Using detailed categories of causes, there was, in 37% of cases, agreement between the underlying cause on death certificates and the main cause identified in hospital records. Using gross categories of causes, the level of agreement was 56%. Disagreement was mostly due to the lack of specificity of the underlying cause on death certificates. The authors suggest ways to improve the quality of registration.Abbreviation ICD International classification of diseases The study was supported by a research grant of the Fonds de la Recherche Scientifique Medicale No 3.9002.85     

Risk status at discharge and cause of death for postneonatal infant deaths: a total population study

OBJECTIVES: To obtain population-based, clinical information regarding potentially modifiable factors contributing to death during the postneonatal period (28 to 364 days), we examined all postneonatal infant deaths in four areas of the United States to determine: (1) the cause of death from clinical and autopsy data rather than vital statistics, (2) whether death occurred during initial hospitalization or after discharge, and (3) the portion of postneonatal mortality attributable to infants who left the hospital with identified high-risk medical conditions. DESIGN AND SETTING: Retrospective medical record review of all postneonatal infant deaths with birth weights greater than 500 g (total N = 386) born to mothers residing in: (1) the city of Boston (1984 and 1985, N = 55), (2) the city of St Louis and contiguous areas (1985 and 1986, N = 123), (3) San Diego County (1985, N = 112), and (4) the state of Maine (1984 and 1985, N = 96). Deaths were identified using linked birth and death vital statistics, and medical record audits of infants' and mothers' charts were performed. Causes of death were obtained from medical record review in conjunction with autopsy if performed (72%, N = 278), medical record alone (17%, N = 67), or vital statistics if no other source was available (11%, N = 41). The medical conditions at the time of discharge for each infant were reviewed and, if judged to confer an increased risk of morbidity or mortality, were classified as high risk. RESULTS: The causes of death were sudden infant death syndrome (47%, N = 181), congenital conditions (20%, N = 77), prematurity-related conditions (11%, N = 43), infections (9%, N = 34), external causes (including injuries, drownings, ingestions, and burns) (7%, N = 25), and other (6%, N = 23). In 24% of congenital and 25% to 44% of prematurity-related deaths, infection was the acute or associated cause of death. Infants born to black mothers were more likely than those born to white mothers to die during the postneonatal period of all major causes of death (7.3 per 1000 vs 3.0 per 1000). Overall, 18% (N = 68) of deaths occurred to infants who never left the hospital; 79% (N = 305) of the infants were discharged before death; and discharge status was unknown in 3% (N = 13). Eighty-one percent of all infants with prematurity-related postneonatal deaths were never discharged, and of the total infants who were initially discharged, only 1% (N = 4) subsequently died of prematurity-related causes. Of all postneonatal deaths, only 16% (N = 62) left the hospital with identified high-risk medical conditions. CONCLUSIONS: These findings suggest that the etiology of postneonatal mortality is heterogeneous, with significant complexity in attributing specific causes of death and making designations of "preventability." The vast majority of infants who died of prematurity-related postneonatal causes never left the hospital, and only a small percentage of all infants that left the hospital before death were identified as being at high medical risk. Therefore, strategies for further decreasing postneonatal mortality must link high-risk follow-up programs to more comprehensive strategies that address risk throughout pregnancy and early childhood.     

Risk factors for early death in transient myeloproliferative disorder without phenotypic features of Down syndrome: a case report and literature review

Not only in newborns with Down syndrome, but newborns without phenotypic features of Down syndrome also develop transient myeloproliferative disorder (TMD). In these cases, trisomy 21 and related chromosomal abnormalities are either constitutionally mosaic or limited to blood cells. Risk factors for early death of these patients are unknown so far. We here report a fatal case of TMD without phenotypic features of Down syndrome and review literature to identify risk factors associated with early death. Not only are gestational age and white blood cell count risk factors for early death in TMD with Down syndrome, but they also appear to be risk factors in TMD without Down syndrome.     

The seasonal distribution of infant deaths by age: A comparison of sudden infant death syndrome and other causes of death

Objective: To examine the possibility that among deaths in infancy the increase in the winter/summer ratio with increasing age is not peculiar to sudden infant death syndrome (SIDS).
Methodology: Details of the winter (December-February)/summer (June-August) ratio among deaths in neonates (<28 days) and post neonates dying in the United States of America between 1979 and 1990 were abstracted from published statistics. The primary causes of death were classified according to the ninth Revision of the International Classification of Diseases.
Results: For every non-traumatic cause of death including SIDS, the winter/summer ratio was higher among postneonates than neonates. This was not seen for deaths due to trauma. Cases of SIDS and deaths due to infection had the highest ratios in both age categories. Causes of death occurring predominantly in the neonatal period (e.g. anencephaly) had the lowest overall ratios.
Conclusions: Neither the greater number of SIDS cases in the winter, nor the increasing winter/summer ratio with increasing age is unique to SIDS.