A Systematic Approach to Evaluate Sudden Unexplained Death in Children.

OBJECTIVE: To evaluate in the Netherlands the national outcomes in providing cause of and insights into sudden and unexplained child deaths among children via the Postmortem Evaluation of Sudden Unexplained Death in Youth (PESUDY) procedure. STUDY DESIGN: Children aged 0-18 years in the Netherlands who died suddenly were included in the PESUDY procedure if their death was unexplained and their parents gave consent. The PESUDY procedure consists of pediatric and forensic examination, biochemical, and microbiological tests; radiologic imaging; autopsy; and multidisciplinary discussion. Data on history, modifiable factors, previous symptoms, performed diagnostics, and cause of death were collected between October 2016 and December 2021. RESULTS: In total, 212 cases (median age 11 months, 56% boys, 33% comorbidity) were included. Microbiological, toxicological, and metabolic testing was performed in 93%, 34%, and 32% of cases. In 95% a computed tomography scan or magnetic resonance imaging was done and in 62% an autopsy was performed. The cause of death was explained in 58% of cases and a plausible cause was identified in an additional 13%. Most children died from infectious diseases. Noninfectious cardiac causes were the second leading cause of death found. Modifiable factors were identified in 24% of non-sudden infant death syndrome/unclassified sudden infant death cases and mostly involved overlooked alarming symptoms. CONCLUSIONS: The PESUDY procedure is valuable and effective for determining the cause of death in children with sudden unexplained deaths and for providing answers to grieving parents and involved health care professionals.

A model for older adults' coping with the death of their child: a grounded theory study.

BACKGROUND: Losing a child at an old age while also facing health problems and physical limitations can have significant negative impacts on parents' lives such as anxiety, depression, and impairment in social functions. The process of coping with the death of a child is particularly unknown among older adults. Therefore, this study aimed to explore how older adults cope with the death of their child. METHOD: This qualitative study was conducted in 2020-2021, using Corbin and Strauss (2015) approach to the grounded theory method. The sampling began purposefully and continued theoretically until theoretical saturation was achieved. Semi-structured interviews were conducted to collect data from Iranian older adults who had experienced the death of their child. To ensure data trustworthiness, the Guba and Lincoln (1985) criteria were utilized. A qualitative data analysis software, MAXQDA2020, was used to manage the data. FINDINGS: The results of this study were obtained from 27 participants. The main concern of older adults was the fear of their lives collapsing following the death of their child. Participants utilized three main strategies to address their concerns: attempting to rebuild themselves, connecting to a higher power, and searching for positivity amidst grief. The central category that emerged from the analysis was "improving physical, mental, and spiritual capacities," resulting in personal growth and improved social relationships. CONCLUSIONS: Through the use of the three aforementioned strategies, older adults were able to overcome their primary concern of the fear of their lives collapsing following the death of their child. Further development of the theory is suggested in order to design a model that can facilitate older adults' coping with this difficult life event.

Intergenerational Clustering of Under-Five Mortality: A Cohort Perspective in Low- and Middle-Income Countries.

A burgeoning demographic literature documents the exceedingly high rates at which contemporary cohorts of women across the Global South experience the death of their children-even amid historic declines in child mortality. Yet, the patterning of maternal bereavement remains underinvestigated, as does the extent to which it replicates across generations of the same family. To that end, we ask: Are the surviving daughters of bereaved mothers more likely to eventually experience maternal bereavement? How does the intergenerational clustering of maternal bereavement vary across countries and cohorts? To answer these questions, we make use of Demographic and Health Survey Program data from 50 low- and middle-income countries, encompassing data on 1.05 million women and their mothers spanning three decadal birth cohorts. Descriptive results demonstrate that maternal bereavement is increasingly patterned intergenerationally across cohorts, with most women experiencing the same fate as their mothers. Multivariable hazard models further show that, on average, women whose mothers were maternally bereaved have significantly increased odds of losing a child themselves. In most countries, the association is stable across cohorts; however, in select countries, the risk associated with having a bereaved mother is shrinking among more recent birth cohorts.

"Grief Explodes all Relationships": Experiences of Grief and Coping Among Parents and Siblings Following the Death of a Child.

The death of a child is an intense loss for families, which impacts the wellbeing of parents, surviving siblings, and the family as a whole. This study expanded on existing literature by collecting qualitative accounts from bereaved parents and siblings about their experiences before, during, and after the death of a child in their family. In total, 15 participants from 9 families completed semi-structured interviews. Findings highlighted three periods of the grieving process, which were not linear but rather ongoing and often happening simultaneously: (1) Crisis; (2) Learning to cope; and (3) Establishment of a new equilibrium. Parents and siblings reported experiences unique to their role in the family and developmental stage, as well as shared experiences within the family system. Findings have implications for palliative care and bereavement professionals in terms of supporting parent, sibling, and family coping before, during, and after the death of a child.

Medical records as screening tools for child death review in Japan.

BACKGROUND: Although many child death review (CDR) systems have been developed in Japan, the optimal system is still being identified. The aim of this study is to identify the etiologies of child deaths and to propose a screening method for initiating the CDR process in Japan. METHODS: Clinical medical records (CMRs) in hospitals and autopsy records were surveyed for cases of deaths of children aged less than 15 years between 2014 and 2016 in Aichi Prefecture, Japan. The data were analyzed in three steps, and the findings were compared with the vital statistics. RESULTS: Of the 695 children whose death certificates were submitted to Aichi Prefecture, 590 could be traced to pediatric care hospitals. The distribution of causes of death was slightly different from the vital statistics, with 11.5% dying of extrinsic causes and 19.7% dying of unknown causes. Maltreatment was suspected in 64 cases, which was much higher than that in government statistics. Overall, 158 (26.8%) deaths were considered preventable. The number of unnatural deaths, which might be screened in, was calculated as 172 (29.2%) in the vital statistics, whereas the survey of CMRs revealed that 241 (40.8%) to 282 (47.8%) should be screened in. CONCLUSIONS: Surveying CMRs in hospitals may be a suitable method to detect and screen deaths to start the CDR process in Japan.

"Everybody Needs to Talk About Their Child": A Descriptive Phenomenological Study of Bereaved Parents' Experiences in Digital Storytelling.

Digital Storytelling (DS) is a narrative intervention that supports participants' ability to find meaning in their life experiences - in this case, bereavement after child death. Thirteen (N = 13) bereaved parents engaged in a DS workshop in which they created a story about the death of their child. Using a descriptive phenomenological approach, researchers explored participants' experience with child death via their completed digital stories. Results highlight connection as a pathway to meaning making for bereaved parents who participate in DS, specifically in regard to connection with other bereaved parents and connection with their deceased child via telling their story.

Barriers, facilitators, and implementation strategies for the initiation of Child Death Review system in Japan: a modified Delphi method study.

BACKGROUND: To further curb preventable child deaths, some countries have implemented Child Death Review (CDR). CDR is a comprehensive multidisciplinary process that investigates, reviews, and registers all child deaths to consider prevention strategies. This study deciphered the barriers, facilitators, and implementation strategies in Japan. METHODS: This study used a three-round modified Delphi method. The expert panel consisted of local government officers and health professionals responsible for the CDR pilot project in Japan. As a modification, the initial list of barriers, facilitators, and implementation strategies to address each barrier and facilitator was prepared based on project reports and interviews with local government officers. Throughout the three rounds, the panel evaluated predefined barriers and facilitators, suggested and evaluated additional items, and appraised the potential effectiveness of the implementation strategies on barriers and facilitators which they were meant to address. The importance of barriers and facilitators, and the potential effectiveness of implementation strategies were evaluated using 5-point Likert scale. The priority of the combinations of barriers, facilitators, and implementation strategies were determined considering their importance and effectiveness. RESULTS: A total of 31 experts participated in the panel. Response rates were 96.8%, 80.6%, and 90.3% for the first, second, and third rounds, respectively. A total of 13 barriers, eight facilitators, and 72 implementation strategies corresponding to the barriers and facilitators reached consensus. At the national government level, a barrier-strategy combination of "lack of legislation (barrier)" and "legislation for CDR (strategy)," and a facilitator-strategy combination of "good multi-agency collaboration (facilitator)" and "official notices from the national government (strategy)" were at the highest priority. At the local government level, combinations of "lack of legislation (barrier)" and "constant budget allocations (strategy)," "lack of legislation (barrier)" and "citizens' acceptance (strategy)," and "good multi-agency collaboration (facilitator)" and "appointment of a full-time staff (strategy)" were at the highest priority. CONCLUSION: This study demonstrated that legislation is the key to better implementation of CDR in Japan. Legislation can address various barriers such as personal information collection, multi-agency collaboration, high workload, and budget instability. Without legislation, careful strategies must be taken to solve difficulties caused by its absence. TRIAL REGISTRATIONS: None.

Gestational exposure to landscape fire increases under-5 child death via reducing birthweight: A risk assessment based on mediation analysis in low- and middle-income countries.

BACKGROUND: Exposure to landscape fire smoke (LFS) is linked to child mortality and birthweight. It is unknown whether gestational exposure to LFS affects child survival rate. We aimed to link under-five death (U5D) to gestational LFS exposure by performing a causal mediation analysis based on birthweight. METHOD: We conducted a sibling-matched case-control study of children under 5 years of age who were affiliated with the same mothers from Demographic and Health Surveys in 54 low- and middle-income countries, during the period from 2000 to 2014. LFS exposure was quantified as the surface concentration of fine particulate matter (PM2.5) attributable to landscape fires, estimated using a global atmospheric model. Three pairwise associations between fire-sourced PM2.5, birthweight, and U5D were assessed using fixed-effects regressions. We used a bootstrap-based mediation test of regression coefficients to examine whether the LFS-birthweight-U5D pathway was statistically significant. We also conducted three pairwise exposure-response functions using nonlinear models and used them to estimate the pathway-specific disease burden from 2000 to 2014. RESULTS: After adjustments for multiple confounders, each 1-µg/m3 increase in gestational exposure to fire-sourced PM2.5 was associated with a reduction of 2.179 (95% confidence interval [CI]: -3.777, -0.580) g in birthweight. Each 1-g birthweight reduction was associated with a 0.072% (95% CI: 0.065%, 0.078%) increase in U5D. Furthermore, each increase in exposure to fire-sourced PM2.5 was associated with a 2.853% (95% CI: 0.835%, 4.911%) increase in U5D; 7.294% (95% CI: 0.710%, 24.254%) of the linkage was explained by LFS-attributable birthweight reduction. Based on the estimated exposure-response functions, from 2000 to 2014, global exposure to fire-sourced PM2.5 contributed a mean birthweight reduction of 10.30 (95% CI: 2.93, 19.47) g, contributing to 60,350 (18,111, 106,619) premature U5Ds annually. CONCLUSION: In low- and middle-income countries, gestational exposure to LFS can increase mortality during infancy; appropriate interventions are needed to promote health in childhood.

Classification of sleep-related sudden unexpected death in infancy: A national survey.

AIM: To identify how British Child Death Overview Panels (CDOPs) and paediatric pathologists classify cause of death for sleep-related Sudden Unexpected Death in Infancy (SUDI). To determine compliance with national requirements for SUDI investigation. METHODS: Electronic survey of CDOPs and pathologists using three vignettes of SUDI cases illustrating: accidental asphyxia, typical Sudden Infant Death Syndrome (SIDS) and SIDS with co-sleeping. RESULTS: Thirty-eight (41%) of 92 CDOPs returned questionnaires, and 32 were complete. Thirteen (14%) of 90 pathologists returned complete questionnaires. Thirty-one (97%) CDOPs and 7 (53%) pathologists agreed with the cause of death in the accidental asphyxia case; 24 (75%) CDOPs and 9 (69%) pathologists in the typical SIDS case; and 11 (34%) CDOPs and 1 (8%) pathologist in the co-sleeping SIDS case. Pathologists used the terms SUDI or unascertained as the cause of death for the accidental asphyxia case (46%) and the co-sleeping SIDS case (77%). These terms were used by CDOPs for the typical SIDS case (25%) and the co-sleeping SIDS case (41%). Seventeen (46%) CDOPs reported compliance with guidelines for investigation in more than 75% of cases. CONCLUSION: There is wide variation in classification of deaths, with only limited agreement between CDOPs and pathologists. The terms SIDS and accidental asphyxia are underused, even in typical cases.

Gender Differences in Mental Health of Bereaved Parents in an Only-Child Society: Evidence From China.

This study examined gender differences in mental health of bereaved parents related to the gender of deceased only child in China, an only-child society with traditional culture of son preference, using data drawn from the China Family Planning Survey on Vulnerable Households in 2017. The findings indicated that parents with deceased only child suffered from more negative mental health symptoms than nonbereaved parents. For only-child-death families, there were no statistically significant gender differences in mental health of parents, and the gender of the deceased only child was basically unrelated to maternal/paternal mental health. Due to the implementation of one-child policy in China, both sons and daughters are highly prized and equally relied on by aging parents owing to the irreplaceability of the only child, which might moderate the effects of traditional culture of son preference on bereaved parental mental health.

Punishing Mothers for Men's Violence: Failure to Protect Legislation and the Criminalisation of Abused Women.

This article explores the gender dynamics of 'causing or allowing a child to die', contrary to the Domestic Violence, Crime and Victims Act 2004, section 5. This offence was intended to allow for prosecution where a child had been killed and it was uncertain who had killed him/her, but also to allow for prosecution of non-violent defendants who failed to protect him/her. More women than men have been charged and convicted of this offence signifying a reversal of usual patterns of prosecution and conviction. This analysis interrogates how section 5 criminalises women who have experienced domestic abuse. Drawing on a case observation, reported cases and media reports of cases, I suggest this offence derives from and perpetuates patriarchal constructs of motherhood. Grounded in a feminist approach building on women's concrete experiences of law, I conclude that section 5 should be amended so that it is only used where it cannot be ascertained which defendant actively harmed a child.

Death-scene investigations contribute to legal protection in unexpected child deaths in Norway.

AIM: This study reviewed cases of sudden unexpected child deaths in Norway to determine the significance of death-scene investigations (DSIs) in establishing cause and manner of death, and thereby it is relevance to legal protection. METHODS: Data from forensic autopsy reports and DSIs were collected and analysed for cases of unexpected deaths in children below 4 years of age in Norway during 2010-2016. RESULTS: Out of 141 cases, the death scene was investigated as a voluntary procedure in 75 cases and by the police in 41 cases. The cause of death remained unexplained in 81/141 (57%) of the cases, of which 46/141 (33%) met the criteria for sudden infant death syndrome (SIDS) or sudden unexplained death in early childhood (SUDC). The manner of death was determined in 102/141 (72%). Voluntary DSI increased the ability to rule out accidental suffocation, facilitated evaluations of environmental risk factors and enabled detection of possible neglect. CONCLUSION: Death-scene investigations illuminate uncertainty about the cause of death, especially in grey-area cases where accidental suffocation, neglect or abuse is suspected. Knowledge about the course of events and the cause of death enhances both the child's and the caregiver's legal protection. Death-scene investigations should therefore be mandatory.

Estimating the Burden of Prematurity on Infant Mortality: A Comparison of Death Certificates and Child Fatality Review in Ohio, 2009-2013.

Introduction Infant mortality is a key population health indicator, and accurate cause of death reporting is necessary to design infant mortality prevention strategies. Death certificates and child fatality review (CFR) both track leading infant causes of death in Ohio but produce different results. Our aim was to determine the frequency and characteristics of differences between the two systems to understand both cause of death ranking systems for Ohio. Methods We linked and analyzed data from death certificates and CFR records for all infant deaths (aged < 1 year) in Ohio during 2009-2013. Death certificate and CFR cause of death assignments were compared. Kappa statistic was used to measure concordance. Death certificate-CFR cause of death pairs were plotted to identify common concordant and discordant pairs. Results A total of 5030 infant deaths with death certificate and CFR records were analyzed. The most common discordant cause of death pair was other perinatal condition on the death certificate and prematurity by CFR (1119). Specific injury categories had higher concordance (kappa 0.71-1.00) than medical categories (kappa 0.00-0.78). Among 456 deaths categorized as sudden infant death syndrome on death certificates, approximately 50% (230) were categorized as missing, unknown, or undetermined by CFR. Discussion Linking death certificate and CFR causes of death provided a more robust understanding of infant causes of death in Ohio. Separately, each system serves distinct and valuable purposes that should be reviewed before selecting one system for ranking leading causes of infant mortality.

Maternal Grief: A Qualitative Investigation of Mothers' Responses to the Death of a Child From Cancer.

This study explored bereaved mothers' responses to the death of a child from cancer, with a focus on identifying adaptive and complicated grief reactions. To understand the unique meaning of their loss, in-depth interviews were conducted with 13 mothers at two time points. Interpretative phenomenological analysis-guided by meaning-making theories of loss-revealed five master categories: the perceptions of the child's life with cancer and death from the disease, changed self-identity, coping style, developing an ongoing relationship to the deceased child, and the postdeath social environment. Each of these master categories and associated subthemes provided insights into the characteristics of the bereaved mothers' adaptive and complicated grief responses to their loss. Given all the mothers evidenced multiple forms or types of these responses over time, they could not be categorized as adaptive or complicated grievers. However, the varying proportions of each of these responses highlighted differences in overall bereavement adaptation.

Health and Demographic Surveillance Systems Within the Child Health and Mortality Prevention Surveillance Network.

Health and demographic surveillance systems (HDSSs) provide a foundation for characterizing and defining priorities and strategies for improving population health. The Child Health and Mortality Prevention Surveillance (CHAMPS) project aims to inform policy to prevent child deaths through generating causes of death from surveillance data combined with innovative diagnostic and laboratory methods. Six of the 7 sites that constitute the CHAMPS network have active HDSSs: Mozambique, Mali, Ethiopia, Kenya, Bangladesh, and South Africa; the seventh, in Sierra Leone, is in the early planning stages. This article describes the network of CHAMPS HDSSs and their role in the CHAMPS project. To generate actionable health and demographic data to prevent child deaths, the network depends on reliable demographic surveillance, and the HDSSs play this crucial role.

Black, White, and Hispanic Children's Health and Function 2-13 Months After Sibling Intensive Care Unit Death.

OBJECTIVE: To describe children's anxiety, depression, behaviors, and school performance at 2-13 months after sibling neonatal/pediatric intensive care unit (NICU/PICU) or emergency department (ED) death and compare these outcomes by child age, sex, race/ethnicity, whether the child saw their sibling in the NICU/PICU/ED, and attended the sibling's funeral. STUDY DESIGN: Children in 71 families were recruited for this longitudinal study from 4 children's hospitals and 14 other Florida hospitals. Children rated anxiety (Spence Children's Anxiety Scale) and depression (Children's Depression Inventory); parents rated child behaviors (Child Behavior Checklist) and reported school performance (detentions, suspensions, requested parent-teacher meetings) at 2, 4, 6, and 13 months post-sibling death. Analyses included repeated measures-ANOVA, t-tests, and 1-way ANOVA. RESULTS: In total, 132 children and 96 parents participated. More children were female (58%), black (50%), and school-age (72%). Of the children, 43% had elevated anxiety and 6% had elevated depression over 13 months post-sibling death. Child-rated anxiety was higher for girls and black vs white children. Child-rated anxiety and depression were lower if they saw their sibling in the NICU/PICU/ED before and/or after the death, and/or attended the funeral. Teens were more withdrawn than school-age children at all time points. Children who did not see their deceased sibling in the NICU/PICU/ED after death had more requests for parent-teacher conferences. CONCLUSIONS: Children's anxiety was more common than depression, especially in girls and black children. Children who saw their siblings in the NICU/PICU/ED before/after death and/or attended funeral services had lower anxiety and depression over the first 13 months after sibling death.

The Effects of Conflict on Fertility: Evidence From the Genocide in Rwanda.

Our study analyzes the fertility effects of the 1994 genocide in Rwanda. We study the effects of violence on both the duration time to the first birth in the early post-genocide period and on the total number of post-genocide births per woman up to 15 years following the conflict. We use individual-level data from Demographic and Health Surveys, estimating survival and count data models. This article contributes to the literature on the demographic effects of violent conflict by testing two channels through which conflict influences fertility: (1) the type of violence exposure as measured by the death of a child or sibling, and (2) the conflict-induced change in local demographic conditions as captured by the change in the district-level sex ratio. Results indicate the genocide had heterogeneous effects on fertility, depending on the type of violence experienced by the woman, her age cohort, parity, and the time horizon (5, 10, and 15 years after the genocide). There is strong evidence of a child replacement effect. Having experienced the death of a child during the genocide increases both the hazard of having a child in the five years following the genocide and the total number of post-genocide births. Experiencing sibling death during the genocide significantly lowers post-genocide fertility in both the short-run and the long-run. Finally, a reduction in the local sex ratio negatively impacts the hazard of having a child in the five years following the genocide, especially for older women.

Firearm suicide among youth in the United States, 2004-2015.

Suicide is a leading cause of death among children in the United States; firearms cause 37% of these deaths. Research is needed to better understand firearm accessibility among youth at risk for suicide. We reviewed data from the National Fatality Review Case Reporting System (NFR-CRS). Firearm suicide deaths of children ages 10-18 occurring 2004 through 2015 with completed suicide-specific section were included. Children who had talked about, threatened or attempted suicide were identified as "Greater Risk" (GR). Odds ratios (OR) and 95% confidence intervals (95%CI) were calculated. Of the 2106 firearm suicide deaths, 1388 (66%) had a completed NFR-CRS suicide section. Of these, 36% (494/1388) met the criteria for GR. Firearms were less likely to be stored in a locked location for GR children [adjusted OR 0.62, (95%CI 0.49-0.98)]. Strategies to limit firearm access, particularly for GR youth, should be a focus of suicide prevention efforts.

Childhood death rates declined in Sweden from 2000 to 2014 but deaths from external causes were not always investigated.

AIM: Countries that conduct systematic child death reviews report a high proportion of modifiable characteristics among deaths from external causes, and this study examined the trends in Sweden. METHODS: We analysed individual-level data on external, ill-defined and unknown causes from the Swedish cause of death register from 2000 to 2014, and mortality rates were estimated for children under the age of one and for those aged 1-14 and 15-17 years. RESULTS: Child deaths from all causes were 7914, and 2006 (25%) were from external, ill-defined and unknown causes: 610 (30%) were infants, 692 (34%) were 1-14 and 704 (35%) were 15-17. The annual average was 134 cases (range 99-156) during the study period. Mortality rates from external, ill-defined and unknown causes in children under 18 fell 19%, from 7.4 to 6.0 per 100 000 population. A sizeable number of infant deaths (8.0%) were registered without a death certificate during the study period, but these counts were lower in children aged 1-14 (1.3%) and 15-17 (0.9%). CONCLUSION: Childhood deaths showed a sustained decline from 2000 to 2014 in Sweden and a quarter were from external, ill-defined or unknown causes. Systematic, interagency death reviews could yield information that could prevent future deaths.

Unintentional Injury Deaths among Children: A Descriptive Study Using Medico-legal Documents in Okayama Prefecture, Japan (2001-2015).

According to the World Health Organization's World Report, approx. 950,000 children and young people < 18 years old die from an injury each year, and unintentional injury deaths account for a large portion of these cases. Here we used medico-legal documents to epidemiologically analyze the cases of unintentional injury deaths among children < 5 years old in Okayama Prefecture, Japan from 2001 to 2015. Age, sex, manner/cause of death, and various circumstances of the incident were investigated. There were 73 unintentional injury deaths during the study period. Drowning (n=29), suffocation (n=24), and transport accidents (n=13) were the major categories of unintentional injury deaths. Twenty-two cases (30.1%) were autopsied. Differences in the characteristics of the unintentional injury deaths by age were observed. Information which cannot be obtained from Vital Statistics was available from medico-legal documents, and detailed characteristics of unintentional injury deaths among children < 5 years old were elucidated. Investigating medico-legal information is one of the meaningful measures for the prevention of unintentional injury deaths among children in Japan.