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Risk status at discharge and cause of death for postneonatal infant deaths: a total population study
A Kempe1, P H Wise, N S Wampler
1Department of Pediatrics, University of Colorado Health Sciences Center, Denver, USA.
Insights
Sudden infant death syndrome is the leading cause of postneonatal mortality. Few infants discharged with high-risk conditions died, suggesting better prenatal and early childhood care strategies are needed.
Area of Science:
- Pediatrics
- Public Health
- Neonatalogy
Background:
- Postneonatal mortality (28-364 days) is influenced by modifiable factors.
- Understanding causes of death and risk factors is crucial for prevention.
- Previous studies often relied on vital statistics, not clinical data.
Purpose of the Study:
- To determine causes of postneonatal death using clinical and autopsy data.
- To identify if deaths occurred during hospitalization or after discharge.
- To assess the proportion of deaths linked to infants discharged with high-risk conditions.
Main Methods:
- Retrospective review of 386 postneonatal infant deaths across four US regions.
- Data sources included medical records, autopsy reports, and vital statistics.
- Infants discharged with high-risk medical conditions were identified.
Main Results:
- Sudden infant death syndrome (SIDS) was the leading cause (47%), followed by congenital conditions (20%).
- Infection was an associated cause in a significant portion of congenital and prematurity-related deaths.
- Only 16% of infants who died postneonatally left the hospital with identified high-risk conditions.
Conclusions:
- Postneonatal mortality has a heterogeneous etiology, making 'preventability' complex to determine.
- Most infants dying from prematurity-related causes never left the hospital.
- Reducing postneonatal mortality requires comprehensive strategies addressing risks throughout pregnancy and early childhood, not solely post-discharge follow-up.
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.
