What guidelines are accepted for an infant death audit to ensure adherence to established standards of care?

Accepted References for Infant Death Audit

For an infant death audit, the most widely accepted reference framework is the American Academy of Pediatrics (AAP) Child Fatality Review guidelines, which mandate that every child death should be investigated appropriately and reviewed by a Child Fatality Review Team (CFRT), with specific emphasis on standardized investigation protocols for sudden unexpected infant deaths (SUID). 1

Core Standards for Infant Death Audit

Required Investigation Components

Every unexpected infant death must have a sudden unexpected infant death investigation reporting form (or jurisdictional equivalent) completed by appropriately trained local death investigators. 1 This standardized approach is critical because:

• Death certificates alone significantly undercount actual causes of infant mortality, with the actual number being 2-3 times larger than reported 1
• Scene investigation and review of clinical history are required in addition to autopsy, as cause of death cannot usually be determined by autopsy alone 1
• Standardized guidelines for conducting thorough case investigations exist but have not been uniformly adopted across the more than 2,000 US medical examiner and coroner jurisdictions 1

Multidisciplinary Review Team Composition

CFRTs should include pediatric physician representation with expertise in neonatal and infant care. 1 The team should comprise:

• Pediatricians or neonatologists who can interpret medical history and disease processes 1
• Medical examiners or coroners 1
• Death scene investigators 1
• Social service representatives 1
• Public health officials 1

Classification and Reporting Standards

Deaths should be classified using standardized terminology and definitions to ensure accurate reporting. 2, 3 Specifically:

• Early neonatal mortality encompasses deaths from day 0 through day 7 after birth 2
• Late neonatal mortality covers deaths between 8 and 28 days after birth 2
• Deaths should be classified by gestational age and birthweight when available 2
• When early neonatal deaths occur in multiple birth sets, this must be explicitly reported 2

Autopsy Requirements

A timely autopsy performed by a certified pediatric forensic pathologist is required for unexpected infant deaths, including SUID cases, when available. 1 This is particularly important because:

• Pathologic findings alone cannot determine suffocation without strong scene investigation evidence 1
• Ancillary studies may be less sensitive in newborns than older children, requiring longer observation periods and repeated examinations 1

Data Collection and Documentation

The National Fatality Review Case Reporting System (NFR-CRS) provides the standardized framework for documenting infant death reviews. 1 Key documentation requirements include:

• Complete medical records from all healthcare providers 1
• Death scene investigation findings 1
• Autopsy results with specific cause determination 1
• Sleep environment details at time of death 1
• Infant health history 1

Common Pitfalls in Classification

Death certifiers represent a diverse group with varying diagnostic preferences, leading to inconsistent reporting. 1 Specific issues include:

• Some certifiers have abandoned using SIDS as a cause-of-death explanation entirely 1
• Others will not classify a death as suffocation without pathologic markers of asphyxia at autopsy, even with strong scene investigation evidence 1
• The term "SIDS" is used less frequently, with increases in "Unknown" and "accidental strangulation and suffocation in bed" classifications 1

Quality Improvement Through Audit

Perinatal mortality audits must use standardized audit tools and adequately trained staff to identify substandard care factors. 4, 5 The audit process should:

• Identify failure in timely detection and management of antenatal maternal and fetal conditions 4
• Document late presentation or failure to escalate care 4
• Complete the audit cycle with continuous re-evaluation of recommended changes 4
• Provide tactful feedback to primary care providers and medical agencies where statutes allow 1

Barriers to Address

Incomplete datasets, nonstandard audit methods and classifications, and inadequate staff training are the primary barriers to successful audit implementation. 4 To overcome these:

• Use uniform classification systems within the organizational jurisdiction 5
• Ensure comprehensive professional training on conducting death reviews 1
• Implement the PSANZ (Perinatal Society of Australia and New Zealand) classification system or equivalent standardized framework 5

Legal and Ethical Considerations

Once the audit criteria are fulfilled and death is declared, families must understand their child meets legal criteria for death, and continuation of medical therapies is no longer an option unless organ donation is planned. 1 The audit process should:

• Never be rushed or take priority over family needs 1
• Provide clear communication using simple terminology 1
• Allow adequate time for families to grieve 1
• Consult medical examiner or coroner as required by state law 1