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Commentary From the Section on Child Death Review and Prevention

September 12, 2023

Commentary From the Section on Child Death Review and Prevention

The Section on Child Death Review and Prevention gained full status from the American Academy of Pediatrics (AAP) in 2019. We are extremely pleased that the AAP has acknowledged our efforts in the important work of preventing child deaths. We have chosen 3 pieces from Pediatrics, one from each of its first 3 quarter centuries, that attest to our process of maturation.

As Dr. Palusci’s commentary reveals, the AAP published a statement supporting child death review (CDR) in the 1990s, although during Pediatrics’ second quarter century, some jurisdictions (eg, Los Angeles County) already had initiated a CDR process. During the first quarter century of Pediatrics, although pediatricians participated in death reviews during morbidity and mortality conferences and others, such as St. Geme, submitted letters to the editor of Pediatrics, there was not a coordinated method of identifying and disseminating the information learned to the medical and legal communities. A more organized process developed and matured in the second quarter century of Pediatrics and has proven its value in the third quarter century as recounted by reports similar to the article by Schnitzer and Ewigman that is highlighted below by Dr. Bechtel.

First Quarter Century (1948–1973)

Precursors of Child Death Review

Howard Needleman, MD, FAAP

Affiliation: Professor of Pediatrics, University of Nebraska Medical Center

Highlighted Article From Pediatrics

Los Angeles County established the first formal CDR team in 1978. Nonetheless, precursors of formal CDR teams can be identified in local morbidity and mortality meetings at hospitals and in papers and letters to the editor that highlighted misadventures in health care.

Among these precursors was a letter to the editor by Dr. Joseph St. Geme in the June 1960 issue of Pediatrics. In his letter, he commented on papers from the Journal of the American Medical Association, American Journal of Diseases of Children, New England Journal of Medicine, and not surprisingly Pediatrics as well as a presentation to the Central Society for Pediatric Research regarding chloramphenicol toxicity in newborn infants. The infants affected generally were treated with chloramphenicol because of prolonged rupture of maternal membranes or “prophylactically” due to an increased risk of sepsis. Many newborns developed a clinical picture of lethargy followed by abdominal distention, cyanosis, and cardiovascular collapse followed by death 3-4 days after the first presentation of illness. The majority of deaths occurred in infants who had received more than 50 mg chloramphenicol/kg per day.

The “gray syndrome,” or as I learned it as the gray baby syndrome, and its association with chloramphenicol has been an example of a neonatal misadventure at least as long as I have been studying neonatology. Neonatology texts warn against high doses of the drug in neonates, and its use in the NICU today is quite uncommon. Other antibiotics (eg, ampicillin and gentamicin) have now replaced chloramphenicol in the treatment approach to “rule out sepsis” in the newborn. More recently, neonatologists have strived to use antibiotics more judiciously throughout an infant’s NICU hospitalization.

While the formal CDR process grew out of concerns primarily from communities focused on preventing child abuse and neglect, many CDR teams expanded those concerns and made strategic recommendations aimed to prevent all child deaths, including those that might have been avoided through better medical care. 

Thanks to Pediatrics and CDR teams, we have come a long way in our efforts to minimize preventable child deaths.

Second Quarter Century (1973–1998)

The AAP Formally Supports Child Death Review

Vincent J. Palusci, MD, MS, FAAP

Affiliation: Professor of Pediatrics, NYU Grossman School of Medicine

Highlighted Article From Pediatrics

As child maltreatment received growing recognition within medicine, it also became recognized that an important number of child deaths were preventable. Communities began multidisciplinary reviews across their systems with the hope of finding common factors that medicine, public health, social services, and other agencies could address to prevent further deaths. This 1993 statement1 from the AAP Committees on Child Abuse and Neglect and Community Health Services first described the problem, the investigation, and the CDR process. It called for pediatricians and AAP state chapters to advocate for proper death investigation and certification, autopsies for children younger than 6 years with trauma, and comprehensive review systems at the local and state levels. This statement asked pediatricians to take on the responsibility to be involved with the death review process and with training death scene investigators.

The AAP issued this 1993 statement at a critical time. Child fatality review started in Los Angeles County in 1978.2 Pediatricians in Colorado had been advocating for CDR for a decade. Ray Helfer, Abe Bergman, David Chadwick, Eli Newberger, Jay Whitworth, Vincent Fontana, and Robert Reece started reviewing cases. Richard D. Krugman, who chaired the AAP Council on Child Abuse and Neglect, and Renee Jenkins, who chaired AAP Committee on Community Health Services, hoped that the AAP would support policy initiatives such as CDR that were directed at preventing childhood deaths. The first report of the US Advisory Board on Child Abuse and Neglect3 recommended an effort to bring agencies together at local, state, and federal levels to address fatal child abuse and neglect, and their fifth and final report4 was devoted solely to child abuse fatalities. By 1992, there were interagency, multidisciplinary child death review teams in 21 States.2 Bernard G. Ewigman and colleagues5 identified that half of death certificates in Missouri were incorrect and put a system in place to improve the identification of why children died. By 2008 it became clear that a formal CDR process provided the most accurate information about how and why children died.

CDR evolved nationally and internationally in every state, the District of Columbia, several territories, and within Native American/Alaskan tribes.7 Diverse agencies share relevant records and use this information to catalyze action. State-level teams review deaths from sudden and unexplained infant deaths, unintentional injuries, accidents, suicide, homicide, abuse and neglect, and deaths in child protective services. Some review every child death of any cause, and 10 states review serious injuries or near fatalities. The National Center for Fatality Review and Prevention, funded by the US Maternal Child Health Bureau, provides technical assistance, training, and data support to programs. The Section on Child Death Review and Prevention, formally approved in 2019, provides information and education for AAP members to fulfill their roles on teams and to advocate for improvements in investigation and services. As this 1993 policy statement continues to evolve, work by the AAP has shown the value of pediatricians in the process and the importance of preventing child deaths.


  1. Committee on Child Abuse and Neglect, Committee on Community Health Services. Investigation and review of unexpected infant and child deaths. Pediatrics. 1993;92(5):734-735
  2. Durfee MJ, Gellert GA, Tilton-Durfee D. Origins and clinical relevance of child death review teams. JAMA. 1992;267(23):3172-3175
  3. Krugman RD. Child abuse and neglect: critical first steps in response to a national The report of the US Advisory Board on Child Abuse and Neglect. Am J Dis Child. 1991;l45(5):513-515
  4. United States Advisory Board on Child Abuse and Neglect. A Nation’s Shame: Fatal Child Abuse And Neglect In the United States: A Report of the S. Advisory Board on Child Abuse and Neglect: Fifth Report. Washington, DC: The Board; 1995
  5. Ewigman B, Kivlahan C, Land G. The Missouri child fatality study: Underreporting of maltreatment fatalities among children younger than five years of age, 1983 through 1986. Pediatrics. 1993;91(2):330-337
  6. Schnitzer PG, Covington TM, Wirtz SJ, Verhoek-Oftedahl W, Palusci VJ. Public health surveillance of fatal child maltreatment: analysis of 3 state Am J Public Health. 2008;98(2):296-303
  7. National Center for Fatality Review and Status of CDR in the United States, 2021.

Third Quarter Century (1998–2023)

Relationship of the Perpetrator to the Child in Maltreatment Fatalities

Kirsten Bechtel MD, FAAP

Affiliation: Professor of Pediatrics and Emergency Medicine, Yale University School of Medicine

Highlighted Article From Pediatrics

Child fatality review was first established in the US in the late 1970s. The purpose of child fatality review is to understand the mechanisms of child death, particularly unexpected and preventable ones, and provide feasible prevention practice, through polices and legislation. Child fatality review teams have been organized in most developed countries; the US has 1,350 of these teams in practice. These teams are most often multidisciplinary, involving professionals from public health, pediatric and adolescent medicine, child welfare, and legislative and law enforcement professionals.

In particular, child fatality review teams examine child maltreatment fatalities. In 2021, there were approximately 1,820 child maltreatment fatalities (2.32 per 100,000 children) in the United States. Racial disparities stand out among these deaths. The rate of Black child maltreatment fatalities is 5.68 per 100,000, which is about 3 times the rate for White children (1.96 per 100,000) and about 4 times the rate for Hispanic children (1.47 per 100,000). There are also sex differences in maltreatment fatalities, as boys have a higher child fatality rate of 3.01 per 100,000 boys in the population compared to a rate among girls of 2.15 per 100,000 girls in the population.

This article by Schnitzer et al was one of the first studies that used comprehensive data collected from the child fatality review process in Missouri to understand the perpetrator relationship to the child in cases of fatal injuries from maltreatment. The authors found that young children who were in homes where unrelated adults resided were almost 50 times more likely to die from maltreatment injury than children living in homes where 2 biological parents resided. The authors were also able to demonstrate that a child living in a home with an unrelated adult male were 8 times more likely to die from maltreatment than those children who lived at home with a single parent. Prevention of fatal maltreatment has used these data to develop thoughtful strategies to mitigate this risk of children living in homes with unrelated adult males.


McCarroll JE, Fisher JE, Cozza SJ, Whalen RJ. Child maltreatment fatality review: purposes, processes, outcomes, and challenges. Trauma Violence Abuse. 2021;22(5):1032-1041

US Department of Health & Human Services, Children’s Bureau. Child Maltreatment 2021.

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