us infant injury mortality secretary’s advisory committee on infant mortality march 30, 2004 mary...
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US Infant Injury MortalityUS Infant Injury Mortality
Secretary’s Advisory Committee on
Infant Mortality
March 30, 2004
Mary D. Overpeck, DrPH
Health Resources and Services Administration
Maternal and Child Health Bureau
Infant Injury DeathsInfant Injury Deaths
• What we know
• How the information is obtained
• What we need to know to support effective prevention
Manner of Infant DeathsManner of Infant Deaths
• Natural Deaths – Congenital malformations– Conditions related to short or complicated
gestation, labor & delivery– SIDS
• Traumatic (Injury) Deaths
What is Injury?What is Injury?
• Injury is caused by acute exposure to energy, such as heat, electricity, or the kinetic energy of a crash, fall or bullet. (Gibson)
• Injury is caused by the sudden absence of essentials, such as heat or oxygen, as in the case of drowning. (Haddon)
Infant Injury Mortality Infant Injury Mortality Trends, US 1991-2001Trends, US 1991-2001
0
5
10
15
20
25
30
35
40
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
De
ath
s p
er
10
0,0
00
liv
e b
irth
s
ICD-9 ICD-10
Natural & Traumatic Deaths:Natural & Traumatic Deaths:Infants and Ages 1-4 YearsInfants and Ages 1-4 Years
Infants 1-4 Years
N % N %
Total, U.S.* 27,847 100% 5,112 100%
Natural 26,508 95% 2,850 56%
Traumatic 1,306 5% 2,237 44%
N = Average Annual Deaths, US, 1999-2001* Total includes deaths due to complications of medical and surgical care
National Sources of National Sources of Injury DataInjury Data
• Deaths– Death certificate
• Nonfatal– Medical treatment records
• hospitalizations
• emergency departments
• physicians office surveys
• Personal surveys
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
De
ath
s p
er
10
0,0
00
po
pu
lati
on
Suffocation TransportRelated
Assault NOS Abuse/ Neglect Drowning
Cause/Mechanism
Nature of Death for Leading CausesNature of Death for Leading CausesInfants and Ages 1-4 YearsInfants and Ages 1-4 Years
US, 1999-2001
<1 year
1-4 years
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
Inju
ries
per
1,0
00
po
pu
lati
on
TransportRelated
Fall StruckBy/Against
Fire/Burn Foreign Body
Cause/Mechanism
Nature of Nonfatal InjuriesNature of Nonfatal InjuriesInfants and Ages 1-4 YearsInfants and Ages 1-4 Years
Source: WISQARS, HCUP, US 2000
<1 year
1-4 years
Contrast of Cause & IntentContrast of Cause & Intent
• External Cause, examples:– drowning– suffocation (mechanical or inhalation/ingestion)– blunt force – motor vehicles– poisoning– firearms– exposures to cold or heat
• Any cause may be classified as intentional, unintentional, or undetermined intent
Determination of CauseDetermination of Cause
• Based on State requirements for examination of unexpected deaths
• State medical examiner/coroner systems
• Injury coding based on manner of death– external causes (ICD-9 ‘e-codes’)
Cause and Intent Cause and Intent for Injury Deathsfor Injury Deaths
• Differs from non-injury (natural deaths): – nature of death may not be included in
e-codes– knowledge of both nature and cause
needed
• Intent determined separately from nature
Determining Injury Intent Determining Injury Intent on Death Certificateson Death Certificates
• Unintentional (accidental)
• Intentional (homicide)
• Undetermined manner or intent
• Pending investigation
Infant Injury DeathsInfant Injury DeathsLeading Causes by IntentLeading Causes by Intent
UnintentionalN=901*
Cause %
Intentional/SuspiciousN=405*
Cause %
1. Suffocation/ 46%strangulation in bed
2. Other suffocation26% (specified nature)
3. Transportation 19%
4. Obstructivesuffocation 8%
5. Drowning 8%
6. Fire/Burn 5%
1. Child abuse/ 31%neglect
2. Assault 31% (unknown nature)
3. Suffocation 18%
4. Drowning 5%
5. Firearm 3%
6. Struck by/against 3%
*average annual deaths, 1999-2000; 2001 as available
Infant Injury DeathsInfant Injury DeathsIntent by Age at DeathIntent by Age at Death
US, 2000
0
1
1
2
2
3
3
4
4
<=6days
7-27days
2 mo 3 mo 4 mo 5 mo 6 mo 7 mo 8 mo 9 mo 10 mo 11 mo 12 mo
Infant Age
Dea
ths
per
100
,000
live
bir
ths
Unintentional
Homicide
Undetermined
Risk Factors for Risk Factors for Infant Injury DeathsInfant Injury Deaths
• Sources: Linked birth and death certificates
• Study by Brenner, et al, of about 10,500 deaths in linked files from 1983 to1991
– ranking: homicides, mechanical suffocation, motor vehicle, choking, fire, drowning
RiskRisk Factors Identified on Birth Factors Identified on Birth CertificatesCertificates
• Total deaths: Odds Ratios >2
– maternal education <12 years
– maternal age <20 years
– no prenatal care
– Native American ethnicity
– at least 2 previous pregnancies
Source: Brenner et al., 1999
Unintentional Injury Deaths: Unintentional Injury Deaths: Risk Factors Vary by CauseRisk Factors Vary by Cause
• Mechanical suffocation: – found in bed or cradle– young maternal age & >2 prior pregnancies
• Choking (from inhalation of food & objects):
– birth weight <1500 gm. or 1500-2400 gm.
• Motor vehicle:– being Native American
Source: Brenner et al., 1999
Homicide Risk FactorsHomicide Risk Factors
• Factors for homicide and undetermined (suspicious) intent very similar
• 1/2 occur by 4th month of life; 2/3 by 6th month
• Being second or later child of a mother <17 or 17-19 years old
• No prenatal care
• Maternal education <12 years
Source: Overpeck et al., 1998
Circumstances of DeathsCircumstances of Deaths
• No information on birth or death certificates
• No way to determine nature of deaths for many classified as child abuse/neglect or intentional assaults
• No information on circumstances to target specific interventions
Other Circumstances shown by Other Circumstances shown by State Record ReviewsState Record Reviews
• Native American motor vehicle deaths due to use of pick-up trucks without needed infant seats as primary family vehicles
• Males more likely to be perpetrator in homicides after 1st week of life
Circumstances of Deaths Circumstances of Deaths shown by shown by State Record State Record
ReviewsReviews– US child abuse deaths
underestimated by more than 60%*
– many deaths classified as SIDS or accidental suffocation probably child abuse or homicides*
*Herman-Giddens, 1999
Classification of SIDSClassification of SIDS
• More specific diagnosis applied recently
• Almost all SIDS cases autopsied
• Diagnostic shift from SIDS to non-specific ‘R96’ ICD classification:
– Other sudden deaths, cause unknown
• More cases reassigned to trauma
Sudden Unexpected DeathsSudden Unexpected Deaths US, 1990-2001 US, 1990-2001
0
20
40
60
80
100
120
140D
ea
ths
pe
r 1
00
,00
0 l
ive
bir
ths
SIDS
Unintentional
Intentional
SIDS and Injury DeathsSIDS and Injury DeathsCause by Age at Death, 1999-2001Cause by Age at Death, 1999-2001
0
2
4
6
8
10
12
14
16
18D
ea
ths
pe
r 1
00
,00
0 l
ive
bir
ths
SIDS
Unintentional
Intentional
ConclusionsConclusions
• Infant and early childhood injury deaths are related to developmental stages
• Risk factors guiding prevention should be specific to cause and circumstances
• Need for more review of circumstances surrounding infant and child deaths
• Need for better classification alternatives for infant and early childhood deaths
HRSA Contact InformationHRSA Contact Information
Mary OverpeckPhone: (301) 443-0694Address: HRSA/MCHB
5600 Fishers Lane, Room 18-41 Rockville, Maryland 20857
HRSA ContactsGeneral Information: (301) 443-3376HRSA Maternal and Child Health Programs: (301) 443-2170