兒童死亡回顧

Child death review

10.6288/TJPH.202002_39(1).107062

梁富文(FU-WEN LIANG)；呂立(FRANK LEIGH LU)；呂宗學(TSUNG-HSUEH LU)；江東亮(TUNG-LIANG CHIANG)；呂鴻基(HUNG-CHI LUE)

兒童死亡回顧 ； 死亡證明書 ； 可預防性 ； 兒童死亡率 ； child death review ； death certificate ； preventability ； child mortality

台灣公共衛生雜誌

39卷1期（2020 / 02 / 26）

8 - 16

繁體中文

台灣已於2019年4月24日公告修正《兒童及少年福利與權益保障法》，第13條新增「中央衛生主管機關應進行六歲以下兒童死亡原因回溯分析並定期公布分析結果」，讓兒童死亡回顧有法源依據。本文包括三個部分：首先解釋為什麼要進行兒童死亡回顧，接著簡述兒童死亡回顧的發展，最後建議如何進行兒童死亡回顧。兒童死亡回顧的定義：由跨單位跨領域代表組成的小組，分享該單位對於該兒童死亡個案相關記錄，勾勒出導致兒童死亡的較完整脈絡情境，找出可改變的因素，提出具體建議，系統性減少類似死亡事件再發生。本文建議各縣市依照四個步驟來推動兒童死亡回顧：步驟一：由府一層主管擔任兒童死亡回顧小組召集人，邀請核心成員固定參與討論；步驟二：由衛生局擔任資料小組與協作平台，整理死亡兒童基本資料與聯絡開會事宜；步驟三：依照議程進行個案討論；步驟四：撰寫會議記錄與建議報告。中央衛生主管機關應彙集不同縣市建議，擬定適當防治（制）策略，有效降低兒童死亡率。

The Protection of Children and Youth Welfare and Rights Act was amended on April 24, 2019. Article 13 indicates that health authorities must conduct a child death review (CDR) for children who die when aged 6 years and younger and periodically release analysis results. The present article includes three sections. First, we explain why CDR should be implemented. Second, we introduced the development of CDR. Third, we suggest appropriate measures to implement a CDR program. CDR is defined as a collaborative process that brings people together from different sectors and multiple disciplines to share and discuss comprehensive information on circumstances leading to the death of a child. Moreover, notable and potentially remediable factors are identified, and recommendations for system improvements are made to prevent future child deaths. Four steps were recommended to implement a CDR program at the city or county government level. Step 1: a deputy mayor or magistrate of the city or county government is appointed as the convener of the CDR team and invites core members to attend regular meetings. Step 2: the health bureau of the city or county is established as the coordinating center for the collection of basic information regarding deceased children and is responsible for arranging the meetings. Step 3: the CDR meeting agenda is followed. Step 4: meeting minutes and recommendations are recorded. Health authorities in the central government collect recommendations from city or county governments and use them to design relevant prevention and control strategies to effectively reduce child mortality.

1. 梁富文, FW,黃雅莉, YL,吳美環, MH,呂鴻基, HC,江東亮, TL,呂宗學, TH(2016)。兒童死亡率：台灣與經濟發展合作組織國家比較。台灣衛誌，35，221-233。
   連結：
2. Chritian, CW,Sege, RD(2010).Policy statement: child fatality review.Pediatrics,126,592-596.
3. Douglas, EM,Cunningham, JM(2008).Recommendations from child fatality review teams: results of a US nationwide exploratory study concerning maltreatment fatalities and social delivery.Child Abuse Rev,17,331-351.
4. Durfee, MJ,Gellert, GA,Tilton-Durfee, D(1992).Origins and clinical relevance of child death review teams.JAMA,267,3172-3175.
5. Fraser, J,Sidebotham, P,Frederick, J,Covington, T,Mitchell, EA(2014).Learning from child death review in the USA, England, Australia and New Zealand.Lancet,384,894-903.
6. Kids and Cars. Parents, consumer and safety groups applaud house committee action today for passing the Cameron Gulbransen Kids Transportation Act. Available at: https://www.kidsandcars.org/wp-content/uploads/2014/07/PR-12-18-07.pdf. Accessed May 25, 2018.
7. Moon, RY,American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome(2016).SIDS and other sleep-related infant deaths: updated 2016 recommendations for a safe infant sleeping environment.Pediatrics,138,e20162938.
8. National Center for Fatality Review and Prevention (NCFRP). Keeping kids alive: a report on the status of child death review in the United States 2017. Available at: https://www.ncfrp.org/wp-content/uploads/NCRPCD-Docs/CDRinUS_2017.pdf. Accessed July 3, 2019.
9. Onwuachi-Saunders, C,Forjuoh, SN,West, P,Brooks, C(1999).Child death reviews: a gold mine for injury prevention and control.Inj Prev,5,276-279.
10. Petrou, S,Fraser, J,Sidebotham, P(2014).Child death in high-income countries.Lancet,384,831-833.
11. Rimsza, ME,Schackner, RA,Bowen, KA,Marshall, W(2002).Can child deaths be prevented? the Arizona child fatality review program experience.Pediatrics,110,e11.
12. Sidebotham, P,Fraser, J,Covington, T(2014).Understanding why children die in high-income countries.Lancet,384,915-927.
13. Sidebotham, P,Fraser, J,Ward-Platt, M,Hain, R(2014).Patterns of child death in England and Wales.Lancet,384,904-914.
14. Sidebotham, P,Pearson, G(2009).Responding to and learning from childhood deaths.BMJ,338,b531.
15. The National Center for Child Death Review (NCCDR). A program manual for child death review. Available at: https://www.ncfrp.org/wp-content/uploads/NCRPCD-Docs/ProgramManual.pdf. Accessed July 3, 2019.
16. National Center for Fatality Review and Prevention (NCFRP). A compilation of actions taken by Fetal and Infant Mortality Review in the United States, 2016. Available at: https://www.ncfrp.org/wp-content/uploads/NCRPCD-Docs/FIMR-FindingsToAction.pdf. Accessed July 3, 2019.
17. 中華民國總統府：司法改革國是會議成果報告。https://www.president.gov.tw/NEWS/21581。引用2019/07/03。Office of the President, Republic of China (Taiwan). Report of the National Conference on Judicial Reform. Available at: https://www.president.gov.tw/NEWS/21581. Accessed July 3, 2019. [In Chinese]
18. 呂宗學, TH(2016)。,台北=Taipei:衛生福利部國民健康署=Health Promotion Administration, Ministry of Health and Welfare, R.O.C. (Taiwan)。
19. 呂宗學, TH(2016)。籌設兒童死亡個案檢討委員會芻議。兒童保健雜誌，22，50-53。
20. 呂宗學, TH,蕭安芝, AJ,徐俊強, CC,彭花春, HC,陳麗華, LH(2013)。死因診斷與死因統計品質。台灣醫學，17，551-557。
21. 呂鴻基, HC(2016)。2015後我國兒童健康福祉建言獻策。兒童保健雜誌，22，10-16。
22. 呂鴻基, HC,吳美環, MH,江東亮, TL(2016).我國兒童健康福祉新願景及建言.台北=Taipei:中華民國兒童健康聯盟=Child Health Alliance Taiwan.
23. 梁富文, FW(2018)。,台北=Taipei:衛生福利部國民健康署=Health Promotion Administration, Ministry of Health and Welfare, R.O.C. (Taiwan)。

1. 張弘潔(2023)。第二次《兒童權利公約》國際審查對台灣兒少公共衛生政策之啟示。台灣公共衛生雜誌，42(3)，271-274。