A third spike in deaths among infants in Scotland has triggered an investigation by public health experts.
The alarm was raised when figures revealed that the post-neonatal mortality rate had breached an upper warning threshold in April, for the first time since monthly monitoring began.
It comes amid an ongoing investigation into unusual levels of neonatal deaths.
Babies who die after they are four weeks old but before their first birthday are counted as post-neonatal deaths.
Previous research has indicated that - besides birth defects - the most common causes of death among infants in this age group include circulatory system diseases, sepsis, and renal failure.
Public Health Scotland (PHS) said there were "no unusual patterns in cause of death" to explain the spike in April, and that there is "no evidence that the increase in infant mortality is due to problems in maternity or neonatal health services".
The investigation was launched automatically when the post-neonatal mortality rate in April hit 2.8 per 1000 live births - slightly above a red line known as the control limit.
It is the first time since monthly surveillance began in July 2017 that this threshold has been exceeded.
READ MORE: Retired consultant appointed to chair review in neonatal deaths spike
PHS use this control limit along with a lower threshold known as the warning limit to gauge whether month-to-month fluctuations are out of the ordinary.
The limits "take into consideration the random variation between months that would be expected by chance" to identify "when values are unexpectedly low or high and require further investigation".
The statistics also reveal that the stillbirth rate in April was the highest since monthly monitoring began, at 6.1 per 1000 births.
In both cases, the stillbirth rate and the post-neonatal mortality rate had returned to normal levels by May.
A spokesman for the Scottish Government stressed that the stillbirth rate in Scotland has fallen by 35% since 2007 and the "overall trend remains downwards".
However, PHS - which reports the findings on a monthly dashboard - states that its analysis has also identified an "upward 'shift' in the infant mortality rate" between October 2022 and May 2023 when compared against the pre-pandemic norm from 2017 to 2019.
A "shift" is observed when there is a sequence of eight months or more of data where the findings are consistently above average.
Between October 2022 and May 2023, the infant death rate - which covers all deaths in the first year of life, but not stillbirths - was consistently above this expected level, known as the "centreline".
PHS states: "This pattern suggests there has been a sustained period when infant mortality rates were higher than pre-pandemic levels, rather than fluctuating around this level as would be expected with random variation."
There was also a shift in infant mortality between April 2021 and November 2021.
Prior to 2021, no such shifts were observed as part of this monthly surveillance.
READ MORE: Investigation launched amid second 'highly unusual' spike in neonatal deaths
Dr Lynda Fenton, a consultant at Public Health Scotland, said: “Every stillbirth and infant death is a tragedy for the families involved.
"PHS has reviewed the death records of the babies that died in the post-neonatal period in April 2023 to confirm that no unusual patterns in cause of death are evident.
"There is also currently no evidence that the increase in infant mortality is due to problems in maternity or neonatal health services."
It comes against the backdrop of an ongoing probe into two mystery spikes in the neonatal mortality rate in Scotland in September 2021 and March 2022, when first 21 and then 18 newborn babies sadly died.
Retired consultant neonatologist, Dr Helen Mactier - a Glasgow-based former president of the British Association of Perinatal Medicine (BAPM) - has been appointed by Healthcare Improvement Scotland to chair the expert review.
It was commissioned by the Scottish Government in September last year to examine all deaths among newborn babies between April 2021 and March 2022 "to find out if there is anything that may have contributed to the increase".
The review is expected to report its findings before the end of the year.
Preliminary evaluations by PHS failed to identify any link to Covid infections in mothers or infants, and worldwide studies have repeatedly shown that Covid vaccinations are safe in pregnant women.
Sarah Stock, a professor in maternal and foetal health at Edinburgh University, previously told the Herald that it was “entirely plausible” that short-staffing and pandemic pressures had played a part.
Since October 2021, a National Hub - jointly operated by Healthcare Improvement Scotland and the Care Inspectorate, with funding from the Scottish Government - has been tasked with reviewing all deaths of children in Scotland up to the age of 18, or 26 for care leavers.
A spokesman for the Scottish Government said: “Every baby’s death is a tragedy and has a profound impact on their loved ones.
"We are committed to ensuring that all maternity care is as safe as possible for mothers and babies and that when deaths occur, any improvements are identified and acted on."
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