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Introduction Infant mortality rate is a sensitive metric for population health and well-being. Challenges in achieving accurate reporting of these data can lead to inaccurate targeting of public health interventions. We analyzed a cohort from a pediatric tertiary care referral medical center to evaluate concordance between autopsy cause of death (COD) and death certificate documentation for infants <1 year of age. We predicted that infant COD as documented through vital records would not correspond to that as determined by autopsy. Methods We conducted a retrospective review comparing causes of infant death reported through Ohio Department of Health documents to those on Cincinnati Children's Hospital Medical Center autopsy reports over an 8-year period from January 1, 2006 through December 31, 2013. Results We analyzed 276 total cases of which 167 (61.5 %) represented infants born preterm. Autopsy reports identified 55 % of cases had a congenital anomaly. Additionally, 34 % of all cases had primary or contributing COD related to infection and 14.5 % of all cases indicated chorioamnionitis. We identified 156 (56.5 %) death certificates discordant with autopsy COD of which 52 (33.3 %) involved infection and 24 (15.4 %) involved congenital anomalies. Discussion There are opportunities to improve COD reporting through training for providers, and improvement of established state certification systems. Future strategies to reduce infant mortality will be better informed through enhancements in vital records COD reporting.

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have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/ investigative use of a commercial product/ device. Educational GapsTwin anemia polycythemia sequence is a rare complication of monochorionic twin pregnancies and has its own classification system that differentiates it from twin to twin transfusion syndrome. Because twin-anemia polycythemia sequence is a newly recognized condition, many clinicians are unfamiliar with the epidemiology, pathogenesis, and treatment options. AbstractTwin anemia polycythemia sequence is a rare condition in monochorionic twin pregnancies that has only recently been described. It can occur spontaneously or as a result of fetoscopic laser surgery for twin to twin transfusion syndrome. The size of the placental connections and the flow of blood between tiny anastomoses allow for chronic changes in the hemodynamic states of each fetus. The chronic nature of the pathophysiology leads to reticulocytosis in the donor twin and limits the fluid-level discrepancies between amniotic sacs, which differentiates it from twin to twin transfusion syndrome, which is thought to be an acute process. Several in utero procedures have been described to treat this condition; however, because of the rarity of the condition, data are limited. Postnatal treatment includes packed red blood cell transfusion for the donor twin and partial exchange transfusion for the recipient twin, along with standard medical neonatal care. Long-term outcomes data are limited; however, one study revealed normal neurodevelopment in a small cohort of patients.Objectives After completing this article, readers should be able to:1. Understand the pathophysiology of twin anemia polycythemia sequence. 2. Recognize diagnostic criteria of twin anemia polycythemia sequence. 3. Incorporate treatment modalities of twin anemia polycythemia sequence. 4. Discuss long-term outcomes of twin anemia polycythemia sequence.