CME Author: Zeena Nackerdien
Study Authors: Rebecca M. Cunningham, Maureen A. Walton, et al.
Target Audience and Goal Statement: Pediatricians and primary care physicians
The goal was to examine the major causes of death in children and adolescents in the U.S.
Background and Questions Addressed:
Every 5 seconds, a child under the age of 15 dies, the 2018 United Nations Inter-Agency Group for Child Mortality Estimation (UN IGME) report found. Most of these deaths happen within the first 5 years of life and can be prevented through improvements in public health measures (e.g., clean water, vaccines, medicines, more health facilities, and doctors).
Fortunately, in the U.S. and other developed countries, death before the age of 5 is no longer a common occurrence; however, the U.S. has the worst child mortality rate among 20 wealthy nations, despite greater per capita spending on healthcare for children.
The investigators sought to address the following questions in their special report:
- What are the leading causes of death in U.S. children and adolescents?
- Can trends be inferred that will enable the development of proactive interventions to prevent or reduce child and teen deaths in the U.S.?
Synopsis and Perspective:
The CDC Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) information management system makes health-related data sets available to all healthcare stakeholders. Topics managed by CDC WONDER include U.S. births, deaths (death certificates from 57 vital-statistics jurisdictions), cancer diagnoses, tuberculosis cases, vaccinations, environmental exposures, and population estimates.
Rebecca M. Cunningham, MD, of the University of Michigan’s Injury Prevention Center in Detroit, and colleagues, sifted through 20,360 childhood and adolescent deaths in the U.S. (ages 1 to 19), as counted by the CDC WONDER database in 2016. Among the leading causes of 2016 child and adolescent death in order of frequency were (crude rates were calculated as deaths per 100,000 with 78,134,923 as the population denominator): all injury-related causes (12,336 deaths; 60.6%) > cancer (1,853 deaths; 9.1%) > suffocation (1,430 deaths; 7%) > drowning (995 deaths; 4.9%) > drug overdose or poisoning (982 deaths; 4.8%) > congenital anomalies (979 deaths; 4.8%) > heart disease (599 deaths; 2.9%) > fire or burns (340 deaths; 1.7%) > chronic lower respiratory disease (274 deaths; 1.3%).
When taking a closer look at all injury-related causes, motor vehicle crashes emerged as the top single cause of death (4,074 deaths; 20.0%), followed closely by firearm-related injury (3,143 deaths; 15.4%). Although prevention efforts have cut the death rate in half for motor vehicle accidents, the number 2 cause of death — all forms of firearm-related injury — has remained relatively unchanged for nearly two decades. That rate of almost 8 children a day is 36.5 times as high as the overall rate observed in 12 other high-income countries (4.02 per 100,000 [95% CI 3.88-4.16] vs 0.11 per 100,000 [95% CI 0.08-0.15]).
Most youths who died did so during adolescence (68%), with injury deaths from motor vehicle crashes, firearms, and suffocation listed as the top three causes of death for those 10-19 years of age. Trends differed for younger children (5-9 years of age), with malignant neoplasms, motor vehicle crashes, and congenital abnormalities being counted as among the leading causes of death. Drowning was the most common cause of death for children 1-4 years of age, followed by congenital abnormalities, and motor vehicle crashes.
Although the proportion of deaths due to malignant neoplasms — the sole non-injury related cause among the top 3 causes of death — is high (9%), this percentage represents a 32% reduction between 1990 and 2016. Cunningham and colleagues ascribed this progress to advances in pediatric cancer prevention and disease management.
Study investigators also noted overall mortality disparities based on other variables (e.g., rural setting, race, ethnic group, and sex). Children in rural settings (33.4 per 100,000; 95% CI 32.4-34.5) were more likely to die compared to those living in suburban (27.5 per 100,000; 95% CI 26.8-28.0) or urban settings (23.5 per 100,000; 95% CI 23.0-23.9). Adolescent males died at higher rates than females, with the most pronounced disparity seen for firearm deaths (5.1 times the rate among females). Mortality rates were also higher for blacks (38.2 per 100,000; 95% CI 37.1-39.3) and American Indians or Alaska Natives (28.0 per 100,000; 95% CI 25.4-30.9) than among whites (24.2 per 100,000; 95% CI 23.8-24.6) and Asians or Pacific Islanders (15.9 per 100,000; 95% CI 14.8-17.0), according to the investigators.
Study limitations include the possibility that CDC WONDER data may have underestimated rates of death among Hispanics. Overall, the information did not include poverty variables. A consensus has emerged from the literature that poverty is a key risk factor for injury across all age groups.
Source Reference: New England Journal of Medicine 379:2468-2475, Dec. 20, 2018
Study Highlights: Explanation of Findings
Using publicly available death certificates from the CDC WONDER database, this study is the first examination of all causes of child and adolescent deaths tallied by both mechanism and intent. It is also the first temporal examination of all the top causes. The major cause of death by far was lethal traumatic injury — approximately 61% vs 9% for cancer. The statistics reflects a mixture of good and bad news.
About 40% of children under the age of 5 used to die from pneumonia, tuberculosis, and diarrhea or enteritis in the 1900s. Because of medical, public health, and other prevention strategies, that is no longer the case. Advances in medical and prevention strategies account for the reductions in deaths due to cancer, drowning, and residential fires. Greater focus on pool safety, installation of smoke detectors, and improved building fire codes are among the reasons cited for lowering the latter two causes of death. Because of safety measures such as seat belts and installation of child safety seats, and other measures, a decrease in deaths due to motor vehicle crashes was also noted between 2007 and 2016.
However, when focusing on the time interval between 2013 and 2016, the investigators noted an annual upward trend in crashes. There may be many reasons for this negative result, including distracted teen driving. Edward W. Campion, MD, NEJM executive editor, in an accompanying editorial, suggested that “tougher laws and enforcement can save lives, but perhaps new technological solutions will be necessary to help keep eyes on the road rather than on small screens.”
Campion also noted that the second-leading cause of injury-related death, firearm injury, was “only a minor contributor to childhood mortality in other developed countries.”
Lead author Cunningham made separate comments to Michigan News in which she noted that “…firearm-related deaths occur at about the same rate in urban, rural and suburban settings. Firearm deaths of children and adolescents are an ‘everybody’ problem, not a problem for just (a) certain population,” she said. “Homicides account for 60% of those deaths, suicide about 35%, unintentional or accidental injuries about 1%, and mass shootings slightly less than 1%.”
Unintentional injuries were the most common cause of injury-related death (57%; 7,047 of 12,336 deaths). Unintentional injuries due to firearms were the leading cause of death for children between the ages of 1 and 9.
Opioid misuse is also woven into the overall grim statistics, with 3.6% of adolescents ages 12 to 17 reporting misuse of these medications in 2016, according to the Office of Adolescent Health, U.S. Department of Health and Human Services.
Campion reiterated a point made in a separate study which found that a child or adolescent in the U.S. was 57% more likely to die by the age of 19 years vs their counterparts in other wealthy nations. For the current study, the investigators acknowledge that comparisons were only made for 2016 data, but point out that their findings were similar to prior analyses using multiple years of data.
Taken together, the editorialist noted that “we ought to agree that in a country with America’s wealth and resources, children should have the opportunity to live, play, and grow to become adults.”
Molly Walker wrote the original story for MedPage Today.