Mortality in older children and adolescents: the forgotten ones
Authors: Harish Nair, Peter Byass
Journal: The Lancet Child & Adolescent Health (2018)

What happens in childhood has profound implications for adult life and for national development. Conventionally, particularly in the Millennium Development Goals era, attention on child health focused on under-5 mortality. Globally, under-5 mortality declined by 55% between 1990 and 2016, with Europe being one of the few regions exceeding a 70% decline.1United Nations Inter-Agency Group for Child Mortality EstimationLevels and trends in child mortality. UNICEF, New York2017https://www.unicef.org/publications/files/Child_Mortality_Report_2017.pdfGoogle Scholar But gains in under-5 mortality have not been consolidated in later childhood. Globally, the decline in mortality in children aged 5–14 years has been a more modest 44%, corresponding to an estimated mean of about 1 million (95% CI 0·9–1·1 million) deaths in 2016.1United Nations Inter-Agency Group for Child Mortality EstimationLevels and trends in child mortality. UNICEF, New York2017https://www.unicef.org/publications/files/Child_Mortality_Report_2017.pdfGoogle Scholar Thus, the continuing mortality burden in children aged 5–14 years in all regions of the world makes the detailed estimates of cause-specific mortality in this age group for the WHO European Region by Hmwe Kyu and colleagues2Kyu HH Naghavi M Mokdad AH Causes of death among children aged 5–14 years in the WHO European Region: a systematic analysis of the Global Burden of Disease Study 2016.Lancet Child Adolesc Health. 2018; (published online March 19.)http://dx.doi.org/10.1016/S2352-4642(18)30095-6Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar particularly welcome. Recognition has been increasing of the fact that, although the first 1000 days of life are crucial, the subsequent 7000 days have a pivotal role in individual development and attainment of healthy adulthood. The World Bank's third edition of Disease Control Priorities in 2017 gave particular attention to child and adolescent health.3Child and Adolescent Health Development.in: Bundy DAP de Silva N Horton S Jamison DT Patton GC Disease Control Priorities. 3rd edition. volume 8. World Bank Group, Washington, DCNovember, 2017Google Scholar The report particularly notes that the narrow focus on the first 1000 days "has not only resulted in a neglect of health services provision", but "also deflected research away" from older children (aged 5–9 years) and younger adolescents (aged 10–14 years). Analyses of cause-specific morbidity and mortality in this age group are generally sporadic, and the estimates by Kyu and colleagues2Kyu HH Naghavi M Mokdad AH Causes of death among children aged 5–14 years in the WHO European Region: a systematic analysis of the Global Burden of Disease Study 2016.Lancet Child Adolesc Health. 2018; (published online March 19.)http://dx.doi.org/10.1016/S2352-4642(18)30095-6Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar are therefore valuable. The primary purpose of these estimates should be to inform policy makers and other health actors to develop targeted intervention policies. Thus, the guiding principles for any such analysis would be what (are the leading causes), where (are deaths occurring), and who (is at risk)? Globally, although communicable diseases continue to be the largest single contributor to mortality, non-communicable diseases and injuries together contribute about half of the mortality in people aged 5–14 years.1United Nations Inter-Agency Group for Child Mortality EstimationLevels and trends in child mortality. UNICEF, New York2017https://www.unicef.org/publications/files/Child_Mortality_Report_2017.pdfGoogle Scholar GBD online estimates suggest that communicable diseases caused 69% of deaths in this age group during 2015 in the WHO African Region, accounting for most of the greater all-cause mortality in that region, in contrast to the rest of the world. Injuries were the leading cause of deaths in children aged 5–14 years in all other WHO Regions apart from the European Region, wher, by 2016, non-communicable diseases are the largest contributor (44% of deaths). In the European Region, communicable diseases (particularly lower respiratory infections) were the leading cause of deaths only in the Commonwealth of Independent States (CIS).2Kyu HH Naghavi M Mokdad AH Causes of death among children aged 5–14 years in the WHO European Region: a systematic analysis of the Global Burden of Disease Study 2016.Lancet Child Adolesc Health. 2018; (published online March 19.)http://dx.doi.org/10.1016/S2352-4642(18)30095-6Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar A recent analysis of injury-related deaths among children younger than 15 years in Europe reported that, in 2015, the leading specific causes were drowning and road traffic accidents.4Sethi D Aldridge E Rakovac I Makhija A Worsening inequalities in child injury deaths in the WHO European Region.Int J Environ Res Public Health. 2017; 14: E1128Crossref PubMed Scopus (12) Google Scholar The analysis reported a wide disparity in mortality rates for all injuries and unintentional injuries when analysed by World Bank income regions (a six-times difference between high-income countries vs low-income and middle-income countries); for some specific causes, the differences were greater, including drowning (nine times), falls (ten times), and poisonings (12 times). The analysis by Kyu and colleagues2Kyu HH Naghavi M Mokdad AH Causes of death among children aged 5–14 years in the WHO European Region: a systematic analysis of the Global Burden of Disease Study 2016.Lancet Child Adolesc Health. 2018; (published online March 19.)http://dx.doi.org/10.1016/S2352-4642(18)30095-6Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar similarly highlights the stark contrast between the most developed countries (EU15) and the least developed countries (CIS) in the WHO European Region, including a four-times difference in mortality rates from road traffic accidents and a 14-times difference from drowning.2Kyu HH Naghavi M Mokdad AH Causes of death among children aged 5–14 years in the WHO European Region: a systematic analysis of the Global Burden of Disease Study 2016.Lancet Child Adolesc Health. 2018; (published online March 19.)http://dx.doi.org/10.1016/S2352-4642(18)30095-6Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar The appendix of Kyu and colleagues' paper and other studies4Sethi D Aldridge E Rakovac I Makhija A Worsening inequalities in child injury deaths in the WHO European Region.Int J Environ Res Public Health. 2017; 14: E1128Crossref PubMed Scopus (12) Google Scholar, 5Morgan C Webb RT Carr MJ et al.Incidence, clinical management, and mortality risk following self harm among children and adolescents: cohort study in primary care.BMJ. 2017; 359: j4351Crossref PubMed Scopus (183) Google Scholar show disparities between the sexes for some causes, although not necessarily agreeing on the rates or direction of change. An analysis of linked routine data in the UK reported that self-harm (which is the sixth leading cause of death in Europe in 10–14 year olds) is not only three-times higher in girls than boys, but showed a sharp 68% increase between 2000 and 2015.5Morgan C Webb RT Carr MJ et al.Incidence, clinical management, and mortality risk following self harm among children and adolescents: cohort study in primary care.BMJ. 2017; 359: j4351Crossref PubMed Scopus (183) Google Scholar By contrast, Kyu and colleagues2Kyu HH Naghavi M Mokdad AH Causes of death among children aged 5–14 years in the WHO European Region: a systematic analysis of the Global Burden of Disease Study 2016.Lancet Child Adolesc Health. 2018; (published online March 19.)http://dx.doi.org/10.1016/S2352-4642(18)30095-6Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar do not report any sex differences in the rates of self-harm across the UK, and in fact, report a 33% decrease in the number of cases of self-harm in the corresponding period. The vast majority of deaths in people aged 5–14 years are preventable, not only in Europe but also globally. GBD analyses generally have been extremely influential in highlighting the cause-specific burden of morbidity and mortality in various age groups. Therefore, similar global and regional analyses for the 5–14 years age group based on the GBD estimates, including sex-disaggregated data for this age group that includes sex-divergent biological and behavioural risks during puberty, would undoubtedly be helpful in creating and raising awareness for child and adolescent health among policy makers and funders. These analyses should lead to improved provision of health care (targeted at the most vulnerable populations) and a will to enact appropriate risk reduction and legislation (eg, health and safety, smoke-free environments, and flour fortification), thereby enabling children and adolescents to attain their maximum potential. HN reports grants from Bill & Melinda Gates Foundation and WHO, outside of the submitted work. PB declares no competing interests. Causes of death among children aged 5–14 years in the WHO European Region: a systematic analysis for the Global Burden of Disease Study 2016Marked progress has been made in reducing the mortality burden in children aged 5–14 years over the past 26 years in the WHO European Region. More deaths could be prevented, especially in CIS countries, through intervention and prevention efforts focusing on the leading causes of death, which are road injuries, drowning, and lower respiratory infections. The findings of our study could be used as a baseline to assess the effect of implementation of programmes and policies on child mortality burden. Full-Text PDF Open AccessSurviving and thriving through childhoodNews that both neonatal and infant mortality have increased for the second year in a row—after years of steady decline—in England and Wales rang alarm bells that progress in child health in these countries is stalling. According to data released last month by the UK Office for National Statistics, neonatal deaths per 1000 livebirths increased from 2·5 to 2·7, and infant deaths per 1000 livebirths from 3·6 to 3·8, between 2014 and 2016. A report by the Nuffield Trust and the UK Royal College of Paediatrics and Child Health (RCPCH) shows that the UK has one of the highest neonatal, infant, and child mortality rates among European countries with a similar level of economic development. Full-Text PDF