Shedding light on a million annual deaths in mid-childhood
Authors: Li Liu, George Patton
Journal: The Lancet (2019)

Premature mortality remains a potent catalyst for health action. For children younger than 5 years, it has been the major driver of policy and programming for the past two decades.1Liu L Oza S Hogan D et al.Global, regional, and national causes of under-5 mortality in 2000–15: an updated systematic analysis with implications for the Sustainable Development Goals.Lancet. 2016; 388: 3027-3035Summary Full Text Full Text PDF PubMed Scopus (1757) Google Scholar By contrast, deaths in older children and younger adolescents have been generally considered relatively low in numbers and have been largely overlooked.2Every Woman Every ChildGlobal strategy for women's, children's and adolescents' health (2015–2030). Every Woman Every Child, New York, NY2015Google Scholar More recent efforts to document patterns of death in 10–14-year-olds have proven challenging, largely because global data systems have focused on other age groups, reflecting earlier policy priorities. The result has been weak primary data at a time of life when patterns of death change markedly with the growth of the individual child.3Patton GC Azzopardi P Missing in the middle: measuring a million deaths annually in children aged 5–14 years.Lancet Glob Health. 2018; 6: e1048-e1049Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar Recent efforts from the UN Interagency Group for Child Mortality Estimation suggested that nearly 1 million 5–14-year-olds die each year, constituting a substantial minority of all childhood and adolescent deaths.4United Nations Inter-agency Group for Child Mortality EstimationLevels & trends in child mortality: report 2018. Estimates developed by the United Nations Inter-agency Group for Child Mortality Estimation. United Nations Children's Fund, New York, NY2018Google Scholar This understanding has brought calls for a better grasp of the causes of death in middle childhood.5Bundy DAP de Silva N Horton S Patton GC Schultz L Jamison DT Investing in child and adolescent and development: key messages from Disease Control Priorities.Lancet. 2017; 391 (3rd Edition): 687-699Summary Full Text Full Text PDF PubMed Scopus (111) Google Scholar Major causes of early childhood death, such as pneumonia and diarrhoea, are recognised to continue into later childhood, whereas deaths due to predominantly adolescent and adult causes, such as injury and maternal causes, emerge from puberty.6Kassebaum N Kyu HH Zoeckler L et al.Child and adolescent health from 1990 to 2015: findings from the Global Burden of Diseases, Injuries, and Risk Factors 2015 Study.JAMA Pediatr. 2017; 171: 573-592Crossref PubMed Scopus (242) Google Scholar These shifting patterns of death have different determinants and require different responses. In this context, data on causes of death at different ages are essential for driving effective policy and programme responses. In The Lancet, Shaza Fadel and colleagues' analysis7Fadel SA Boschi-Pinto C Yu S et al.Trends in cause-specific mortality among children aged 5–14 years from 2005 to 2016 in India, China, Brazil, and Mexico: an analysis of nationally representative mortality studies.Lancet. 2019; (published online March 12.)http://dx.doi.org/10.1016/S0140-6736(19)30220-XSummary Full Text Full Text PDF PubMed Scopus (29) Google Scholar of data on 244 401 deaths in children aged 5–14 years from nationally representative mortality studies provides important insights into causes of death across these middle years of childhood for four populous middle-income countries. India stands out with its continuing high rates of child deaths from communicable or nutritional diseases, with about 74 000 deaths in 2016, more than half of which were caused by diarrhoea, malaria, and pneumonia. These deaths constitute just under half of 160 000 all-cause deaths in India among children aged 5–14 years8Masquelier B Hug L Sharrow D et al.Global, regional, and national mortality trends in older children and young adolescents (5–14 years) from 1990 to 2016: an analysis of empirical data.Lancet Glob Health. 2018; 6: e1087-e1099Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar—a fraction much higher than that in China, Brazil, and Mexico. Injury rates, including drowning and traffic accidents for boys and drowning for girls, also remained high, leading to about 47 000 deaths in India in 2016. China has continued to make great progress around communicable diseases, but road traffic injuries and drowning together with non-communicable diseases now stand out as priorities, comprising nearly 80% of deaths in children aged 5–14 years in 2016.7Fadel SA Boschi-Pinto C Yu S et al.Trends in cause-specific mortality among children aged 5–14 years from 2005 to 2016 in India, China, Brazil, and Mexico: an analysis of nationally representative mortality studies.Lancet. 2019; (published online March 12.)http://dx.doi.org/10.1016/S0140-6736(19)30220-XSummary Full Text Full Text PDF PubMed Scopus (29) Google Scholar For both Brazil and Mexico, non-communicable diseases are now the predominant cause of death, although excess injury deaths in younger adolescent males contribute to marked gender differences in mortality. Fadel and colleagues' study represents an important step forwards while also highlighting the challenges ahead in collecting the data needed to set policy and research priorities and monitor change. The authors were unable to include any high-burden countries because of their poor data quality. Sub-Saharan Africa now accounts for more than half of all deaths in 5–14-year-olds, a proportion that will grow in the coming decades as a result of demographic change.8Masquelier B Hug L Sharrow D et al.Global, regional, and national mortality trends in older children and young adolescents (5–14 years) from 1990 to 2016: an analysis of empirical data.Lancet Glob Health. 2018; 6: e1087-e1099Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar Fadel and colleagues7Fadel SA Boschi-Pinto C Yu S et al.Trends in cause-specific mortality among children aged 5–14 years from 2005 to 2016 in India, China, Brazil, and Mexico: an analysis of nationally representative mortality studies.Lancet. 2019; (published online March 12.)http://dx.doi.org/10.1016/S0140-6736(19)30220-XSummary Full Text Full Text PDF PubMed Scopus (29) Google Scholar used new sources of data to estimate causes of death, but these different sources have limits such as under-reporting in the China Disease Surveillance Points System. Regarding the causes of deaths, suicide is likely to have been poorly captured due to under-reporting, even though Fadel and colleagues show that it becomes an important cause of death among children aged 10–14 years.7Fadel SA Boschi-Pinto C Yu S et al.Trends in cause-specific mortality among children aged 5–14 years from 2005 to 2016 in India, China, Brazil, and Mexico: an analysis of nationally representative mortality studies.Lancet. 2019; (published online March 12.)http://dx.doi.org/10.1016/S0140-6736(19)30220-XSummary Full Text Full Text PDF PubMed Scopus (29) Google Scholar Maternal deaths in younger adolescents might also be under-reported with changing legislation around the age of marriage in India and other countries, leading to misreporting of maternal age. Finally, in large and diverse countries such as China, India, Mexico, and Brazil, national estimates have a limited utility because different states and provinces will differ markedly in both all-cause mortality and cause-specific rates.9He C Liu L Chu Y et al.National and subnational levels and causes of child mortality in 1996–2015 in China: implications for the Sustainable Development Goals.Lancet Glob Health. 2016; 5: e186-e197Summary Full Text Full Text PDF PubMed Scopus (103) Google Scholar Many of the actions needed to reduce the death rates will be multisectoral. Responding to high rates of road traffic injury will require enforcement of appropriate legislation as well as road infrastructure to ensure that vulnerable users such as children and younger adolescents can travel safely. The prevention of drowning deaths in China or firearm deaths in Latin America will similarly be driven by policies adopted outside the health sector. Yet Fadel and colleagues' findings also indicate a need for greater action from the health sector. In India, the scaling up of vaccination has the potential to reduce diarrhoeal, meningitis, and pneumonia deaths. In low-income countries, progress in reducing mortality from non-communicable diseases has been slow and the most effective interventions will, given current knowledge, be the delivery of high-quality health care. Collecting more primary data and producing better estimates on causes of death across these middle years of childhood is now a priority.8Masquelier B Hug L Sharrow D et al.Global, regional, and national mortality trends in older children and young adolescents (5–14 years) from 1990 to 2016: an analysis of empirical data.Lancet Glob Health. 2018; 6: e1087-e1099Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 10Hill K Zimmerman L Jamison DT Mortality risks in children aged 5–14 years in low-income and middle-income countries: a systematic empirical analysis.Lancet Glob Health. 2015; 3: e609-e616Summary Full Text Full Text PDF PubMed Scopus (28) Google Scholar Initiatives such as the Countrywide Mortality Surveillance for Action programme, combining electronic registration of vital events by key informants with subsequent verbal autopsy and minimally invasive tissue sampling, might provide one strategy for gaining timely cause-specific mortality data in sub-Saharan Africa,11Institute for International ProgramsCountrywide mortality surveillance for action in Mozambique.https://www.jhsph.edu/research/centers-and-institutes/institute-for-international-programs/current-projects/countrywide-mortality-surveillance-for-action-comsa-in-mozambique/index.htmlDate accessed: February 3, 2019Google Scholar prior to the eventual scaling up of vital registration systems. With mortality in 5–14-year-olds sitting at the interface of childhood and adolescent or adult causes, there is likely to be value in extending surveillance methods used in younger and older age groups—eg, through a platform similar to the Child Health and Mortality Prevention Surveillance System.12CHAMPS NetworkMortality surveillance protocol, version 1.3. Child Health and Mortality Prevention Surveillance, Atlanta, GA2016Google Scholar Deaths from maternal causes, violence, road traffic injury, and suicide will require special efforts, but extending surveillance for these specific causes down from older adolescents and adults into these younger groups would make great sense. With growing calls to rebalance research investments toward generating better primary data, deaths in middle childhood are a high priority.13Boerma T Victora C Abouzahr C Monitoring country progress and achievements by making global predictions: is the tail wagging the dog?.Lancet. 2018; 392: 607-609Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar We declare no competing interests. Trends in cause-specific mortality among children aged 5–14 years from 2005 to 2016 in India, China, Brazil, and Mexico: an analysis of nationally representative mortality studiesMost of the deaths that occurred between 2005 and 2016 in children aged 5–14 years in India, China, Brazil, and Mexico arose from preventable or treatable conditions. This age group is important for extending some of the global disease-specific targets developed for children younger than 5 years of age. Interventions to control non-communicable diseases and injuries and to strengthen cause of death reporting systems are also required. Full-Text PDF Open Access