Although life expectancy in industrialized countries has lengthened over the past century, increases in life expectancy in the U.S. ceased after 2010, a trend attributed to rising death rates among people ages 25 to 25. 64 years old . Although midlife mortality rates have increased over the past decade, mortality rates among children and older adults have continued to decline. The COVID-19 pandemic disrupted this trend and resulted in a sharp increase in mortality among older adults, an unsurprising result. However, pediatric mortality rates also increased, and COVID-19 contributed little to this increase. This increase in pediatric all-cause mortality has ominous implications. A nation that begins to lose its most beloved population, its children, faces a crisis like no other.
A close examination of mortality data from 1999-2020 and provisional data from 2021 explains the problem. Between 2019 and 2020, the all-cause mortality rate for ages 1 to 19 increased by 10.7%, and increased an additional 8.3% between 2020 and 2021 (Figure, A). These increases, the largest in decades, followed a period of great progress in reducing pediatric mortality rates. Although most of the increase in pediatric mortality was attributed to deaths in older children (ages 10 to 19), all-cause mortality in younger children (ages 1 to 9) also increased in 2021 (by 8.4%). Infants (<1 year) were the only age group that did not experience a significant increase in mortality.
A, The term injury refers to all external causes of morbidity and mortality International Classification of Diseases, Tenth Revision (ICD-10) codes V01-Y89. Injuries involve multiple mechanisms, including transportation, firearms, and poisoning. Since 2016, more than 90% of poisoning deaths among ages 10 to 19 have occurred from unintentional drug overdoses. Non-injury includes all other causes of death (ICD-10 codes A00-U99), including pediatric diseases.
B, Indicates the mortality rates from COVID-19 (ICD-10 code U07.01) and the main causes of death due to injuries between 1 and 19 years of age: transportation (ICD-10 codes V01-V99), homicide (codes ICD-10 X85- Y09), suicide (ICD-10 codes X60-X84) and poisoning (ICD-10 codes X40-X49). Suicide refers to deaths resulting from intentional self-harm. Deaths from unintentional poisoning, such as those resulting from unintentional drug overdoses or alcohol poisoning, are considered distinct from suicides involving drugs. A large proportion of suicides and homicides are classified as firearm-related deaths.
Source, WONDER database from the Centers for Disease Control and Prevention.
As panel B of the figure demonstrates, this reversal in the trajectory of pediatric mortality was not caused by COVID-19, but by injuries . In 2020, the COVID-19 death rate in ages 1 to 19 was 0.24 deaths per 100,000, but the absolute increase in injury deaths alone was nearly 12 times greater (2.80 deaths per 100,000). ). As a group, mortality from all causes of death other than injuries and COVID-19 (i.e., all pediatric diseases combined) was reduced by 0.33 deaths per 100,000. COVID-19 death rates among ages 1 to 19 nearly doubled in 2021 but accounted for only 20.5% of that year’s increase in all-cause mortality.
The increase in pediatric injury deaths predates the COVID-19 pandemic (Figure, B). Suicides among people aged 10 to 19 began to increase in 2007, and homicide rates in this age group began to increase in 2013. Between these nadirs and 2019, on the eve of the COVID-19 pandemic, mortality rates by suicide increased by 69.5% and homicide rates increased by 32.7%. Possible contributors to both trends include increased access to firearms and a deepening mental health crisis among children and adolescents . Access to opioids (e.g., fentanyl) also increased, and overdose death rates for people ages 10 to 19 began to increase shortly before the COVID-19 pandemic. 5
Although the pandemic did not start these trends, it may have added fuel to the fire. Injury mortality among ages 10 to 19 increased by 22.6% between 2019 and 2020. Much of this increase involved homicides , which increased by 39.1%, and drug overdose deaths , which increased by 113. 5 %. Transportation -related deaths among ages 10 to 19, which had been declining for decades due to improved vehicle safety measures and increased use of occupant restraints, increased 15.6 percent in 2020. Among children ages 1 to 9, injuries accounted for two-thirds (63.7%) of the increase in all-cause mortality in 2021, including a 45.9% increase in deaths from fires or burns.
Not all young people faced the same risk of death from injury. The increase in injury deaths that occurred in 2020 primarily involved men (Figure, A). The risk also varied by race and ethnicity. For example, non-Hispanic black youth represented two-thirds (62.9%) of homicide victims ages 10 to 19; In 2021, the homicide rate among non-Hispanic Black youth ages 10 to 19 was 6 times higher than that of Hispanic youth and more than 20 times higher than that of non-Hispanic Asian/Pacific Islander youth and White youth . Even greater racial and ethnic disparities existed between the sexes: the homicide rate for non-Hispanic black men ages 10 to 19 was 61 times that of non-Hispanic white women.
Racial and ethnic disparities varied by injury. Transportation -related mortality rates at ages 10 to 19 were highest in the non-Hispanic American Indian/Alaska Native population, but rates among non-Hispanic black youth increased, surpassing those of non-Hispanic white youth in 2019. Suicides ages 10 to 19 were more than twice as likely among American Indian/Alaska Native youth and non-Hispanic Black youth as suicides among non-Hispanic White youth. Historically, non-Hispanic white youth ages 10 to 19 have died at higher rates from drug overdoses , but increasing rates in the Hispanic and non-Hispanic black populations closed the gap, reaching statistical equivalence with rates in the white population. non-Hispanic in 2020.
The increases in fatal injuries that preceded and may have been exacerbated by the COVID-19 pandemic mark a tragic reversal in years of progress in reducing pediatric mortality rates through advances in injury prevention (e.g. ., safer cars, occupant restraint systems, bicycle helmets, smoke detectors) and the prevention and treatment of fatal pediatric diseases (e.g., prematurity, neoplasms, congenital disorders). These advances have reduced pediatric deaths, but the recent increase in all-cause mortality means that these advances are now completely offset by injuries, primarily those involving violence, self-harm, and drug abuse .
Research and policy efforts to address underlying causes, e.g. depression, suicidality, opioid use, systemic racism, growing inequalities, social conflict , are urgently needed, as is redesign of the system to provide help to people affected by these conditions. American children and adolescents have experienced a significant increase in mental illness and suicidality in recent years, but decreased access to mental health services and a growing shortage of mental health and substance abuse professionals, especially in rural areas. . The pandemic tested the broader US healthcare system, disrupting routine and specialized care for pediatric patients. Growing social inequalities, segregation and structural racism are likely precipitants of increased violence in black communities that must be mitigated to reduce mortality rates.
Firearms play a central role in this crisis.
They are the leading cause of death among youth ages 1 to 19 and accounted for nearly half (47.8%) of the increase in all-cause mortality in 2020. Current efforts to understand gun violence, overcome political gridlock and enact policies are not moving at the speed that pediatric suicides and homicides require.
Medicine and public health have made remarkable progress in reducing pediatric mortality rates, but the lives they have saved are now endangered by man-made pathogens . Bullets, drugs and cars are now causing enough youth deaths to push up all-cause mortality rates, the largest such increase in recent history. Without bold action to reverse the trend, children’s risk of not reaching adulthood may increase.
