Editors’ pickHealth

Over Half of Deaths Among Youths Preventable in US

Children and adolescents in the United States have a higher risk for death before age 19 than youths in other wealthy countries, such as Sweden, Australia, England, and Austria. More than half of the deaths are preventable, new research indicates.

Findings by Rebecca M. Cunningham, MD, an emergency medicine physician, who is director of the University of Michigan Injury Prevention Center in Ann Arbor, and colleagues were published online December 19 in a special report in the New England Journal of Medicine.

Vehicle crashes were the top cause of death for all US children and adolescents through age 19 (20.0% of all deaths), followed by firearm deaths (15.4% of all deaths), in 2016, the most recent year for which data were available.

The third most common cause of death among youths in the US was malignant neoplasms, the authors note, which accounted for 9.1%. Malignant neoplasms were the only non-injury-related cause of death in the top five leading causes. Deaths from malignant neoplasms decreased 32% from 1990 to 2016. The other two causes in the top five were suffocation (7.0%) and drowning (4.9%).

Overall, the US lost 20,360 children and adolescents in 2016, and 60.6% of the deaths were from preventable injuries, the authors report.

Edward W. Campion, MD, executive editor and online editor of the NEJM, said pointedly in an accompanying editorial, “In recent decades, there has been progress, but the United States is clearly not effectively protecting its children.”

Vehicle Crash Deaths Triple Those of Other Wealthy Countries

Cunningham and colleagues report that the rate for youths dying in vehicle crashes in the US was three times the overall rate for 12 other developed countries (5.21 per 100,000 [95% confidence interval (CI), 5.06 – 5.38] vs 1.63 per 100,000 [95% CI, 1.49 – 1.77]).

The rate of firearm deaths in this age group in the US was 36.5 times higher than that in the other 12 countries (4.02 per 100,000 [95% CI, 3.88 – 4.16] vs 0.11 per 100,000 [95% CI, 0.08 – 0.15]).

Among those firearm deaths in the US, 59% were homicides, 35% were suicides, and 4% were from unintentional injuries, such as accidental discharge.

Most of the data for this article were derived from death certificates in the Centers for Disease Control and Prevention’s Wide-ranging Online Data for Epidemiologic Research (WONDER) system. Rates of death in countries other than the US are from the World Health Organization Mortality Database. The 12 wealthy countries included for comparison were England and Wales, Scotland, Sweden, the Netherlands, Lithuania, Iceland, Hungary, the Czech Republic, Cyprus, Croatia, Austria, and Australia.

The study is the first to calculate all causes of child and adolescent death by both mechanism and intent, the authors said in a press release.

They stated, “Although these comparisons use only 2016 data, the findings are similar to those of previous analyses that used multiple years of data.”

28% Increase in Firearm Deaths in 3 Years

The authors found a 28% relative increase in the rate of firearm deaths in children and adolescents from 2013 to 2016. The rate was driven by a 32% increase in firearm homicide and a 26% increase in firearm suicide. Rates of nonfirearm homicide decreased 4% in those years, and rates of nonfirearm suicide increased 15%.

Cunningham and colleagues report they found that firearm death rates were similar in urban, rural, and suburban settings.

“Firearm deaths of children and adolescents are an ‘everybody’ problem, not a problem for just certain population,” Cunningham said in the press release.

Study coauthor Patrick Carter, MD, assistant director of the Injury Prevention Center, said in the release that there’s a message in the numbers for physicians.

“Firearm risk to children and adolescents, whether from unintentional or intentional use of a gun, is a serious medical issue that all of us in the profession can help address,” he said. “The results from this study certainly have inspired me as a physician to know that we need to be doing better. We hope that these findings will also encourage other physicians to know that this is indeed their ‘lane’ to be working in, to be preventing firearm related injury and death.”

Vehicle Crash Deaths Up in Recent Years

The biggest change over the past decade in cause of death among youths was for those from vehicle crashes, which saw a relative decrease of 38% between 2007 and 2016. According to the article, that decrease was largely attributed to widespread use of seatbelts, more appropriate use of child safety seats, cars with better safety features, better licensing programs, better roads, and campaigns to reduce teen drinking and driving.

The reduction in crash deaths came despite increases in the overall number of vehicles and miles traveled.

However, the trend has started to reverse, and deaths from vehicle crashes increased each year from 2013 to 2016, the authors point out.

“Although the cause of this reversal is not yet clear, it probably is multifactorial and includes such factors as an increase in distracted driving by teenagers (eg, because of peer passengers or cell-phone use),” the authors write.

NEJM’s Campion says tougher laws and enforcement may help reverse the trends, “but perhaps new technological solutions will be necessary to help keep eyes on the road rather than on small screens.”

Accidents Can Be Prevented

Campion also says the biggest barrier to reducing the number of deaths is the helplessness associated with what people consider to be “accidents.”

“Car crashes and lethal gunshots are not random results of fate. Both individuals and the larger society need to understand that there is much that can be done to reduce the rate of fatal trauma. Strong leadership by the medical and public health communities is needed,” he said.

Campion writes that physicians are well positioned to lead efforts to change laws and promote programs that enhance gun safety and work for equal access to healthcare for children and adolescents that includes mental health and social supports.

“The approach to this underrecognized public health problem has to be social as well as technological, and the risks are highest in areas of poverty and social isolation,” Campion notes.

Cunningham hopes this analysis can help inform allocation of resources.

She said in the press release, “By using a data-driven approach to studying these deaths, I hope we can guide the US to apply our resources to help us understand what we can do to prevent these deaths across the country.”

The authors have disclosed no relevant financial relationships. Dr Campion is executive editor and online editor of the NEJM.

N Engl J Med. Published online December 19, 2019. Abstract, Editorial

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