Pediatric Annals

EDITORIAL 

A Pediatrician's View: Causes of Death Among the Young

Robert A Hoekelman, MD

Abstract

This issue of Pediatrie Annuls addresses injury control. Its Guest Editor, Frederick R Rivara, MD, MPH, from the University of Washington, has brought together a group of distinguished authors who present up-to-date information on morbidity and mortality from drowning, burns, firearm injuries, and suicide, as well as on prevention and rehabilitation of injuries from those and other causes. Recently, the Children's Safety Network1 published more extensive data on injuries to children and adolescents, indicating among many other things that for every childhood death caused by an injury, there are 42 hospitalizations and 1120 emergency room visits. Thus, the morbidity from injuries as well as the mortalities must give us cause for great concern. Violence as a cause of injury and death has grown beyond belief so much so that the entire May 5, 1992 issue of the Journal of the American Medical Association was devoted to interpersonal violence in America, particularly as it relates to the use of firearms, and its June 17, 1992 issue featured domestic violence as a major cause of injury and death.

Accidents, homicide, and suicide ranked first, fourth, and fifth, respectively, as causes of death among the young (birth through 24 years of age) in 1989, the most recent year for which mortality figures for the United States are available.2 The Table compares 1975 data3 with the 1989 data on leading causes of death in this age group.

The Table shows a decline in the death rates per 100 000 population for all causes, except for homicide and suicide, as well as a decline in the population of this age group and the actual overall rate and number of deaths during this 15 -year period. What it doesn't show is that homicides and suicides, along with accidents, accounted for 76% of the 36 488 deaths occurring in persons 15 through 24 years of age during 1989.

Despite this, one of the most striking declines in death rates between 1975 and 1989 in persons under 25 years of age occurred for accidents, which fell 29%- from 38.3 to 27.2/100 000. Most of this decline was accounted for by non-motor vehicle accidents - those that occurred in the home, in recreational settings, and in the work place - as a result of active and passive accident prevention measures. Along with this, the death rate from motor vehicle accidents decreased from 22 to 18 per 100000 young persons during that period, even though motor vehicle accidents accounted for a greater proportion of accidental deaths among the young in 1989 than in 1975 (67% versus 57%). Despite that proportional increase, the number of deaths from motor vehicle accidents in this group fell from 20611 in 1975 to 16428 in 1989. This decline can be attributed to passing and enforcing speed limits up to 55 miles per hour, requiring annual inspection of motor vehicles, imposing severe penalties for driving while intoxicated, and mandating the use of seat belts and infant car seats. Improvements in automotive design and construction, rearand side-view visual aids, head and brake lights, turn signals, and speed-control mechanisms have also helped to reduce the number of automotive deaths.

Death rates from homicides among the young increased 21% between 1975 and 1989, increasing 49% among infants, 23% among 1 through 4 year olds, 67% in 5 through H year olds, and 17% in 15 through 24 year olds during that time. The increase during the first 2 to 3 years of life may reflect a growing awareness on the part of practicing physicians, medical examiners, and law enforcement agents of the potential for child abuse, thereby classifying as…

This issue of Pediatrie Annuls addresses injury control. Its Guest Editor, Frederick R Rivara, MD, MPH, from the University of Washington, has brought together a group of distinguished authors who present up-to-date information on morbidity and mortality from drowning, burns, firearm injuries, and suicide, as well as on prevention and rehabilitation of injuries from those and other causes. Recently, the Children's Safety Network1 published more extensive data on injuries to children and adolescents, indicating among many other things that for every childhood death caused by an injury, there are 42 hospitalizations and 1120 emergency room visits. Thus, the morbidity from injuries as well as the mortalities must give us cause for great concern. Violence as a cause of injury and death has grown beyond belief so much so that the entire May 5, 1992 issue of the Journal of the American Medical Association was devoted to interpersonal violence in America, particularly as it relates to the use of firearms, and its June 17, 1992 issue featured domestic violence as a major cause of injury and death.

Accidents, homicide, and suicide ranked first, fourth, and fifth, respectively, as causes of death among the young (birth through 24 years of age) in 1989, the most recent year for which mortality figures for the United States are available.2 The Table compares 1975 data3 with the 1989 data on leading causes of death in this age group.

The Table shows a decline in the death rates per 100 000 population for all causes, except for homicide and suicide, as well as a decline in the population of this age group and the actual overall rate and number of deaths during this 15 -year period. What it doesn't show is that homicides and suicides, along with accidents, accounted for 76% of the 36 488 deaths occurring in persons 15 through 24 years of age during 1989.

Despite this, one of the most striking declines in death rates between 1975 and 1989 in persons under 25 years of age occurred for accidents, which fell 29%- from 38.3 to 27.2/100 000. Most of this decline was accounted for by non-motor vehicle accidents - those that occurred in the home, in recreational settings, and in the work place - as a result of active and passive accident prevention measures. Along with this, the death rate from motor vehicle accidents decreased from 22 to 18 per 100000 young persons during that period, even though motor vehicle accidents accounted for a greater proportion of accidental deaths among the young in 1989 than in 1975 (67% versus 57%). Despite that proportional increase, the number of deaths from motor vehicle accidents in this group fell from 20611 in 1975 to 16428 in 1989. This decline can be attributed to passing and enforcing speed limits up to 55 miles per hour, requiring annual inspection of motor vehicles, imposing severe penalties for driving while intoxicated, and mandating the use of seat belts and infant car seats. Improvements in automotive design and construction, rearand side-view visual aids, head and brake lights, turn signals, and speed-control mechanisms have also helped to reduce the number of automotive deaths.

Death rates from homicides among the young increased 21% between 1975 and 1989, increasing 49% among infants, 23% among 1 through 4 year olds, 67% in 5 through H year olds, and 17% in 15 through 24 year olds during that time. The increase during the first 2 to 3 years of life may reflect a growing awareness on the part of practicing physicians, medical examiners, and law enforcement agents of the potential for child abuse, thereby classifying as homicidal those deaths that were formally attributed to accidents, sudden infant death syndrome, or illdefined conditions. Older children are no less likely to be physically abused, but rarely suffer death from such abuse. The increases in homicides among older children, adolescents, and young adults reflect societal changes that have generated acts of violence toward them by their peers and others. Firearms play a major role in homicides, accounting for 10 deaths per 100 000 among 15 to 19 year olds during 1989.4 The rate of homicidal firearm fatalities among African-American males in this age group is sevenfold higher.1 A recent Gallup poll showed that firearms were present in 46% of American households; more than half of those firearms were hand guns,5 which are used most frequently in homicides and suicides.

Table

TABLELeading Causes of Death: United States, Birth Through 24 Years of Age, 1975 and 1989*

TABLE

Leading Causes of Death: United States, Birth Through 24 Years of Age, 1975 and 1989*

Suicide rates among the young rose 9.6% between 1975 and 1989 (5.2 to 5.7 per 100000); however, among 5 to 14 year olds they rose 56% and among 15 to 24 year olds, 21% (the National Center for Health Statistics does not classify any deaths among children under the age of 5 years as suicide). More striking is the rise in suicide rates for 1 5 to 24 year olds from 3 to 13.3/100 000 between 1950 and 1989. This is clearly the result of societal changes that have led to increased stress and depression among adolescents and young adults. It may also reflect better reporting, resulting from less stigma being attached to suicide in recent years. Experts agree that suicides are underreported because many deaths reported as accidents, such as those from drowning, falls, motor vehicles, or firearms, are really suicides.

While we have made great gains in reducing mortality from virtually every cause among our younger population, we still have much to do in stemming and reversing their rising rates of death from acts of violence. Homicides and suicides reflect societal ills - family dissolution, school failure, unemployment, poverty, despair, substance abuse, crime, and easy access to firearms. Unless we heal those ills, we will have little hope of reducing mortality rates from these causes. Can Ross do it? Can anyone?

REFERENCES

1. Children's Safety Netwrk. A Data Boofc on CliiW and Adolescent Injury. Washington, DC: National Center far Education in Maternal and Child Health; i991. [Copies available from the National Maternal and Child Health Clearinghouse, 38th and R Streets, NW, Washington, DC 20057; telephone (202) 625-8410 or (708) 821-0955 ext 254.]

2. Advance report of final mortality statistics, 1989. MuniWj VÍiaí Statistics fiepoti. Hyattsville, Md. National Centet for Health Statistics; January 7, 1992.

3. Final mortality statistics, 1975, advance report. Monthly Vital Statistics Report. Rockville, Md: National Centet for Health Statistics, February 11, 1977.

4. Fingerhut LA, Ingram DD, Feldman JJ. Firearm and nonfirearm homicide among persons 15 through 19 years of age. JAMA. 1992;267:3048-3053.

5. Handgun Ownership in America. Princeton, NJ: The Gallup Organization; 1991.

TABLE

Leading Causes of Death: United States, Birth Through 24 Years of Age, 1975 and 1989*

10.3928/0090-4481-19920701-04

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