We have compiled this third annual global report to detail the levels, trends, causes, and correlates of health loss from birth through age 19 years. First, we have generated a complete set of internally consistent demographics estimates, with uncertainty intervals UIs , for age-specific fertility, population, and all-cause mortality. Third, in addition to adding many new sources of data, we have improved data-processing algorithms.
Methods for redistributing deaths coded to nonspecific, implausible, or intermediate causes of death were updated to incorporate statistical uncertainty of cause reassignment. Clinical administrative data hospital and claims processing methods were updated to better account for hospital readmissions, multiple clinical visits, and ordering of discharge codes by age, sex, location, and time.
Fourth, we have improved the epidemiological transition analysis through improved estimation of the SDI. Comprehensive descriptions of each analytic component of GBD are detailed elsewhere 1 , 7 - 12 and compliant with the Guidelines for Accurate and Transparent Health Estimates Reporting. Data sources for each cause-level analysis are available online at the Global Health Data Exchange. Estimates were produced for male individuals and female individuals separately in each of 23 standard age groups. Each of diseases and injuries were arranged in a 4-level mutually exclusive and collectively exhaustive cause hierarchy; most were analyzed as causing both death and disability.
The first level level 1 of the cause list has 3 categories: communicable, maternal, neonatal, and nutritional conditions CMNN ; NCDs; and injuries. At level 2, there are 22 cause groups, and level 3 includes more disaggregated causes of burden causes , as does level 4 causes. All-cause mortality, cause-specific mortality, and years of life lost YLLs were estimated using standardized approaches of data identification, extraction, and processing to address data challenges such as incompleteness, variation in classification systems and coding practices, and inconsistent age group and sex reporting.
Nonfatal estimates were generated using data from literature, hospital discharge and claims data systems, cross-sectional surveys, cohort studies, case notification systems, and disease-specific registries. Unlike confidence intervals, which only capture sampling error in a single statistical test, UIs also incorporate uncertainty from other associated steps.
Aggregate estimates eg, DALYs, combined age groups, geographical groups were calculated by summing draw-level results assuming independence of each quantity. We performed 3 secondary analyses for this report. First, we decomposed probability of death from birth to 19 years to illustrate how cause-specific trends are associated with overall survival improvements.
Second, we explored the historical association between burden metrics and the SDI, a composite indicator of development based on per capita income, adult education, and total fertility rate for individuals younger than 25 years. Observed values are the actual disease burden rates in each location-year, while expected values were determined by Gaussian process regression on the range of rates observed for each level of SDI.
Third, given the intricate association between the health of women and their children, we examined the historical association between maternal mortality and DALY rates of children and adolescents. We present a number of different formulations of results in the GBD We refer to those younger than 28 days as neonates , those younger than 1 year as infants , those younger than 10 years collectively as children , and those aged 10 to 19 years as adolescents. We focus on presenting aggregate results for the global level, SDI quintiles, and the GBD regions, either for birth to 19 years en bloc or for infants, children, and adolescents separately.
Except when noted, results are for both sexes combined. Premature mortality is the dominant component of health loss in children and adolescents. The Table shows deaths by age group globally and by SDI quintile.
All-cause child and adolescent deaths decreased More than half Improvements by age were similar across SDI quintiles. Decomposition of changes in probability of death between birth and age 20 years from to revealed different level 2 cause-level drivers across GBD regions Figure 1 ; country results are in eFigure 2 in the Supplement. Decreases in deaths owing to infectious diseases, neonatal disorders, and unintentional injuries drove improvements at the global level and for many less-developed regions eg, CMNN deaths were virtually absent in high-SDI regions.
In western, central, and eastern SSA, the probability of surviving to adulthood increased from to western SSA: , The total decrease in mortality from these causes was Decreased mortality from other NCDs primarily congenital birth defects and hemoglobinopathies and neonatal disorders contributed the most to survival improvements in most of high-middle—SDI and high-SDI regions decrease in death rate, , for congenital birth defects: high-SDI countries, Exceptions to broad survival improvements included a 0.
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There were a total of 50 countries where the probability of death by self-harm and interpersonal violence increased between and Nine of them had increase of more than 0. Global DALYs owing to injuries decreased by Despite decreasing rates in of countries between and , injuries caused an increasing proportion of overall DALYs with advancing age of children and adolescents global rates of injury DALYs per age group: years, The slope of the SDI gradient decreased with increasing age for all causes.
In this group, the DALY rate was also higher. A trend toward increasing DALY rates owing to injury in children aged 5 to 9 years and 10 to 19 years was seen at the lower end of the development spectrum. Before , countries improved more than expected on the basis of SDI changes, while countries did so after On the other end of the performance spectrum, 38 countries performed worse than expected in both periods.
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However, many countries that underperformed expectations before reversed course post Syria was also an outlier in how much worse than expected observed DALY rates were in children and adolescents O:E ratios in all-cause, 0. Corresponding maps depicting data for children younger than 1 year, 1 to 4 years, 5 to 9 years, and 10 to 19 years for CMNN, NCDs, and injuries separately are shown in eFigure 7 and eTable 3 in the Supplement.
For most countries in sub-Saharan Africa, improvements were much faster than expected between and for children aged 1 to 4 years in particular, with several countries also having more rapid DALY improvement than expected in children younger than 1 year and aged 5 to 9 years. Among adolescents, on the other hand, there was little evidence of accelerated improvement after the turn of the century, with almost half of the countries in sub-Saharan Africa lagging behind expected improvements in DALY rates. Globally, for all children and adolescents, only 1 primarily nonfatal disease ranked in the top 10 of global DALYs: iron-deficient anemia eighth; O:E ratio, 2.
The rest of the top 10 are also leading causes of death, including neonatal disorders O:E ratio, 1. Neonatal disorders or congenital birth defects were ranked either first or second in most other countries. Important country-specific exceptions included natural disasters ranked first in Puerto Rico O:E ratio, Sudden infant death syndrome also accounted for 3.
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Rates of YLDs decreased only slightly and nonsignificantly between and Amidst a backdrop of decreasing premature childhood death and population growth, global YLDs increased 4. In this case, there was barely any association between SDI level and the YLL-to-YLD ratio until the highest SDI strata, which may have reflected a poor penetration of prevention and treatment services for congenital birth defects and neoplasms outside of high-income countries.
A similar association was found in the case of injuries children younger than 1 year, This could possibly reflect poorer prevention and treatment access for these causes and the effect of wars and natural disasters on disease burden. Iron-deficient anemia or asthma sometimes lead most low and low-middle SDI countries, with neonatal disorders leading in most middle, high-middle, and high SDI countries. Neonatal disorders was the only level 3 cause that ranked in the top 10 of both mortality and disability globally, ranking among the top 10 causes of YLDs in many countries in North Africa and the Middle East and sub-Saharan Africa.
Musculoskeletal and mental health disorders including anxiety disorders, conduct disorder, depression, autism spectrum disorders, and drug use disorders were all highly ranked in high-income countries, in central and eastern Europe, and throughout Asia, Latin America, and the Caribbean. Hemoglobinopathies, such as sickle cell disorders and thalassemias, were also in the top 10 by O:E ratio in a number of countries, including Yemen O:E ratio, 2.
Protein-energy malnutrition was in the top 10 causes in India O:E ratio, Malaria was ranked in the top 5 causes in most countries of western and central sub-Saharan Africa, as well as Mozambique O:E ratio, 2. Diarrhea, onchocerciasis, and intestinal nematode infections were the other CMNN causes among the top 10 causes of YLDs in certain countries. Injuries did not rank high in most countries, with notable exceptions of Iraq where conflict ranked ninth; O:E ratio, To evaluate the association between population-level trends in child and adolescent DALYs and those of their mothers, we compared percentage change from to in all-cause DALY rates for children younger than 1 year, 1 to 4 years, 5 to 9 years, and 10 to 19 years with percentage change in death rates owing to maternal disorders for women aged 10 to 54 years eFigure 11 in the Supplement.
Only 8 countries had divergent trends throughout the entire time period, with all examples of divergence having increases in maternal mortality and decreases in all-cause child and adolescent DALY rates: American Samoa Children and adolescents in every country in the world were more likely to reach their 20th birthday in than ever before, but progress in improving health outcomes has been uneven. Mortality reductions were most rapid in children between the ages of 1 and 4 years, driven by global declines in deaths owing to diarrhea, lower respiratory infection, and other common infectious diseases.
Improvements accelerated after A vast unfinished agenda in child and adolescent health remains. While malaria has decreased dramatically across the African continent, there are many countries, especially in western sub-Saharan Africa, where parasite transmission, acute illness, and mortality from malaria remain high. Lower respiratory infection, diarrhea, and acute malnutrition also remain among the top killers of children and adolescents in the world in Investment in programs targeting prevention and effective syndromic treatment of CMNN disorders clearly pays dividends, and these investments must continue.
In locations with higher SDIs, a continuing shift toward nonfatal health loss from NCDs, such as congenital birth defects, mental and behavioral disorders, injuries, and asthma are challenging health systems to adapt. The burden of injuries in adolescents surpasses that of CMNN causes throughout the study period for middle-SDI through high-SDI countries, and with the relative faster decline of CMNN causes in low and low-middle countries, the relative ranking of injuries may switch in those locations in the near future.
Overall health improvements were slowest in adolescents. Few locations showed any evidence of improvements in health among adolescents that exceeded the trends expected with general societal development gains. Adolescence is a key phase of the life course and human development, including a phase of growth and maturation of the reproductive, musculoskeletal, neurodevelopmental, endocrine, metabolic, immune, and cardiometabolic systems into adulthood.
https://acvilestcis.tk In terms of family and home life, key issues include the improvement of sanitary and living conditions, stable food systems, quality education, and gainful employment. The large and growing burden of mental health and substance use disorders among older children and adolescents also is an emerging threat to the thrive component of the SDG survive and thrive agenda.
While the psychological needs of children and adolescents show similarities across geographical settings, 24 - 27 comparatively little is understood about modifiable risk factors or effective prevention programs for childhood mental illness, outside of ensuring that caregivers are attuned to the link between mental health disorders and self-harm. While many types of injuries, such as those arising from war and natural disasters, may not be preventable with health sector—based approaches, diligent preparedness planning can help mitigate the immediate health aftermath of them.
At the other end of the age spectrum, neonatal disorders remain a major prevention and treatment challenge, especially for countries outside the high-SDI quintile that lack the same level of financial and human resources to dedicate to the intensive care needs of sick neonate. Investment is needed to develop and implement cost-effective interventions for neonatal disorders that take into account the dynamics of maternal health, risk-factor exposures during pregnancy, clinical care systems, supportive equipment needs, and the cultural differences around how families and communities care for newborns.
It is important also to invest in the ongoing care of children who survive perinatal emergencies only to develop long-term complications, such as cerebral palsy. Congenital birth defects and hemoglobinopathies are 2 other groups of causes for which there is little evidence of improved outcomes outside the high-SDI quintile, perhaps reflecting the resource-intensive nature of averting deaths owing to such conditions and societal barriers to care 38 but also likely because of a failure of recent clinical advances to be adopted in lower-resource settings.
The close linkage between trends in maternal and child health reinforces the notion that the health of different population segments are closely interconnected. Challenges are likely to arise whenever funding streams are decoupled, education or family planning programs are disrupted, or the health of young women is not prioritized. The epidemiological transition has unique implications for the health of children and adolescents and the potential trajectory of socioeconomic development.
In particular, as more children survive, the human capital potential societies will expand, but as more children with health problems are also surviving, there is potential for increased burden on health and education systems. The cost of sustaining progress on child and adolescent health and well-being is not insignificant. To achieve the goal of surviving and thriving and realized the human capital potential of children and adolescents, all countries must make strategic investments in education and health systems, including human resources for health, supply chains, infrastructure, governance, and increased support for children with developmental disabilities.
Alignment of funding around interconnected drivers of human development and health loss is also required to achieve the SDGs. The SDGs are expansive, but they should not be considered a comprehensive rubric for achieving improved child and adolescent health. This blind spot in international health targets, planning, and prevention fails to capture the complex transitions occurring during adolescence in particular. Many additional nonhealth SDG indicators also focus on reducing poverty, expanding education, stabilizing environments, strengthening economies, and reducing overall socioeconomic inequality within each country and throughout the world, all of which are relevant to the health and well-being of young persons.
The GBD study is an iterative process and, despite continued methodological advancements and improvements in data, this study has a number of limitations. Second, these summary measures of population health are influenced by data availability. Time lags in the reporting of health information by national authorities and thus subsequent incorporation into the GBD estimation mean that these estimates are based on data that are already out of date.