What were the risks and patterns of childhood deaths before and during the COVID-19 pandemic?

The coronavirus disease 2019 (COVID-19) pandemic led to worldwide disruption of childhood healthcare services, and excess mortality has been reported in many countries over the pandemic years. A new study published in JAMA Network Open describes the pattern of childhood deaths over 2019-21, the first two years of the pandemic, hoping to help identify the risks associated with these events.

Introduction

Earlier research has shown that over 100,000 deaths occurred in excess of expected in England and Wales since the pandemic began, in keeping with almost five million excess deaths globally. The pandemic had the least impact on children, however, in terms of directly causing death.

However, the changes in social and support structures, coupled with shifts in healthcare provision, necessitated by the surge in the number of cases requiring hospitalization and intensive medical care, as well as the large number of deaths linked to COVID-19, did have a large albeit indirect effect on childhood health and mortality.

What did the study show?

The scientists found that just over 3,400 deaths occurred among children between April 2019 and March 2020. In comparison, there were just over 3030 deaths during the next 12 months, but almost 3,430 deaths from April 2021 to March 2022.

Almost two-thirds of the children who died were infants less than a year old, and ~57% were male. Remarkably, almost 90% were living in cities. The risk of childhood death dropped by 10% in urban areas compared to 27% in rural locations. There was no difference in the risk of death over the age of nine years.

This shows a reduction in child deaths during the first pandemic year, with an approximate drop in mortality risk by 20%. This was not observed during the second period, taking the first period mentioned above as the reference. This indicates a significant drop in all-cause mortality during the first year of the pandemic but a return to pre-pandemic rates of pediatric deaths over the next year.

Overall, the number of deaths over three years appeared to be four percent less than expected from the risk levels existing during the 2019-20 levels. This could be due to fewer-than-expected deaths from infection and underlying disease.

Sudden unexpected deaths in infancy and childhood (SUDIC) showed no clear changes, some of which could be due to underlying disease. A disturbing trend was a significant rise in the risk of children dying from trauma, by almost a third, during 2021-22.

The biggest drops in childhood mortality occurred among those aged 1-4 years, by over 30%, and 5-9 years, by 20%. A smaller decrease of ~5% was observed in infants (<1 year). Ethnicity and deprivation appeared to play little to no role.

Children below 14 years were less likely to die in 2020-21 vs. 2019-20 or 2021-22, but older children (15-17 years) did not show fewer infection-related deaths over the first period. Conversely, their death risk increased by over 2.5 times in 2021-22 compared to 2019-20.

What are the implications?

During the first year of the COVID-19 pandemic, child mortality in England was the lowest on record, but if this trend will continue, or if unrecognized morbidity during the first year of the pandemic will manifest as increased deaths over the next few years is unclear.”

Deaths from infections were reduced significantly in children up to the age of 15, with no increase in deaths over the winter during 2021-22, in contrast to the years before and after. This would also explain why children aged 1-4 years, who were unlikely to die of COVID-19 but are known to die of other infections, fell significantly, while those among children aged 15-17 years went up during 2021-22.

The reduction in childhood deaths from any cause during the first pandemic year occurred concurrently with an overall reduction in deaths among the whole population, compared to the expected number of deaths. The historic low in childhood deaths during the first period is welcome. However, scientists are waiting to see if the next few years will show unwanted rises in childhood deaths due to diseases that went undiagnosed and untreated during these years.

Meanwhile, older children are now facing higher risks of death than before the pandemic began, and trauma-related deaths in children have also increased over the whole study period of three years. In contrast, deaths due to underlying medical conditions have shown a persistent downturn, perhaps due to the increased protection from infectious diseases associated with pandemic control conditions.

Encouragingly, deprivation is not related to the chances of reduced mortality risk, indicating that “community actions can reduce the social-economic patterning of childhood mortality in England.” However, the failure to register a decline in SUDIC could signal an early increase in deaths due to increasing poverty as a delayed fallout of the pandemic years.

Written by

Dr. Liji Thomas

Dr. Liji Thomas is an OB-GYN, who graduated from the Government Medical College, University of Calicut, Kerala, in 2001. Liji practiced as a full-time consultant in obstetrics/gynecology in a private hospital for a few years following her graduation. She has counseled hundreds of patients facing issues from pregnancy-related problems and infertility, and has been in charge of over 2,000 deliveries, striving always to achieve a normal delivery rather than operative.