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Firearms now represent the leading cause of death in U.S. children. Therefore, this study aimed to determine if state-level rates of gun ownership, guns in circulation, and strictness of firearm-related laws are related to firearm-related mortality among both juveniles and overall populations. State firearm mortality rates among the juvenile and overall populations were obtained from 2010 to 2020. The number of weapons registered with the Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF) and federal firearms licensees for each state were also recorded. Giffords Law Center Scorecard Rankings, a relative measure of the restrictiveness of each state's gun laws, were also collected. Unadjusted linear regressions modeled the relationships between firearm-associated mortality and ATF-registered weapons, federal firearm licensees, Giffords Center rankings, and gun ownership rates. Multivariable (adjusted) analyses were performed to control for poverty, unemployment, and poor mental health. Unadjusted analyses demonstrated that higher gun ownership rates and more lenient gun laws were associated with increased firearm-associated mortality among juveniles. Similarly, these measures as well as increased ATF-registered weapons and ATF federal firearm licensees were associated with increased firearm mortality in the overall population. In the adjusted analyses, more ATF-registered weapons, more ATF federal firearm licensees, higher gun ownership rates, and more lenient firearm laws were associated with increased firearm-related mortality in the overall population, while increased gun ownership and higher Giffords Center rankings were associated with increased firearm-associated mortality in the pediatric population. To reduce the toll of gun violence in the United States, policymakers should focus on implementing more restrictive firearm laws and reducing the prevalence of guns in their communities. [ABSTRACT FROM AUTHOR]

In the United States, older parents who have experienced the death of their only child constitute an extremely understudied group. Based on a conceptual framework developed from Worden's "mediators of mourning," this cross-sectional study hypothesized that older bereaved parents who experience severe grief symptoms would differ from those with less severe grief on age, time since death, attachment style, coping strategy, social support, and spirituality. It further aimed to investigate the association between the above factors and aggravated or alleviated grief symptoms. A sample of 183 bereaved adults over age 50 was recruited and an online survey was utilized to collect data. A 47.54% prevalence rate of Prolonged Grief Disorder was found in the sample. Participants who experienced more severe grief showed significant differences in the aforementioned study variables, compared to those who experienced less severe grief. Results of the hierarchical multiple regression model indicated that the higher severity of grief symptoms was related to utilizing more avoidant coping strategies and having a fearful attachment style. Less severe grief was associated with increased time since death, a greater perception of social support from friends, and more daily spiritual experiences. As the U.S. population ages and more families have only one child, it is imperative that academic and helping professionals recognize older bereaved parents' unique vulnerability and develop effective intervention strategies. This study reinforces the call for increased social awareness and acceptance of prolonged grief and policy changes to address the needs of older bereaved parents. [ABSTRACT FROM AUTHOR]

Although non-accidental trauma continues to be a leading cause of morbidity and mortality among children in the United States, the underlying factors leading to NAT are not well characterized. We aim to review reporting practices, clinical outcomes, and associated disparities among pediatric trauma patients experiencing NAT. A literature search utilizing PubMed, Google Scholar, EMBASE, ProQuest, and Cochrane was conducted from database inception until April 6, 2023. This review includes studies that assessed pediatric (age <18) trauma patients treated for NAT in the United States emergency departments. The evaluated outcome was in-hospital mortality rates stratified by race, age, sex, insurance status, and socioeconomic advantage. The literature search yielded 2641 initial articles, and after screening and applying inclusion and exclusion criteria, 15 articles remained. African American pediatric trauma patients diagnosed with NAT had higher mortality odds than white patients, even when adjusting for comparable injury severity. Children older than 12 mo experienced higher mortality rates compared to those younger than 12 mo, although some studies did not find a significant association between age and mortality. Uninsured insurance status was associated with the highest mortality rate, followed by Medicaid and private insurance. No significant association between sex and mortality or socioeconomic advantage and mortality was observed. Findings showed higher in-hospital mortality among African American pediatric trauma patients experiencing child abuse, and in patients 12 mo or older. Medicaid and uninsured pediatric patients faced higher mortality odds from their abuse compared to privately insured patients. [ABSTRACT FROM AUTHOR]

Little is known about the impact of child welfare system-level factors on child mortality as an outcome within foster care. Using data from the Adoption and Foster Care Analysis and Reporting System, 2009–2018, we examined the associations between county-level sociodemographic, foster care performance, and judicial reform characteristics with all-cause mortality rates. Results of random effects negative binomial regression analyses showed that higher proportions of younger children (<1 year: IRR = 1.06, 95% CI [1.02, 1.11]; 5–9 years: IRR = 1.05, 95% CI [1.01, 1.09]); children of color (i.e., non-Hispanic Asian: IRR = 1.07, 95% CI [1.01, 1.13]; multiracial: IRR = 1.03, 95% CI [1.01, 1.04]; non-Hispanic Black: IRR = 1.02, 95% CI [1.01, 1.02]; Hispanic: IRR = 1.01, 95% CI [1.01, 1.02]); and male children (IRR = 1.10, 95% CI [1.05, 1.15]) were associated with higher mortality risks at the county level. Current class action lawsuits (IRR = 0.79, 95% CI [0.63, 0.99]) and active consent decrees (IRR = 0.77, 95% CI [0.63, 0.94]) were associated with lower mortality risks. None of the foster care performance characteristics (e.g., foster care entry, placement stability, permanency) were associated with mortality risks. These findings have implications for addressing health disparities and reforming foster care systems through programmatic and policy efforts. [ABSTRACT FROM AUTHOR]

Cancer is the second most common cause of death in children aged 1–14 years in the United States, with 11,000 new cases and 1200 deaths annually. Pediatric cancers typically have lower mutational burden compared to adult-onset cancers, however, the epigenomes in pediatric cancer are highly altered, with widespread DNA methylation changes. The rarity of pediatric cancers poses a significant challenge to developing cancer-type specific biomarkers for diagnosis, prognosis, or treatment monitoring. In the current study, we explored the potential of a DNA methylation profile common across various pediatric cancers. To do this, we conducted whole genome bisulfite sequencing (WGBS) on 31 recurrent pediatric tumor tissues, 13 normal tissues, and 20 plasma cell-free (cf)DNA samples, representing 11 different pediatric cancer types. We defined minimal focal regions that were differentially methylated across samples in the multiple cancer types which we termed minimally differentially methylated regions (mDMRs). These methylation changes were also observed in 506 pediatric and 5691 adult cancer samples accessed from publicly available databases, and in 44 pediatric cancer samples we analyzed using a targeted hybridization probe capture assay. Finally, we found that these methylation changes were detectable in cfDNA and could serve as potential cfDNA methylation biomarkers for early detection or minimal residual disease. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Gun violence in the United States is a public health crisis. In 2019, gun injury became the leading cause of death among children aged birth to 19 years. Moreover, the United States has had 57 times as many school shootings as all other major industrialized nations combined. The purpose of this study was to understand the frequency of school-related gun violence across a quarter century, considering both school shootings and school mass shootings. METHODS: We drew on 2 publicly available datasets whose data allowed us to tabulate the fre- quency of school shootings and school mass shootings. The databases contain complementary data that provide a longitudinal, comprehensive view of school-related gun violence over the past quarter century. RESULTS: Across the 1997--1998 to 2021--2022 school years, there were 1453 school shootings. The most recent 5 school years reflected a substantially higher number of school shootings than the prior 20 years. In contrast, US school mass shootings have not increased, although school mass shootings have become more deadly. CONCLUSIONS: School shootings have risen in frequency in the recent 25 years and are now at their highest recorded levels. School mass shootings, although not necessarily increasing in frequency, have become more deadly. This leads to detrimental outcomes for all the nation's youth, not just those who experience school-related gun violence firsthand. School-based interventions can be used to address this public health crisis, and effective approaches such as Multi-Tiered Systems of Supports and services should be used in support of students' mental health and academic and behavioral needs. [ABSTRACT FROM AUTHOR]

The article describes how socioeconomic inequities contribute to discrepant unintentional injury risks and calls for an expansion of investment in innovative and targeted prevention strategies to narrow this disparity. Topics include the impact of poverty on injury, barriers and opportunities to implementation of injury prevention, and recommendations for advocacy groups, health care organizations, and community organizations.

Thyroid cancer is the most common endocrine malignancy in the pediatric population. A recent study has revealed a recent decline in overall US thyroid cancer incidence rates. The aim of this study is to assess whether there has been a corresponding decline in incidence rates in the pediatric population. We used the Surveillance, Epidemiology, and End Results (SEER) database to analyze the pediatric thyroid cancer incidence rate. The results demonstrate that the incidence rate of pediatric thyroid cancer continued to increase from 2000 to 2018. Future studies are needed to understand how recent changes in guidelines are affecting incidence rates. [ABSTRACT FROM AUTHOR]

Purpose: Racial disparities in infant mortality in the United States persist after adjustment for known confounders of race and mortality association, as well as heterogeneity assessment. Epidemiologic and clinical data continue to show the survival disadvantages of Black/AA children: when Black/AAs are compared to whites, they are three times as likely to die from all-cause mortality. The persistent inability to remove the variance in race–mortality association is partly due to unobserved, unmeasured, and residual confounding, as well as implicit biases in public health and clinical medicine in health equity transformation. This current epidemiologic-perspective explanatory model study aimed to examine the possible explanation of racial differences in U.S. infant mortality using medical misadventures as errors and mistakes, and infants' involvement in motor vehicular traffic accidents. Materials and Method: Using CDC WONDER ecologic data from 1968 to 2015, we assessed the infant mortality-rate ratio and percent change associated with medical misadventures as well as motor vehicular accidents or trauma. The rate ratio and percent change were estimated using stratification analysis and trend homogeneity, respectively. Results: There was a Black–white racial difference in medical misadventures during the study period. Relative to the years 1968–1978 (rate ratio [RR], 1.43), there was a steady increase in the mortality-rate ratio in 1979–1998 (52%, RR = 1.52), and mortality was more than two times as likely in 1999–2015 (RR = 2.37). However, with respect to motor vehicular accident/trauma mortality, the mortality ratio, although lower among Blacks in 1968–1978 (RR, 0.92), increased in 1979–1998 by 27% (RR = 1.27) but decreased in 1999–2015 (RR, 1.17), though there was still an excess of 17% mortality among Black/AAs. The percent change for medical misadventures indicated an increasing trend from 9.3% in 1998 to 52% in 2015. However, motor vehicular-related mortality indicated a positive trend in 1998 (38.5%) but a negative trend in 2015 (−8.4%). Conclusions: There were substantial race differentials or variances in infant mortality associated with medical misadventures compared to traffic accidents, and Black/AA children relative to whites experienced a survival disadvantage. These comparative findings are suggestive of medical misadventures and motor vehicular trauma as potential explanations for some of the persistent Black–white disparities in overall infant mortality in the U.S. From these findings, we recommend a national effort to address these issues, thus narrowing the observed disparities in the U.S. infant mortality burden among Black/AAs. [ABSTRACT FROM AUTHOR]

This study focused on the content of 1186 Child Fatality Review Board individual case reports collected nationally over a 24‐year period (1995–2019). This information, in contrast to group data, may yield important insights into the causative factors, especially for child fatality resulting from neglect and inflicted injury. The reports were collected from six of the 50 states and evaluated for the quality and amount of information. They were also surveyed for data identifying causative factors for neglect and inflicted injury. Only 25 (2 per cent) of 1186 reports that are publicly available contained sufficient information about the four major causative factors—cause of death, prior child protection agency involvement by the family, evidence of professional negligence or error and family history of at‐risk circumstances. The 25 cases were then reviewed and coded for presence of information about these factors. The findings demonstrate the need for federal intervention to provide specific guidelines for the states to track their cases, to use a common nomenclature, to investigate common causative factors and to practice common reporting procedures. In this way, a robust national database can be developed. [ABSTRACT FROM AUTHOR]

Cancer is as the second leading cause of death among children in the United States. The mortality rate for cancer has witnessed a decline, dropping from 6.5 per 100,000 in 1970 to 2.3 per 100,000 in 2016. Second malignant neoplasms (SMNs) represent novel primary malignancies emerging after the initial cancer diagnosis, particularly prominent as late effects of cancer therapy in children. The incidence of SMNs sees a substantial increase over time, reaching nearly 10% even a decade after the initial diagnosis. A comparative analysis between the general population and child cancer survivors reveals a six-fold higher risk of developing SMNs among the latter. Various factors contribute to the elevated risk of second cancers, with age, lifestyle, environmental influences, primary cancer treatment, and genetic predisposition playing pivotal roles. Noteworthy risk factors for SMNs in children encompass radiation therapy, chemotherapeutic agents, topoisomerase inhibitors, genetic factors, hematopoietic stem cell transplantation, and ionizing radiation, as elucidated in the present study. Despite these findings, further research is imperative to accurately quantify the risks associated with etiological factors, enabling the identification of individuals at a heightened risk for second cancers and facilitating proactive screening and preventive measures. [ABSTRACT FROM AUTHOR]

With only a few exceptions, the historical study of individual-level correlates of child mortality in the United States has been limited to the period surrounding the turn of the twentieth century, when children ever born and children surviving data collected by the 1900 and 1910 censuses allow indirect estimation of child mortality. The recent release of linked census data, such as the IPUMS MLP datasets, allows a different type of indirect estimation over a longer period. By following couples across subsequent decennial censuses, it is possible to infer child mortality by measuring whether couples' own children in the first census were still present in the second census. We focus our analysis on children aged 1–3 in the first of two linked censuses, who were less likely to be undercounted by the census than infants, and unlikely to be living apart from their parents in the second census. We estimate child mortality over the intervening decade and use OLS regression to correlate that mortality to the residence location and socioeconomic characteristics of their parents' households. We limit our analysis to three panel datasets for married couples linked between the 1850–60, 1860–70, and 1870–80 censuses, when real estate and personal estate wealth data were collected. Our results indicate a significant negative relationship between wealth and child mortality across all regions of the United States and over the entire period examined. [ABSTRACT FROM AUTHOR]

A growing body of research considers racial residential segregation to be a form of systemic racism and a fundamental cause of persistent racial disparities in health and mortality. Historical research examining the impact of segregation on health and mortality, however, is limited to a few studies with poor data and inconsistent results. In this study, we examine the association between racial residential segregation and child mortality in the South at the turn of the 20th century. We rely on the new IPUMS 1900 and 1910 complete‐count databases to estimate child mortality in the 5 years before each census and construct segregation measures at the census enumeration district (ED), the lowest level of geography consistently available in the census. We calculate the proportion of households headed by Black individuals in each ED, and the Sequence Index of Segregation (SIS), which is based on the racial sequencing of household heads within each district. We construct models of child mortality for rural and urban areas, controlling for a wide variety of demographic and socioeconomic variables. The results indicate that proportion Black and SIS were strongly and positively associated with the mortality of Black children in most models and in both rural and urban areas. Proportion Black was also positively but more moderately correlated with the mortality of White children, while SIS was not correlated or negatively correlated. These results suggest that racial segregation was a long‐standing fundamental cause of race disparities in health and mortality in the United States. [ABSTRACT FROM AUTHOR]

The article focuses on the impact of recent abortion bans in South Carolina and North Carolina, U.S. It discusses that the ban resulted in the denial of standard pregnancy and abortion care for most women in the South and parts of the Midwest; bans have forced women to travel long distances to states where abortion care is legal; and healthcare providers are hesitant to provide evidence-based care due to legal restrictions.

Firearms are a substantial cause of death for pre-school children (ages 0–5 years). The purpose of this study was to characterize fatal firearm violence in this age group. The Web-Based Injury Statistics Query and Reporting System (WISQARS) data from the Centers for Disease Control and Prevention (CDC) were analyzed for the years 2010–2020. There were 1,220 firearm deaths during the study period with a 75% increase in the rate of deaths per 100,000 population. Most deaths (two-thirds) were among males. Non-Hispanic Blacks comprised 56.4% of all deaths in 2020, a 172% increase from 2010 and the rate for non-Hispanic Whites increased by 15.4% from 2010 to 2020. The majority of the deaths occurred in the South. Almost two-thirds (65.9%) of all firearm deaths were homicides, 30% were unintentional, and 4.1% were undetermined. Homicides were also the majority of deaths for non-Hispanic Blacks (64.9%), non-Hispanic Whites (60.8%), and Hispanics (81.3%). The years of potential life lost before 80 years of age were 94,105, with a plurality (43.3%) of losses occurring among non-Hispanic Black children. Sustained awareness campaigns should be implemented to make parents and guardians aware of the profound dangers of unlocked and loaded or unsafely stored firearms in the home. Child healthcare providers should counsel parents and guardians on firearm safety in households. Public health professionals should advocate for laws that can help protect children from firearm violence (e.g., Domestic Violence Restraining Orders, Child Access Prevention laws, and Extreme Risk Protection Order laws). [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Fatal poisoning is a preventable cause of death among young children. Understanding factors surrounding these deaths will inform future prevention efforts. Our objective was to describe the characteristics of fatal pediatric poisonings using child death review data. METHODS: We acquired data from 40 states participating in the National Fatality Review-Case Reporting System on deaths attributed to poisonings among children aged ≤5 years from 2005 to 2018. We analyzed select demographic, supervisor, death investigation, and substance-related variables using descriptive statistics. RESULTS: During the study period, 731 poisoning-related fatalities were reported by child death reviews to the National Fatality Review-Case Reporting System. Over two-fifths (42.1%, 308 of 731) occurred among infants aged <1 year, and most fatalities (65.1%, 444 of 682) occurred in the child's home. One-sixth of children (97 of 581) had an open child protective services case at time of death. Nearly one-third (32.2%, 203 of 631) of children were supervised by an individual other than the biological parent. Opioids (47.3%, 346 of 731) were the most common substance contributing to death, followed by over-the-counter pain, cold, and allergy medications (14.8%, 108 of 731). Opioids accounted for 24.1% (7 of 29) of the substances contributing to deaths in 2005 compared with 52.2% (24 of 46) in 2018. CONCLUSIONS: Opioids were the most common substances contributing to fatal poisonings among young children. Over-the-counter medications continue to account for pediatric fatalities even after regulatory changes. These data highlight the importance of tailored prevention measures to further reduce fatal child poisonings. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Research has linked neighborhood opportunity to health outcomes in children and adults; however, few studies have examined neighborhood opportunity and mortality risk among children and their caregivers. The objective of this study was to assess associations of neighborhood opportunity and mortality risk in children and their caregivers over 11 years. METHODS: Participants included 1 025 000 children drawn from the Mortality Disparities in American Communities study, a cohort developed by linking the 2008 American Community Survey to the National Death Index and followed for 11 years. Neighborhood opportunity was measured using the Child Opportunity Index, a measure designed to capture compounding inequities in access to opportunities for health. RESULTS: Using hazard models, we observed inverse associations between Child Opportunity Index quintile and deaths among child and caregivers. Children in very low opportunity neighborhoods at baseline had 1.30 times the risk of dying over follow-up relative to those in very high opportunity neighborhoods (95% confidence interval [CI], 1.15-1.45), and this excess risk attenuated after adjustment for household characteristics (hazard ratio, 1.15; 95% CI, 0.98-1.34). Similarly, children in very low opportunity neighborhoods had 1.57 times the risk of experiencing the death of a caregiver relative to those in very high opportunity neighborhoods (95% CI, 1.50-1.64), which remained after adjustment (hazard ratio, 1.30; 95% CI, 1.23-1.38). CONCLUSIONS: Our analyses advance understanding of the adverse consequences of inequitable neighborhood contexts for child well-being and underscore the potential importance of place-based policies for reducing disparities in child and caregiver mortality. [ABSTRACT FROM AUTHOR]

Objective The aim of the study is to examine the impact of maternal interpregnancy body mass index (BMI) change on subsequent offspring mortality risk. Study Design This is a retrospective cohort study of women who had two consecutive live singleton deliveries of at least 20 weeks' gestation from the Utah Population Database. Our exposure was defined as interpregnancy BMI change from the date of first delivery to the conception date of subsequent pregnancy. We categorized BMI change as: < − 1, −1 to 0, 0 to <1 (reference), 1 to 2, 2 to 4, ≥4 kg/m 2. Our primary outcome was all-cause age-specific mortality during four time periods: neonatal (≤28 days), infant (29 days to <1 year old), childhood ((≥1 to <5 years old), and late childhood (5 to <18 years old). We also examined mortality specifically attributed to congenital anomalies. Analyses used Cox proportional hazard models stratified by full term (≥37 weeks) and preterm (<37 weeks) deliveries. All models were adjusted for relevant confounders. Results Of 266,752 women, among full-term deliveries, women with a BMI increase of 4 kg/m 2 or more had an increased risk of neonatal mortality in their subsequent pregnancy (hazard ratio or HR = 1.72, 95% confidence interval or CI: 1.23–2.41) Women who lost 1 kg/m 2 or more between deliveries also had increased neonatal mortality (HR = 1.46, 95% CI: 1.04–2.05). There were no differences in infant, early, or late childhood mortality by interpregnancy BMI change. Maternal interpregnancy interval weight loss of 1 kg/m 2 or more and weight gain of ≥4 kg/m 2 also had increased risk of mortality associated with congenital anomalies or conditions arising during the neonatal period following their subsequent delivery. Conclusion Women with significant interpregnancy weight gain and modest weight loss have a significant increased risk of neonatal mortality following their subsequent pregnancy. Key Points Significant weight gain between deliveries increases the risk of neonatal death. Modest weight loss between deliveries increases the risk of neonatal death. This risk may be partially explained by increased risk of congenital malformations. [ABSTRACT FROM AUTHOR]

Drowning is a leading cause of death for US children. Teaching youth to swim in a formal setting from certified instructors is a consistent drowning prevention recommendation. Purposes for this investigation was to examine type of swimming instruction and ability to swim and compare to attitudes toward swimming among US youth. Methods were similar to previous USA Swimming studies in 2008 and 2010. YMCA associations in five cities were used to recruit adolescent survey respondents (n=600) aged 12-18 years. Results showed African American youth had the lowest rate of formal swimming instruction (29%) compared to White (32%) and Hispanic (42%) peers. Free/reduced lunch qualifiers reported a 23% formal instruction rate as compared to 43% of non-qualifiers. Formally instructed youth were 2.35 times more likely to report being a skilled swimmer (86%) compared to informally instructed youth (72%). Formal swimming instruction is recommended, and interventions need to target underserved populations. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Congenital heart disease (CHD) is a leading cause of premature death in infants and children. Currently limited data are available regarding lesion specific mortality over time. Our study aimed to describe pediatric mortality trends by CHD lesion in the United States. METHODS: We conducted a 19 year analysis (1999 to 2017) of publicly available, deidentified multiple cause of death data compiled and produced by the National Center for Health Statistics. Analysis was stratified by CHD diagnosis and age using 3 age categories (infants, 1 to 4 years, and 5 to 17 years). Temporal trends of CHD mortality and the effect of contributing risk factors were analyzed by using joinpoint regression. RESULTS: Mortality was highest for in infants for all CHD lesions, in particular for total anomalous pulmonary venous return. Significant declines in infant CHD mortality occurred for most other lesions. Contributing risk factors, including prematurity, extracardiac birth defects, and genetic conditions, occurred in 19% of infant CHD deaths and demonstrated worse mortality trends in the majority of lesions. Mortality rates remained highest for single ventricle lesions in all ages, with an infant mortality rate plateau in the later half of the study and progressive increasing mortality rates for childresn 5 to 17 years. CONCLUSIONS: CHD mortality is decreasing for most lesions. Because of the heterogenicity of CHD lesions, there is expected variability in mortality trends by lesion and age group. Single ventricle lesions continue to contribute most heavily to premature death because of CHD demonstrated by significant increases in mortality rate for children aged 5 to 17 years. [ABSTRACT FROM AUTHOR]

Background: Physical and mechanical restraints used in treatment, care, education, and corrections programs for children are high-risk interventions primarily due to their adverse physical, emotional, and fatal consequences. Objective: This study explores the conditions and circumstances of restraint-related fatalities in the United States by asking (1) Who are the children that died due to physical restraint? and (2) How did they die? Method: The study employs internet search systems to discover and compile information about restraint-related fatalities of children and youth up to 18 years of age from reputable journalism sources, advocacy groups, activists, and governmental and non-governmental agencies. The child cohort from a published study of restraint fatalities in the United States from 1993 to 2003 is combined with restraint fatalities from 2004 to 2018. This study's scope has expanded to include restraint deaths in community schools, as well as undiscovered restraint deaths from 1993 to 2003 not in the 2006 study. Results: Seventy-nine restraint-related fatalities occurred over the 26-year period from across a spectrum of children's out-of-home child welfare, corrections, mental health and disability services. The research provides a data snapshot and examples of how fatalities unfold and their consequences for staff and agencies. Practice recommendations are offered to increase safety and transparency. Conclusions: The study postulates that restraint fatalities result from a confluence of medical, psychological, and organizational causes; such as cultures prioritizing control, ignoring risk, using dangerous techniques, as well as agencies that lack structures, processes, procedures, and resources to promote learning and to ensure physical and psychological safety. [ABSTRACT FROM AUTHOR]

1. Describe two major patterns of symptom trajectories over time among children receiving palliative care services. 2. Identify three clinical and research implications of the two major symptom trajectory patterns observed in pediatric palliative care. Patients receiving pediatric palliative care services, broadly speaking, experience either persistent or declining levels of symptoms over the course of months-to-years of time, with the latter pattern associated with greater than 50% mortality. These findings provide prognostic information and prompt redoubled attention to improving symptom management regarding persistently elevated symptoms. A foundational goal of pediatric palliative care (PPC) is to relieve patient suffering attributable to various symptoms that occur during serious illness. While pediatric patients receiving PPC are known to experience often high levels of polysymptomatology, much less is known about how symptom levels change over time and how they relate to mortality. Identify patterns of symptom trajectories and association with mortality among patients receiving pediatric palliative care. 2-year cohort study of patients, birth to 30 years of age, receiving PPC services from 7 PPC programs across the United States with data collected at 0, 2, 6, 12, 18, and 24 months from 2017 to 2022. We identified latent group trajectories of total symptom score of 20 symptoms over time. Two symptom score trajectories were identified in this cohort of 603 patients. Just less than half (n= 287, 47.6%) demonstrated a "persistent" symptom trajectory. While individual patients in this group had symptoms scores that fluctuated up and down one measure to the next, their scores over months-to-years persisted in a stable range. By contrast, the other group (n= 316, 52.4%) demonstrated a "declining" symptom trajectory. Patients in this group initially had higher overall symptom scores that, while fluctuating, declined substantially over time. Patient age, conditions, race, and ethnicity were not associated with these patterns, but mortality was. While 8.4% of the persistent trajectory group died during the study period, more than half (52.4%) of the declining trajectory group died. Most but not all patients receiving PPC experience declining levels of symptoms over months-to-years, a pattern associated with high mortality; the remainder experience fluctuating but stably persistent symptom levels with much lower mortality. These findings provide prognostic information and prompt redoubled attention to improving symptom management regarding persistently elevated symptoms. Pediatrics/Pain and symptom control [ABSTRACT FROM AUTHOR]

Background: Significant levels of funding have been provided to low- and middle-income countries for development assistance for health, with most funds coming through direct bilateral investment led by the USA and the UK. Direct attribution of impact to large-scale programs funded by donors remains elusive due the difficulty of knowing what would have happened without those programs, and the lack of detailed contextual information to support causal interpretation of changes. Methods: This study uses the synthetic control analysis method to estimate the impact of one donor's funding (United States Agency for International Development, USAID) on under-five mortality across several low- and middle-income countries that received above average levels of USAID funding for maternal and child health programs between 2000 and 2016. Results: In the study period (2000–16), countries with above average USAID funding had an under-five mortality rate lower than the synthetic control by an average of 29 deaths per 1000 live births (year-to-year range of − 2 to − 38). This finding was consistent with several sensitivity analyses. Conclusions: The synthetic control method is a valuable addition to the range of approaches for quantifying the impact of large-scale health programs in low- and middle-income countries. The findings suggest that adequately funded donor programs (in this case USAID) help countries to reduce child mortality to significantly lower rates than would have occurred without those investments. [ABSTRACT FROM AUTHOR]

Background: Motor-vehicles crashes are a leading cause of death among children. Age- and size-appropriate restraint use can prevent crash injuries and deaths among children. Strategies to increase child restraint use should be informed by reliable estimates of restraint use practices. Objective: Compare parent/caregiver-reported and observed child restraint use estimates from the FallStyles and Estilos surveys with the National Survey of the Use of Booster Seats (NSUBS). Methods: Estimates of child restraint use from two online, cross-sectional surveys—FallStyles, a survey of U.S. adults, and Estilos, a survey of U.S. Hispanic adults—were compared with observed data collected in NSUBS. Parents/caregivers of children aged ≤ 12 years were asked about the child's restraint use behaviors in FallStyles and Estilos, while restraint use was observed in NSUBS. Age-appropriate restraint use was defined as rear-facing child safety seat (CSS) use for children aged 0–4 years, forward-facing CSS use for children aged 2–7 years, booster seat use for children aged 5–12 years, and seat belt use for children aged 9–12 years. Age-appropriate restraint users are described by demographic characteristics and seat row, with weighted prevalence and corresponding 95% confidence intervals (CI) calculated. Results: Overall, child restraint use as reported by parents/caregivers was 90.8% (CI: 87.5–94.1) (FallStyles) and 89.4% (CI: 85.5–93.4) for observed use (NSUBS). Among Hispanic children, reported restraint use was 82.6% (CI: 73.9–91.3) (Estilos) and 84.4% (CI: 79.0–88.6) for observed use (NSUBS, Hispanic children only). For age-appropriate restraint use, estimates ranged from 74.3% (CI: 69.7–79.0) (FallStyles) to 59.7% (CI: 55.0–64.4) (NSUBS), and for Hispanic children, from 71.5% (CI: 62.1–81.0) (Estilos) to 57.2% (CI: 51.2–63.2) (NSUBS, Hispanic children only). Conclusion and Practical Application: Overall estimates of parent/caregiver-reported and observed child restraint use were similar. However, for age-appropriate restraint use, reported use was higher than observed use for most age groups. [ABSTRACT FROM AUTHOR]

BACKGROUND: To determine the association between states' total spending on benefit programs and child maltreatment outcomes. METHODS: This was an ecological study of all US states during federal fiscal years 2010--2017. The primary predictor was states' total annual spending on local, state, and federal benefit programs per person living #100% federal poverty limit, which was the sum of (1) cash, housing, and inkind assistance, (2) housing infrastructure, (3) child care assistance, (4) refundable Earned Income Tax Credit, and (5) Medical Assistance Programs. The main outcomes were rates of maltreatment reporting, substantiations, foster care placements, and fatalities after adjustment for relevant confounders. Generalized estimating equations adjusted for federal spending and estimated adjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs). RESULTS: States' total spending was inversely associated with all maltreatment outcomes. For each additional $1000 states spent on benefit programs per person living in poverty, there was an associated 4.3% (adjusted IRR: 0.9573 [95% CI: 0.9486 to 0.9661]) difference in reporting, 4.0% (adjusted IRR: 0.903 [95% CI: 0.9534 to 0.9672]) difference in substantiations, 2.1% (adjusted IRR: 0.9795 [95% CI: 0.9759 to 0.9832]) difference in foster care placements, and 7.7% (adjusted IRR: 0.9229 [95% CI: 0.9128 to 0.9330]) difference in fatalities. In 2017, extrapolating $1000 of additional spending for each person living in poverty ($46.5 billion nationally, or 13.3% increase) might have resulted in 181 850 fewer reports, 28 575 fewer substantiations, 4168 fewer foster care placements, and 130 fewer fatalities. CONCLUSIONS: State spending on benefit programs was associated with reductions in child maltreatment, which might offset some benefit program costs. [ABSTRACT FROM AUTHOR]

The Safe Systems Improvement Tool (SSIT) is a retrospective critical incident review tool designed for use in child welfare systems, which centers on the systems-level influences that contributed to casework practice in critical incidents. The SSIT output is structured and standardized, allowing for data aggregation both within and across systems. The SSIT demonstrates reliability at the tool and item level, and it is being widely used to review critical incidents across the United States. Learnings from aggregated SSIT data can be leveraged into systems-level quality improvement to enhance the safety and care of children and families. [ABSTRACT FROM AUTHOR]

A contemporary, age-specific model for the distribution of burn mortality in children has not been developed for over a decade. Using data from TriNetX, a global federated health research network, and the American Burn Association's Nation Burn Repository (NBR), we investigated nonsurvival distributions for pediatric burns in the United States. Pediatric burn patients aged 0 to 20 between 2010 and 2020 were identified in TriNetX from 41 Healthcare Organizations using ICD-10 codes (T.20-T.30) and identified as lived/died. These were compared to the nonsurvival data from 90 certified burn centers in the NBR database between 2016 and 2018. The patient population was stratified by age into subgroups of 0 to 4, 5 to 9, 10 to 14, and 15 to 20 years. Overall, mortality rates for pediatric burn patients were found to be 0.62% in NBR and 0.52% in TrinetX. Boys had a higher incidence of mortality than girls in both databases (0.34% vs 0.28% NBR, P = .13; 0.31% vs 0.21% TriNetX, P < .001). Comparison of ethnic cohorts between 2010 to 2015 and 2016 to 2020 subgroups showed that nonsurvival rates of African American children increased relative to white children (TriNetX, P < .001); however, evidence was insufficient to conclude that African American children die more frequently than other ethnicities (NBR, P = .054). When analyzing subgroups in TriNetX, burned children aged 5 to 9 had significantly increased frequency of nonsurvival (P < .001). However, NBR data suggested that children aged 0 to 4 experience the highest frequency of mortality (P < .001). The nonsurvival distributions between these two large databases accurately reflect nonsurvival rates in burned children. [ABSTRACT FROM AUTHOR]

We explore the role of social mobility as a driver of economic development by constructing a panel data set that includes measures of intergenerational mobility of education at the sub-national level in Latin America. First, we map the geography of educational mobility for 52 Latin American regions, as well as its evolution over time. Then, through a novel weighting procedure that considers the participation of cohorts to the economy in each year, we estimate the effect of changes in mobility on economic indicators, such as income per capita, poverty, child mortality, and luminosity. Hereby, we control for several covariates, including migration, educational expansions, initial conditions, and unobserved cross-regional heterogeneity. Our findings show that increasing social mobility had a significant and robust impact on the development of Latin American regions. [ABSTRACT FROM AUTHOR]

Objective: Unintentional injuries, the leading cause of death for American children, are caused by a range of psychosocial factors, including risk behavior. One factor that may impact child risk-taking is modeling of superhuman risk-taking from superhero media, both immediately following superhero exposure and based on lifetime exposure and engagement.Methods: Fifty-nine 5-year-olds were randomly assigned to view either a 13-min age-appropriate superhero television show or a comparable nonsuperhero show. After the viewing, children engaged in three risk-taking measures: (a) activity room, unsupervised play for 5 min with assortment of apparently dangerous items that might encourage child risk-taking; (b) picture sort, 10 illustrations of children in risk situations, with participant response concerning intended risk-taking in that situation; and (c) vignettes, 10 stories presenting situations with varying degrees of risk, with participant response on intended choice. Parents completed questionnaires concerning children's long-term superhero media exposure and individual superhero engagement (e.g., if child's most recent Halloween costume was of a superhero). Correlations and regressions evaluated effects of immediate superhero exposure, lifetime superhero exposure, and lifetime superhero engagement on children's risk-taking.Results: Mixed results emerged. Lifetime superhero exposure was significantly related to children's risk-taking outcomes in two bivariate (vignettes and picture sort) and one multivariate (picture sort) model. Neither immediate superhero exposure nor lifetime superhero engagement was strongly related to risk-taking.Conclusions: Children's lifetime superhero exposure may influence children's risk-taking. Given American children's substantial media exposure, research should continue to unpack the role of superhero media on children's unintentional injury and other health risk behaviors. [ABSTRACT FROM AUTHOR]

Background: Respiratory conditions are the leading cause of hospitalization and death in children with Trisomy 21 (T21). Diffuse alveolar hemorrhage (DAH) occurs at higher frequency in children with T21; yet, it is not widely studied nor is there a standardized approach to diagnosis or management. The objective of this study was to identify children with T21 and DAH in order to understand contributing factors and identify opportunities to improve outcomes. We identified 5 children with T21 at a single institution with histology-proven DAH over 10 years and discuss their presentation, evaluation, management, and outcomes. We also reviewed the cases in the literature. Case presentation: Patient 1 died at age seven due to secondary hemophagocytic lymphohistiocytosis. DAH was seen on autopsy. Patient 2 was a three-year-old with systemic-onset juvenile idiopathic arthritis diagnosed with DAH after presenting for hypoxia. Patient 3 was diagnosed with DAH at age nine after presenting with recurrent suspected pneumonia and aspiration. Patient 4 was diagnosed with DAH at age eight after presenting with pallor and fatigue. She had additional ICU admissions for DAH with infections. Patient 5 developed hemoptysis at age three and had recurrent DAH for 10 years. Four patients responded positively to immune-modulation such as intravenous immunoglobulin, glucocorticoids, and rituximab. Of the 19 patients identified in the literature, only one was from the United States. The majority had anemia, respiratory distress, autoantibodies, and recurrences. Very few patients had hemoptysis. Idiopathic pulmonary hemosiderosis was the most common diagnosis. Almost all received glucocorticoids with or without additional immunosuppression. The majority of our patients and those in the literature had positive auto-antibodies such as anti-neutrophil cytoplasmic antibodies and anti-nuclear antigen antibodies. Diagnostic clues included respiratory distress, hypoxia, anemia, recurrent pneumonia, and/or ground glass opacities on imaging. We identified four contributors to DAH: structural lung abnormalities, pulmonary arterial hypertension, infection/aspiration, and autoimmune disease/immune dysregulation. Conclusion: These cases demonstrate the need for an increased index of suspicion for DAH in children with T21, particularly given the low frequency of hemoptysis at presentation, enrich the understanding of risk factors, and highlight the favorable response to immunosuppressive therapies in this vulnerable population. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Road traffic accidents are a leading cause of child deaths in the United States. Although this has been examined at the national and state levels, there is more value in acquiring information at the county level to guide local policies. We aimed to estimate countyspecific child mortality from road traffic accidents in the United States. METHODS: We queried the Fatality Analysis Reporting System database, 2010-2017, for road traffic accidents that resulted in a death within 30 days of the auto crash. We included all children,15 years old who were fatally injured. We estimated county-specific age- and sexstandardized mortality. We evaluated the impact of the availability of trauma centers and urban-rural classification of counties on mortality. RESULTS: We included 9271 child deaths. Among those, 45% died at the scene. The median age was 7 years. The overall mortality was 1.87 deaths per 100 000 children. County-specific mortality ranged between 0.25 and 21.91 deaths per 100 000 children. The availability of a trauma center in a county was associated with decreased mortality (adult trauma center [odds ratio (OR): 0.59; 95% credibility interval (CI), 0.52-0.66]; pediatric trauma center [OR: 0.56; 95% CI, 0.46-0.67]). Less urbanized counties were associated with higher mortality, compared with large central metropolitan counties (noncore counties [OR: 2.33; 95% CI, 1.85-2.91]). CONCLUSIONS: There are marked differences in child mortality from road traffic accidents among US counties. Our findings can guide targeted public health interventions in high-risk counties with excessive child mortality and limited access to trauma care. [ABSTRACT FROM AUTHOR]

Background: Trauma is the leading cause of death for children and adolescents. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive method of hemorrhage control used primarily in adults. We aimed to characterize REBOA use in pediatric patients.Methods: The American Association for the Surgery of Trauma (AAST) Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry was queried for patients <18 years old undergoing REBOA placement (2013-2020). The primary outcome was mortality. Secondary outcomes included injury severity score (ISS), additional interventions, and complications.Results: Eleven patients with a median age of 17 years old had REBOA placed, with a survival rate of 30%. Inflation of the REBOA balloon resulted in a significant increase in systolic blood pressure (SBP) (median SBP pre-REBOA 53 mmHg vs. post-REBOA 110 mmHg, p=0.0007). Patients were severely injured with a median ISS of 29 (interquartile range 16-42). There were no access-site complications. All three surviving patients had a discharge Glasgow Coma Scale of 15.Conclusion: REBOA is used in patients <18 years old, but all reported patients in this registry were adolescents. No REBOA-related complications were reported. Identifying pediatric patients who may benefit from REBOA and modifying currently existing technology for this group of patients is an area of ongoing research. [ABSTRACT FROM AUTHOR]

Background: Factors associated with red blood cell (RBC), plasma, and platelet transfusions in hospitalized neonates and children across the United States have not been well characterized.Methods: Data from the Kids' Inpatient Database (KID) 2016 were analyzed. KID is a random sample of 10% of all uncomplicated in-hospital births and 80% of remaining pediatric discharges from approximately 4200 US hospitals. Sampling weights were applied to generate nationally representative estimates. Primary outcome was one or more RBC transfusion procedures; plasma and platelet transfusions were assessed as secondary outcomes. Analysis was stratified by age: neonates (NEO; ≤28 d), and nonneonates (PED; >28 d and <18 y). Multivariable logistic regression was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs).Results: Among 5,604,984 total hospitalizations, overall prevalence of transfusions was 1.07% (95% CI, 0.94%-1.22%) for RBCs, 0.17% (95% CIs, 0.15%-0.21%) for plasma and 0.35% (95% CI, 0.30%-0.40%) for platelet transfusions. RBC transfusions occurred among 0.43% NEO admissions and 2.63% PED admissions. For NEO admissions, RBC transfusion was positively associated with nonwhite race, longer length of hospitalization, highest risk of mortality (aOR, 86.58; 95% CI, 64.77-115.73) and urban teaching hospital location. In addition to the above factors, among PED admissions, RBC transfusion was positively associated with older age, female sex (aOR, 1.10; 95% CI, 1.07-1.13), and elective admission status (aOR, 1.62; 95% CI, 1.46-1.80). Factors associated with plasma and platelet transfusions were largely similar to those associated with RBC transfusion, except older age groups had lower odds of plasma transfusion among PED admissions.Conclusions: While there is substantial variability in the proportion of neonates and nonneonatal children transfused nationally, there are several similar, yet unique, nonlaboratory predictors of transfusion identified in these age groups. [ABSTRACT FROM AUTHOR]

This paper reports results from a second study which examines the knowledge and training of child welfare professionals with regard to risk factors for fatal child maltreatment. This multi-state, online study (n = 619) shows that workers have gaps in their knowledge of risk factors for maltreatment-related deaths. The majority of workers had received training, but it had little impact on worker knowledge. Workers reported receiving a variety of trainings on risks for fatalities, with different sources, length of training, and foci. Workers who received training that focused on research-based risk factors had higher levels of knowledge than other workers. [ABSTRACT FROM AUTHOR]

Background: Submersion injuries are a leading cause of injury death in children in the United States. The clinical course of a submersion patient varies depending on the presence of anoxic brain injury and acute respiratory failure.Objective: We studied changes in clinical findings and chest radiograph findings and determined the sensitivity/specificity of the presenting chest radiograph in predicting clinical improvement within the first 24 h in pediatric submersion cases.Materials and Methods: We conducted a cross-sectional study of pediatric submersion patients through age 18 years treated at a children's hospital from 2010 to 2013. We reviewed demographics, comorbidities, prehospital/hospital course and chest radiographic findings. Clinical improvement occurred when a child demonstrated normal vital signs and mentation. We compared radiographic findings among children based on clinical improvement up to 24 h post submersion. Using odds ratios, we calculated associations between radiographic findings and clinical improvement. We studied the sensitivity/specificity of the presenting chest radiograph in predicting clinical improvement within 24 h.Results: One hundred forty-two of 262 (54%) patients had initial chest radiographs; 41% had follow-up radiographs. The odds of an abnormal initial chest radiograph were 4 times higher in children with respiratory distress or abnormal mentation at emergency department (ED) presentation compared to children without these findings (odds ratio [OR]=4.83; 95% confidence interval [CI]=2.1-10.85; P<0.001). Improvement in radiographic findings occurred in 85% of children within 24 h. Children with an abnormal initial chest radiograph were 87% less likely to improve clinically by 24 h (P<0.001). A presenting chest radiograph that was normal or with mild pulmonary edema/atelectasis predicted clinical improvement within 24 h (sensitivity 95%, specificity 57%).Conclusion: Most chest radiographic findings improve in pediatric submersion patients who recover within the first 24 h. An initial chest radiograph that is normal or with mild pulmonary edema/atelectasis satisfactorily predicts clinical improvement by 24 h post submersion. [ABSTRACT FROM AUTHOR]

• TBI mortality declined from 1999–2013 due to the decrease from transport crash. • TBI mortality increased from 2013–2017, driven by an increase in suicide mortality. • The spectrum of leading causes of TBI mortality changed across age groups and years. • Age-adjusted TBI mortality varied greatly across U.S. states. To examine recent traumatic brain injury (TBI) mortality changes among Americans aged 0–19 years by sex, age, urbanicity, state, and intent/causes of injury. Method: TBI mortality per 100,000 population and average annual percent changes (AAPCs), plus 95% confidence intervals (CIs) based on Joinpoint regression models. Results: Age-adjusted TBI mortality among Americans aged 0–19 years declined consistently, though at varying rates between 1999 and 2013 (AAPC = −4.8%, 95%CI: −6.3%, −3.2%), and then significantly increased from 4.42 per 100,000 population in 2013 to 5.17 per 100,000 population in 2017 (AAPC = 3.4%, 95% CI: 1.7%, 5.1%). During the study time period, boys, rural children, and youth aged 15–19 years had higher TBI mortality rates than girls, urban children, and younger children, respectively. TBI mortality from unintentional transport crashes decreased substantially in all age groups between 1999 and 2017, and especially from 1999 to 2010. TBI mortality from suicide increased significantly from 2008 to 2017 in the 10–14-year age group (AAPC = 14.6%, 95% CI: 12.6%, 16.6%) and from 2007 to 2017 in the 15–19-year age group (AAPC = 6.3%, 95% CI: 3.8%, 8.7%). Unintentional transport crashes were the leading cause of TBI-related mortality in 46 states in 1999, but by 2017, suicide became the first leading cause in 14 states. Conclusions: Pediatric TBI mortality declined consistently between 1999 and 2013 and increased significantly from 2013 to 2017, driven primarily by the mortality decrease from unintentional transport crashes and increase in suicide mortality. The spectrum of leading causes of pediatric TBI mortality changed across age groups and over time from 1999 to 2017. Practical Applications: TBI mortality increases in the United States since 2013 are driven primarily by increasing suicide rates, a trend that merits the attention of policy-makers and injury researchers. Action should be taken to curb growing TBI mortality rates among adolescents aged 10–19 years. [ABSTRACT FROM AUTHOR]

Traumatic brain injury (TBI) is a leading cause of death and disability for children and adolescents in the U.S. and other developed and developing countries. Injury to the immature brain varies greatly from that of the mature, adult brain due to numerous developmental, pre-injury, and injury-related factors that work together to influence the trajectory of recovery during the course of typical brain development. Substantial damage to brain structure often underlies subsequent functional limitations that persist for years following pediatric TBI. Advances in neuroimaging have established an important role in the acute management of pediatric TBI, and magnetic resonance imaging (MRI) techniques have a particular relevance for the sequential assessment of long-term consequences from injuries sustained to the developing brain. The present paper will discuss the various factors that influence recovery and review the findings from the present neuroimaging literature to assess altered development and long-term outcome following pediatric TBI. Four MR-based neuroimaging modalities have been used to examine recovery from pediatric TBI longitudinally: (1) T1-weighted structural MRI is sensitive to morphological changes in gray matter volume and cortical thickness, (2) diffusion-weighted MRI is sensitive to changes in the microstructural integrity of white matter, (3) MR spectroscopy provides a sensitive assessment of metabolic and neurochemical alterations in the brain, and (4) functional MRI provides insight into the functional changes that occur as a result of structural damage and typical developmental processes. As reviewed in this paper, 13 cohorts have contributed to only 20 studies published to date using neuroimaging to examine longitudinal changes after TBI in pediatric patients. The results of these studies demonstrate considerable heterogeneity in post-injury outcome; however, the existing literature consistently shows that alterations in brain structure, function, and metabolism can persist for an extended period of time post-injury. With larger sample sizes and multi-site cooperation, future studies will be able to further examine potential moderators of outcome, such as the developmental, pre-injury, and injury-related factors discussed in the present review. [ABSTRACT FROM AUTHOR]

Pediatric mortality rates in the US have declined since 1999, although rates among non-Hispanic black and American Indian/Alaska Native children remain higher than those among non-Hispanic white children. We used mortality data from the Centers for Disease Control and Prevention to ascertain whether children living in rural areas experienced declines in mortality over the period 1999-2017 that paralleled those for the nation as a whole. Throughout the study period and across all age groups, rural children experienced higher mortality rates than their urban peers. Among rural children, non-Hispanic black infants and American Indian/Alaska Native children were particularly at risk. To reduce unnecessary rural pediatric and adolescent deaths, we recommend ongoing surveillance of rural children's health accompanied by policies targeting the leading causes of death in this population: unintentional injury and suicide. [ABSTRACT FROM AUTHOR]

Aims: To assess whether having multiple convictions for driving while under the influence of alcohol (MDUI) in women is a risk factor for maternal, infant and child mortality. Design Retrospective cohort design using record linkage, comparing women with MDUI convictions with propensity‐matched women without alcohol‐related driving offences ascertained through state records, on rates of maternal, infant and child mortality. Setting: Missouri, United States. Participants: MDUI women (n = 1658) and women with no alcohol‐related driving convictions (control, n = 184 252) who gave birth from 2000 to 2004. Measurements Data were obtained from state administrative records and US Census data. The outcomes were maternal, infant and child mortality. The input variable was presence or absence of MDUI convictions. Propensity‐matching variables were maternal (smoking during pregnancy, delayed prenatal care, previous child deaths, age at birth, mother Missouri‐born, education, pre‐pregnancy obesity, marital status), reproductive partner (un‐named partner, race/ethnicity, education, DUI status) and census tract (socio‐economic advantage, urbanicity) characteristics. Findings Women with MDUI convictions had higher odds of maternal, infant and child mortality than propensity‐matched controls [odds ratio (OR) = 2.65, 95% confidence interval (CI) = 2.07–3.40 and OR = 1.75, 95% CI = 1.17–2.61, respectively]. Conclusions: Having multiple convictions for driving under the influence of alcohol in women appears to be a risk factor for increased maternal, infant and child mortality. [ABSTRACT FROM AUTHOR]

In the United States, cancer remains the leading cause of disease-related death in children. Although survival from any pediatric cancer has improved dramatically during past decades, a number of cancers continue to yield dismal prognoses, which has motivated the continued study of novel therapeutic strategies. Furthermore, even patients cured of pediatric cancer often experience severe adverse effects of treatment and other long-term health implications, such as cardiotoxicity or loss of fertility. For these patients, improved risk stratification to identify those who could safely receive alternate or less-intensive therapy without affecting prognosis is a key objective. Fortunately, pediatric cancers are rare overall, but even among patients with the same narrow cancer type, there is often broad heterogeneity in terms of prognosis, molecular features or pathology, current treatment strategies, and scientific objectives. As a result, the design of clinical trials in the pediatric cancer setting is challenged by a number of practical issues that must be addressed to ensure trial feasibility for this vulnerable group of patients. In this review, we discuss some of the unique trial design considerations often encountered in any rare tumor setting through the lens of our experiences as faculty statisticians for the Children's Oncology Group, the largest organization in the world dedicated exclusively to pediatric cancer research and clinical trials. These topics include risk stratification within individual trials, relaxation of trial operating characteristics and parameters, use of historical controls, and address of noninferiority-type objectives in small cohorts. We review each in terms of practical motivation, present challenges, and potential solutions described in the literature and implemented in selected example trials from the Children's Oncology Group. [ABSTRACT FROM AUTHOR]

Objectives: We examine the association between several dimensions of parental socioeconomic status (SES) and all-cause and cause-specific mortality among children and youth (ages 1–24) in the United States. Methods: We use Cox proportional hazard models to estimate all-cause and cause-specific mortality risk based on data from the 1998 to 2015 National Health Interview Survey-Linked Mortality Files (NHIS-LMFs), restricted to children and youth ages 1–17 at the time of survey followed through age 24, or the end of the follow-up period in 2015 (N = 377,252). Results: Children and youth in families with lower levels of mother's education, father's education, and/or family income-to-needs ratio exhibit significantly higher all-cause mortality risk compared with children and youth living in higher SES families. For example, compared to children and youth living with mothers who earned college degrees, those living with mothers who have not graduated high school experience 40% higher risk of early life mortality over the follow-up period, due in part to higher mortality risks of unintentional injuries and homicides. Similarly, children/youth whose fathers did not graduate high school experience a 41% higher risk of dying before age 25 compared to those with fathers who completed college. Conclusions: Today's children and youth experience clear disparities in mortality risk across several dimensions of parental SES. As the U.S. continues to lag behind other high-income countries in health and mortality, more attention and resources should be devoted to improving children's health and well-being, including the family and household contexts in which American children live. [ABSTRACT FROM AUTHOR]

This study examines the roles of age, period, and cohort in influenza mortality trends over the years 1959-2016 in the United States. First, we use Lexis surfaces based on Serfling models to highlight influenza mortality patterns as well as to identify lingering effects of early-life exposure to specific influenza virus subtypes (e.g., H1N1, H3N2). Second, we use age-period-cohort (APC) methods to explore APC linear trends and identify changes in the slope of these trends (contrasts). Our analyses reveal a series of breakpoints where the magnitude and direction of birth cohort trends significantly change, mostly corresponding to years in which important antigenic drifts or shifts took place (i.e., 1947, 1957, 1968, and 1978). Whereas child, youth, and adult influenza mortality appear to be influenced by a combination of cohort- and period-specific factors, reflecting the interaction between the antigenic experience of the population and the evolution of the influenza virus itself, mortality patterns of the elderly appear to be molded by broader cohort factors. The latter would reflect the processes of physiological capital improvement in successive birth cohorts through secular changes in early-life conditions. Antigenic imprinting, cohort morbidity phenotype, and other mechanisms that can generate the observed cohort effects, including the baby boom, are discussed. [ABSTRACT FROM AUTHOR]

In 2020, firearm injury became the leading cause of death in U.S. children and adolescents. This study examines sequelae of firearm injury among children and adolescents in terms of health care costs and use within a family over time using an event study design. Using data from a large U.S. commercial insurance company from 2013 to 2019, we identified 532 children and adolescents aged 1–19 years who experienced any firearm-related acute hospitalization or emergency department (ED) encounter and 1667 of their family members (833 parents and 834 siblings). Outcomes included total health care costs, any acute hospitalization and ED visits (yes/no), and number of outpatient management visits, each determined on a quarterly basis 2 years before and 3 years after the firearm injury. Among injured children and adolescents, during the first quarter after the firearm injury, quarterly total health care costs were $24,018 higher than pre-injury; probability of acute hospitalization and ED visits were 27.9% and 90.4% higher, respectively; and number of outpatient visits was 1.8 higher (p <.001 for all). Quarterly total costs continued to be elevated during the second quarter post-injury ($1878 higher than pre-injury, p <.01) and number of outpatient visits remained elevated throughout the first year post-injury (0.6, 0.4, and 0.3 higher in the second through fourth quarter, respectively; p <.05 for all). Parents' number of outpatient visits increased during the second and third years after the firearm injury (0.3 and 0.5 higher per quarter than pre-injury; p <.05). Youth firearm injury has long-lasting impact on health care within a family. • Examining the impact of youth firearm injury within a family over time. • Costs of injured youth increased by $24,000 in the first quarter post-injury. • Parents' outpatient visits increased during the second and third years post-injury. • No change of health care costs and use among siblings post-injury. [ABSTRACT FROM AUTHOR]

The major concern for social work, namely child abuse‐related deaths (CARD), involves parental neglect. Societal neglect, when measured by child mortality rates (CMR), is considered by bodies such as UNICEF to be indicative of how a nation meets the needs of its children. This population‐based study analyses CARD and CMR for children aged from newborn to four years old between 1989–91 and 2013–15 to identify any relative child neglect in the USA and 20 other developed nations (ODN). World Health Organization data were used for CARD, CMR and undetermined deaths (UnD), a possible source of unreported CARD, juxtaposed against World Bank income inequality data. The USA had the highest number of CARD, the highest CMR and the worst income inequality. Five countries reduced their CARD significantly more than the USA, and 14 countries reduced their CMR more than the USA. Income inequality and CMR were correlated. Had the USA matched the CMR of Japan, where income inequality was narrowest, there would have been on average 16 745 fewer child deaths annually. CARD and UnD correlated, suggesting that UnD may contain unreported CARD. US CMR data indicate that services in the USA are less effective than those in ODN, possibly due to income inequality. These results will be unwelcome but child protection services must dare to speak truth to power. 'This population‐based study analyses CARD and CMR for children aged from newborn to four years old between 1989–91 and 2013–15 to identify any relative child neglect in the USA and 20 other developed nations' Key Practitioner Messages: The richest country in the world, the USA, has the highest rates of child abuse and total child mortality in the Western world.The USA has the highest income inequality in the West, highlighting the statistical link between child mortality and poverty.Children's services should lead the call for the necessary changes and 'speak truth to power'. [ABSTRACT FROM AUTHOR]

Mortality is a crucial indicator of well-being, and recent mortality trends have been a subject of public debate in many Western countries. This paper compares mortality inequality in Canada and the United States over the period 1990/91 through 2010/11. In Canada, mortality inequality remained constant among the youngest but increased for men over 24 and women over 14. In contrast, in the United States, mortality inequality fell for children and youth and either modestly increased or held steady at older ages. By 2010/11, the initially higher US rates of infant and child mortality had almost converged to their Canadian counterparts. [ABSTRACT FROM AUTHOR]

Background: Childhood acute respiratory infection remains the commonest global cause of morbidity and mortality among under-five children. In Ethiopia, it remains the highest burden of the health care system. The problem varies in space and time, and exploring its spatial distribution has supreme importance for monitoring and designing effective intervention programs. Methods: A two stage stratified cluster sampling technique was utilized along with the 2016 Ethiopian Demographic and Health Survey (EDHS) data. About 10,006 under-five children were included in this study. Bernoulli model was used to investigate the presence of purely spatial clusters of under-five acute respiratory infection using SaTScan.ArcGIS version 10.1 was used to visualize the distribution of pneumonia cases across the country. Mixed-effect logistic regression model was used to identify the determinants of acute respiratory infection. Result: In this study, acute respiratory infection among under-five children had spatial variations across the country (Moran’s I: 0.34, p < 0.001). Acute respiratory infection among under-five children in Tigray (p < 0.001) and Oromia (p < 0.001) National Regional States clustered spatially. History of diarrhoea (Adjusted Odds Ratio (AOR) = 4.71, 95% CI: (3.89–5.71))), 45–59 months of age (AOR = 0.63, 95% CI: (0.45–0.89)), working mothers (AOR = 1.27, 95% CI: (1.06–1.52)), mothers’ secondary school education (AOR = 0.65; 95% CI: (0.43–0.99)), and stunting (AOR = 1.24, 95% CI: (1.00–1.54)) were predictors of under-five acute respiratory infection. Conclusion and recommendation: In Ethiopia, acute respiratory infection had spatial variations across the country. Areas with excess acute respiratory infection need high priority in allocation of resources including: mobilizing resources, skilled human power, and improved access to health facilities. [ABSTRACT FROM AUTHOR]

We explore neonatal and infant mortality rates among children who apply for Supplemental Security Income (SSI) payments before reaching 1 year of age. We examine mortality-rate trends across several SSI policy regimes, and compare SSI applicants with the U.S. population overall. We also examine selected characteristics of infant SSI applicants, focusing specifically on the cohort of children who applied in 2015. We find that neonatal mortality among SSI applicants closely follows national trends, but that infant mortality among SSI applicants is roughly five times that of all children. Among children awarded SSI before reaching age 1 in 2015, those diagnosed with low birth weight are less likely to die by age 1 than are children with other impairments. Children living in Medicaid institutions have the highest infant mortality rates while children living with their parents have the lowest mortality rates. [ABSTRACT FROM AUTHOR]

We explore the first period of sustained decline in child mortality in the United States and provide estimates of the independent and combined effects of clean water and effective sewerage systems on under-5 mortality. Our case is Massachusetts, 1880–1920, when authorities developed a sewerage and water district in the Boston area. We find the two interventions were complementary and together account for approximately one-third of the decline in log child mortality during the 41 years. Our findings are relevant to the developing world and suggest that a piecemeal approach to infrastructure investments is unlikely to significantly improve child health. [ABSTRACT FROM AUTHOR]