Mortality rates for children are rising at rates not seen in at least half a century, interrupting a long era of progress in shepherding America’s youth to adulthood. 

The death rate for children and adolescents rose by nearly 20 percent between 2019 and 2021, according to an analysis published March 13 in the Journal of the American Medical Association.  

“These increases, the largest in decades, followed a period of great progress in reducing pediatric mortality rates,” the authors wrote. They assigned blame to “manmade pathogens,” particularly guns and drugs. 

Pediatric death rates are rising mostly because of injuries, as opposed to diseases such as cancer and COVID-19. Boys are dying at nearly twice the rate of girls. Black and Hispanic boys are dying in homicides at much higher rates than non-Hispanic whites.  

But researchers found the death rate rising for children of both genders and multiple races and across several causational categories, from car accidents to drug overdose. 

Child mortality rates trended downward for decades, the collective result of several successful public health campaigns. Fewer children are dying of diseases that vaccines can prevent. Smoke detectors, bicycle helmets and seat belts all have contributed to lower death rates among the young. 

In recent years, however, several new and alarming trends have conspired to change the course of pediatric health. One overarching factor is firearms: between homicides and suicides, guns accounted for nearly half of the overall increase in child mortality in 2020, the report found. 

Fatal vehicular accidents, which declined for years, have rebounded and are elevating the youth death toll. Another factor is alcohol and drugs, which caused twice as many child deaths in 2021 as in 2019, mostly via accidental overdose. A spiraling mental health crisis looms across the landscape of child mortality. 

“We are at a point where the threat to children’s health is not coming from a microorganism or a cancer cell,” said Steven Woolf of Virginia Commonwealth University, lead author of the report. “It’s coming from bullets and drugs and cars.” 

Woolf serves as director emeritus and senior advisor at the VCU Center on Society and Health. He wrote the journal article with Elizabeth Wolf, an assistant professor of pediatrics at VCU, and Frederick Rivara, a professor of pediatrics at the University of Washington. Their report draws on death-certificate data collected by the Centers for Disease Control and Prevention.   

The childhood death rate has risen before, typically for a year or two, before resuming its downward course.  

“But an increase of this magnitude has not occurred in half a century,” Woolf said, “and perhaps has not occurred since the influenza pandemic,” which ended in 1919.  

The rising child death rate puts a sad and ironic twist on the broader trend of rising death rates in the U.S. population. The COVID-19 pandemic caused the largest jump in annual deaths in a century and, according to Woolf, single-handedly lowered American life expectancy by two years. 

But the rise in pediatric deaths is not really about COVID-19. Pandemic-related deaths accounted for only a small fraction of the increase in child mortality in 2020 and 2021.     

Woolf and other health experts cautioned against dismissing the new data as a phenomenon of COVID-19. The analysis found that suicide rates among children have been rising since 2007, while pediatric homicides have been climbing since 2013. Overdose deaths began to rise in 2019, a year before the pandemic. 

Homicides, suicides and accidental overdoses “are all preventable. That’s the thing that really stood out to me here,” said Chris Rees, assistant professor of emergency medicine in the department of pediatrics at Emory University. “There are ways that we know to prevent these things.” 

For many years, disease killed more children than any other cause. In the 1960s, car accidents eclipsed disease as the most common cause of child deaths. In 2020, firearms surpassed car accidents as the leading killer of American children.  

Rees has done extensive research on gun violence, a rising cause of both homicides and suicides. His research shows that firearm deaths rose 45 percent between 2004 and 2021.  

Firearms sales surged during the pandemic, Rees found, with more than 7 million Americans purchasing their first guns and exposing millions of spouses and children to firearms in their homes.  

“We have more firearms than people in this country, and we have way more firearms per person than any other country in the world that has data on firearm ownership,” said Robert Allan Hummer, the Howard W. Odum Distinguished Professor of Sociology at the University of North Carolina.  

Homicides among children rose by two-fifths between 2019 and 2021, according to CDC data. Most of the deaths involved guns. 

Many more boys than girls are dying from gun violence, and Black boys are dying at higher rates than other boys. Woolf’s analysis found that Black youths accounted for two-thirds of homicide victims ages 10 to 19. The homicide rate for Black boys was 61 times the rate for white females.  

Another force driving up child mortality is the nation’s ongoing mental health crisis. The child suicide rate nearly doubled between 2007 and 2021, from 2.1 deaths per 100,000 children to 3.8, according to CDC data.  

“We have a dramatic lack of appropriate mental health services for children,” said Leticia Ryan, an associate professor of pediatrics at Johns Hopkins University and director of pediatric emergency medicine at the Johns Hopkins Children’s Center.  

“It has become very routine in many hospital emergency departments to have children waiting for days after a suicide attempt, or after suicidal ideation, waiting for a bed,” she said. “This has gone on for years.” 

Ryan said the new report “very much aligns with what we have been seeing over the last few years,” a time of rising hospital admissions for pediatric injuries, including gun violence, suicide attempts and car wrecks. 

“I think we’re seeing a convergence of a number of concerning risk factors and trends,” she said. “It should be a wake-up call for all of us.”