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Causes of Child Death

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Neonatal deaths comprise 37 percent of all child deaths.²
The leading causes of death are severe infection (sepsis or pneumonia, tetanus and diarrhea), birth asphyxia, complications of prematurity and low birth weight, and congenital conditions. It is estimated that 18 million babies are born each year with a low birth weight (2,500 grams or about 5.5 pounds).³
Nearly all (98 percent) of neonatal deaths each year occur in developing countries and more than half of neonatal deaths occur in five countries: India, Nigeria, Democratic Republic of Congo, Pakistan and China.³

Where and Why do Newborns Die? ^{2, 4}

Percent of Newborn Mortality, by Source ^{1, 2}

Cause of Death	State of the World’s Children 2009 Data from 2000	Global Burden of Disease 2004 – Update 2008 Data from 2004
Neonatal infections (sepsis, pneumonia, etc.)	26	25
Preterm	27	31
Asphyxia	23	23
Tetanus	7	3
Diarrheal diseases	3	3
Congenital	7	7
Other	7	9

The perinatal period (from birth through the first week of life) is the riskiest time, with three quarters of all child deaths occurring during this period.¹ In fact, the highest number of deaths occur on the first day of life.

A quarter of the 3 million babies who are stillborn each year die during the birthing process.⁵
Over half of births in Africa and nearly one third in Asia take place without a skilled attendant present, increasing the risk of death or disability for both mother and newborn.⁶
Incomplete records of vital statistics and underreporting of deaths among newborns are common, suggesting that deaths during the perinatal period may actually be much higher.

Low birth weight. The World Health Organization (WHO) cites under-nutrition as the largest single contributor to premature death, as infants weighing less than 2,500 grams or 5.5 pounds at birth are at greater risk of death and disease than those with normal birth weight (2,500 – 4,000 grams, or up to about 8.5 pounds). Two key interventions for low birth weight infants are breastfeeding and management of the newborn’s temperature. Since the majority of infant deaths occur at home, educating mothers about the importance of immediate and exclusive breastfeeding is one of the most cost-effective survival solutions known.

Skin-to-skin contact between mother and newborn, (the Kangaroo method) helps keep the infant warm, promotes breastfeeding, and assists with forming a bond between mother and baby.
Low birth weight is associated with the mother being underweight or having poor nutrition. Maternal vitamin and mineral deficiencies substantially increase infant mortality. Therefore, efforts during pregnancy to provide healthy food and supplements of essential vitamins and minerals such as Vitamin A, iron and Zinc can have high impact.
Breast milk provides not only the safest and best food source but strengthens the infant’s immune system; it confers protection against infections.⁷
In comparison with giving the newborn milk-based fluids or solids in addition to breast milk, immediate (within an hour of birth) and exclusive breastfeeding has been shown to reduce neonatal deaths from all causes by 22 percent.⁸

A study in Uttar Pradesh, India demonstrated a 50 percent decline in neonatal mortality through raising awareness in the community of such simple survival strategies as cleaning, drying and warming the newborn, skin-to-skin contact with the mother, and exclusive breastfeeding for the first six months.⁹

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Pneumonia
Acute respiratory infections, primarily pneumonia, cause about 2 million deaths in children under age five every year.¹⁰

Each year, there are more than 150 million cases of childhood pneumonia and nearly two million children under five lose their lives to an acute bout of pneumonia or another acute respiratory infection.^{2, 11} Pneumonia is the leading cause of death for children under the age of five – more than AIDS, malaria and measles combined.^{1, 12}

Ninety-five percent of all pneumonia infections in children under the age of 5 occur in developing countries. Of these, 75 percent of all infections occur in just 15 countries: India, China, Nigeria, Pakistan, Bangladesh, Indonesia, Brazil, Ethiopia, Democratic Republic of Congo. Philippines, Afghanistan, Egypt, Mexico, Sudan and Viet Nam. Forty-four million cases occur in India alone.¹¹
About 200,000 child deaths that are attributed to pneumonia each year occur in the neonatal period, and pneumonia and sepsis are responsible for a quarter of all neonatal deaths.
Most deaths due to pneumonia occur in developing countries where poor children’s immune systems are already weakened by malnutrition and other diseases, including malaria, measles, or HIV/AIDS.

Pneumonia is the most serious of the lower respiratory infections, despite the fact that it can usually be effectively prevented and treated.^11,13 It is primarily a bacterial infection of the lungs that makes breathing difficult.

The two main pathogens that cause pneumonia among children in the developing world are Streptococcus pneumoniae and Haemophilus influenzae type b (Hib). Studies indicate that S. pneumoniae is responsible for over 50 percent of severe cases in Africa and a larger proportion of deaths, and Hib causes about 20 percent of severe cases.
Other pathogens that cause pneumonia are respiratory synctial virus (RSV), influenza, Staphlococcus aureaus, Klebsiella pneumoniae, and Pneumocystis jiroveci; the latter is problematic for young children with AIDS.
Pneumonia can also be a complication of other diseases, including measles, particularly when the child is weakened by co-infection, a compromised immune system, or malnutrition.
The pneumococcal conjugate vaccine (against S. pneumoniae) and the Hib vaccine are important prevention tools.
Prevention of conditions in which pneumonia can develop is also critical to reduce cases of pneumonia. Adequate nutrition (e.g., exclusive breastfeeding and zinc supplementation) and measles immunization can reduce the risk of developing pneumonia. Infants who are exclusively breastfed in the first six months of life are five times less likely to die of pneumonia than those who are not breastfed. Zinc reduces both the incidence of pneumonia and the severity of illness.
Antibiotics can effectively treat children with pneumonia, though only one in five caregivers can identify the early signs of pneumonia and only about half of children in need of care are taken to a health care provider.¹⁴ The diagnosis of pneumonia is complicated by its overlapping symptoms with malaria, including high fever, coughing, and fast breathing.⁴

Diarrhea
Diarrhea claims the lives of about 2 million children under the age of five every year

Cholera, shigellosis, rotavirus, typhoid, dysentery and other diarrheal diseases kill nearly 2 million children each year, accounting for 16 percent of childhood deaths.¹⁵

Diarrhea is a symptom of infection by water- or food-borne parasites, resulting in dehydration and electrolyte imbalances. Contaminated water causes 90 percent of diarrheal cases among children.
Children are more vulnerable than adults to the effects of diarrhea because their immune systems are less able to respond to these infections.¹⁶ In children, severe diarrhea may quickly lead to death, particularly among those who have vitamin deficiencies and other infections. Severe diarrhea can kill quickly if a child becomes dehydrated and goes into shock.¹⁷ Many care givers don’t recognize the danger until it is too late.¹⁸

Millions of children live in communities with little or no access to safe water and adequate sanitation, making prevention of food- and water-borne diarrheal infections extremely difficult.

While nearly all fatalities attributed to diarrhea can be averted through the use of an inexpensive solution of glucose and sodium (oral rehydration salts), repeat episodes are inevitable in the absence of safe water and improved hygiene practices. Without these, diarrhea will remain a leading global health threat for the world’s children.

Although respiratory and diarrheal diseases combined are responsible for more than half of child deaths, funding to address these specific causes is largely absent. Interventions to reduce occurrence of these diseases are known, but prevention and treatment tools have not been delivered effectively, especially in low-resource settings. More research is needed to determine the best delivery approaches and to monitor and evaluate the effectiveness of interventions.

The Global Forum for Health Research’s Child Health and Nutrition Research Initiative (CHNRI) has developed a research priority-setting framework that takes into account likely effectiveness of the intervention, deliverability, affordability, sustainability and potential to relieve disease burden.¹⁵ When health researchers in South Africa used this approach to set research priorities, they highlighted the importance of pneumonia and diarrhea research and interventions. Child health policy and systems research to increase handwashing with soap, promote antibiotic treatment of pneumonia, exclusive breastfeeding, case management of pneumonia, and use of oral rehydration salts, as well as to reduce the costs of safe water systems, were among the top 10 priorities identified.

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Malaria
Malaria kills approximately 850,000 children under age five annually.¹⁹

About 3 billion of the world’s population is at risk of malaria and nearly one million people die from this disease each year.¹⁹ Because malaria deaths may be attributed to other co-infections, the actual number of deaths due to malaria may be as high as three million. The majority of malaria deaths occur among young children.²⁰

About 85 percent of malaria deaths occur in children under the age of five, mostly in Africa (88 percent) and the Eastern Mediterranean (76 percent).¹⁹
Pregnant women are also particularly vulnerable to malaria, which can result in both maternal and fetal death, low birth weight in newborns, and anemia.^{4, 21}

Four parasites cause malaria – Plasmodium falciparum, P. vivax, P. ovale and P. malariae – and all are transmitted through the bite of an Anopheles mosquito.¹⁸ Symptoms include fever, headache and vomiting. There are effective and affordable measures to prevent and treat malaria.²⁰

Malaria deaths can be prevented through the use of insecticide treated bednets and indoor spraying with insecticides to prevent mosquito bites. Yet, only one in 25 children in sub-Saharan Africa sleeps under an insecticide-treated bednet.²³
Antimalraial drugs, i.e., artemisinin-based combination therapies (ACTs), are effective in treating malaria and are relatively affordable.
Resistance has developed in many countries to chloroquine and sulfa-doxine-pyrimethemine, formerly first-line drugs for treating malaria, which are now ineffective in these countries. Resistance undermines efforts to prevent and treat the disease through treatment failure, prolonged illness, hospitalization and death, and through increased transmission of resistant parasites. It requires additional surveillance to monitor its development, and research to address the potential impact and to find a new solution.²⁴

Injuries
Injuries cause 3-4 percent of child deaths per year, killing nearly 350,000 children under the age of five.²⁵

Injuries kill hundreds of thousands of children and hospitalize millions more every year. Most injuries are unintentional and occur in low- and middle-income countries, although causes of death vary widely by region and over time due to differences in environmental conditions and outbreaks of armed conflict. Overall, boys are at an increased risk of injury than girls, possibly because boys are more likely to engage in risky behaviors than girls and have fewer limitations to exploration. The risk of various injuries varies greatly according to age; for children ages 1-4, drowning, road traffic injuries, and fire-related burns are some of the leading causes of death.²⁵

Drowning is the leading cause of injury-related death for children under 5 years of age, although it is likely that current data underestimates mortality. Risk of drowning varies greatly with location, possibly because of variations in physical topography (rivers, streams, lakes, etc.). Few studies have examined the long-term health consequences of drowning, but limited evidence suggests that children who survive may develop neurological deficits.
Road traffic accidents are the second leading cause of injury-related death for children under 5 years of age, and appear to be increasing. Due to their short stature and limited understanding of speed and distance, children are particularly vulnerable to these accidents. Head and arm injuries are common in road traffic accidents, as are chest and abdominal injuries, which may damage internal organs.
Fire-related burns are the third leading cause of injury-related death for children under 5 years of age, with infants having the highest death rates. Burns from open fires and hot liquids are particularly common, posing a threat to young girls who are often involved in food preparation and work in the kitchen. Long-term consequences of burns including disability and scarring, which may cause the victim psychological distress.

HIV/AIDS
HIV/AIDS causes 2-3 percent of child deaths.²⁶

An estimated 2 million children under age 15 are infected with HIV; more than 370,000 young children become infected with HIV each year.^{12, 27} More than 95 percent of HIV-infected infants acquired their infection in utero (before birth), during delivery, or through breast milk. About one-third of infected infants die within one year and more than half die before age two years unless they receive treatment. In 2007, 270,000 children under the age of 15 died from AIDS-related causes and nearly all lived in sub-Saharan Africa.²⁶

From 2005 to 2007, the number of HIV-positive children receiving anti-retroviral drugs has increased by 70 percent in developing countries. This represents an increase from 75,000 in 2005 to 127,000 in 2006.²⁶

Anti-retroviral drugs can substantially reduce the risk of transmitting HIV from a mother to her child. In 2007, only one third of HIV-positive pregnant women living in developing countries received anti-retroviral drugs, and only 18 percent of pregnant women were tested for HIV.²⁷ A single dose of an antiretroviral drug costing only US $1-5 can cut the mother-to-child transmission of HIV by 50 percent.

In the absence of an inexpensive antiretroviral treatment to prevent infection, there is a 35 percent chance that HIV will be transmitted to a newborn.
About 15 to 20 percent of HIV-infected infants are infected during pregnancy, half became infected during delivery, and one-third is infected through breastfeeding.

HIV-infected parents may not survive or be well enough to care for their children. In sub-Saharan Africa, 12.1 million children under the age of 18 have lost one or both parents to AIDS. This represents a 100 percent increase from 2000 to 2007.²⁶
Exclusive breastfeeding for six months carries a significantly lower risk of HIV infection than does supplementing breast milk with formula or solid foods. UNAIDS advises, “Where replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding is recommended. Otherwise, exclusive breastfeeding is recommended for the first few months of life.”
Despite the risk of contracting HIV through breast milk, children in low-resource settings without access to safe water and sanitation are often at even greater risk of death from causes other than HIV if they are not breastfed. Infants who are not breastfed are seven times more likely to die of diarrhea and five times more likely to die of pneumonia than infants who are exclusively breastfed.

Measles
Measles kills just under 200,000 children per year.²⁸

Until recently, measles killed nearly 900,000 children each year. Following a joint WHO and UNICEF plan to expand measles vaccine coverage, deaths have declined by 74 percent since 2000—to about 197,000.²⁸ Despite this, over 500 children per day continue to die from an entirely preventable disease.

Over 95 percent of measles deaths occur in low-income countries, the majority of which occur in children under the age of five.
Widespread vaccination efforts have significantly reduced the number of infections worldwide. Between 2000 and 2007, measles incidents and deaths fell by about 90 percent in Africa and the Easter Mediterranean.

Caused by a virus, measles is highly communicable and is transmitted by contact with nasal or throat secretions emitted through sneezing or coughing of infected persons.

Measles symptoms typically consist of a high fever, cough, runny nose and a generalized rash.
Complications that develop with measles, such as pneumonia and diarrhea, as well as undernutrition, contribute to fatalities for children in developing countries.
Measles remains endemic in a number of countries. Because it is highly infective, high vaccine coverage is needed if measles is to be eradicated.

In Southern Africa, measles has been nearly eliminated as a cause of child death in just four years through a vaccination campaign costing just $1.10 per child.²⁹

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Other
Other infectious and parasitic diseases kill hundreds of thousands of children every year, and have long-term health consequences for millions more.²

Meningitis is often difficult to diagnose in children, and may be misdiagnosed as malaria because both infectious have similar symptoms (headache, fever, altered consciousness).³⁰ Fatality rates for meningitis vary, and neonates at greater risk than older children. Survivors may suffer from deafness or neurological damage.³¹
Neglected Tropical Diseases, including trypanosomiasis, Chagas disease, schistosomiasis, leishmaniasis, lymphatic filariasis and onchocerciasis, often leave children weak, malnourished, or with permanent physical and mental disabilities. For example, intestinal worms are a major cause of malnutrition, stunting and impaired development among children.³² Over half of the victims of soil-transmitted helminthiasis are children, and in some areas of Burkina Faso, all children are infected with schistosomiasis.³³ Infectious diseases also contribute to declines in school attendance.
Tetanus kills approximately 180,000 women and children annually, most in developing countries.³⁴ However, it is likely that the number of infant deaths due to tetanus is much larger, as most infants die at home and are not registered at birth. Newborns rarely survive neonatal tetanus, with most of these deaths occurring before two years of age.^{34, 35} In neonates, the onset and progression of the disease are particularly rapid.³⁴ If newborns survive, they may have neurological damage, often resulting in cognitive impairment.
Tuberculosis (TB) kills approximately 40,000 children every year, and constitutes 20 percent or more of the TB case-load in high-burden countries.^{2, 36} TB is difficult to diagnose in children, even with sputum microscopy and culture.³⁶ Children with HIV are particularly susceptible to TB, as are the children of HIV-positive mothers. More data is needed on childhood tuberculosis, including diagnosis and treatment.

Non-communicable Diseases
Non-communicable diseases cause hundreds of thousands of child deaths annually, including digestive, respiratory (including asthma), and cardiovascular diseases; malignant neoplasms; neuropsychiatric disorders (including epilepsy); and endocrine disorders.

Child Health and Malnutrition
Maternal and child undernutrition – too few nutrients to sustain growth and development – contributes to 3.5 million deaths each year and is responsible for about 11 percent of the global disease burden.^{37, 38} In children under 5 years of age, just over 2 million deaths are directly attributed to stunting, severe wasting, and restricted intrauterine growth, and about 1 million to vitamin A and zinc deficiencies.³⁷

Stunting Versus Wasting³⁹

Stunting: “Observed height for age at least two standard deviations below the mean for 0-5 year old children.”

Wasting: “Observed weight for height at least two standard deviations below mean for 0-5 year old children.

About one-third of children under age 5 living in developing countries – an estimated 178 million children – have stunted growth.³⁷ Nearly all of these children live in Asia (111.6 million) and Africa (56.9 million).
Wasting impacts nearly 20 million children under age 5 in developing countries, many of which are also stunted. Similar to stunting, the large majority of these children live in Asia (13.3 million) and Africa (5.6 million).³⁷
Africa is the only continent in which malnutrition among children is rising, but child malnutrition remains most pervasive in Asia.⁴⁰
Poor nutrition as a child may result in poor health as an adult. Child undernutrition is associated with shorter adult height, lower levels of academic achievement, reduced adult income, and low birth weight of their progeny.⁴¹ Millions of undernourished children are also at increased risk of infectious diseases in childhood and chronic diseases in adulthood.^{41, 42}
Vitamin A deficiency increases the risk of child death from diarrhea, measles and malaria by 20-24 percent and zinc deficiency increases the risk of death from diarrhea, pneumonia and malaria by 13-21 percent.^{43, 44}
Children in poor families are much more likely to be deficient in essential micronutrients such as vitamin A, iron, and zinc. The effects of chronic malnutrition in the first two years of life on cognitive ability are largely irreversible.⁴⁵

Learn More...

Fact Sheet: The Importance of Nutrition for Child Survival | read PDF

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²	World Health Organization. Global burden of disease report: 2004 update; 2008. Available from: www.who.int/healthinfo/global_burden_disease/2004_report_update/en/index.html
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⁴	UNICEF. The state of the world's children 2008; 2008. Available from: www.unicef.org/sowc08/
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