Trends in US Children's Mortality, Chronic Conditions, Obesity, Functional Status, and Symptoms

Abstract

Importance: Recent scientific and policy statements suggest that child health may be worsening in the US.

Objective: To determine how US children's health has been changing from 2007 to 2023 using multiple data collection methods and a comprehensive set of health indicators.

Design, setting, and participants: Repeated, cross-sectional analyses using mortality statistics from the US and 18 comparator high-income nations from the Organisation for Economic Co-operation and Development (OECD18), 5 nationally representative surveys, and electronic health records from 10 pediatric health systems (PEDSnet). The populations included individuals younger than 20 years old. Unweighted denominator sample size ranges were 1623 to 95 677 across the surveys, 1 026 926 to 2 114 638 for PEDSnet, 81.9 million to 83.2 million in the US, and 118.4 million to 121.1 million in the OECD18 for mortality statistics.

Exposure: Calendar time.

Main outcomes and measures: Rate ratios (RRs) and annual incidence for mortality and prevalence for chronic physical, developmental, and mental health conditions, functional status, and symptoms.

Results: From 2007 to 2022, infants (<1 year old) were 1.78 (95% CI, 1.78-1.79) and 1- to 19-year-old individuals were 1.80 (95% CI, 1.80-1.80) times more likely to die in the US than in the OECD18. The 2 causes of death with the largest net difference between the US and OECD18 were prematurity (RR, 2.22 [95% CI, 2.20-2.24]) and sudden unexpected infant death (RR, 2.39 [95% CI, 2.35-2.43]) for infants 12 months or younger, and firearm-related incidents (RR, 15.34 [95% CI, 14.89-15.80]) and motor vehicle crashes (RR, 2.45 [95% CI, 2.42-2.48]) for 1- to 19-year-old individuals. From 2011 to 2023, the prevalence of 3- to 17-year-old individuals with a chronic condition rose from 39.9% to 45.7% (RR, 1.15 [95% CI, 1.14-1.15]) within PEDSnet, and from 25.8% to 31.0% (RR, 1.20 [95% CI, 1.20-1.20]) within the general population. Rates of obesity, early onset of menstruation, trouble sleeping, limitations in activity, physical symptoms, depressive symptoms, and loneliness all increased during the study period.

Conclusions and relevance: The health of US children has worsened across a wide range of health indicator domains over the past 17 years. The broad scope of this deterioration highlights the need to identify and address the root causes of this fundamental decline in the nation's health.

Figure 1.. All-Cause Mortality Rates per 100 000 in the US vs OECD18 for <1-Year-Old Infants and 1- to 19-Year-Old Individuals, 2007-2022

Data are from the Human Mortality Database (HMD). From 2007 to 2022, deaths among infants younger than 1 year old declined in both the US and 18 comparator high-income nations from the Organisation for Economic Co-operation and Development (OECD18) (A), but infants were 78% more likely to die in the US (C). B, Although deaths among 1- to 19-year-old individuals declined in the OECD18, they rose in 2015 and again in 2020 in the US. D, During the 2020 to 2022 interval, 1- to 19-year-old individuals were more than twice as likely to die in the US. Vertical lines through dots in panels C and D represent the 95% CIs for the rate ratios.

Figure 2.. Net Difference in Cause-Specific Mortality Rates in the US vs OECD18 for <1-Year-Old Infants and 1- to 19-Year-Old Individuals, 2007-2022

Counts of cause-specific deaths were obtained from World Health Organization data while the Human Mortality Database provided population counts. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes were clustered according to World Health Organization guidance.^, The net difference in rates was obtained by subtracting those of the 18 comparator high-income countries from the Organisation for Economic Co-operation and Development (OECD18) from the US rates. A, US infants younger than 1 year had higher death rates than OECD18 infants for prematurity, congenital anomalies, sudden unexpected infant deaths, and respiratory infections, but lower rates for birth asphyxia/trauma. B, Deaths among 1- to 19-year-old individuals were higher in the US than the OECD18 for firearms, motor vehicle crashes, substance use, and homicide. The difference between the US and OECD18 among 1- to 19-year-old individuals in the firearm and substance use categories increased markedly from 2020 to 2022.

Figure 3.. Annual Prevalence Rates of Chronic Conditions Based on Parent Report of 15 Conditions (National Survey of Children’s Health [NSCH]) and Clinical Diagnoses for 97 Conditions (PEDSnet), 3- to 17-Year-Old Individuals, 2011-2023

The chronic conditions in the NSCH available in multiple years beginning in 2011-2012 were attention-deficit/hyperactivity disorder, anxiety, asthma, autism, cerebral palsy, conduct disorder/behavioral problems, depression, developmental delay, diabetes (diabetes in 2011-2021 but type 2 diabetes in 2022 only), hearing problems, learning disability, seizure disorder, speech problems, Tourette syndrome, and vision problems. Data on these conditions were not obtained in the NSCH from 2012 to 2015. The PEDSnet chronic health conditions were selected from the list of Johns Hopkins Adjusted Clinical Groups System’s Expanded Diagnosis Clusters based on the likelihood that they would affect a child for at least 12 months.

Figure 4.. Temporal Trends (2023 vs 2011-2012) for 15 Chronic Conditions Among 3- to 17-Year-Old Individuals Assessed Using the National Survey of Children’s Health (NSCH) and PEDSnet Data

The NSCH used parent-reported information to identify children with a chronic condition, while PEDSnet was based on clinician-recorded diagnoses in electronic health records. The annual prevalence of 15 conditions was computed by dividing the 2023 rate by the 2011-2012 (NSCH) or 2011 (PEDSnet) rates. The 95% CIs for these rate ratios were so small that they are not shown because they were included in the size of the dots. A rate ratio of 1.0 means that the rate between the 2 time periods did not change. Anxiety had the largest increase, while asthma decreased in both data sources.

Figure 5.. Change in Annual Prevalence for Obesity, Onset of Menarche, Limitations in Activity, Physical Symptoms, and Emotional Symptoms in US Children, 2007-2023

The time trend comparisons showing declines in health are significantly different for all the health indicators. Obesity was assessed by physical examination. Parents’ reports were used for early onset of menstruation, trouble sleeping, and activity limitations. Youth self-reports were obtained for feeling sad/hopeless and feeling alone. Physical symptoms from PEDSnet data relied on physicians’ diagnoses recorded in electronic health records. For each outcome, blue dots represent the earlier time point and orange dots, the later. NHANES indicates National Health and Nutrition Examination Survey; NHIS, National Health Interview Survey; PSID, Panel Study of Income Dynamics; and YRBS, Youth Risk Behavior Surveillance System.