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Mortality in a cohort of 3.1 million children, adolescents and young adults
  1. Joel G Ray1,2,3,
  2. Astrid Guttmann3,4,
  3. Jose Silveira2,
  4. Alison L Park3
  1. 1 Medicine, and Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
  2. 2 Psychiatry, University of Toronto, Toronto, Ontario, Canada
  3. 3 ICES, Toronto, Ontario, Canada
  4. 4 Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
  1. Correspondence to Dr Joel G Ray, Medicine, and Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, M5B 1W8, Canada; joel.ray{at}


Background Many youth deaths occur in the first year of life, from prematurity and anomalies. Detailing mortality after age 1 year may differentially guide preventive strategies in children, adolescents and young adults.

Methods A cohort study in Ontario, Canada comprised 3 139 698 children born from 1990 to 2016. Adjusted HR (aHR) for death between 1 and 24 years were generated, comparing demographic variables and parity.

Results After a median of 13.7 years of follow-up, 6930 deaths occurred between ages 1 and 24 years (incidence rate 17.0 per 100 000 person-years), peaking at age 23 years (43.7 per 100 000). The aHR for death was higher among males than females (1.44, 95% CI 1.37 to 1.51), rural versus urban areas (1.48, 95% CI 1.39 to 1.58), lowest versus highest income areas (1.39, 95% CI 1.29 to 1.51) and at parity 1 (1.16, 95% CI 1.10 to 1.23), parity 2 (1.34, 95% CI 1.23 to 1.45), parity 3+ (1.96, 95% CI 1.74 to 2.21), each relative to a child without an older sibling. Among males, the proportion of deaths due to injury jumped from 30% before age 15 years to 65% thereafter, and in females, from 28% to 51%. Intentional self-harm/assault explained 11% of injury-related deaths among males before age 15 years, and 20% thereafter, with respective figures of 18% and 17% for females. Deaths outside of hospital increased with age, from 35% at age 1 year, to 66% at age 22 years.

Conclusion There is a heightened susceptibility of dying starting at age 15 years, especially among males, from injury, and arising outside of hospital.

  • child health
  • drug misuse
  • injury
  • mortality
  • suicide

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  • Contributors JGR, ALP: study concept, analysis and interpretation of the data, drafting of manuscript, manuscript revision, approval of final version. AG, JS: analysis and interpretation of the data, manuscript revision, approval of final version.

  • Funding This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). This study was also received funding from the Canadian Institutes of Health Research (CIHR).

  • Disclaimer The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. Parts of this material are based on data and information compiled and provided by MOHLTC and CIHI. The analyses, conclusions, opinions and statements expressed herein are those of the author and do not necessarily reflect those of the funding or data sources; no endorsement is intended or should be inferred. Parts of this report are based on Ontario Registrar General information on deaths, the original source of which is ServiceOntario. The views expressed therein are those of the author and do not necessarily reflect those of ORG or Ministry of Government Services.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available.

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