• Involve road accidents, falls, drownings, train accidents, burns, cut injuries, poisonings, sharp trauma, asphyxia, hanging 

Unnatural deaths among children include accidental deaths involving road traffic accidents, falls, drownings, train accidents, burns, cut injuries, poisonings, sharp trauma, and asphyxia, and suicides involving hanging and drowning.

These findings were made in a research article on ‘Unnatural childhood deaths in two tertiary care hospitals in Sri Lanka: A retrospective study’ which was authored by M.S. Siddique, A.N. Vadysinghe, K.A.S. Kodikara and E.M.N.K. Ekanayake (all attached to the Peradeniya University's Medical Faculty's Forensic Medicine Department), and published in the Sri Lanka Journal of Forensic Medicine, Science and Law's 16th Volume's Special Issue, last month (May).

The death of a child is a sentinel event in a community and a defining marker of a society’s policies of safety and health. An unnatural child death is a tragic outcome that can occur anywhere in the world. During the last century, child mortality has fallen to very low rates in developed countries. From a medical perspective, a natural death refers to a death that occurs solely due to a disease or natural processes. Unnatural deaths include homicide, suicide, and accidents. "All of these cases are potentially preventable because the death occurs due to an external process". An understanding of the nature and patterns of childhood death and factors contributing to childhood deaths is essential to drive preventive initiatives (P. Sidebotham, J. Fraser, P. Fleming, M. Ward-Platt and R. Hain's ‘Patterns of child death in England and Wales’).

The World Health Organisation (WHO) defines a child as a person less than 18 years of age. Childhood is a critical phase of life with major physical, physiological, psychological, and behavioural changes, with changing patterns of social interactions and relationships. During this turbulent phase of life, young individuals are exposed to various needs, demands, challenges, failures, conflicts, and problems. This group will grow up to become fundamental contributors to the development of a country (R.A. Webster, P.G. Schnitzer, C. Jenny, B.G. Ewigman and A.J. Alario's ‘Child death review: The state of the nation’).

The global under-five-year mortality rate has significantly decreased over the past few decades. A 60% reduction reflects improvement in child health worldwide. Despite this progress in reducing child mortality, conditions such as pneumonia, diarrhoea, malaria, preterm births, and intrapartum-related complications remain, according to new mortality estimates released by the United Nations Children's Fund (UNICEF) and the WHO Population Division (the UNICEF's ‘Levels and trends in child mortality’). In 2019, the child mortality rate for Sri Lanka was 7.1 deaths per 1,000 live births, after falling gradually from 70.1 deaths per 1,000 live births in 1970 (UNICEF's ‘Sri Lanka - Demographics, health and infant mortality’).

A medico-legal autopsy is an important solution to many unanswered questions that may arise after death. Information revealed after a child’s death is mandatory to improve childhood survival and to strengthen child welfare services. The majority of unnatural deaths was due to accidents, including road traffic accidents, falls from a height, snake bites, lightning, electrocution, animal attacks, drowning, poisoning, hanging, and burns (L. Bøylestad, A. Stray-Pedersen, A. Vege, S. Osberg and T. Rognum's ‘Death-scene investigations contribute to legal protection in unexpected child deaths in Norway’ and I.D.G. Kitulwatte and P.A.S. Edirisinghe's ‘Study on unnatural childhood deaths presented to the Ragama Colombo North Teaching Hospital’).

Methods 

Siddique et al.'s study was a descriptive one, done retrospectively, that included all unnatural deaths among individuals under the age of 18 years. Data was retrieved from the databases of the two Hospitals (the Kandy National Hospital and the Kegalle District General Hospital) from 1 January 2020 to 31 December 2023. 

Results 

There were 23 unnatural deaths at the Kegalle Hospital for the given period and 72 unnatural deaths at the Kandy Hospital. All the children above five years of age were attending school, whilst others were at pre-school or being taken care of by their families. Among the unnatural deaths, 65/67.7% were male and 31/32.3% were female. These unnatural deaths consisted of 34/10.2% suicides and 62/18.61% accidental deaths. No homicides were reported.

The majority of the unnatural deaths occurred among teenagers, accounting for 65 deaths/72.2%, out of the total. In the three-to-12-year age group, there were 14/15.5% unnatural deaths, while among toddlers, nine/10% unnatural deaths were recorded. Unnatural deaths were the lowest among infants, with only two/2.2% cases reported. In the analysis of suicides, the majority of the children (88.23%) died from hanging (30), drowning (two) and other causes (two).

Unnatural deaths occurred under a variety of accidental circumstances. Road traffic accidents were the most frequent, accounting for nearly half of the unnatural deaths (41.6%). Falls were the second leading cause at 23.3%, followed by accidental drowning in 18.3%. Less common causes included train accidents (6.6%), burns (5%), and cut injuries (1.6%). The remaining 3.3% of unnatural deaths were attributed to other causes such as poisoning, accidental sharp trauma, and asphyxia.

Discussion 

Despite advancements in medicine, natural deaths remain the leading cause of death among both children and adults. Although natural causes remain a major contributor to child mortality in Sri Lanka, deaths from unnatural causes have increased over the last four years, principally due to hanging and road traffic accidents.

This study revealed that 67.7% of male child deaths were unnatural deaths. Male children have a higher tendency to undertake risky behaviours compared to their female counterparts. However, the underlying mechanisms driving this gender-based mortality disparity remain complex and not fully elucidated. Various biological and social factors, along with modifiable behaviours like substance abuse and violence, may play a significant role in the reduced life expectancy observed in male children (P.K. Debata, S. Deswal and M. Kumath's ‘Causes of unnatural deaths among children and adolescents in Northern India – A qualitative analysis of postmortem data’).

Several interconnected factors contribute to female child mortality. These include emotional and social situations, such as romantic relationships, and psychosocial disturbances, including mental health issues like depression and anxiety, which also play a crucial role. Socioeconomic factors like poverty, family dynamics, domestic violence, neglect, peer pressure, and societal influence potentially create a vulnerable, high-risk environment for female children, placing them at a higher risk for unnatural deaths (Y.D. Wado, K. Austrian, B.A. Abuya, B. Kangwana, N. Maddox and C.W. Kabiru's ‘Exposure to violence, adverse life events and the mental health of adolescent girls in Nairobi slums’).

The largest proportion of unnatural deaths (72.2%) was observed among teenagers. 

In the instant study, accidental deaths constituted two-thirds of all unnatural deaths. 

Access to lethal means significantly influences suicide methods. Hanging is the most common method of suicide among teenagers globally, a trend also observed in Sri Lanka. A thorough understanding of suicidal behaviour in children is essential for developing effective prevention strategies. In a European context, the most common suicide methods included hanging, jumping from heights, and railway suicides, followed by intoxication and firearms. In the United States, among children who committed suicide, strangulation/suffocation was the most frequent method, followed by firearm use.

While suicidal poisoning is a common method in Sri Lanka for adolescents and adults, its incidence has decreased due to stricter pesticide regulations and public awareness compared to previous years (I.D.G. Kitulwatte, P.A.S. Edirisinghe and T. Ratnayake's ‘Child victims in medico-legal autopsy’). Globally, poisoning accounts for 7% of accidental injuries in children under five. Child mortality from poisoning is around 2% in developed countries but is higher, exceeding 5%, in developing countries.

V. Berg, R. Kuja-Halkola, L. Khemiri, H. Larsson, P. Lichtenstein and A. Latvala's ‘Parental alcohol and drug abuse and offspring mortality by age 10: A population-based register study’ has revealed that the use of drugs and alcohol can contribute to the occurrence of any type or circumstance of unnatural death. Addiction to narcotic drugs is also a contributing factor to unnatural deaths among children.

The study highlights the need for economic policies that promote health equity and reduce premature deaths.

Limitations 

The autopsies were mostly negative for alcohol, and other toxicology data were incomplete. The study context, being urban Sri Lanka, may limit its application to rural areas due to differing socioeconomic and cultural contexts. 

Conclusion 

Unnatural deaths are avoidable and preventable in comparison with natural deaths. Conducting public awareness campaigns, educating caretakers on safety precautions, and advocating for mental health and safety legislation can be addressed. Authorities should identify children at risk and take necessary action.