Canadian Indian mortality during the 1980s

This study concerns itself with an investigation of general and cause-specific mortality differentials between Canadian Registered Indians (a subset of all aboriginals) and the larger Canadian population over two points in time, 1981 and 1991. Multivariate analyses are executed separately across four segments of the life cycle: adulthood, infancy, early childhood and late childhood. With respect to adults, Indians share relatively high rates of suicide, homicide and accidental causes of death; over time, their conditional risks of death due to cancer and circulatory afflictions have gone up significantly. Mortality disadvantages for the Indians are also pronounced in infancy, early childhood (ages 1-4) and late childhood (ages 5-14). Suicide, accidents, and violence constitute serious problems among 5-14 year olds, while infectious/parasitic, respiratory and circulatory complications, plus accidents and violence, are principle killers in infancy. For children aged 1-4, respiratory problems and accidents/violence are prime causes of premature death. This less-than-optimal mortality profile is reflective of persistent problems associated with prolonged socioeconomic marginalization. The temporal pattern of change in chronic/degenerative disease mortality among adult Indians suggests a movement of this population toward a mature stage of epidemiological transition.     

Canadian Indian mortality during the 1980s

Abstract

This study concerns itself with an investigation of general and cause‐specific mortality differentials between Canadian Registered Indians (a subset of all aboriginals) and the larger Canadian population over two points in time, 1981 and 1991. Multivariate analyses are executed separately across four segments of the life cycle: adulthood, infancy, early childhood and late childhood. With respect to adults, Indians share relatively high rates of suicide, homicide and accidental causes of death; over time, their conditional risks of death due to cancer and circulatory afflictions have gone up significantly. Mortality disadvantages for the Indians are also pronounced in infancy, early childhood (ages 1–4) and late childhood (ages 5–14). Suicide, accidents, and violence constitute serious problems among 5–14 year olds, while infectious/parasitic, respiratory and circulatory complications, plus accidents and violence, are principle killers in infancy. For children aged 1–4, respiratory problems and accidents/violence are prime causes of premature death. This less‐than‐optimal mortality profile is reflective of persistent problems associated with prolonged socioeconomic marginalization. The temporal pattern of change in chronic/degenerative disease mortality among adult Indians suggests a movement of this population toward a mature stage of epidemiological transition.     

Sudden infant death syndrome and the age‐cause proxy relationship in infancy

Abstract

Evidence from a longitudinal study of the relationship between socioeconomic status and infant mortality in metropolitan Ohio is presented in an effort to throw additional light on the continuing debate over the validity of the age‐cause proxy relationship in infancy. The results indicate that while there is a fairly strong and consistent association between neonatal mortality and endogenous causes of death that is little affected by the classification of Sudden Infant Death Syndrome, the nature of the association between postneonatal mortality and exogenous causes of death varies from weak to moderate depending upon where this cause is included. Additional evidence pertaining to the role of SIDS in contributing to the long‐standing inverse association between infant mortality and socioeconomic status is presented, thus further emphasizing the need for continued research to clarify the etiologic mechanisms of this poorly understood condition.     

Causes of Early Childhood Deaths in Urban Dhaka,Bangladesh

Data on causes of early childhood death from low-income urban areas are limited. The nationally representative Bangladesh Demographic and Health Survey 2007 estimates 65 children died per 1,000 live births. We investigated rates and causes of under-five deaths in an urban community near two large pediatric hospitals in Dhaka, Bangladesh and evaluated the impact of different recall periods. We conducted a survey in 2006 for 6971 households and a follow up survey in 2007 among eligible remaining households or replacement households. The initial survey collected information for all children under five years old who died in the previous year; the follow up survey on child deaths in the preceding five years. We compared mortality rates based on 1-year recall to the 4 years preceding the most recent 1 year. The initial survey identified 58 deaths among children <5 years in the preceding year. The follow up survey identified a mean 53 deaths per year in the preceding five years (SD±7.3). Under-five mortality rate was 34 and neonatal mortality was 15 per thousand live births during 2006–2007. The leading cause of under-five death was respiratory infections (22%). The mortality rates among children under 4 years old for the two time periods (most recent 1-year recall and the 4 years preceding the most recent 1 year) were similar (36 versus 32). The child mortality in urban Dhaka was substantially lower than the national rate. Mortality rates were not affected by recall periods between 1 and 5 years.     

Socioeconomic status during childhood and health status in adulthood: the Wrocław growth study

It has been widely observed that socioeconomic status (SES) is associated with frequency of cardiovascular disease. Both men and women of low socioeconomic position have increased risk of cardiovascular disease morbidity and premature death. In this study the relationship between SES in childhood, and health status at the age of 50 years was examined. Socioeconomic status in childhood was measured using objective (father's educational level and number of children in the family) and subjective (self-assessed SES in childhood declared in early adulthood) indicators. Data from the Wroclaw Growth Study were completed when subjects were 50 years old, and information concerning health status was added. The results indicated that the objective, universally used measures of SES in childhood such as father's educational level and size of family did not show any essential relationships with health outcomes in adulthood, both for men and women. By contrast, retrospective, self-assessed SES (as better, average or worse as compared with peers) in childhood was significantly associated with the appearance of cardiovascular disease among women aged 50 years. Women who at the beginning of their adult life declared better socioeconomic condition in childhood were significantly healthier at the age of 50 years (OR=3.43; p=0.02). Moreover, this appeared to be independent of BMI, SES and life-style in adulthood. For men, retrospective self-assessed SES showed no relation to health status at the age of 50 years. The gender differences in the relationships between self-assessed SES in childhood and health status in adulthood are explained by possible selective premature mortality among men from lower childhood SES and/or sex differences in cognitive abilities.     

Using birth defects registry data to evaluate infant and childhood mortality associated with birth defects: an alternative to traditional mortality assessment using underlying cause of death statistics

BACKGROUND: Although birth defects are a leading cause of death in infancy and early childhood, the proportion of all deaths to children with clinically diagnosed birth defects is not well documented. The study is intended to measure the proportion of all deaths to infants and children under age 10 occurring to children with birth defects and how and why this proportion differs from the proportion of deaths due to an underlying cause of congenital anomalies using standard mortality statistics. METHODS: A linked file of Michigan livebirths and deaths was combined with data from a comprehensive multisource birth defects registry of Michigan livebirths born during the years 1992 through 2000. The data were analyzed to determine the mortality rate for infants and children with birth defects and for children with no reported birth defect. Mortality risk ratios were calculated. The underlying causes of death for children with birth defects were also categorized and compared to cause- specific mortality rates for the general population. RESULTS: Congenital anomalies were the underlying cause of death for 17.8% of all infant deaths while infants with birth defects were 33.7% of all infant deaths in the study. Almost half of all Michigan deaths to children aged 1 to 2 were within the birth defects registry, though only 15.0% had an underlying cause of death of a congenital anomaly based upon standard mortality statistics. The mortality experience among children with birth defects was significantly higher than other children throughout the first 9 years of life, ranging from 4.6 for 5 year olds to 12.8 for children 1 to 2. Mortality risk ratios examined by cause of death for infants with birth defects were highest for other endocrine (28.1), other CNS (28.1), and heart (21.9) conditions. For children 1 through 9, the highest differential risk was seen for other perinatal conditions (39.0), other endocrine (29.7), other CNS (24.5), and heart (21.4). CONCLUSIONS: Childhood mortality analyses that incorporate birth defects registry data provide a more comprehensive picture of the full burden of birth defects on mortality in infant and children and can provide an effective mechanism for monitoring the survival and mortality risks of children with selected birth defects on a population basis.     

Diarrheal Illness and Healthcare Seeking Behavior among a Population at High Risk for Diarrhea in Dhaka,Bangladesh

Diarrhea remains one of the major causes of death in Bangladesh. We studied diarrheal disease risk and healthcare seeking behavior among populations at high risk for diarrhea in Dhaka, Bangladesh. Data were obtained from a cross-sectional survey conducted during April and September 2010. The prevalence of diarrhea was calculated by age-group and sex. A generalized estimating equation with logit link function was used to predict diarrheal disease risk and seeking care from a professional healthcare provider. Of 316,766 individuals, 10% were young children (<5 years). The prevalence of diarrhea was 16 per 1000 persons among all ages; young children accounted for 44 per 1000 persons. Prevalence of diarrhea was significantly higher (p=.003) among younger males (<15 years) compared to that among younger females. In contrast, prevalence of diarrhea was significantly higher (p<.0001) among older females (≥15 years) compared to that among older males. An increased risk for diarrhea was observed in young children, males, and those staying in rented houses, lower family members in the house, using non-sanitary toilets, living in the area for short times, living in a community with less educated persons, living in a community with less use of safe water source for drinking, or living close to the hospital. About 80% of those with diarrhea sought care initially from a non-professional healthcare provider. Choice of the professional healthcare provider was driven by age of the patient, educational status of the household head, and hygienic practices by the household. The study reaffirms that young children are at greater risk for diarrhea. Like other developing countries most people in this impoverished setting of Dhaka are less likely to seek care from a professional healthcare provider than from a non-professional healthcare provider, which could be attributed to a higher number of diarrheal deaths among young children in Bangladesh. Dissemination of information on health education, increasing the supply of skilled healthcare providers, and low-cost and quality healthcare services may encourage more people to seek care from professional healthcare providers, thus may help reduce child mortality in the country. Further studies are warranted to validate the results.     

Parental death in childhood and pathways to increased mortality across the life course in Stockholm,Sweden: A cohort study

BackgroundPrevious studies have shown that the experience of parental death during childhood is associated with increased mortality risk. However, few studies have examined potential pathways that may explain these findings. The aim of this study is to examine whether familial and behavioural factors during adolescence and socioeconomic disadvantages in early adulthood mediate the association between loss of a parent at age 0 to 12 and all-cause mortality by the age of 63.Methods and findingsA cohort study was conducted using data from the Stockholm Birth Cohort Multigenerational Study for 12,615 children born in 1953, with information covering 1953 to 2016. Familial and behavioural factors at age 13 to 19 included psychiatric and alcohol problems in the surviving parent, receipt of social assistance, and delinquent behaviour in the offspring. Socioeconomic disadvantage in early adulthood included educational attainment, occupational social class, and income at age 27 to 37. We used Cox proportional hazard regression models, combined with a multimediator analysis, to separate direct and indirect effects of parental death on all-cause mortality.Among the 12,582 offspring in the study (men 51%; women 49%), about 3% experienced the death of a parent in childhood. During follow-up from the age of 38 to 63, there were 935 deaths among offspring. Parental death was associated with an elevated risk of mortality after adjusting for demographic and household socioeconomic characteristics at birth (hazard ratio [HR]: 1.52 [95% confidence interval: 1.10 to 2.08, p-value = 0.010]). Delinquent behaviour in adolescence and income during early adulthood were the most influential mediators, and the indirect associations through these variables were HR 1.03 (1.00 to 1.06, 0.029) and HR 1.04 (1.01 to 1.07, 0.029), respectively. After accounting for these indirect paths, the direct path was attenuated to HR 1.35 (0.98 to 1.85, 0.066). The limitations of the study include that the associations may be partly due to genetic, social, and behavioural residual confounding, that statistical power was low in some of the subgroup analyses, and that there might be other relevant paths that were not investigated in the present study.ConclusionsOur findings from this cohort study suggest that childhood parental death is associated with increased mortality and that the association was mediated through a chain of disadvantages over the life course including delinquency in adolescence and lower income during early adulthood. Professionals working with bereaved children should take the higher mortality risk in bereaved offspring into account and consider its lifelong consequences. When planning and providing support to bereaved children, it may be particularly important to be aware of their increased susceptibility to delinquency and socioeconomic vulnerability that eventually lead to higher mortality.

In this cohort study, Ayako Hiyoshi and colleagues show associations between parental death in a child’s life and mortality risk later in that child’s life.     

Epidemiologic transition in an isolated indigenous community in the Valley of Oaxaca, Mexico

The objective of the present study is to analyze age-specific mortality in a rural indigenous community in the throes of a secular increase in size in the Valley of Oaxaca, southern Mexico, over 30 years, 1970-1999. Variation in mortality by age group was analyzed over time for evidence of an epidemiological transition. The seasonal rain pattern in the Valley of Oaxaca (83% from May through September) was evaluated for its relationship with mortality in wet and dry months. Mortality and causes of death changed markedly over the 30-year interval. Infant and preschool mortality, overall mortality, and causes of death changed from the 1970s through the 1990s. Prereproductive deaths (<15 years) predominated in the 1970s and were largely due to gastrointestinal and respiratory diseases, with periodic outbreaks of measles. Deaths of adults 65+ years predominated in the 1990s and were largely due to degenerative diseases usually associated with aging. The marked changes in age and causes of death over the three decades (epidemiologic transition from Stage I to Stage II) occurred concurrently with significant secular increases in body size in children, adolescents, and young adults, highlighting improved health and nutritional conditions in the community which is in early Stage II of the demographic transition. The demographic transition to Stage II is a leading indicator (15-25 years lag) for the onset of the secular trend, while the epidemiologic transition to Stage II is a predictor that the secular increase is in process in the study community.     

Childhood cancer mortality in Australia

Aim: To determine current rates of childhood cancer mortality at a national level for Australia and to evaluate recent trends. Methods: Using population-based data from the Australian Paediatric Cancer Registry, we calculated cancer-related mortality counts and rates for the 3-year period 2006-2008 and trends between 1998 and 2008 by sex, age group, and cause of death (defined according to the International Classification of Childhood Cancers, third edition). Rates were directly age-standardised to the 2000 World Standard Population, and linear regression was used to determine the magnitude and significance of trends. The standardised mortality ratio for non-cancer deaths among children with cancer was also estimated. Results: A total of 282 children (23 per million per year) died from cancer in Australia between 2006 and 2008. Large decreases were observed in cancer mortality rates over the study period, particularly for boys (-5.5% per year; p<0.001), children aged 10-14 years old (-5.5% per year; p=0.001), and leukaemia patients (-9.4% per year; p<0.001). However, there was no significant change in mortality due to tumours of the central nervous system. Children with cancer were twice as likely to die from non-cancer causes compared to other children (SMR=2.06; p=0.001). Conclusions: While ongoing improvements in childhood cancer mortality in Australia are generally encouraging, of concern is the lack of a corresponding decrease in mortality among children with certain types of tumours of the central nervous system during the past decade. The results also highlight the need for intensive monitoring of childhood cancer patients for other serious diseases that may subsequently arise.     

Do fat babies stay fat?

A total of 203 children included in a study of feeding practices and weight in infancy were reviewed four to five years later. Although in infancy 28 (14%) of the children were obese and a further 52 (26%) overweight, in childhood most were of normal weight and fatness, with only 5 (2-5%) obese and 22 (11%) overweight, Three of the five obese children were also obese as infants, but only one in nine obese infants was obese at 5 years. Weight in infancy does not necessarily indicate later body size. Tall stature of the children was probably related to their socioeconomic environment.     

Decline in diarrhea mortality and admissions after routine childhood rotavirus immunization in Brazil: a time-series analysis

Background

In 2006, Brazil began routine immunization of infants <15 wk of age with a single-strain rotavirus vaccine. We evaluated whether the rotavirus vaccination program was associated with declines in childhood diarrhea deaths and hospital admissions by monitoring disease trends before and after vaccine introduction in all five regions of Brazil with varying disease burden and distinct socioeconomic and health indicators.

Methods and Findings

National data were analyzed with an interrupted time-series analysis that used diarrhea-related mortality or hospitalization rates as the main outcomes. Monthly mortality and admission rates estimated for the years after rotavirus vaccination (2007–2009) were compared with expected rates calculated from pre-vaccine years (2002–2005), adjusting for secular and seasonal trends. During the three years following rotavirus vaccination in Brazil, rates for diarrhea-related mortality and admissions among children <5 y of age were 22% (95% confidence interval 6%–44%) and 17% (95% confidence interval 5%–27%) lower than expected, respectively. A cumulative total of ∼1,500 fewer diarrhea deaths and 130,000 fewer admissions were observed among children <5 y during the three years after rotavirus vaccination. The largest reductions in deaths (22%–28%) and admissions (21%–25%) were among children younger than 2 y, who had the highest rates of vaccination. In contrast, lower reductions in deaths (4%) and admissions (7%) were noted among children two years of age and older, who were not age-eligible for vaccination during the study period.

Conclusions

After the introduction of rotavirus vaccination for infants, significant declines for three full years were observed in under-5-y diarrhea-related mortality and hospital admissions for diarrhea in Brazil. The largest reductions in diarrhea-related mortality and hospital admissions for diarrhea were among children younger than 2 y, who were eligible for vaccination as infants, which suggests that the reduced diarrhea burden in this age group was associated with introduction of the rotavirus vaccine. These real-world data are consistent with evidence obtained from clinical trials and strengthen the evidence base for the introduction of rotavirus vaccination as an effective measure for controlling severe and fatal childhood diarrhea. Please see later in the article for the Editors'' Summary     

Socioeconomic variation in estimated growth velocity of schoolchildren from a rural, subsistence agricultural community in southern Mexico

Socioeconomic variation in estimated growth velocities (annual growth increments) of several anthropometric dimensions was considered in schoolchildren from a rural, subsistence agricultural community in the Valley of Oaxaca in southern Mexico. The children (114 males, 99 females), 6-13 years of age, were measured twice, approximately one year apart. Annual growth increments were computed by subtracting measurements taken in the fall of 1978 from those taken in the fall of 1979. Information on household land holdings and appliances and parental occupation was used to compute an index of socioeconomic status (SES). Analysis of annual increments among upper SES (65 males, 45 females) and lower (49 males, 54 females) children indicated negligible differences. The results suggest that growth deficits evident in the children at school age occurred in infancy and early childhood so that there was little, if any, SES variation in growth rate at the school ages.     

Modelling Survival and Mortality Risk to 15 Years of Age for a National Cohort of Children with Serious Congenital Heart Defects Diagnosed in Infancy

Background

Congenital heart defects (CHDs) are a significant cause of death in infancy. Although contemporary management ensures that 80% of affected children reach adulthood, post-infant mortality and factors associated with death during childhood are not well-characterised. Using data from a UK-wide multicentre birth cohort of children with serious CHDs, we observed survival and investigated independent predictors of mortality up to age 15 years.

Methods

Data were extracted retrospectively from hospital records and death certificates of 3,897 children (57% boys) in a prospectively identified cohort, born 1992–1995 with CHDs requiring intervention or resulting in death before age one year. A discrete-time survival model accounted for time-varying predictors; hazards ratios were estimated for mortality. Incomplete data were addressed through multilevel multiple imputation.

Findings

By age 15 years, 932 children had died; 144 died without any procedure. Survival to one year was 79.8% (95% confidence intervals [CI] 78.5, 81.1%) and to 15 years was 71.7% (63.9, 73.4%), with variation by cardiac diagnosis. Importantly, 20% of cohort deaths occurred after age one year. Models using imputed data (including all children from birth) demonstrated higher mortality risk as independently associated with cardiac diagnosis, female sex, preterm birth, having additional cardiac defects or non-cardiac malformations. In models excluding children who had no procedure, additional predictors of higher mortality were younger age at first procedure, lower weight or height, longer cardiopulmonary bypass or circulatory arrest duration, and peri-procedural complications; non-cardiac malformations were no longer significant.

Interpretation

We confirm the high mortality risk associated with CHDs in the first year of life and demonstrate an important persisting risk of death throughout childhood. Late mortality may be underestimated by procedure-based audit focusing on shorter-term surgical outcomes. National monitoring systems should emphasise the importance of routinely capturing longer-term survival and exploring the mechanisms of mortality risk in children with serious CHDs.     

Mortality in achondroplasia.

Standardized mortality ratios (SMRs) were determined for a historical cohort of achondroplastic individuals identified through the Medical Genetics Clinics of the University of Texas Health Science Center at Houston and Johns Hopkins Hospital, Baltimore. Mortality was increased at all ages, with an overall SMR of 2.27 (95% confidence interval 1.7-3.0). Sudden death accounted for the excess deaths in those less than 4 years of age, and brain-stem compression was identified as the cause in half of these deaths. Central nervous system and respiratory causes were not significantly increased but accounted for half of the deaths in those 5-24 years of age. SMRs were not significantly increased for those greater than 34 years of age. However, deaths attributed to cardiovascular causes were increased in the 25-54-year-old age group, accounting for 10 of 17 deaths. The overall cardiovascular SMR was 5.2 (95% confidence interval 2.5-9.6). Within this group, severe disability resulting from marked spinal canal stenosis was present in a majority of individuals and may have been a contributing factor in these deaths. This study suggests that the bony abnormalities associated with achondroplasia--i.e., foramen magnum and spinal canal stenosis--may have a significant effect on mortality at all ages but particularly in children. Efforts to minimize these complications are recommended.     

Diarrhea, pneumonia, and infectious disease mortality in children aged 5 to 14 years in India

Background

Little is known about the causes of death in children in India after age five years. The objective of this study is to provide the first ever direct national and sub-national estimates of infectious disease mortality in Indian children aged 5 to 14 years.

Methods

A verbal autopsy based assessment of 3 855 deaths is children aged 5 to 14 years from a nationally representative survey of deaths occurring in 2001–03 in 1·1 million homes in India.

Results

Infectious diseases accounted for 58% of all deaths among children aged 5 to 14 years. About 18% of deaths were due to diarrheal diseases, 10% due to pneumonia, 8% due to central nervous system infections, 4% due to measles, and 12% due to other infectious diseases. Nationally, in 2005 about 59 000 and 34 000 children aged 5 to 14 years died from diarrheal diseases and pneumonia, corresponding to mortality of 24·1 and 13·9 per 100 000 respectively. Mortality was nearly 50% higher in girls than in boys for both diarrheal diseases and pneumonia.

Conclusions

Approximately 60% of all deaths in this age group are due to infectious diseases and nearly half of these deaths are due to diarrheal diseases and pneumonia. Mortality in this age group from infectious diseases, and diarrhea in particular, is much higher than previously estimated.     

Patterns of mortality in second generation Irish living in England and Wales: longitudinal study.

OBJECTIVE--To examine the mortality of second generation Irish living in England and Wales. DESIGN--Longitudinal study of 1% of the population of England and Wales (longitudinal study by the Office of Population Censuses and Surveys (now the Office for National Statistics)) followed up from 1971 to 1989. SUBJECTS--3075 men and 3233 women aged 15 and over in 1971. MAIN OUTCOME MEASURES--Age and sex specific standardised mortality ratios for all causes, cancers, coronary heart disease, cerebrovascular diseases, respiratory diseases, and injuries and poisonings. Deaths were also analysed by socioeconomic indicators. RESULTS--786 deaths were traced to men and 762 to women. At working ages (men, aged 15-64; women, 15-59) the mortality of men (standardised mortality ratio 126) and women (129) was significantly higher than that of all men and all women. At ages 15-44, relative disadvantages were even greater both for men (145) and for women (164). Mortality was raised for most major causes of death. Significant excess mortality from cancers was seen for men of working age (132) and for women aged 60 and over (122). At working ages mortality of the second generation Irish in every social class and in the categories of car access and housing tenure was higher than that of all men and all women in the corresponding categories. Adjusting for these socioeconomic indicators did not explain the excess mortality. CONCLUSION--Mortality of second generation Irish men and women was higher than that of all men and all women and for most major causes of death. While socioeconomic factors remain important, cultural and lifestyle factors are likely to contribute to this adverse mortality.     

The Relationship of Rapid Weight Gain in Infancy to Obesity and Skeletal Maturity in Childhood

Objective: Children with birth weight appropriate for gestational age (AGA) who also demonstrate rapid weight gain in infancy have a greater risk of being overweight or obese during childhood. A concurrent advancement in skeletal maturity would account for their greater size and would, therefore, not necessarily pose a threat of greater risk during adolescence and early adulthood. This study aims to determine whether children with rapid weight gain during infancy have advanced skeletal maturity during childhood. Research Methods and Procedures: One hundred and ninety‐three African children (boys = 108; girls = 85) of normal birth weight and gestational age were assessed from birth to 9 years. Body composition was assessed at 9 years of age by whole‐body DXA, and skeletal maturity was assessed using the Tanner‐Whitehouse II technique. Rapid weight gain in infancy was defined as a +0.67 change in weight‐for‐age Z‐score between birth and 2 years. Results: Rapid weight gain was experienced by over 20% of the sample. Children with rapid weight gain were significantly lighter at birth and significantly taller, heavier, and fatter throughout childhood. Chronological age and Tanner‐Whitehouse II technique skeletal ages at 9 years were not significantly different between groups or between sexes within groups. Discussion: Because AGA children with rapid weight gain have a greater risk of overweight and obesity but are not advanced in skeletal maturity, later adolescent adjustments toward average weight and fatness values are unlikely. The identification and monitoring of such children is of importance in reducing their risk of morbidity.     

Health inequalities: new concerns about the children of single mothers.

OBJECTIVES--To show that the exclusion from conventional class based analyses of child mortality of children whose parents are classified as "unoccupied" produces a misleading picture of health inequalities. DESIGN--Reanalysis of data published in the childhood supplement of the registrar general''s decennial supplement on occupational mortality in England and Wales, which compares numerator data for registrations of deaths in children over the age of 1 but below their 16th birthday in 1979, 1980, 1982, and 1983 with data about children aged 1-15 who were enumerated at the 1981 census. RESULTS--Parents who are classified as "unoccupied" largely consist of economically inactive single mothers. Their children are estimated to represent 89% of the 614,000 aged 1-15 classified as "unoccupied" in the childhood supplement. They have the worst mortality record of all social groups--an age specific death rate of 68.8/100,000 a year, 42% worse than in social class V (48.4/100,000) and worse than that of social class I (22.8) by a factor of 3. At older ages (10-15 years) these children have a relative risk of death of 4.14 relative to classes I and II; the risk is 2.58 in children 0-4 and 2.56 in those 5-9. Relative risks of child mortality in social classes I and II in comparison to classes IV and V suggests a progressive shallowing from 2.08 at ages 1-4 to 1.37 at ages 10-15. When unoccupied parents were combined with classes IV and V and compared with classes I and II, however, inequalities seemed to be pervasive throughout childhood; the relative risks were 2.21 for those aged 1-4 and 1.98 for those aged 10-15. CONCLUSION--Children classified as unoccupied are almost certainly living in poverty as well as experiencing relatively high risks of mortality. Class based analyses which exclude them therefore produce a misleading picture of inequalities in child health. The implications for health policy are profound. Strategies to promote the nation''s health should acknowledge the importance of material and social deprivation more explicitly.