Unintentional injuries are a major threat to child and adolescent health worldwide (1). Each year, injuries claim about 5 million lives of all ages, and roughly 12% of these deaths occur in children (2). Unintentional causes – such as road traffic crashes, drowning, burns, falls, and poisonings – account for the vast majority of injury deaths in those under 20 years old (3). In total, over 900,000 children and adolescents under the age of 18 die annually from unintentional injuries making injuries one of the leading causes of death and disability in this young population (4). As childhood infectious disease mortality has declined in recent decades, injuries now represent an increasingly prominent cause of preventable loss of life and health. Thousands of children who survive early childhood illnesses are later killed or disabled by injuries and injuries (both unintentional and intentional) constitute about one-third of all deaths among adolescents globally (5, 6). These figures underscore the urgent public health significance of child and adolescent injuries. The burden of unintentional injuries is unevenly distributed, with low- and middle-income countries (LMICs) bearing a disproportionate share. The majority of child injury deaths occur in LMIC settings, where safety regulations are limited and access to prompt trauma care is often inadequate (7). For example, an estimated 1,900 children and adolescents die every day from injuries, and most of these fatalities are in low-SDI (Socio-demographic Index) regions (8). By contrast, high-income countries have achieved substantial reductions in child injury mortality through improved safety legislation (e.g., road safety laws, pool fencing, smoke alarms) and strengthened health systems. Nevertheless, even in high-SDI settings, injuries remain a leading cause of pediatric mortality (9), indicating that no country is immune to this challenge. Major causes of unintentional injury deaths vary by context – road traffic injuries and drowning are among the top killers globally, while falls contribute heavily to non-fatal injury burden – but in all regions, these causes are largely preventable.

In light of this significant yet preventable burden, there is a strong rationale for a comprehensive global trend analysis of child and adolescent injuries. Understanding long-term trends and disparities in injury incidence and outcomes is crucial for guiding prevention efforts and policy. Previous analyses have highlighted the heavy toll of transport and other unintentional injuries among youth (10), but an updated global assessment is needed to evaluate progress over the past three decades and to inform future strategies. Using the latest Global Burden of Disease (GBD) 2021 data, which includes comprehensive estimates for 204 countries and territories up to the year 2021, we can quantify trends in injury incidence, mortality, and disability-adjusted life years (DALYs) with consistent methods. Such an approach allows us to monitor whether interventions and socioeconomic changes since 1990 have reduced the burden, and to identify persistent gaps.

In this study, we found that the global burden of unintentional injuries in children and adolescents has declined substantially over the past three decades. From 1990 to 2021, Incidence, mortality, and DALY rates for unintentional injuries all showed downward trends worldwide. Notably, the decline in mortality outpaced the decline in incidence, suggesting improvements in trauma care and injury survival. By 2019, the global age-standardized mortality rate for injuries under 20 years old had fallen to roughly 23 per 100,000 (10), and our 2021 estimates indicate further reductions. This progress reflects significant global efforts in injury prevention and health system response. However, the gains have been uneven. Males consistently experienced higher injury rates than females, and while both sexes saw mortality reductions, the gap between boys and girls persists. We also observed distinct age patterns: adolescents 15–19 years had the highest incidence of injuries, yet children under 5 years suffered the highest rates of injury mortality and long-term disability. This implies that young children, though less frequently injured, are especially vulnerable to fatal or life-altering outcomes when injuries occur, likely due to frailty and supervision gaps (21). Meanwhile, older adolescents engage in more high-risk activities, driving up injury incidence (22). These sex and age disparities in injury burden have remained remarkably consistent over time, highlighting the need for tailored interventions (for example, adolescent-targeted safety programs and enhanced protection for preschool-age children).

Our analysis underscores that global improvements mask stark regional and socioeconomic inequalities. Children in low-SDI regions continue to face a much higher risk of injury death and disability than those in high-SDI regions (1). This pattern suggests that children in poorer regions are not inherently injured more often, but their injuries are far more likely to be fatal or disabling – a reflection of underlying disparities in safety infrastructure and medical care. High-SDI settings tend to have extensive injury prevention measures (e.g., safer roads, fire safety, poison control) and robust emergency care systems that improve survival, whereas many low-SDI countries lack these life-saving advantages (23–25). The result is a preventable inequity: a child in a low-income country is several times more likely to die from the same injury than a child in a high-income country. This inequality is also evident on a regional level (26). For example, in 2017, the Eastern Mediterranean Region had an injury mortality rate of 43.2 per 100,000 – well above the global average of 27.2 – largely due to a combination of road traffic crashes and other hazards in contexts of conflict and limited resources (8). Sub-Saharan Africa and South Asia similarly remain regions of high concern, contributing a large share of global child injury deaths each year. By contrast, high-income regions (e.g., Western Europe, North America) have among the lowest injury rates and showed the steepest declines over the study period, owing to long-standing investments in injury prevention. These findings highlight that despite overall progress, a persistent “injury gap” remains between higher- and lower-SDI parts of the world. Children in certain countries, notably those in parts of sub-Saharan Africa, South Asia, and conflict-affected Middle Eastern nations, still bear an unacceptably high burden of unintentional injuries. Tackling this disparity should be a global priority.

Beyond macroeconomic development captured by SDI, socio-cultural contexts shape exposure, supervision, and care-seeking. Gender norms often lead to earlier engagement of boys in risk-prone activities (traffic, heights, open water), higher sensation-seeking, and greater tolerance of risk, aligning with the persistent male excess we observed across ages. Family structure and caregiver availability influence supervision quality; single-caregiver or skip-generation households and caregiver labor demands (e.g., agriculture, informal work) may increase unsupervised time for younger children, elevating drowning and burn risks.

Educational attainment and safety literacy affect hazard recognition and protective behaviors (helmet use, safe storage of fuels/chemicals). Urbanization changes risk profiles: while dense traffic elevates RTI risk, urban areas may provide faster emergency response; conversely, rural settings often combine water exposure, solid-fuel use, and longer transport times to definitive care. Cultural practices (e.g., cooking at floor level; seasonal migration of caregivers) and child labor also contribute. Integrating injury prevention into school curricula, community childcare solutions, and context-specific behavior-change programs can address these drivers and complement system-level interventions.

Mechanism-specific patterns underscore the need for tailored prevention. For road injuries, proven measures include graduated driver licensing and helmet/seatbelt/child-restraint enforcement, speed management, safer road design, and post-crash care strengthening. Drowning prevention should prioritize barriers and supervised safe play near water, community-based swim and rescue training, and childcare options in settings where caregivers’ workload limits supervision. Falls prevention requires safer built environments (window guards, stair gates, playground surfacing) and sports safety programs for adolescents. Fire/burn prevention is linked to clean cooking transitions, safer stoves and fuels, and household fire-safety education. For poisoning, child-resistant packaging and safe storage are critical. Aligning investments with the dominant local mechanism mix can accelerate declines beyond those projected from recent trends alone.

Several factors likely explain the observed declines and differences in unintentional injury burden. Improvements in health systems and trauma care have played a key role in reducing mortality (27). Over 30 years, many countries expanded emergency medical services, trauma centers, and surgical care for injuries, leading to better outcomes for injured children. This is evidenced by the faster fall in death rates compared to incidence rates – injuries may not be dramatically less frequent in some settings, but children who are injured have a better chance of survival today than in 1990. Advanced trauma care and prompt treatment of severe injuries (such as hemorrhage control, ventilatory support, and infection management) have particularly benefited high- and middle-SDI regions (28). In low-SDI regions, however, such care is often less accessible, contributing to higher case fatality and DALY rates (29).

At the same time, safety regulations and preventive measures have helped curb injury incidence and severity, especially in higher-SDI countries (30). Over the past decades, many nations enacted and enforced laws mandating child safety restraints in cars, motorcycle helmets, seat-belt use, safe storage of toxic substances, and fencing of pools or wells (31). Engineering improvements (such as safer road design, traffic calming, and flame-retardant materials in homes) have reduced exposure to hazards. Public health campaigns have raised awareness about supervising children around water, using smoke alarms, and other injury prevention behaviors. Collectively, these interventions have led to marked declines in certain injury types, reflecting efforts in countries like China to implement community water safety programs. Road traffic injury mortality among children has also decreased in many regions due to better road safety legislation and vehicle safety standards, although the extent varies. High-income countries saw dramatic reductions in child passenger fatalities with the adoption of car seats and seat-belt laws, whereas some low-income countries, undergoing rapid motorization without equivalent safety measures, struggled to reduce road deaths (32). The net effect worldwide has been a gradual downward trend in transport-related deathspmc.ncbi.nlm.nih.gov. In short, where strong safety policies and environmental protections have been put in place, injury rates have fallen, demonstrating that unintentional injuries are largely preventable with known interventions.

Differences in environmental exposures and societal factors also contribute to regional trends. Children in poorer rural areas may be more exposed to hazards like open water (leading to drowning) or cooking fires (burn injuries) due to a lack of protective infrastructure (33). In contrast, urbanization and industrial development bring other risks (traffic, high-rise falls) but can also facilitate better emergency response. Cultural and behavioral factors (such as risk-taking tendencies among adolescent males or traditional cooking practices that raise burn risk) influence injury patterns as well. For instance, the slower decline in adolescent male injury mortality observed in our study is consistent with risk behaviors (speeding, alcohol use, etc.) that remain challenging to change. Many low-SDI countries have youthful populations engaged in labor or chores that expose them to injuries (e.g., farming, fetching water, caring for siblings around hazards), whereas high-SDI countries have largely mitigated such risks (34). Additionally, climate and environmental changes may be affecting injury trends: more frequent floods can increase drowning incidents, and extreme heat or wildfires can raise burn and heat-related injuries, potentially offsetting some gains in certain regions. These complex factors mean that while the overall trajectory is positive, some subpopulations and injury causes have not improved as quickly (35). Our projections should be interpreted as trend-continuation forecasts rather than scenario-based futures. They may understate accelerated gains that could follow scale-up of proven policies (e.g., universal child-restraint/helmet enforcement, speed management, clean cooking adoption, swimming instruction at population scale) or overstate progress if emerging countervailing forces intensify (rapid motorization without safety infrastructure, climate-related flood exposure, conflict). To enhance policy relevance, future work could incorporate exploratory scenarios that vary key levers, road-safety enforcement, emergency care capacity, water-safety programming, and climate or conflict shocks, and could triangulate BAPC estimates with alternative specifications (e.g., different priors, shorter calibration windows, ARIMA/baseline GAMs) as sensitivity analyses.

In conclusion, this comprehensive global assessment reveals significant progress in reducing unintentional injuries among children and adolescents since 1990, but also delineates the considerable work still required. Injury burden has fallen overall, yet remains a leading cause of death and disability for young people and is marked by deep inequities between and within regions.