This study provides an analysis and description of external causes of death in the pediatric population, in Portugal, between 2014 and 2023.

The leading causes of pediatric deaths in this period were land transport injuries, suffocation, fire-related injuries, and falls.

The study showed a predominance of male adolescents among those who died from external causes, aligning with findings from multiple studies [4, 7, 10, 11, 26]. This higher vulnerability in male adolescents may be related to factors such as impulsivity and inquisitive nature, as well as a greater exposure to risk behaviors [26,27,28].

Over this period, there was no consistent downward trend in pediatric deaths from exogenous causes. A notable decline in deaths was observed in 2023, which may be partially attributed to the possibility that some autopsy reports were not included in the database at the time of data collection, rather than a true decline in deaths. However, this decline could also be associated with factors such as: improved and efficient safety measures and advancements in medical response to pediatric trauma. Further research would be required to determine the exact reasons for this fluctuation.

The observed increase in pediatric deaths during the COVID-19 pandemic aligns with existing research highlighting the heightened vulnerability of the juvenile population during periods of external stress [16,17,18]. While the surge in suicides was modest, it reinforces concerns about the long-term psychological impact of the pandemic on younger populations.

These findings may be attributed to several pandemic-related factors, including social isolation, limited access to mental health support, and increased family stressors [16,17,18]. Disruptions in healthcare services and emergency response systems could have also played a role in delaying critical interventions. Ensuring adherence to treatment for mental health disorders, along with improved mental health support and crisis intervention strategies, is essential for mitigating the impact of such crises on pediatric populations in the future.

Although the overall number and specific causes of death fluctuated over time, there was little to no decline in any cause of traumatic death over the past decade.

Fire-related injuries - the only exception to this tendency– peaked in 2017, which correlates with the devastating wildfires in the central region of Portugal (Pedrógão Grande, Leiria), in June of that year, triggered by an intense heatwave, which resulted in the deaths of 6 minors and 60 adults. This underscores the significant impact of environmental factors, such as natural disasters, on pediatric mortality.

Epidemiological data from World Health Organization (WHO) demonstrated a discrepancy in mortality rates by this mechanism between high-income countries, such as Portugal, and low-income countries [5, 29]. The high frequency in young children, as shown in our study, may be explained by a growing curiosity about fire and experiment with matches, lighters or firework, or even the act of copying caregivers’ tasks, like ironing or cooking [5].

Typically, deaths by burn-injuries or carbon monoxide poisoning are strongly connected to unsafe environments and products. Recommended prevention strategies vary from installing smoke alarms and sprinkler systems to the reinforcement of legislation restricting children’s access to fireworks. The development of child-resistant ignition devices could also significantly reduce the number of fires started by children. Additionally, educational programs for children and parents — focused on fire safety and the risks of storing flammable products at home—have proven to be effective [30].

For children over the age of 1, land transport injury was the most common cause of traumatic death, a finding supported by WHO data, which ranks road traffic injuries as the leading cause of death among children in the European region [5, 29]. In fact, the high child mortality rate due to land transport injury has been a major concern in Portugal since the 1980s, as the country has one of the highest child mortality rates in Europe [5, 31].

The fluctuating pattern in the number of land traffic injury-related deaths shown in our study (Fig. 4) could be attributed to a combination of multiple factors, such as: the effects of new safety campaigns; the implementation or changes in road safety laws; weather patterns; economic downturns; pandemic restrictions (e.g., travel restrictions during COVID-19); as well as changes in patterns of transport and exposure.

Several risk factors related to deaths from traffic accidents have been identified, such as driving under the influence of alcohol, stress or fatigue, excessive speed, poor road signs or conditions, and factors related to vehicles (inadequate tire, brake and engine maintenance and a lack of efficient airbags) [5, 26]. Over the last decade, measures to improve traffic safety have been implemented, however, these types of deaths have sustained their position as the leading cause of fatal injury, raising concerns about social compliance and the effectiveness of these strategies.

The increase in land transport-related deaths with age observed in our study may be linked to a greater propensity for engaging in risky behaviors. Recent data also shows that distraction by mobile technologies may play a role. A multisite observational study of 34 000 students crossing in school zones found that 1 in 5 high school students were observed to be inattentive using cellular phones or listening to music [32].

For neonates and infants, suffocation was the most common mechanism of death, mainly due to airway obstruction by inhalation of food or other objects. This finding is in agreement with study results from the UK [4], US [10], Brazil [26] and Canada [33].

As an initiative to prevent this issue, child health care providers should discuss choking-prevention strategies with parents and school staff. As recommended by the Canadian Peadiatric Society [34], it is pertinent to revise national laws related to child products sales, to include known hazards that are not currently regulated, but are associated with fatal incidents.

Portugal has a low drowning mortality rate compared to other European countries [5], with accidental drownings (88.31% of cases) being most common. While deaths in younger age groups are usually related to lack of supervision or absence of a pool barrier, in adolescents a common risk factor is alcohol/drug abuse.

A wide selection of effective interventions is recommended in order to reduce the national burden of drowning injuries: placing pool fences or covering pools; supervision of lifeguards and use of appropriate signage in public swimming sites; swimming education in and out of schools; and the use of personal floatation devices.

In contrast, Portugal is considered to have a relatively high mortality rate by fall-related injuries [5], which is in accordance with our results. Additionally, a higher prevalence of fall-related deaths among adolescents was observed, primarily of suicidal intent, whereas accidental falls were more common in the other age groups.

The circumstances of injuries produced by this mechanism also differ between ages: infants and toddlers are more likely to fall from stairs or playground structures or by being dropped, whereas children and adolescents mostly fall from balconies, windows or roofs.

In Europe, great strides have been made in terms of preventive measures, particularly regarding environmental and engineering changes. For example, implementing playground standards and installing safety equipment at home (e.g. window guards, stair gates, guardrails on beds) have proven to be useful [5].

According to guidelines from the Portuguese Association for Child Safety, balcony barriers should be at least 110 cm high, with gaps no wider than 9 cm and neither be climbable nor encourage climbing [35].

To further prevent fall-related deaths in children, increased supervision when near high places can help prevent falls. Providing information on childproofing homes and teaching children about the dangers of climbing can be helpful.