The research team, led by Maureen Moyo-Chilufya of Stellenbosch University together with colleagues at the London School of Hygiene & Tropical Medicine, searched five major databases—Embase, Global Health, MEDLINE, PubMed and PsycInfo—and screened 12,664 records to arrive at their final set of studies. To be included, studies had to compare mortality between children aged 0 to 19 with and without disabilities, apply a clear definition of disability, and report mortality data separately for young people rather than folding them into adult figures. Sixteen of the 29 studies provided sufficiently adjusted estimates for the pooled meta-analysis, contributing 26 comparative analyses.

The headline number conceals striking variation by age. Among children aged 0 to 5 years, the mortality gap was widest: those with disabilities died at 7.51 times the rate of their non-disabled peers. For older children and adolescents aged 6 to 19, the ratio was 4.68. The elevated risk in the earliest years of life points to a critical window, the authors suggest, where early identification, family-centred support and access to primary healthcare could make the greatest difference to survival.

Even more dramatic differences emerged when the researchers broke the results down by type of impairment. Children with neurological disabilities—conditions such as cerebral palsy and congenital Zika virus syndrome—experienced an 11.71-fold higher mortality, the largest disparity of any category examined. Those with intellectual and developmental disabilities, including autism, attention deficit hyperactivity disorder and Down syndrome, faced a 4.45-fold higher risk. By contrast, the analysis found no statistically significant difference in mortality for children with physical impairments such as achondroplasia and osteogenesis imperfecta, although the authors caution that only a small number of comparison groups were available in that category, limiting the precision of the estimate.

Statistically, the synthesis was far from straightforward. The studies displayed very high heterogeneity—an I-squared statistic of 98 percent in the overall pooled estimate—reflecting wide variation in how disability was defined, how mortality was ascertained, and which confounding factors were adjusted for. The researchers used random-effects models on the logarithmic scale, applied the DerSimonian and Laird method for estimating between-study variance, and conducted subgroup analyses by age and impairment type to probe the sources of that variability. Sensitivity analyses restricted to a single estimate per study, and separate pools for age-sex-adjusted versus multivariable-adjusted estimates, both confirmed that the direction and magnitude of the association held firm.

The team also checked for publication bias, the tendency for studies with dramatic findings to be published more readily than null results. Visual inspection of the funnel plot suggested some asymmetry, but Egger’s regression test did not reach statistical significance, offering no clear evidence of small-study effects. Risk of bias was assessed with the Joanna Briggs Institute critical appraisal checklist for cohort studies, and all included studies were rated as low to medium risk.

Why do children with disabilities die more often? The authors outline three interacting pathways. The first is social: children with disabilities are disproportionately exposed to poverty, limited education, inadequate housing, stigma, social isolation, violence and abuse—all of which erode health. The second is biological: the underlying impairment itself can amplify risk, as with the elevated rates of leukaemia and congenital heart defects seen in Down syndrome. The third is systemic: inaccessible facilities, negative provider attitudes, and insufficient training among health professionals create barriers to quality care, from routine vaccination to emergency treatment.

Crucially, the diversity of impairments included in the review suggests the elevated mortality cannot be explained by impairment alone. Evidence from cause-specific studies points to many deaths from common, preventable conditions such as pneumonia and other infectious and respiratory diseases, alongside deaths from injuries, poisoning, nervous system diseases and suicide. The UK Confidential Inquiry into premature deaths of people with intellectual disabilities previously identified high proportions of avoidable deaths linked to delayed diagnosis and inequities in the quality of care—findings that resonate with the global pattern now documented in children.

The review also exposes deep gaps in the evidence base itself. Nearly all included studies came from high-income countries, with 16 of 29 from Europe alone; four WHO regions were represented but South-East Asia and the Eastern Mediterranean were entirely absent. Most studies relied on administrative or medical records, meaning children whose disabilities are never clinically identified or recorded were likely missed. Sex-disaggregated data were unavailable in most studies, and there was too little information to analyse mortality by cause, disability severity, or world region. With roughly 240 million children with disabilities worldwide—the majority living in low- and middle-income countries—the absence of data from precisely the settings where the burden is greatest is itself a finding.

The authors call for disability to be embedded in routine health policy, planning and financing, for strengthened primary healthcare with clear pathways between community services, rehabilitation and specialised paediatric care, and for investment in accessible facilities, assistive technology and communication supports. They also urge researchers to adopt standardised measures such as the Washington Group questions, to link disability identifiers into demographic surveillance and mortality databases, and to investigate which deaths are avoidable. What is needed now, the review concludes, is not simply more documentation of the gap, but rigorous evidence on what actually works to close it.

Subject of Research: The association between disability and all-cause mortality among children and adolescents worldwide

Article Title: The association between disability and mortality among children and adolescents: A systematic review and meta-analysis

Article References: Moyo-Chilufya, M., Nguweneza, A., Rotenberg, S., Kuper, H., & Smythe, T. (2026). The association between disability and mortality among children and adolescents: A systematic review and meta-analysis. PLOS Medicine, 23(9), e1004947. https://doi.org/10.1371/journal.pmed.1004947

Image Credits: AI Generated

DOI: 10.1371/journal.pmed.1004947

Keywords: disability, child mortality, adolescent health, meta-analysis, systematic review, health equity, neurological disability, intellectual disability, global health, PLOS Medicine, health systems, pediatrics