1. Child Health
Chapter 10: Child Health
Chapter 10

2. The Importance of Child Health
6.3 million children under the age of 5 die each year.
Many of these deaths are preventable.
Children are a particularly vulnerable population.
Closely linked with poverty.
Insufficient progress has been made in certain parts of the world in reducing childhood morbidity and mortality.
Improvements in child health are a good measure of societal progress—hence the Millennium Development goals contains a specific goal explicitly stating the need to reduce childhood mortality as well as other goals relating to children as well (i.e. improving education rates, reducing poverty rates).  Infant and child mortality rates have traditionally been (and still are) used as sensitive markers for the overall health of nations as a whole. More than 17,000 children under 5 die every day. A lot of these deaths are preventable and could be avoided through low cost interventions. Children are put on global health agenda because of their vulnerability, poverty, lack of access to education and the disparity they face because of belonging to particular geographical location.

3. Since 1980 to 2011 there has been significant progress in under 5 child mortality however to reduce MDG4 we still need to put emphasis on certain sectors.

4. The world has made substantial progress in improving child survival in the past 25 years. The global under-five mortality rate dropped 53 (50, 55) percent, from 91 (89, 92) deaths per 1,000 live births in 1990 to 43 (41, 46) in 2015 (Table 1).
Source: UNICEF Accessed Jan 17, 2016

5. Key Terms
Perinatal : first week of life Neonatal : referring to the first month of life
Infant : referring to the first year of life Under-5 : referring to children 0-4 years old
Let us focus on some key terms that we will be referring to for this chapter.

6. Selected Terms Relating to Causes of Child Illness and Death
We also need to familiarize ourselves with some key definitions as applied to diseases and death for children.

7. The Burden of Childhood Illness
Children Under 5 Years
99% of childhood deaths are in low- and middle-income countries.
Half of these deaths occur in India, Nigeria, Democratic Republic of the Congo, Pakistan, and China.
44% of under-5 child deaths occur among neonates.
Rates and causes vary across and within countries.
General trend is decline, but rates of decline also vary considerably by region.
Almost half of the under five deaths occur in 5 large countries, India, Nigeria, Democratic Republic of the Congo, Pakistan, and China. 44% of these deaths occur in neonates and more than one third of these deaths occur within the very first day of their life. Neonatal mortality rates are highest in Africa, SE Asia and Eastern Mediterranean region. Sub Saharan Africa has 12 times more under-five mortality rate than high income countries. The differences we see in the rural and urban area child health is also important. Rural population in Latin America and Caribbean are about 1.7 times more likely to die than the urban population.

8. Underlying Causes/Determinants of Disease and Malnutrition
Poverty
Inadequate/Relative Poverty
Lack of access to care
Lack of maternal education
Conflict/War/Disaster
A number of reasons act as underlying causes for children death and they are
Poverty
Inadequate/Relative Poverty
Lack of access to care
Lack of maternal education
Conflict/War/Disaster

9. Neonatal Mortality Rate, by WHO Region, 2010
This slide shows the neonatal mortality rates among different WHO region. As we have discussed earlier, neonatal mortality rates are higher among Africa, Eastern Mediterranean and South-East Asia.

10. Neonatal, infant, and Under-5 Mortality
Global under-five, infant and neonatal mortality rates and number of deaths,
Source: UNICEF

11. Causes of Neonatal Deaths, by Percentage, 2008
Every year nearly 45% of all under 5 child deaths are among newborn infants, babies in their first 28 days of life or the neonatal period.
Three quarters of all newborn deaths occur in the first week of life.
In developing countries nearly half of all mothers and newborns do not receive skilled care during and immediately after birth.
Up to two thirds of newborn deaths can be prevented if known, effective health measures are provided at birth and during the first week of life.
So many newborn babies die for reasons that are preventable. The implementation of several proven interventions before birth, during delivery, and in the minutes, hours and days after birth could significantly improve the likelihood of survival for newborns.
Source: WHO

12. Leading causes of death in post-neonatal children: risk factors and response
Children under the age of five:
Under-five deaths are increasingly concentrated in sub-Saharan Africa and Southern Asia, while the proportion in the rest of the world dropped from 32% in 1990 to 18% in 2013.
Children in sub-Saharan Africa are more than 15 times more likely to die before the age of five than children in developed regions. About half of under-five deaths occur in only five countries: China, Democratic Republic of the Congo, India, Nigeria and Pakistan. India (21%) and Nigeria (13%) together account for more than a third of all under-five deaths.
Children are at greater risk of dying before age five if they are born in rural areas, poor households, or to a mother denied basic education.
More than half of under-five child deaths are due to diseases that are preventable and treatable through simple, affordable interventions. Strengthening health systems to provide such interventions to all children will save many young lives.
Malnourished children, particularly those with severe acute malnutrition, have a higher risk of death from common childhood illness such as diarrhoea, pneumonia, and malaria. Nutrition-related factors contribute to about 45% of deaths in children under five years of age.

13. Declines in Under-5 Child Mortality, by Region, 2015
There is marked reduction in child mortality over the 20th century. From 1990 to 2008 period, Europe had the lowest mortality and that reduced further. Europe and Latin America have achieved significant success in reducing child mortality. South Asia and Middle East have been achieving success at a lower rate. Africa has done poorly in terms of reducing maternal mortality , part of the reason of it is AIDS epidemic within different regions of Africa.

14. Additional Comments on Selected Causes of Morbidity and Mortality
Acute Respiratory Infections
Leading cause of death in low- and middle-income countries.
More severe and cause higher rates of death in low- and middle-income countries than in high-income countries.
Upper respiratory tract infections include the common cold and ear infections, lower respiratory infections include bronchiolitis and pneumonia.
Pneumonia is the leading cause of infectious death globally in children under 5 years.
Nutrition (exclusive breastfeeding, Vit A, and Zinc supplement) avoidance of indoor pollution, early recognition of symptoms and appropriate administration of full course antibiotic could reduce ARI death significantly.
Acute respiratory tract infections namely pneumonia is one of the leading causes of death in low and middle income countries. Upper respiratory tract infections, common cold, ear infections are also responsible for child mortality and morbidity. Pneumonia kills an estimated 1.2 million children under the age of five years every year – more than AIDS, malaria and tuberculosis combined. Pneumonia can be caused by viruses, bacteria or fungi. The most common forms of bacterial pneumonia are Streptococcus pneumonia, and Haemophilus influenza. Pneumonia can be prevented by immunization, adequate nutrition and by addressing environmental factors.

15. Diarrhea Caused by bacteria, viruses, protozoa, and helminths.
Causes dehydration, loss of nutrition or wasting, and damage to the intestines.
Infants 6-11 months are particularly vulnerable because they have been introduced to unsafe water and foods.
Death occurs due to
Dehydration
Electrolyte imbalance
Interventions like adequate supply of water, sanitation
and access to clean water could reduce mortality.
A number of different agents are responsible for diarrhea. Among them are virus, bacteria, protozoa, and helminthes. Diarrhea is transmitted by fecal oral route and generally a result from unsafe water, poor sanitation, and poor hygiene. Rapid diarrhea due to loss of fluid or dehydration could be fatal. An estimated 4 million cases of acute infectious diarrhea occurs worldwide. Children younger than 5 years in developing countries have 3-4 episodes of diarrhea each year. They are specially vulnerable to the dehydration and electrolyte loss which can result to death. Diarrhea is defined by the passage of 3 or more loose or liquid stools per day, or more frequently than is normal for the individual. 16% of post-neonatal death under-5 globally occur due to diarrheal disease.

16. Diarrhea Treatment Interventions
ORT
Continued breastfeeding
It is estimated that ORT is saving 1 million lives/year.
Zinc supplement
Question:
How much does a sachet of ORS cost?
Answer: 5-10 cents
Prevention and treatment of diarrhea is to replace the water loss through oral rehydration therapy. Homemade sugar/salt/water solutions, increased fluid intake and consumption of oral rehydration salts reduce the mortality risk. ORT is safer and much less costly. It is also important to continue feeding the baby as diarrhea leads to malnutrition and make susceptible to other infections. Zinc supplement given for days during acute diarrhea episode reduces duration and severity of episodes.

17. Malaria 600,000 children die from malaria each year.
Malaria is the leading cause of death in children under 5 years of age in sub- Saharan Africa.
People in endemic areas of sub-Saharan Africa will have almost five episodes of malaria a year.
Associated with premature birth and intrauterine growth retardation, which reduce chances of survival.
Malaria prevention interventions include vector control.
Insecticide treated nets can reduce overall under five mortality rates about 20% in malaria endemic countries.
Malaria has enormous impact on child mortality and morbidity. It is estimated that in Sub Saharan Africa a child is likely to have case of malaria every 40 days. The direct fatal effect of malaria is cerebral malaria that has a case fatality rate of 20%. Malaria has adverse effects on fetus health if pregnant mothers contract malaria. It is associated with premature birth, intrauterine growth retardation, low birth weight, and increased child and maternal mortality.91% of death from Malaria happens in Africa. Malaria prevention measures should include vector control that is control of mosquito. Other measures such as insecticide treated bed nets, insecticide spraying, and availability of antimalarial drugs have proven to be effective to reduce mortality from malaria.

18. HIV/AIDS
Can be transmitted from mother to child during birth or breastfeeding.
Number of HIV-infected children has generally declined with the use of antiretroviral drugs.
There are 200,000 newborns infected with HIV and more than 90%of them were in sub-Saharan Africa.
About 2% of deaths of children under 5 globally are a result of HIV infection.
Video: WHO strategy on HIV/AIDS for :
Question: Has anything changed since then?
The significance of HIV/AIDS in respect to child’s health is its capability of transmission from mother to child. This transmission could take place during delivery or during breastfeeding.

19. Measles
Acute respiratory infection with complications including pneumonia, diarrhea, encephalitis, and blindness.
Measles is a leading cause of vaccine preventable disease.
Children who are vitamin A deficient or infected with HIV are more at risk of death.
Extremely contagious if a population is not vaccinated.
Deaths from measles has decreased by 75% globally between 2000 and 2013.
Still accounts for about 2% of deaths of children under 5 years.
Video : The last Measle
Measles is an acute respiratory disease but it can lead to complications like diarrhea, pneumonia or encephalitis that are responsible for children mortality. It is a leading cause of vaccine preventable diseases. Children who are HIV positive and are vitamin A deficient are at increased risk of death. It is highly contagious and in the absence of vaccination, almost 100% of the population will get the disease.
The number of measles deaths decreased globally by 75% between 2000 and Despite this global progress, some populations remain unprotected.

20. Helminths
880 million children were t risk of infectious from soil-transmitted helminths.
Only 305 of these children receive appropriate treatment.
Infections can lead to severe morbidity, such as iron deficiency anemia.
The burden of several species of worms is highest in children around 6 or 7 years old.
The most common infections come from roundworm, hookworm, and whipworm million children were at risk of helminth exposure in 2012.

21. Additional Comments on Neonatal Mortality
44% of children under 5 who die annually, actually die in the first month.
Little progress in reducing neonatal death rate.
Every day that a child lives increases the likelihood that he or she will stay alive.
To reduce childhood death rates, the world needs to focus more precisely on when the deaths occur.
2.8 million children under 5 who die annually, actually die in the first month. To reduce the under-five mortality, it is therefore essential to reduce neonatal mortality. Every day a child lives, increases the likelihood that he or she will stay alive. To achieve this goal, we need to focus on where, how and when the deaths are taking place.
Figure: The share of neonatal deaths among under-five deaths has increased in all regions   Proportion of under-five deaths occur in neonatal period (percent), by UNICEF region, 1990 and 2011

22. Risk Factors for Neonatal, Infant and Child Deaths
Nutrition status.
Household income and education of mother.
Access to trained healthcare provider to attend birth and provide counseling.
Water quality and sanitation.
Risk factors that are established for neonatal, infant and child deaths are nutrition status, household income and education of mother, access to trained healthcare provider to attend birth and provide counseling, water quality and sanitation.

23. The Cost and Consequences of Child Morbidity and Mortality
High costs of caring for a sick child.
Potential long-term disability.
Poor school attendance and performance.
There are enormous costs and consequences to child morbidity and mortality. The direct and indirect costs of caring for a sick child can be very high, as parents have to spend parts of their limited financial resources to buy medical care or are unable to work because they are attending to a sick child. Also, childhood illnesses can lead to permanent disability and the related costs to families and to society that are associated with it. Additionally, in order to have children that will survive to adulthood, many poor families will have more children than they would have otherwise.

24. Future Challenges
Seven countries reduced the rate of under-5 child mortality by more than two-thirds between 1990 and 2012.
Either other countries have decreased the rate of under-5 child mortality by more than 50%, but less than 66% at the same time.
However, challenges to improving health in children remain.
Two thirds of childhood deaths that occur every year could be prevented by effective implementation of simple technology (e.g. ORT, bednets, etc).
Most of the progress that we have seen in reducing childhood mortality was targeted towards children between 1-5 years of age. Neonatal mortality has not been targeted to reach the target of MDGs. Interventions that are low cost and effective in reducing morbidity has not been implemented in the most needed areas.

25. Progress in Child Health
The global polio eradication initiative (Polio is now only endemic in three countries.)
Progress against measles (548,000 deaths in 2000 to 158,000 in 2011).
Progress towards universal immunization of children (in 2013, 111 million infants, or 84% of children, were vaccinated).
Some changes that occurred in global health: polio, measles, and immunizations.

26. Addressing Key Challenges in Child Health
Critical Child Health Interventions
Ensuring nutrition and health of the mother and mother-to-be.
Essential newborn care, extra care for small babies, and emergency care for newborns.
Preventing and managing diarrhea with hygiene, proper nutrition, measles vaccinations, and ORT.
Basic vaccinations.
Health care worker should inform the parents about:
Necessary immunizations and the schedule to follow
How to avoid anemia and parasitic disease in children over 6 months of age
Why deworming is important
Ways to ensure enough nutrient consumption such as iron and vitamin A.
To implement critical child health interventions we need to focus more precisely on the target population. The first of these categories are the mother and mother to be. It is essential to ensure nutrition and health of the mother and mother-to-be for example they should get enough nutrient, have proper antenatal care, and have the birth delivered by skilled birth attendant. As the first month is the most vulnerable period of a child’s life, the extra emphasis should be given on care for babies like early and exclusive breastfeeding, infection control, educate the mother about emergency preparedness and such. Diarrhea, the second leading cause of death, could easily be avoided by following some simple low cost interventions like to be engage in better personal hygiene, hygienic food preparation, ensuring proper nutrition, measles vaccination, and the use of ORT in cases of diarrhea.

27. Addressing Key Challenges in Child Health
Community-Based Approaches to Improving Child Health
Women’s groups to raise awareness of maternal, fetal, and neonatal issues.
Community-based promotion of hygiene, umbilical cord care, and keeping the baby warm
Video: Community project: Mothers helping mothers fight HIV (18:30)
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Community based interventions could lead to significant gain in health. Community awareness and the engagement of women’s group have been highly effective in improving health and survival of newborn. Integrated management approach in childhood illness is another notion in global child health which bases on the idea that a child should be viewed as whole and should be taken into account all the possible factors that are responsible for overall good health of a child. To achieve this goal, healthcare workers were trained at all level in particular home and community based workers. This approach is increasingly acknowledged as it has the potential of reducing children mortality at a minimal cost.
The video link here is an example of community based approach where a group of mother united to combat the challenge of HIV/AIDS in Africa.

28. Addressing Key Challenges in Child Health
Integrated Management of Childhood Illness
Integrated healthcare approach for children because of many interrelated factors.
Healthcare workers trained at all levels, particularly home and community- based .
In order to help tackle the challenge of child health there needs to be an integrated healthcare approach for children due to the many interrelated factors, as well as the need to have more healthcare workers trained at all levels, particularly home and community-based.