Child Health | Essentials of Global Health with Richard Skolnik

Welcome. Today we're going to speak about the health of children. By the time you finish this session, you should be able to understand the most important causes of illness and death among young children globally, discuss the importance of neonatal death, describe why some children survive and others die, and describe the most cost-effective child health interventions. Let's begin with two vignettes. Tirtha was born in far western Nepal seven months ago. She was the fourth child in her family. She was already eating some baby foods as well as continuing to breastfeed. One day, Tirtha developed persistent diarrhea and became feverish. Her mother wanted to take Tirtha to the health center, but living in far western Nepal, that center was two hours away by foot. So the mother decided to see how Tirtha was feeling the next day. Unfortunately, the next morning, Tirtha was dead from the dehydration caused by diarrheal disease. Elizabeth, why is diarrhea so prevalent in low-income countries, and how can families address it in the short and longer run? So there were already some examples in the vignette, including the fact that Tirtha wasn't exclusively breastfed, so she wasn't able to take full advantage of her mother's antibodies, and also when other foods are introduced, sometimes they're introduced in an unhygienic way, and so she might have contracted something from that as well. And what are some of those causes of poor hygiene, for example, that one might find in places like far western Nepal? Lack of infrastructure, water, sewage, and sanitation, and sometimes people just aren't educated about how to practice hygiene correctly. Okay. Let's move to another vignette. Juan was born in the highlands of Bolivia to an indigenous family. The family did what they could to keep the new baby warm, but it was very cold in the mountains. Several days after birth, Juan began to breathe heavily. The family called the community health worker for assistance, and the health worker treated Juan for pneumonia with an antibiotic that she had just learned to use through a program called Saving Newborn Lives in Bolivia. She also gave the family advice about how to take care of the baby. The last child born to the family had died of pneumonia, but Juan survived. Emily, how important is pneumonia to the burden of childhood disease in low-income countries, and what are some of the measures that might be done to reduce that burden? Pneumonia is among the leading causes of childhood disease and death in low- and middle-income countries, and families should be educated on the signs and symptoms of pneumonia so that they know when they should seek help. Okay. A third one. Princess is a young girl in Rwanda. Prior to the last decade, it's likely that Princess and her friends would not have been fully vaccinated. Today, thanks to the effort of the government and global cooperation, almost all children in Rwanda are vaccinated. As a result, many fewer children are dying in Rwanda of measles, tetanus, and pertussis, among other things. Rachel, why are vaccines so important to the global health agenda and the health of young children in so many countries? Well, so many of the diseases that affect young children are preventable with vaccines, and vaccines are one of the most cost-effective ways to reduce the burden of disease among children. Vaccines cost very little but produce, in fact, very substantial results. So let's now begin to talk about the importance of child health, and I want to suggest, before we look at their health status, three reasons why their health is so important for all of us. First, there's been an enormous amount of progress in reducing young child deaths, and yet 17,000, I repeat, 17,000 under five children die every year, every day. 17,000 children die every day in the world. Second, children are vulnerable. Young children, children under five years of age, clearly cannot take care of themselves. And thirdly, children are the future. This is trite but really important, and the health of those children is central to their ability to develop physically, their ability to develop cognitively, and the likelihood they'll go to school, thrive there, and become productive and healthy adults. So let's look now at the health status of children and look first at some of the important progress that has been made in saving the lives of young children. This graphic looks at declines in under five child mortality by World Bank region from 1990 to 2013. What we'll see as we go region by region is that in all of these regions, young child deaths have declined, and in several of them they've declined very substantially. Here what we see is high-income countries, and of course they already had very low levels of young child deaths, so we wouldn't expect the decline to be very great. But the good news here, and there's clearly good news, is that over this 23-year period, the number of deaths per 1,000 live births of children under five years of age has moved in the right direction in all regions of the world, and many fewer children are dying today than they did 20, 25 years ago. So let's look at the child life cycle and start by looking at neonatal mortality rates for World Bank regions, high-income countries, and globally. And here what we'll see, and we'll see in the other related graphics as well, is a consistent pattern in which two regions of the world have substantially higher rates of death of neonates than do the other World Bank regions, high-income countries, or the global average. And those two regions are South Asia and Sub-Saharan Africa. Here what we see, in fact, and this isn't the best comparison, but it's an important one as I'll explain, the rate of neonatal death in Sub-Saharan Africa per 1,000 live births is seven times, and in South Asia it's eight times the rate in high-income countries. This seems to be perhaps an irrelevant comparison, but in a way it's really important because what this means is that, in principle, if these countries are able to, they should be able to bring neonatal deaths down to this level as well. So the vast majority, the overwhelming majority of these deaths of neonates are, in fact, preventable deaths, as we'll discuss further. Let's look now at the deaths of infants, and a neonate, I should have said, is a child who is under 28 days of age, and an infant is a child who is under one year of age. So here we're going to look at infant mortality rates for every 1,000 live births for World Bank regions, high-income countries, and globally again, and what we see is a similar pattern to what we saw in the last graphic, although in this case the rate in sub-Saharan Africa is ten times higher than the rate in high-income countries, and the rate in South Asia is more than seven times the rate in the high-income countries. And again, most of these deaths are preventable, and what these countries want to do is move to the point where almost no young children are dying. Do we know why the infant mortality rate and the under-five mortality rate are kind of switched in the sense that South Asia is the worst in the under-five mortality rate, while sub-Saharan Africa is the worst for infant mortality, and why they're not consistent for those five years? We might predict that the rate of neonatal mortality should be higher in sub-Saharan Africa than in South Asia, but in fact what we saw was the opposite. This is a good question. I'm not completely sure of the answer, but one possibility is that in South Asia, countries have made important progress in reducing deaths among children one to five, but they haven't yet been able to pay sufficient attention to reducing the deaths of children in the neonatal period, who in many respects are much more difficult to get to. That would be one among several hypotheses, and it's a very good question. Let's turn now to under-five child mortality, and clearly a child under five is a child under five. We'll see again a similar pattern, and in this case, following Yafet's question, the rate of children who die for every 1,000 live births is substantially higher in sub-Saharan Africa than it is in South Asia. In this case, it's more than 12 times the rate in high-income countries, and here it's about eight times, more than eight times higher. But this consistent pattern with two regions really lagging behind others in the rates of neonatal infant and young child deaths for every 1,000 live births. I want to show you one of my favorite graphics, and this is a graphic that combines neonatal infant and under-five child mortality. I think this is also a graphic that I hope you'll find quite enlightening. The main point that I want to bring out with the help of this graphic, and this is neonatal, the yellow is infant, and the green is under five child mortality. What I want to bring out here is that as countries get richer, children face fewer and fewer risks of young child death, and therefore the overwhelming majority of under-fives who die will actually die of neonatal-related causes. So here, when you look at the high-income countries, two-thirds of all the under-fives who die actually die in the neonatal period. By contrast, at the extreme other end, we have sub-Saharan Africa, and here what you see is a somewhat unique pattern, although a little bit mirrored in this, and that is that the risks to under-five children in sub-Saharan Africa are almost equally distributed, the risks of death, between the neonatal period, the period between their 28th day and their first year, and between their first year and their fifth year. About 90 under-five children will die in sub-Saharan Africa for every 1,000 live births, and among those who die, about a third will die in the neonatal period, another third will die between their 29th day and their first birthday, and the last third will die between their first birthday and their fifth birthday. And all of these, one would hope, can eventually be brought down to much, much lower levels. Let's go ahead. I just have a quick clarification question. So because under-five incorporates the other two categories, that's why you see the increase, is that correct, in the graphic for the visualization? So I think, Shaelyn, if I might, in a way the easiest way to consider what I've just tried to highlight is just think about these bars as themselves having dividing lines. This bar is simple, this is neonatal. This bar from here to here is neonatal, but from here to here it's the 29th day to the first year. This bar from here to here is neonatal, from here to here is the 29th day to the first year, and from here to here is the first year to the fifth. Perhaps we should have shown it as a single green bar divided into different kind of diagonal lines, but in some other respects I hope you'll find that this highlights the point, but that's a thoughtful question. Let's look now more specifically at the leading causes of under-five deaths more broadly, and then we'll drill down to the deaths of neonates and post-neonates. So here what we see is a pattern of deaths of young children that we in some respects sadly might expect. For low- and middle-income countries we see that these causes of death are overwhelmingly related to communicable diseases like pneumonia, malaria, diarrhea, to nutrition such as protein, energy, malnutrition, and then to a number of causes, neonatal-related causes like congenital anomalies and preterm birth complications. By contrast when we look at the high-income countries we see as we saw really in the last graphic that the conditions from which under-five children die are overwhelmingly related to neonatal causes and to those risks that kids face in high-income countries like drowning, like road injuries, or like swallowing a foreign object. And this again is very much like we would anticipate, and what we're hoping of course over time we'd like children to live long and healthy lives, but we certainly don't want to continue seeing young children die of so many preventable causes. Now let's drill down a bit and look more specifically at the causes of neonatal death. And here what we see is preterm birth complications are the leading cause, but followed by birth asphyxia. In this case kids are born alive, but they can't breathe. And this can be addressed through very simple means of training those who attend the birth to suction out the baby so that like those of us who are fortunate enough to have been born or have had children in high-income countries or countries where the health services are good, you're waiting for that baby to cry. And the staff, the attendants take a number of steps to be sure that the baby is kept warm, wiped down, and suctioned out in order to avoid this problem of birth asphyxia, which is such an important cause of death. And sepsis of course is an infection that becomes systemic. And again, when we look at this, and we'll talk further about it in a few minutes, we'll talk about the ways in which these preventable problems can be addressed often at low cost, often on a community basis, often in sustainable and doable ways. Let's look now at the causes of post-neonatal death. And these are the causes that affect children from one month of age to five years of age. And what you'll see here is a pattern that's consistent in the low- and middle-income countries. And that is among the most important causes of young child death will be pneumonia or lower respiratory infections, diarrheal diseases, almost everywhere. But then almost uniquely in sub-Saharan Africa, malaria and HIV-AIDS will also be important causes of young child death. We'll also see in here, regrettably, a number of diseases that can be prevented by vaccines, but which continue to affect those children who are not yet being vaccinated against them. So let's look at some of the risk factors for why it is that children get sick and die of some of these causes. And here what we'll see is, in the low- and middle-income countries, a pattern of risk factors for under-five child death that generally relates to the conditions of impoverishment, to families that are not so well-educated, not so well-informed about appropriate child-caring behaviors, or unable, by virtue of their place in life, to carry out those behaviors in ways that they might wish. Childhood under nutrition is an extraordinarily important issue, and you'll see here four of the ten concern nutrition. Childhood under nutrition, suboptimal breastfeeding, vitamin A deficiency, and zinc deficiency. And others relate to the environmental circumstances in which the children are growing up, and that includes household air pollution, unsafe water, unsafe sanitation, and the failure to wash hands with soap at the right time, as well as indoor air pollution as well. And this unsafe sex is primarily related to HIV and the congenital transmission from mother to children of HIV. In the high-income countries, we'll still see that there are issues related to nutrition, and even this, which I have to admit to you, I can't explain very easily. But we also see what happens is unsafe sex, which in this case is more likely to be, which is likely to relate to both HIV and other sexually transmitted infections like syphilis. And we'll also see here issues related to substance abuse, in which some mothers and mothers-to-be engage, and that sadly have an important impact on the likelihood that their child will be born healthy and then thrive. Now as we begin to talk about how it is that these issues might be addressed, it's really important to think about what we call a life course perspective and to think broadly about the issues, the risk factors, and what might be done about them. And a number of those who work on global health have suggested, for example, that if we want to address the health issues that affect young children and do so in cost-effective ways, we need to think about the pre-pregnancy period of adolescent girls, the period of pregnancy, labor birth, and the first week after birth, the postnatal period during infancy, and then of course that period between their first and their fifth year. And what we'll see is the risks to the future health of the child differ along each of the parts of this life course and therefore suggest to us different measures that might have to be taken if one is going to try to ensure that the child is born healthy, begins to thrive, and then continues to thrive afterwards. There are a number of interventions that have been suggested for newborns who are at risk, and let's look at those. And here what we see is they're divided into three parts. One is essential newborn care, the second is extra care for small babies, and the third is emergency care. Many of these can be taken at the community level and wherever possible, that would of course in many respects be best in circumstances where people are living relatively rural, poorer places where they don't have easy access to health services. And many of these, as you'll see, have to do with knowledge and behavior. They don't have to do very much with expensive investments. And I'm just going to highlight a few. One can't highlight enough the importance of exclusive breastfeeding, which the World Health Organization recommends be done for six months. One can't highlight enough the importance of keeping the baby warm, wiping the baby down, putting a cap on the baby, not bathing the new baby, keeping the baby warm. Of course it's also really important to try to avoid infection through clean cord cutting and good hygiene. And here, as we talked about before, measures need to be taken in too many instances to try to address birth asphyxia. If you're dealing with a child who's relatively small but otherwise healthy, there's good evidence now that kangaroo mother care can be an effective effort at trying to keep young children alive. And in this case, the families basically keep the baby in contact with their own skin, like a kangaroo mother might do, and over time give these babies an opportunity to thrive in a place where, for example, one doesn't have an incubator and to which such a baby might be put were such an incubator available. And then there are a number of other interventions that need to be taken if, for example, the child needs more critical emergency services. But clearly, these are services that do require provision by trained health care practitioners who are not always so accessible in the lowest income countries. Now, let's end by talking about some measures that have been also shown to be very important to trying to save the lives of young children. And it's been suggested that these measures, if taken to scale, could save about 15% of the 17,000 young child deaths per day in the world. And clearly, one wants to begin, for example, with the mother and the health and nutritional status of the mother. One hopes that the mother gets sound prenatal care and micronutrient supplementation during her prenatal period. One wants, certainly, to avoid the risks of maternal to child transmission of HIV, and there are protocols for doing that, and more and more countries are doing it well. It's very important, we found, for the birth to be attended by a skilled birth attendant who can identify complications in the mother and address issues like birth asphyxia in the child. We know that families, communities, and health workers need to be able to identify in early stage health problems and refer for them. We've talked about breast feeding already. We know that when complementary foods are introduced, hopefully at six months, that they will hopefully be introduced in hygienic ways that don't cause the young child to suddenly become ridden with diarrheal disease, which often happens in the lowest income and most impoverished settings. Childhood immunization is critical. It's a best buy in global health, and a number of diseases are preventable through vaccination. Especially in places where malaria is important, we want everyone to be sleeping under a bed net, and when children do get diarrheal disease, we also want families to be aware and for families to be able to give the children oral rehydration solution plus zinc, which we know can have a very valuable impact on trying to keep them alive and well under such circumstances. There are a variety of measures that can be taken, but I want to encourage all of you to think about children, what it is that they get sick and die from, how needlessly so many of these illnesses and deaths are, to think about these through the life course, to consider neonates here and under fives there, and to be thinking about the kind of interventions that at relatively low cost, if taken to scale, and most of these are doable at the community level, can make a real difference to whether or not children live and thrive or they die. In the next session, we'll speak more about immunization.