Module 7: Issues in Child Survival

The Problem

In low- and middle-income countries, poor children suffer a disproportionate burden of morbidity and mortality. Ever year, 6 million children die before their fifth birthday, though this is 17,000 less than the amount of children dying per day than in 1990. Progress has been made, yet the relative amount of child deaths in sub-Saharan Africa and Southern Asia has actually increased over the same period. Children are more likely to live past the age of five if their mothers are educated, even if they only have primary schooling.(1) The Sustainable Development Goals (SDGs) seek to improve childhood survival aiming to “end preventable deaths of newborns and children under 5 years of age, with all countries” and to “reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births.”(2) The reduction in child mortality has been predominantly attributed to the increase in vaccination coverage, specifically of measles, tetanus, and tuberculosis. (3) Vaccination coverage, though rising in many areas, has greatly decreased in countries in conflict, with potentially devastating consequences for infants and children.(4)

There are two leading causes of death for children under the age of 5 living in low- and middle-income countries: pneumonia (or other severe respiratory infections) and diarrhea. Treatment of respiratory infections often requires antibiotics. Oral rehydration salts (ORS) are often used to treat cases of pediatric diarrhea. The risk that children will contract pneumonia or diarrhea can be greatly reduced through preventative measures including vaccinations, exclusive breastfeeding, and adequate nutrition.(5)

Successes

By 2015, 62 countries had met Millennium Development Goal 4 of reducing infant and child mortality rate by at least two-thirds, but over 70 countries still have a childhood mortality rate of over 25 deaths per 1000 live births.(6) The SDGs also aim to continue improving under-5 mortality, and several initiatives have been created, including a “comprehensive implementation plan on maternal, and infant and young child nutrition” and a “global action plan for the prevention and treatment of pneumonia and diarrhea” in order to reach these goals.(7)

Proven Interventions to Reduce Child Mortality

Success has been achieved by identifying cost-effective best practices in child and infant health. James Grant, Executive Director of UNICEF from 1980–1995, was a leader in identifying these practices and sought to implement a series of interventions, which would later be abbreviated GOBI-FFF(8): Growth monitoring, Oral rehydration, Breast feeding, Immunization, Female education, Family spacing, and Food supplements. Most of these practices were then adopted and integrated into the Lives Saved Tool (LiST) as guidelines for policies and programs in the 21st Century.

The Lives Saved Tool was originally developed in 2003 and has been continually updated since it was first created. As a part of the Child Survival Series in The Lancet, LiST was originally created so that the outcomes of child health interventions could be estimated, thus highlighting successful interventions.(9) Of the interventions that best reduce child mortality, the following has been identified as effective: (10)

1. Promotion of breastfeeding: There is evidence that exclusive breastfeeding can protect a newborn child from a plethora of diseases, including common deadly diseases for infants such as infections of the respiratory tract and diarrheal diseases. Exclusive breastfeeding is recommended to be performed at minimum until 6 months of age, if not continued for longer.(11)

2. Prevention, detection, and treatment of acute malnutrition: It has been known that malnutrition can affect a person’s health including survival, growth, intellectual development, and reproductive abilities. Addressing malnutrition can better individuals lives, especially allowing more children reach adulthood, based on evidence that found direct associations between a reduction in childhood malnutrition and childhood mortality in low- and middle-income countries.(12)

3. Immunizations: Immunizations have been proven to be successful and low-cost methods for preventing the development of lethal diseases, including diphtheria, measles, and pertussis. Routine immunizations recommended by the WHO for low- and middle-income countries include DTP, BCG, polio, Hepatitis B, Rotavirus, Rubella, and Measles vaccines.(13) Vaccinations have been shown to reduce childhood mortality, especially in locations where the diseases they are meant to prevent are still prevalent.(14)

4. Antiretroviral therapy for HIV-positive children: The WHO estimated that 90% of the children living with HIV are from Sub-Saharan Africa, and only 24% of these children are on the antiretroviral therapy that they need.(15) In fact, HIV/AIDS is the most common cause of death for children in Sub-Saharan Africa, though if there were greater access to antiretrovirals, this would not hold true.(16) With proper antiretroviral therapy, children can live long and healthy lives, turning HIV from a deadly disease into a chronic illness. (17)

5. Education regarding handwashing and safe disposal of children’s stool: WASH, or Water, Sanitation, and Hygiene, are three interdependent core factors that directly affect an individual’s health, especially women and children; education on handwashing and stool disposal can be effective interventions at maintaining child health. Many studies, including one in Eastern Ethiopia, show WASH educational intervention can lead to reduced rates of diarrheal diseases, a major cause of death among children and infants.(18)

6. Prevention of malaria: An estimated 70.6% of deaths caused by malaria occur in children under the age of five. In order to prevent these deaths, the WHO recommends using long-lasting insecticidal nets, detection and prompt treatment of malaria infections, and preventative therapy that involves intermittent malaria treatment until the age of five. (19)

7. Detection and treatment of serious infections: One of the most serious infections that many children face is pneumonia, an acute respiratory infection of the lungs. Pneumonia can be caused by numerous infectious agents, including viruses, fungi, and bacteria. Preventing pneumonia can be done by having children adequately vaccinated, reducing exposure to indoor air pollution, and addressing preexisting infections. Pneumonia is diagnosed by chest wall indrawing during inhalation and is treated with antibiotics.(20)

These practices can significantly reduce child mortality and can be administered through a community health worker, primary healthcare center, or hospitals. It has been estimated that scaling up these practices could prevent over 1.5 million child deaths.(21) Beyond preventing deaths, many of these interventions can benefit the child as they grow into their adult life by improving physical and cognitive development, educational performance, and future earning capacity. (22)

Toward the Future

In looking toward the future of child health, we must recognize that we do not have to wait for development to occur to address child mortality. As discussed above, we have the knowledge and instruments to reduce child mortality, yet children continue to die because interventions are not reaching them. (23)(24)

The persistent and growing inequalities in child survival demand renewed commitment and concerted action for child health. Increased efforts are required to ensure that child survival interventions achieve scale to reach poor and vulnerable children. Greater commitment to effective, equitable, and sustainable child health service delivery strategies can lead to concrete progress towards the Sustainable Development Goals of improving childhood mortality.

Footnotes

(1) United Nations. “Goal 3: Ensure healthy lives and promote well-being for all at all ages.” Sustainable Development Goals: 17 Goals to Transform Our World. http://www.un.org/sustainabledevelopment/health/.

(2) Ibid.

(3) Feikin DR, Flannery B, Hamel MJ, et al. Vaccine preventable diseases in children. In: Jamison DT, Gelband H, Horton S, et al., editors. Disease Control Priorities in Developing Countries. 3rd ed. Atlanta, GA: Centers for Disease Control and Prevention; In press.

(4) “Progress and Challenges with Achieving Universal Immunization Coverage: 2015 Estimates of Immunization Coverage.” WHO & UNICEF. July 2016. https://www.unicef.org/immunization/files/unicef-who-immunization-coverage-2015.pdf.

(5) Ibid.

(6) Jones G, Steketee R W, Black R E, Bhutta Z A, Morris S S and Bellagio Child Survival Study Group. 2003. “How Many Child Deaths Can We Prevent This Year?” The Lancet, 362 (9377): 65–71.

(7) “Progress and Challenges with Achieving Universal Immunization Coverage: 2015 Estimates of Immunization Coverage.” WHO & UNICEF. July 2016. https://www.unicef.org/immunization/files/unicef-who-immunization-coverage-2015.pdf.

(8) "UNICEF's GOBI - FFF Program." Diarrhoea, Diarrhea, Dehydration, Oral Rehydration, Mother and Child Nutrition, Water, Sanitation, Hygiene. Rehydration Project. Updated 23 April 2014. https://rehydrate.org/facts/gobi-fff.htm.

(9) Jones G, Steketee R W, Black R E, Bhutta Z A, Morris S S and Bellagio Child Survival Study Group. 2003. “How Many Child Deaths Can We Prevent This Year?” The Lancet. 362 (9377): 65–71.

(10) Black, RE, et al. Chapter 1: Reproductive, Maternal, Newborn, and Child Health: Key Messages of This Volume. Reproductive, Maternal, Newborn, and Child Health: Disease Contol Priorities, Third Edition (Volume 2). Washington (DC): The International Back for Reconstruction and Development/The World Bank; 2016 Apr 5.

(11) Lassi, ZS, et al. 2014. Essential interventions for child health. Reprod Health. 11(Suppl 1): S4.

(12) Pelletier, DL & DA Frongillo. January 2017. Changes in Child Survival Are Strongly Associated with Changes in Malnutrition in Developing Countries. J. Nut. 133(1):107-119.

(13) WHO. April 2017. “WHO recommendations for routine immunization – summary tables.” Immunization, Vaccines, and Biologicals. http://www.who.int/immunization/policy/immunization_tables/en/.

(14) Lehmann, D., et al. 2005. Benefits of outline immunizations on childhood survival in Tari, Southern Highlands Province, Papua New Guinea. Int J Epidemiol. 34(1):138-148.

(15) UNAIDS. Gap Report, 2014. http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2014/UNAIDS_Gap_report_en.pdf.

(16) World Health Organization. Health for the World's Adolescents: A Second Chance in the Second Decade. Geneva, Switzerland: World Health Organization; 2014.

(17) Schlatter, AF, et al. 2016. The Need for Pediatric Formulations to Treat Children with HIV. AIDS Res Treat 2016: 1654938.

(18) Hashi, A., A Kumi, & J Gasana. 2017. Hand washing with soap and WASH educational intervention reduces under-five childhood diarrhoea incidence in Jigjiga District, Eastern Ethiopia: A community-based cluster randomized controlled trial. Prev Med Rep. 6:361-368.

(19) WHO. April 2017. “Malaria in children under five.” Malaria. http://www.who.int/malaria/areas/high_risk_groups/children/en/.

(20) WHO. September 2016. “Pneumonia.” Media Centre. http://www.who.int/mediacentre/factsheets/fs331/en/.

(21) Black, RE, et al. Chapter 1: Reproductive, Maternal, Newborn, and Child Health: Key Messages of This Volume. Reproductive, Maternal, Newborn, and Child Health: Disease Control Priorities, Third Edition (Volume 2). Washington (DC): The International Back for Reconstruction and Development/The World Bank; 2016 Apr 5.

(22) Victora, C. G., Adair, L., Fall, C., Hallal, P. C., Martorell, R., Richter, L., ... & Maternal and Child Undernutrition Study Group. (2008). Maternal and child undernutrition: consequences for adult health and human capital. The Lancet, 371(9609), 340-357.

(23) Victora, C. G., Wagstaff, A., Schellenberg, J. A., Gwatkin, D., Claeson, M., & Habicht, J. P. (2003). Applying an equity lens to child health and mortality: more of the same is not enough. The Lancet, 362(9379), 233-241.

(24) USAID. "Child Health." https://www.usaid.gov/global-health/health-areas/maternal-and-child-health/technical-areas/child-health. 8 November 2019.