Introduction to Child HealthChapter 1

Pediatrics can be defined as the branch of medical science that deals with the care of children from conception to adolescence in health and illness. It is concerned with preventive, promotive, curative and rehabilitative care of children.

Children are major consumers of health care. In India, about 35 percent of total population are children below 15 years of age. They are not only large in number but vulnerable to various health problems and considered as special risk group. Majority of the childhood sickness and death are preventable by simple low-cost measures. Disease patterns and management of childhood illness are different than that of adult. Children always need special care to survive and thrive. Good health of these precious members of the society should be ensured as prime importance in all countries. As said by Karl Meninger “What is done to children, they will do to the society.” Children are the wealth of tomorrow.

A child is unique individual, he or she is not a miniature adult, not a little man or woman. The childhood period is vital because of socialization process by the transmission of attitude, customs, and behavior through the influence of the family and community. Family's cultural and religious belief, educational level and ways of living influence the promotion and maintenance of child health. Children are vulnerable to disease, death and disability owing to their age, sex, place of living, socio-economic status and a host of other variables. They need appropriate care for survival and healthy development.

The triad problems, poverty, population explosion and environmental stress are great threat towards child health in developing countries. Better nutrition, education (especially of girls) and family planning are essential aspects to improve child health. Healthy well nourished children develop better mentally and benefit more from education. Better education associated with more health knowledge, better health practices and more use of health services.

Maternal health is a major determinant of child health. The healthy mother brings forth a healthy baby with better chance of survival (Figures 1.1A to D). Child health is adversely affected, if the mother is malnourished or diseased. Mother's age, parity, prepregnant health, antenatal care and lack of spacing between two children affect the health of the child.

Child health is greatly depending upon family health. It depends upon family's physical and social environment which includes the lifestyle, culture, customs, taboos, rituals, religious practices, traditional habits, child bearing and child rearing practices, like son-complex, neglect to female child, etc. Family size, family relationship and family stability also influence the child health. For example, number of episodes of childhood diarrhea increases with the size of the family and prevalence of malnutrition increases with more than four children in a family. So, fewer children would mean better nutrition, better health care, less morbidity and lower infant mortality.

The socio-economic condition of the family is a very important factor in child health. The physical and intellectual development of children varies with the socio-ecomomic status of the family. Parent's education, profession, income, housing, urban or rural living, industrial life etc, are significant factors which influence on child health. Poverty, ignorance, superstition, illiteracy especially mother's illiteracy and sickness pass from one generation to the next. The differences in health status between rich and poor can be observed in all age groups but particularly striking among children.

Environment plays a very great role as determinants of infant and childhood morbidity and mortality. Insanitary and hostile environment are responsible for various illnesses like infections, infestations, accidents, etc. Home and family hygiene, local epidemiological conditions, insufficient supply of safe water, inadequate disposal of human excreta and other waste, an abundance of insects and other disease carriers are the continuous threat to child health. Healthy environmental stimulation as inter-personal relationship is an essential factor for child's development. Congenial family relationship, healthy interaction with neighbors, teachers, schoolmates and playmates, exposure to mass media like radio. television, magazines are significant requirements for psychological and intellectual development of children.

Social support measures from the community and organized health care systems are indispensable for improvement and maintenance of health status of children (Figures 1.2A to F).

The world's first Pedatricians were two Indians, Kashyapa and Jeevaka, of sixth century BC. Their pioneering works on child care and childhood disease are as relevant today as many of the modern concepts of child health. Sushruta, also wrote many aspects of child rearing and Charka wrote about care and management of newborn.

Child health care has changed dramatically in recent years due to advances in medical knoweldge and understanding of emotional response of children. Advancement of understanding of different aspect of human development influences the changing concept of health. Health exists when an individual meets minimum physical, physiological, intellectual, psychological and social aspects to function appropriately for their age and sex level. Illness is the situations when individual experiences a disturbance in any of these areas that prevents functioning at appropriate level. Thus, attention is directed to psychosocial as well as physiological characteristics of health and illness.

Modern concept of child health emphasizes on continuous care of ‘Whole child’. According to UNICEF, assistance for meeting the needs of children should no longer be restricted to only one aspect like nutrition, but it should be broad based and geared to their long-term personal development ensuring holistic health care of children.

At present, in child health care more emphasis given on preventive approach rather than curative care only. Primary health care concept with team approach and multidisciplinary collaboration are adopted for child care. The challenge of this time is to study child health in relation to community, to social values and social policy. Increased public awareness, consumerism and family participation in child care are newer trends. Family health, a new concept is accepted for the care of children in their families and families in society. Need based, problem oriented, risk approach care is practiced for better child health.

5In developed countries child health care extended upto adolescent, whereas in developing countries and in India, child care is extended upto 10 to 12 years of age. Recently special emphasis is given on adolescent health through RCH package services in our country. Special attention is given on the children at-risk like, orphans, destitutes, disasterous, pavement dwellers, slum dwellers, child labors and handicapped children. Movement against gender bias, female fetocide, child abuse and neglect and maltreatment are in highlight at present.

Interest of the political leaders and understanding the importance of child health, constitution of national health policy for children and implementation of various health programs for improvement of child health are great achievements for children. Population control and family welfare approach, improvement of educational status specially women education and women empowerment, involvement of Govt. and Non-Govt. organizations, political commitment and special budgetary allocation for child health activities, international guidance by WHO, UNICEF and other child welfare organizations for improvement of child health are promising aspects towards survival, health and well-being of children.

Growth of sub-specialities for the super-specialized care of children is recent trend. The sub-areas are neonatology, perinatology, pediatric surgery, pediatric cardiology, pediatric neurology, pediatric hematology. pediatric nephrology, preventive pediatrics, child psychology, child psychiatry, pediatric intensive care unit, neonatal intensive care unit etc.

Medical science is advancing in every moments. So child health will also progress by various movements towards the aims to improve the survival and well being of all children, as per WHO theme of the year 2005, “Healthy mothers and healthy children.”

The presence of large numbers of problems in child health summon for acceptance of priority-based risk approach care. It is applicable in child health to minimise the childhood morbidity and mortality by appropriate management in time with special intensive care. The basic criterias for identifying ‘at risk’ infants and children include the followings ––

It is observed in our health institutions that upto one-third of total pediatric admissions are due to diarrheal diseases and up to 17 percent of all deaths in indoor pediatric patients are diarrhea related. Diarrheal diseases are major public health problem among children under the age of 5 years.

Acute respiratory infections (ARI) are another major cause of death. Hospital records show that up to 13 percent of inpatient deaths in pediatric wards are due to ARI. The proportion of death due to ARI in the community is much higher as many children die at home. About 14 percent hospital admission are due to ARI.

Another important cause of pediatric admissions in hospitals is vaccine preventable diseases, that is approximately 15.5 percent. Death due to vaccine preventable diseases is as high as about 25 percent.

Neonatal and perinatal conditions are responsible for about 4.6 percent of hospital admission and approximately 13 percent of all Deaths. Other various conditions are responsible for one-third of total hospital admission in children and also for childhood death.

The common medical conditions found in the pediatric units are mainly meningitis, encephalitis, typhoid fever, hepatitis, nephrotic syndrome, acute glomerulonephritis, malaria, tuberculosis, kala-azar, thalassemia, etc. Gross malnutrition and serious systemic infections are found in combination in majority of the cases.

The common surgical conditions requiring hospital admissions in children are mainly related to congenital malformations. Other conditions are intestinal obstructions, acute abdomen, road traffic accidents, burns, fractures, etc.

In many countries, mortality rates are still the only sources of information about child health. The frequently used mortality indicators of child health care are perinatal, neonatal, postneonatal, infant and under 5 mortality rates.

Perinatal mortality rate has assumed greater significance as a yardstick of obstetrics and pediatrics care before and around the time of birth. It gives a good indication of the extent of pregnancy wastage as well as quality and quantity of health care available to the mothers and children.

Perinatal mortality is a problem of serious dimensions in all countries. It now accounts for about 90 percent of all fetal and infant mortality in the developed countries. In India, the perinatal mortality rate was reported about 33 per 1000 total births with about 36 for rural and 20 for the Urban areas (2003) as per SRS estimates. The national goal was to achieve a perinatal mortality rate between 30 and 35 by the year 2000 AD.

A number of social and biological factors are known to be associated with perinatal mortality. The risk factors are low socio-economic status, high or low maternal age, high parity, short stature mother, bad obstetrical history, maternal malnutrition and severe anemia, multiple pregnancy, etc.

The causes of perinatal mortality are mainly antenatal, intranatal or postnatal asphyxia, LBW babies, congenital anomalies, birth injury and perinatal infections.

Reduction and prevention of perinatal mortality can only be possible with better maternal and child health services.

Neonatal mortality is most difficult part of infant mortality to change. WHO estimates that during the year 1995, globally there were 36 neonatal deaths per 1000 live births, most of them are found in the developing countries. In India, it was about 37 per 1000 live births (2003). About 55 to 60 percent of all infant deaths occur within neonatal period and approximately 50 percent of them die during the first week of birth and first 24 hours is the greatest risk time.

Neonatal mortality is greater in boys throughout the world due to more fragility of boys than girls. The common causes of neonatal mortality include LBW, postnatal asphyxia, birth injury, difficult labor, congenital anomalies, hemolytic diseases of newborn, conditions of placenta and cord, diarrheal diseases, ARI and tetanus. Neonatal deaths can be reduced by adequate antenatal and intranatal care including essential neonatal care at all levels by preventing and managing the causes.

Postneonatal mortality is dominated by exogenous factors, i.e. environmental and social factors. The main causes of death during post neonatal period are diarrhea and ARI. Malnutrition is the additional factor which predisposes various infections. In developed countries it is mainly caused by congenital anomalies. Postneonatal deaths increase with birth order and the girl children die more frequently than boys due to neglected care to the female children in terms of nutrition and health care.

In India, postneonatal mortality rate is estimated to be 25 in rural areas, 16 in urban areas and 23 per 1000 live births combined in rural and urban areas (2003).

IMR is universally regarded as a most important sensitive indicator of the health status of community. It is considered as an indicator of level of living of people and effectiveness of MCH services.

There are wide variations between countries or regions in the level of infant mortality. The world average of IMR for 2004 has been estimated at about 54 per 1000 9live births. The worst rates were in Afghanistan (165) and Sierra Leone (165) and the lowest IMR of 3 per 1000 livebirths in Japan, Sweden and Switzerland.

India is still among high IMR countries, though it has come down to 58 per 1000 livebirths in 2004. There is statewise variation with Orissa having IMR of 77 and Kerala as low as 12 per 1000 live births. National target is set to bring down the IMR to less than 30 per 1000 live births within the year 2010.

The principal causes of IMR in India are LBW, ARI, diarrheal diseases, congenital malformations, and infections, especially umbilical sepsis. There are several factors which interact to cause infant mortality. Biological and socio-economical factors influence more on the infant death. There is no single specific health program or a single set of action that can reduce IMR. As the etiology of IMR is multifactorial, so it requires multipronged approaches. Certain important measures to reduce IMR include lowest birth rate, highest literacy rate, specially female literacy and improvement of primary health care. Other preventive measures include prenatal nutrition, prevention of infections including six-killer diseases, exclusive breast-feeding, growth monitoring, family planning, environmental sanitation, simple hygienic measures and socio-economic development.

Child mortality rate measures the probability of dying in between birth and exactly 5 years of age. UNICEF considered this rate as the best single indicator of social development and well being rather than GNP per capita. It reflects nutritional status, income, health care and level of basic education of the population.

The global average for under -5 mortality rate in 2004 was 79 per 1000 live births. In developed countries the rate was 7 per 1000 live births and in least developed countries, it was 158 per 1000 live births in 2002.

In India, child mortality rate in 2004 was 85 per 1000 live births. It is about 34 percent of all deaths. It was 242 per 1000 live births in 1960 and has declined significantly during the past years due to decline in infant mortality. This reduction is largely related to drop in deaths due to vaccine preventable diseases as well as drop in deaths from ARI and diarrhea.

The major causes of child mortality among children under 5 years in developing countries are acute respiratory infections, neonatal and perinatal threats, diarrhea, malaria, pertussis, neonatal tetanus, tuberculosis, measles, malnutrion, accidents and HIV related diseases.

The basic measure of infant and child survival is the reduction of under five mortality. The difference in the survival rates of children in developed and developing countries is a grim pointer to the third world's need for preventive services. The child survival can be best achieved by breastfeeding, adequate nutrition, clean water supply, immunization coverage, oral rehydration therapy and birth spacing.

On the occasion of World Health Day, 2005, WHO reported that one child in twelve does not reach his/her fifth birthday. Each year 10.6 million children under the age of five years die from a handful of preventable and treatable conditions. Nearly all these deaths occur in low and middle income countries. WHO, celebrated World Health Day on 7th April, 2005, with the theme “Healthy mothers and healthy children” and the slogan “Make every mother and child count”, to make the health of women and children a higher priority and to improve survival, health and wellbeing of these precious group.

Childhood period can be customarily divided for purpose of effective care into the different age-groups, i.e. infancy, preschool, school age, and adolescence.

Children under the age of 5 years are grouped with the mothers considering as vulnerable and risk group comprising about 32 percent of total population in India.

The mother and child health (MCH) services is the method of delivering health care to these special groups. The MCH services contain the preventive, promotive, curative and social aspects of obstetrics, pediatrics, family welfare, nutrition, child development and health education. The ultimate objective of MCH services is life-long health. The specific objectives for the services include reduction of morbidity and mortality rates for mother and children and promotion of reproductive health along with child health. Promotion of physical and psychological development of the child within the family can be possible by family participation in the comprehensive care of children through the MCH services.

The components of MCH services include six sub-areas, i.e., maternal health, family planning, child health, school health, care of handicapped children and care of children in special setting such as day care centers.

The MCH services, at present, are provided through reproductive and child health (RCH) program. The RCH program incorporates the components related to child survival and safe motherhood (CSSM), family planning and prevention of RTIs/STDs and AIDS. The services are provided in client-oriented, target-free, demand driven, high quality, participatory and decentralized approaches on the basis of needs of community.

Other than RCH program, various health programs are initiated by the Govt. of India to improve the survival of children. Non-Govt. organizations and child welfare organizations also contributing towards better child health. Other child health services include integrated child development services (ICDS) scheme, Under-5 clinics, school-health services, postpartum services through PP units, baby-friendly hospital initiative, child guidance clinic, etc.

Child health services are delivered through Anganwadi centers (ICDS-center) at village level, subcenter clinics, PHC clinics, outreach services by home visit and camps and in hospital as indoors and outdoors. The child care is planned in various health institutions by the health workers in integrated and risk approach. Primary health care is now recognized as a way of making essential health care available to all, including children, by the multipurpose health workers, professional health workers, voluntary workers and field workers, like community health guides, traditional birth attendants, anganwadi workers etc. The services are available both in urban and rural areas through different infrastructres. The specific low cost simple measures are organized for the child health care through various approaches for saving lifes of millions of children on priority basis.

The ten basic rights of the child are –

A non-governmental organization (NGO), Defence for Children International, Geneva; has been in operation since 1979, the International Year of the Child, to ensure ongoing, systemic international action, especially directed towards promoting and protecting the Right of the Child.

The World Summit for children (1990) agreed on a series of specific goals for improving the lives of children including measurable progress against malnutition, preventable diseases and illiteracy. The vital vulnerable years of childhood should be given priority on society's concerns and capacities. A child has only one chance to develop normally and demands protection and commitment that never be superseded by any other priorities.

The realization that children have special needs and hence the special rights has given birth to an international law in the shape of convention on the ‘Rights of the child’. The provisions of the convention were confirmed in 1990 by the World Summit for Children.

The convention defines children as people below the age 18 years whose best interests must be taken into account in all situations. It protects children's right to survive and develop to their full potential with highest attainable standard of health care.

The social goals that have been accepted by almost all nations following the 1990 World Summit for Children were —

The policy declares : “ It shall be the policy of the state to provide adequate services to children, both before and after birth and through the period of growth, to ensure their full physical, mental and social development. The state shall progressively increase the scope of such services so that, within a reasonable time, all children in the country enjoy optimum conditions for their balanced growth.”

12According to the declaration, the development of children has been considered as integral part of national development. The policy recognizes children as the “nation's supremely important asset” and declares that the nation is responsible for their “nurture and solicitude”. It also emphasizes the priorities of children's program and special focus on child health, child nutrition and welfare of the handicapped and destitute children.

A number of programs were introduced by the Govt. of India, after the declaration of national policy for children. The important programs are ICDS scheme, programs of suplementary feeding, nutrition education, production of nutritious food, welfare of handicapped children, national children's fund, CSSM programs, etc.

The principles of India's National Policy for Children are as follows –

The Juvenile Justice Act, 1986, provides a comprehensive scheme for care, protection, treatment, development and rehabilitation of delinquent juveniles. The new Act has come into force from 2nd October 1987, after rectification of the inadequacies of the Children Act (1960).

The needs of children and our duties towards them are enshrined in our constitution. The relevant articles are as follows —

Other important Acts for child welfare are: “The Child Labour (Prohibition and Regulation) Act, 1986”, “The Child Marriage Restraint Act 1978” and “The Hindu Adoptions and Maintenance Act, 1956”.

Special attention has been given to the welfare of children in the five-year plans by the Government of India. Various schemes and programs have been introduced and implemented to achieve the goals of child health services.

Healthy children are future healthy citizens of the countries. So every attempts should be made towards better tomorrow for better survival of this precious group and to help them to grow into healthy adult. Promotion of child health should receive priority attention in all levels as new challenge of the 21st century. WHO, in 2005, emphasizes on healthy mothers and children. The aims and objectives of World Health Day, 2005, is to create momentum that compel national governments, international community, civil society and individuals to take action to ensure the health and wellbeing of mothers and children. These can be achieved by raising awareness, increasing understanding about the existing solutions and generating movement to stimulate collective responsibility and action to improve the survival, health and wellbeing of all mothers and children.