1 Health Status of Children

Global and Local Perspectives

More than 20 years ago, the United Nations (UN) Children’s Fund (UNICEF) held the Convention on the Rights of Children and enacted a legal document asserting a broad range of human rights inherently due to children. Children, because of their vulnerability, need special care and protection (Forum on Child and Family Statistics, 2010; UNICEF, 2009). The United Nations Convention on the Rights of Children (UNCRC) sets minimum entitlements and freedoms that should be respected by governments. Box 1-1 presents a summary of the articles from the Convention that addresses the rights of protection (UNICEF, 2009). The document applies to children globally and is founded on respect for the dignity and worth of each individual, regardless of race, color, gender, language, religion, opinions, origins, wealth, birth status, or ability. Unfortunately there are many children who do not live in nurturing family environments and who lack freedom from armed conflict, violence, and exploitation. The UNCRC continues to work on ensuring that all children have basic human rights and freedoms.

The UNCRC places special emphasis on primary care, the responsibility and strength of families, and the vital role of the international community to protect and secure the rights of children, including access to health care. The UNCRC has been ratified by 193 nations and remains the standard for the care and nurturing of children everywhere. It also provides a framework for the global definition of health of children and a broad measure of child health status.

This chapter presents an overview of the current status of children’s health globally and in the U.S. The health priorities from the UN Millennium Development Goals and Healthy People 2020 are presented. Health disparities and the effect on child health outcomes are addressed, as well as the effect of health care reform in the U.S. on access to care for children and adolescents. Finally, the important role pediatric health care providers have in advocating for polices that foster optimal health care services for all children and families is discussed.

Global Health Status of Children

Despite improved child health interventions and socioeconomic improvements in many countries, 8.8 million children younger than the age of 5 years die each year worldwide (Black et al, 2010). Sixty-eight percent of the deaths in infants and children occur from often-preventable infectious diseases. The largest percentage of deaths is due to pneumonia; 18% of children younger than 5 years of age die from pneumonia worldwide, 15% from diarrheal diseases, and 8% from malaria. Although malnutrition is a primary contributory factor to neonatal and childhood deaths from infectious diseases, it is often not reflected in census data. Vitamin A and zinc deficiencies, suboptimal breastfeeding patterns, and overall nutritional deficiencies contribute as underlying causes in one third of deaths globally for children younger than 5 years of age (Black et al, 2008).

Forty-one percent of all deaths globally occur in neonates. Birth asphyxia and preterm birth complications comprise the largest proportion of these neonatal deaths. Half of the mortality worldwide occurs in children in five countries—India, Nigeria, Democratic Republic of Congo, Pakistan, and China. The high rate of mortality concentrated in these countries is due not only to economic and social conditions but also large concentrations of populations of children younger than 5 years; 43% of the pediatric population globally lives in these five countries (Black et al, 2010). Afghanistan and Ethiopia also have high rates of death due to pneumonia and diarrheal diseases. Fifty-one percent of all deaths due to acquired immunodeficiency syndrome (AIDS) occur in South Africa, Nigeria, Mozambique, Tanzania, and Uganda. Malaria accounts for 57% of the deaths in Nigeria, Democratic Republic of Congo, Uganda, Sudan, and Tanzania (Black et al, 2010).

Successful vaccination programs have markedly reduced the mortality caused by some infectious diseases, particularly measles and tetanus; however, tetanus is still responsible for 1% of deaths in children younger than 5 years of age. Figure 1-1 illustrates the global, regional, and national causes of child mortality (Black et al, 2010).

FIGURE 1-1 Global, regional, and national causes of child mortality. Data are separated into deaths of neonates 0-27 days and children aged 1-59 months. Causes that led to less than 1% of deaths are not presented.

(From Black RE, et al: Global, regional, and national causes of child mortality in 2008: a systematic analysis, Lancet 375(9730):1973, 2010.)

The Child Health Epidemiology Reference Group (CHERG) of the World Health Organization (WHO) and UNICEF have been charged with developing improved evidence on the causes and determinants of neonatal and childhood morbidity and mortality and evaluating the effectiveness of interventions to inform global priorities and programs (CHERG, 2009). Their goal is to provide timely estimates on the causes and determinants of child mortality, improve knowledge on the causes of maternal mortality, determine the relationship between disease burden and risk factors for maternal and childhood morbidity and mortality, and assist countries in planning and monitoring child health interventions. The CHERG estimates on mortality and determinants of death have assisted countries to target programs and interventions to reduce health disparities.

Millennium Development Goals

The UN Millennium Development Goals aim to reduce childhood mortality by two thirds in children younger than 5 years of age by 2015 and to provide benchmarks for tackling extreme poverty both globally and locally (United Nations, 2000). The eight goals consist of 21 quantifiable targets that are measured by 60 health indicators (Fig. 1-2). They provide a framework for the international community to ensure socioeconomic development reaches all children. If these goals are achieved, poverty could be reduced by 50% worldwide. To reach this goal, expansion and acceleration of the interventions by the WHO to target the leading causes of death are required in the target countries.

FIGURE 1-2 United Nations Millennium Development Goals.

The UN has made progress toward these goals in many regions. Malaria prevention has expanded to sub-Saharan Africa with the use of insect-treated bed nets for children younger than 5 years of age. Access to safe drinking water has reached 1.6 billion people over the past decade, but the safety of water supplies remains a challenge. Enrollment of children in primary school reached 90% in 2006 in almost all developing regions with the exception of sub-Saharan Africa, where it continues to hover around 70% despite recent increases in enrollment (UNICEF, 2009). Maternal mortality remains high despite improvements in some regions, with the highest maternal mortality in southern Asia and sub-Saharan Africa, where the risk of maternal death from pregnancy-related complications and childbirth is 1 in 22 births during the childbearing years.

The economic growth potential remains strong in many of the developing regions, and partnerships between developing countries and nongovernmental organizations (NGOs) continue to provide significant sources of developmental assistance. Developing countries will require further debt relief, reduced trade barriers, improved access to technologies for renewable energy production, and enhanced protection from and response to environmental disasters to sustain current advances. Further, global political efforts will be required to support achievement of the Millennium Development Goals by 2015 and a renewed commitment to the future health and well-being of children everywhere.

Food Insecurity and Effect on Child Health

Hunger and undernutrition are the largest contributing risk factors in the mortality of children less than 5 years of age in developing countries. Undernutrition refers to a form of malnutrition resulting in stunting and wasting caused by deficiencies of essential vitamins and minerals (Black et al, 2008). Globally, undernutrition is an important determinant of maternal and child health and is estimated to cause 3.5 million deaths annually. It is a known underlying cause of 35% of the global disease burden in children less than 5 years of age. Vitamin A and zinc deficiencies remain the largest disease burden among the nutritional deficiencies, with vitamin A deficiency causing 600,000 deaths annually in children less than 5 years of age (Black et al, 2008). Although rates of exclusive breastfeeding have increased for infants less than 6 months of age in all but one of the developing regions, suboptimal breastfeeding remains responsible for 1.4 million deaths annually (UNICEF, 2009). Preventable nutritional deficiencies are a compelling case for further implementation of the Millennium Development Goals and increased support for micronutrient supplementation for children in developing regions.

Hunger and undernutrition are often referred to as food insecurity, the condition that exists when people do not have “physical and economic access to sufficient, safe, nutritious, and culturally acceptable food to meet their dietary needs” (United Nations Millennium Project, 2006, p 20). Poverty and food insecurity are primary contributors to maternal and child undernutrition. Food insecurity occurs in impoverished populations in developing countries and in industrialized nations particularly among migrant populations. Children affected by migration and family separation are at risk for food insecurity and are vulnerable to further health consequences including exposure to exploitation and child trafficking. Growing evidence on climate change indicates the dramatic effect on food crops that lead to food distribution issues, one of the primary contributors to food insecurity. Figure 1-3 illustrates the relationship between climate change, food availability, and malnutrition.

FIGURE 1-3 Pathways by which climate change affects health.

(Used with permission from World Health Organization: Children’s health & environment: a review of the evidence, p 29, 2002. [WHO adapted from Patz JA, McGeehin MA, Bernard SM et al: The potential health impacts of climate variability and change for the United States: executive summary of the report of the health sector of the US National Assessment, Environ Health Perspectives,108:367-376, 2000]).

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