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Child Health: Overview. Dr E Malek, Principal Specialist Department of Paediatrics, University of Pretoria, Witbank Hospital Acknowledgements. Dr Joy Lawn (Save the Children Fund) DR Lesley Bamford (National DOH) Dr Debbie Bradshaw (MRC NBD unit)

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Child Health: Overview

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Child Health: Overview

Dr E Malek, Principal Specialist

Department of Paediatrics, University of Pretoria, Witbank Hospital


  • Dr Joy Lawn (Save the Children Fund)

  • DR Lesley Bamford (National DOH)

  • Dr Debbie Bradshaw (MRC NBD unit)

  • Prof T Duke (CICH, University of Melbourne)

  • Dr M Weber (WHO-CAH, Geneva)

  • Dr N McKerrow (PMB Hospital)

  • DR Macharia (UNICEF, Pretoria)

  • Dr N Rollins (UKZN)

  • DR C Sutton (MEDUNSA, Polokwane)


  • Global child health

  • Child Health in South Africa

Global Context (1)

  • Child Health Inequity

  • Causes of global child mortality

  • Child disability and development

  • Neonatal Health

  • Adolescent Health

  • Children in complex emergencies

  • Effect of poor child health on communities

Global Context (2)

  • Child Health in context of Maternal Health

  • International Conventions and child health

  • Evidence for effective intervention in reducing child mortality

  • Pathways to & principles of global child health

10 million child deaths – Why?

For these 4 causes, ~ 53% of deaths are malnourished children

AIDS is much bigger proportion in Southern Africa.

Source: Bryce J et al for the Child Health Epidemiology Reference Group. The Lancet, March 2005. As used in WHR 2005

Three causes account for 86% of all neonatal deaths

4 million newborn deaths – Why?

60 to 90% of neonatal deaths are in low birth weight babies, mostly preterm

Source: Lawn JE, Cousens SN, Zupan J Lancet 2005. for 192 countriesbased on cause specific mortality data and multi cause modelled estimates. As used in World Health Report 2005














U5MR (deaths per 1000 births)






















South Asia

Middle East &

East Asia and

Latin America




North Africa


& Caribbean



Under five mortality rates: Trends from 1990-2000

Slide: Ngashi Ngongo

Source: UNICEF, 2001

International Conventions

  • Declaration of Alma Ata: “Health for All by the year 2000”

  • UN Convention of the Rights of the Child (1990)

  • UN Millenium Development Goals (MDGs)

1. Eradicate extreme

poverty and hunger

2. Achieve universal primary education

3. Promote gender equality

and empowerment of


4. Reduce child mortality

by two thirds

5.Reduce MMR by three


6. Combat HIV/AIDS, malaria

and other diseases

7. Ensure environmental


8. Develop global partnerships

for development

Millennium Development Goals (MDGs)

Integrated Management of Chilldhood Illness (IMCI)

IMCI facility based usage in Bangladesh (Lancet, 2004)

WHO Initiatives to improve quality of care for children at hospital level: state of the art and prospects

Martin Weber, Harry Campbell, Susanne Carai, Trevor Duke, Mike English, Giorgio Tamburlini

25th International Congress of Paediatrics,

Athens, 25-30 August 2007

Standards of Hospital Care for Children: Hospital IMCI

Evidence-Based Guidelines

Child Health in South Africa

  • Child Health Inequity

  • Causes of Child Mortality

  • Neonatal Health

  • National interventions for improving child health

  • Children’s Act (Amendment Bill: 2007)

  • Challenges

UNICEF remarks at opening of SA Child Health Priorities conference (Dec 2007, Durban)

Distribution of Resources

Slide: Ngashi Ngongo

South Africa progressto MDG 4

Under 5 mortality is increasing, related to HIV (73 000 a year)

Neonatal mortality is probably static and accounts for ~30% of under five deaths (23,000 newborn deaths a year)

Source: Lawn JE, Kerber K Opportunities for Africa’s Newborns. PMNCH, 2006

Causes of U5M

Source: MRC 2003

Every Death Counts

Challenges: Health Service in South Africa

Child Mortality (1)

  • The National Burden of Disease study estimated just over half a million deaths of which

  • 106 000 were of children under the age of 5 years

  • A further 7800 were children aged 5-14 years.

  • An estimated 4564 deaths are from protein-energy malnutrition (Kwashiorkor)

  • In general, young babies are much more vulnerable than older

  • The cause of death patterns in the different age groups are very different.

Top twenty specific causes of death in childrenunder 5 years, South Africa 2000 (NBD)

Leading causes of death among infants under 1 year of age, South Africa 2000

Leading causes of death among infants under 1 year of age, South Africa 2000

Child Mortality (2)

  • The NBD study estimates that by the year 2000,

    • the Infant Mortality Rate had risen to 60 per 1000 live births and

    • the Under-5 mortality rate had risen to 95 per 1000.

  • This deterioration in child health occurred despite the introduction of free health care and nutrition programmes and was attributable to paediatric AIDS, commensurate with the high prevalence of HIV observed among pregnant women.

Leading causes of death among children aged 1-4 years, South Africa 2000

Leading causes of death among children aged 1-4 years, South Africa 2000

Child Mortality (3)

  • As children get older, external causes of death (eg. road traffic injuries and drowning) rise in importance.

  • This is particularly noticeable among boys who die in greater numbers than girls. This pattern becomes particularly marked among the 10 -14 year age group, where road traffic accidents is the leading cause of death.

  • Homicide and suicide feature in the top causes among the 10-14 year age group, homicide is the second leading cause of death.

HIV test

~ 54% tested

26% +ve

20% exposed

Only 8% tested -ve

HIV clinical stage

~ 58% staged

of which half were Stages III & IV

Child deaths in RSA - Why?

Child PIP in Mpumalanga:

ChPIP Data:

Witbank Hospital had 2244 child admissions & 101 child deaths in 2006; overall case fatality rate 4.5;

31% of all deaths within 1st 24 hours of admission

ChPIP Sites:

2004: Witbank

2006: Witbank & Barberton

2007: above plus 8 new sites

88% HIV if exclude neonatal

Most deaths 1 month to 5 yrs

* Source: WHO World health Statistics 2006

Causes of death of children in hospitals(n = 1695)

Child Mortality: HIV/AIDS

  • 1998 SADHS U5MR 61/1000 (1994-8)

  • 2003 SAHDS U5MR 58/1000 (1999-2003)?

  • Without PMTCT one third of babies born to HIV+ mothers will be infected: of these, 60% expected to die before 5 years of age

  • 40% U5 hospital deaths due to AIDS

  • Child mortality in SA too high for middle-income country, and increasing, despite children’s rights

Child mortality: HIV/AIDS

  • Vertical transmission rate 20.8% (KZN)

  • <50% pregnant women being tested

  • 2/3 all HIV+ infants needing ART by 10 months of age – without access to ARV 1/3 of HIV+ children die in 1st year of life

  • One in 6 qualifying children get ARV

Policy Brief: Child Mortality

  • The Medical Research Council published the Initial Burden of Disease Estimates for South Africa, 2000 in March 2003.

  • A major finding of the study was the quadruple burden of disease experienced in South Africa resulting from the combination of the pre-transitional causes related to underdevelopment, the emerging chronic diseases, the injury burden and HIV/AIDS.

Policy Implications (1)

  • The mortality data indicates that many of the child deaths occurring in South Africa are preventable.

  • We have identified three broad areas that will require differing approaches for intervention:

Policy Implications (2)

1. The prevention of mother-to-child transmission of HIV, even at its current efficacy, is the single most effective intervention to reduce mortality among under-5-year olds, eclipsing all other interventions for other causes of death combined.

Policy Implications (3)

2. Although dominated by the rise of HIV/AIDS, the classic infectious diseases such as diarrhoea, respiratory infections and malnutrition are still important causes of mortality.

Environment and development initiatives such as access to sufficient quantities of safe water, sanitation, reductions in exposure to indoor smoke, improved personal and domestic hygiene as well as comprehensive primary health care will go a long way to preventing these diseases.

Poverty reduction initiatives are also important in this regard.

Policy Implications (4)

3. Road traffic accidents and violence, which includes homicide and suicide is another group of high mortality conditions that will require dedicated interventions.


  • Most important intervention to reduce HIV infection in children

  • Almost all ANC services provide PMTCT, but many barriers to testing and effective treatment.

  • Cotrimoxazole prophylaxis from 6 weeks of age reduces HIV related child mortality by as much as 43%


  • Recommendation: Mandatory testing all children at 6 week immunisation visit & double testing of pregnant women

  • Currently 300 000 HIV infected children – 50-60% expected to currently need ARV’s

  • SA is one of only 9 countries world-wide where child mortality is increasing


  • Routine provider-initiated testing for all 6 week old infants is currently excluded from the NSP on HIV/AIDS

  • Memorandum of concern: Maternal & Child survival (2007)

  • TAC Media Statement: Call for finalisation of Revised PMTCT Guidelines (Jan 2008)

Key Child Survival Strategies

  • Infant and Young Child Feeding (including EBF)

  • Immunisation

  • Treatment of common childhood illnesses

  • Care of children with HIV-infection

  • Provision of Vitamin A


National Health Targets


Focused ANC


Skilled attendant deliveries


Family planning


Basic neonatal care


LBW care

Early EBF



Infection management

Key MCH interventions


  • Infant and Young Child Feeding

  • HIV care

  • IMCI (clinic)

  • Hospital care

  • EPI

  • Vitamin A

  • HIV testing, cotrim, ARV

South Africa:Coverage along the MNCH continuum of care

The days

of highest risk

have the lowest

coverage of care

Source: Lawn JE, Kerber K Opportunities for Africa’s Newborns. PMNCH, 2006

Infant and Young Child Feeding

  • Exclusive breastfeeding (BFHI)

  • Provision of good quality complementary feeds

  • Appropriate care of children with malnutrition

Only 12% of infants EBF by 6 months

Source: Demographic Health Survey 2003

Slide: Ngashi Ngongo


  • Good coverage

  • Major reduction in number of children with measles

  • South Africa declared polio free

  • Need to ensure high coverage is maintained, and to use every opportunity to immunise children

  • Community outreach programmes RED STRATEGY

  • Management issues e.g. cold chain, monitoring coverage

  • Not linked to HIV screening (6 week visit!)

Existing norms and standards

  • Primary Health Care package

  • District Hospital package

  • Regional hospital package

  • Service Transformation Plan

  • Modernization of Tertiary Services

Existing norms and standards

  • IMCI

  • Clinic supervisors manual

  • EDL

  • WHO pocketbook

Staffing norms

  • No official staffing norms for the country

  • Various systems have been used

Service transformation plan

  • PHC clinics: 1 for 10 000 people

  • CHC: 1 for 60 000 people

  • District hospital: 1 for 300 000 people

  • Regional (Level II) hospital:1 for 1.2 million

  • Tertiary (Level III) hospital:1 for 3-3.5million people

Standard Treatment Guidelines & Essential Drug List

Prevention is key

Early diagnosis and preventive care

Staging and referral for ART when appropriate

Psychosocial support

Care of children with HIV-infection


Appropriate infant feeding


Nutrition (Vitamin A)

Care of HIV infected children

IMCI: Bringing it all together

Maternal Health



Active Site

Future Site












Witbank NNMR 2000-2005 trend (=/> 1000 grams)




  • SA IMCI chart booklet: UP Intranet (Block 10)









“There can be no keener revelation of a society’s soul than the way it treats its children”

Nelson Mandela, 1988

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