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Children and their health

Chapter map

Children under the age of 16 comprise 20% of the population of the UK and of most industrialized countries, but in many developing countries, children represent more than 50% of the population. In all countries, the management of children's health problems is a high proportion of the medical workload. Many GPs find that 30% of their consultations are for children, particularly preschool children (under 5 years) (medical students in the middle of a 2‐ or 3‐month paediatric attachment may wonder why only 5% of their training should be devoted to children!). This chapter sets the scene for your study of paediatrics, starting with an overview of child health globally and in the UK. We then review societal factors relevant to paediatrics, community and social aspects of child health and finally the child in hospital.

1. 1.1 Early life is key
2. 1.2 Global Child Health
3. 1.3 Child mortality and morbidity in the UK
   1. 1.3.1 Infant mortality
   2. 1.3.2 Child mortality
   3. 1.3.3 Childhood morbidity
4. 1.4 Children in society
   1. 1.4.1 Socioeconomic inequalities
   2. 1.4.2 Changes in family structure
   3. 1.4.3 Ethnicity
   4. 1.4.4 Laws relating to the young
   5. 1.4.5 Ethics and children's rights
5. 1.5 Child health in the community
   1. 1.5.1 Health personnel
   2. 1.5.2 Health surveillance and promotion
   3. 1.5.3 Schools and nurseries
6. 1.6 Social aspects of child health and care
   1. 1.6.1 Parental responsibility
   2. 1.6.2 Social services
   3. 1.6.3 Voluntary services
   4. 1.6.4 Adoption
7. 1.7 Children in hospital
8. 1.8 Research and evidence‐based medicine
9. Summary

1.1 Early life is key

What happens to a child during pregnancy, and the first couple of years of life is crucial to later physical and emotional health. This is mediated through a range of mechanisms:

• programming (the Developmental Origins of Health and Disease, or Barker hypothesis). This may adapt the child for an adverse environment – but with a long‐term cost;
• early cognitive experience, parenting and attachment (see Section 12.1) (which help to form the growing brain);
• adverse childhood experiences – these have been shown to negatively affect later long‐term health;
• nutrition, including lack of food or micronutrients, and obesity.

Optimizing pregnancy and early childhood is therefore one of the best investments a society can make. This applies across the world, whether in industrialized or developing countries.

1.2 Global child health

Children make up about two billion of the world's population. Health inequalities between nations are seen most starkly in childhood indicators, such as child mortality rates (Figure 1.1). Most childhood deaths occur in sub‐Saharan Africa and South Asia (Figure 1.2), and malnutrition causes or contributes to at least half of them, along with many other factors (Figure 1.3). There has been a sustained international effort in the last few decades to address inequalities, through the Millennium Development Goals adopted in 2000 by all members of the United Nations, which were then succeeded by the Sustainable Development Goals in 2015. These set measurable targets in relation to poverty, maternal and child health and combating disease such as human immunodeficiency virus (HIV) and malaria. In the last three decades, the number of global child deaths has more than halved, from 12.6 million in 1990 to 5.4 million in 2017. This is great progress, but much remains to be done.

Figure 1.1 Changes in worldwide child mortality rates.

Source: UN Population Division (2017 Revision),”Child and Infant Mortality” ourworldindata.org/child‐mortality. Licensed under CC‐BY‐4.0.

Under‐5 mortality rate (rate/1000 live births)

The under‐5 mortality rate is a useful measure of child health internationally. While similar to the infant mortality rate, it detects trends that the infant mortality rate might miss, because in some countries infants dying in the first few weeks are not recorded.

Child mortality

This is the same measure, but expressed as a percentage.

Figure 1.2 Worldwide child mortality rates in year 2017. There was a large reduction of about 65% from 1960 to 2000, and progress has accelerated in the past two decades.

Source: UN Inter‐agency Group for Child Mortality Estimation,”Child and Infant Mortality” ourworldindata.org/child‐mortality. Licensed under CC‐BY‐4.0.

Figure 1.3 Global causes of child morbidity and mortality. The leading cause of death is pneumonia.

RESOURCE

• See the United Nations Development Programme site (www.undp.org) and click the link for ‘Sustainable Development Goals' to find out more about these ambitious targets.
• Health Metrics and Evaluation has a superb site to explore health and other data (www.healthmetricsandevaluation.org). Go to ‘GBD compare’ in the top menu to review the global burden of different diseases by age and region. Or under ‘Results’, look at the data visualization on Child Mortality.
• Visit www.gapminder.org for another great site to compare health and other data between countries and historically.

1.3 Child mortality and morbidity in the UK

The causes of death and the patterns of illness in children differ markedly from those in adults. They are influenced by a diversity of factors, which include sex, social class, place of birth and season of the year. The decline in child mortality in the past century has resulted more from preventative (public health) measures than from improved treatment. Today virtually the entire population of the UK has safe food and water, free immunization and easy access to local health care. This is not the case in non‐industrialized countries.

In the UK, child mortality is concentrated in the perinatal period (Table 1.1 UK mortality rates – see chapter text). The only remaining scope for a major reduction in child deaths lies in better obstetric, neonatal and infant care.

Table 1.1 UK mortality rates

1.3.1 Infant mortality

• Stillbirth: a child born dead after the twenty‐fourth week of pregnancy
• Abortion or miscarriage: a fetus born dead before 24 weeks of gestation
• Live birth: any newborn with signs of life (e.g. heartbeat) at birth at any gestation.

• UK infant mortality continues to fall (currently 3.8 per 1000 live births in 2018) (Figure 1.4).
  • But two thirds of the countries in the European Union have lower rates.
  • Several East European countries have infant mortality rates 2–3 times higher.
  • Some non‐industrialized countries have rates over 150.
• Improvement in UK infant mortality:
  • Mainly due to reduction in neonatal mortality
  • Less improvement in postneonatal mortality (1 month to 1 year).
• Some deaths result from persistent, serious congenital abnormalities and perinatal problems, others due to accidents or diagnosable disorders, but many are infants who die at home, for whom no cause of death is found at post‐mortem (Section 16.3).

1.3.2 Child mortality

• The major causes of childhood death are neoplasms and accidents (Figure 1.5).
• Deaths are concentrated in early...