Promoting Neonatal, Infant, Child, and Adolescent Health

18.1 Progress in child survival

One of the greatest success stories in global health is the steady reduction in child mortal- ity
that has been achieved in recent decades. The under-5 mortality rate (U5MR), the number of
children who die before their fifth birthdays per 1000 live births, signifi- cantly improved between
1950 and the pres- ent (FIGURE 18–1). The infant mortality rate (IMR), the number of deaths of
infants per 1000 live births, has also steadily improved (FIGURE 18–2).1 In just the 25 years from
1990 to 2015, the under-5 child mortality rate dropped by more than 50%, from 12.7 million deaths in
1990 to 5.9 million under-5 child deaths worldwide in 2015 (FIGURE 18–3).2 The improvements
were observed in all age groups for young children. The number of deaths in the first month after birth
dropped from 5.1 million to 2.7 million over that 25-year period. The number of postneonatal deaths
within the first year of life dropped from 8.9 million to4.5 million.2 Improvements in neonatal,
infant, and under-5 child mortality have occurred in countries of all income levels (FIGURE 18–4).3

However, even with the remarkable down- ward trend in child mortality, the Millennium
Development Goals (MDGs) target for improv- ing child survival was not met. The aim was to reduce
the U5MR by two-thirds between 1990 and 2015 (MDG 4), to 30 deaths per 1000 live births.4 In
2015, the U5MR was 42.5 per 1000 live births, a rate that was considerably higher than the targeted
30 per 1000 (FIGURE 18–5). The Sustainable Development Goals (SDGs) aim to reduce the under-5
child mortality rate to less than 25 deaths per 1000 live births in all countries by 2030 (SDG 3.2).5
This will require a decrease in the global U5MR of more than 40% between 2015 and 2030 (FIGURE
18–6).4 Because most high-income and upper-middle-income countries already have U5MR rates
below this threshold, there will still be a gap in child sur- vival between high- and low-income
countries even if the U5MR target is met by 2030. It would be technologically possible to achieve a
“grand convergence” of health metrics by the year 2030 by reducing the maternal mortality and child
mortality rates in low-income countries to the already-low levels in high-income countries, but this
ambitious goal would require doubling funding for maternal and child health.6

The underlying cause of most child deaths worldwide is poverty.7 Nearly all child mortality
occurs in lower-income countries, where limited access tomedical carefornewborns, common but
usually preventable child infections like diarrhea and pneumonia, and undernutrition continue to cause
millions of deaths each year. Most children who die in low-income countries would not have become
ill if they lived in high-income countries. If they had become ill in a high-income country rather than a
low-income one, most of these chil- dren would have survived their illnesses and not died from them.
Numerous low-cost interven- tions are effective at improving infant and child survival, but interventions
that address specific health problems need to be accompanied by socioeconomic development to
break the cycle of poverty that makes children born into extreme poverty so much more likely to die
than children who happen to be born into wealthier families. The successes in decreasing child
mortality during the MDG years were achieved, in part, because the MDGs addressed the
socioeconomic and environmental conditions that put some children at especially high risk of illness,
dis- ability, and death.8 The SDGs call for continued improvements in poverty reduction, sustainable
economic growth, and access to nutrition, educa- tion, clean water, sanitation, electricity, employ- ment,
safety, peace, and the other tools that will enable more children around the world to enjoy long, healthy,
productive lives (FIGURE 18–7).
1.2.1 Proportion of children living below the national poverty line

2.1.1 Prevalence of undernourishment

 2.1.2 Prevalence of food insecurity

2.2.1 Prevalence of stunting among children under 5 years of age

2.2.2 Prevalence of malnutrition (wasting and overweight) among children under

5 years of age
3.2.2 Neonatal mortality rate (deaths per 1000 live births)

3.2.1 Under-5 mortality rate (deaths per 1000 live births)

3.3.3 Incidence of malaria per 1000 persons per year

3.7.2 Adolescent birth rate (aged 10–19 years) per 1000 women in that age group

3.8.1 Coverage of essential health services (including access to essential

medicines and vaccines, newborn and child health services, and other
services)
4.2.1 Percentage of children under 5 years of age who are developmentally on
track in health, learning, and psychosocial well-being

8.7.1 Percentage and number of children aged 5–17 years engaged in child labor

16.2.1 Percentage of children aged 1–17 years who experienced any

physical punishment or psychological aggression by caregivers in the
last month
FIGURE 18–7 Examples of Sustainable Development Goals targets related to newborn,
child, and adolescent health.

18.2 Improving neonatal survival

Neonatal mortality accounts for an increasing percentage of pediatric deaths. The

percentage of deaths before the 15th birthday that occur during the first month after birth
increased from about one in three under-15 deaths in 1990 to nearly 40% in 2015
(FIGURE 18–8).9 This increasing proportion is evidence that the mor- tality rates among
neonates have not decreased as quickly as the mortality rates among older infants and
children. The SDGs aim to reduce the neonatal mortality rate (NMR) to less than 12 deaths
per 1000 live births in all countries by 2030 (SDG 3.2).4 This will require a decrease in the
global NMR of more than 35% between 2015 and 2030 (FIGURE 18–9). The Every New-
born action plan endorsed by the World Health
Assembly establishes a more ambitious goal, aiming for every country in the world to have an NMR of
less than 10 deaths per 1000 live births and a stillbirth rate of less than 10 stillbirths per 1000 total births
by 2035.10

The risk of death is higher on the day of birth than on any subsequent day.11 Globally, 15%
of all under-5 child deaths occur on the day of birth (FIGURE 18–10). This proportion does not
include stillbirths. If preventable stillbirths related to birth complications were added to the total, the
proportion would be even higher. In some high-income countries that already have very low NMRs,
clinicians are aggressive about attempting to resuscitate very low birthweight neonates who would
be considered stillbirths in places where advanced technologies are not available. Intensive
resuscitation measures sometimes add newborns with a high risk of neonatal death to the denominator
of live births, mak- ing the NMR look worse, but those actions enable some fragile newborns to take a
first breath and possibly live. In lower-income countries where resuscitation tools are not routinely
available, currently high NMR rates might be artificially low because they do not include late-
term stillbirths in the cal- culations. In all countries, interventions on the day of birth are critically
important for improving the percentage of pregnancies that result in healthy newborns who will
survive into healthy childhood.
Just three conditions account for more than four in five newborn deaths: preterm birth,
asphyxia and other complications during labor and delivery, and neonatal infec- tions. 10 These
major causes of neonatal mor- tality can be addressed with interventions from preconception through
the weeks after birth.12 Immunizing pregnant women with tetanus toxoid protects their babies from
teta- nus infection. During the intrapartum period, women and their babies can be saved with actions
like giving corticosteroids to women who go into preterm labor in order to prepare the lungs of
fetuses to breathe, having skilled attendants care for women during labor and delivery in a clean
environment, and manag- ing complications with caesarian sections and other advanced emergency
obstetrical proce- dures. After delivery, newborn resuscitation, prevention of hypothermia, and
initiation of breastfeeding keep newborns alive. Neonatal mortality is also reduced by treating
maternal infections, such as malaria and syphilis, and by managing maternal health issues, such as
diabetes.13 In addition to preventing mortal- ity, these interventions help reduce the risk of
neurodevelopmental impairment and other long-term disabilities in surviving babies.14
A variety of inexpensive packages of interventions could potentially enable major
improvements in neonatal survival.15 For example, a package of four easy-to-deliver interventions—
corticosteroid injections for women in preterm labor, newborn resus- citation devices, chlorhexidine
to clean the umbilical cord and prevent infections, and injectable antibiotics to treat newborn sepsis
and pneumonia—would cost only a few dol- lars per baby and could save one million neo- nates each
year.11 Spending just $1 or $2 more per person each year to increase access to qual- ity antenatal care,
assisted labor and delivery, and newborn care in low- and middle-income countries could be enough
to reduce neona- tal deaths by up to 70% and stillbirths by up to 33%. 15 These types of interventions
may also save money in the long term by reducing healthcare costs associated with disability and by
increasing economic productivity. 14 The biggest barriers to expanding access to neo- natal health
programs are not having enough funding, not having enough trained health workers to provide
obstetric and neonatal health services, and not having the resources and leadership to manage the
logistics of scal- ing up delivery of quality care.16 These barriers can be overcome when citizens and
communi- ties call for change, when governments choose to prioritize progress on child health, and
when partners make commitments to provide support and accountability.2
© Kristina Bessolova/Shutterstock

18.3 Promoting infant and child health

Some of the earliest international health ini- tiatives focused on child health. In the 20th
century, several large-scale multinational initiatives improved the lives of millions of children
around the world.17 One of the first efforts heavily promoted by the World Health Organization
(WHO) and UNICEF supported primary health
care (PHC), a community-based approach
to health that employs community health workers and focuses as much on prevention as on cures. 18
PHC became the focus of most international health work following the Alma-Ata Con- ference of
1978, which developed the goal of achieving “Health for All by 2000” through the reduction of
barriers to healthcare access, espe- cially in poor and rural areas.19 PHC prioritizes prevention of
locally common infectious dis- eases, provision of essential medications and treatments for common
diseases and injuries, promotion of nutrition, coordination of health services with traditional health
practitioners, and programming for maternal and child health, including immunization and family
planning.20 PHC is a “horizontal” approach to health care that emphasizes routine access to
comprehensive primary care, rather than a “vertical” approach that targets selected dis- eases with
specific interventions (like special vaccination days) that are managed outside the public healthcare
system.21
A hallmark of PHC is regularly sched- uled health clinics for children younger than 5 years old
in order to monitor child growth and provide recommended immunizations. 22 The Expanded
Program on Immunization (EPI) was started in 1974 by WHO to expand the number and types of
vaccines routinely given to children. More than four decades later, the pro- gram is still supporting
the delivery of essential vaccines to children across the globe. 23 When all children, whether sick or
healthy, have fre- quent interactions with the healthcare system through under-5 health clinics,
warning signs for potentially life-threatening conditions in relatively healthy children can be
detected early and treated. For example, growth mon- itoring tracks child weight so that caregivers
will know if a child has lost weight or is failing to gain weight. Weight loss or stagnation can be a
sign of serious illness, and early detection means that a nutritional intervention can be implemented
before a health crisis occurs.
GOBI, an initiative started in the 1980s by UNICEF, focused on increasing child survival by
promoting four simple interven- tions: Growth monitoring, Oral rehydra- tion therapy for
diarrhea, Breastfeeding, and Immunization.24 Later, a partnership between UNICEF, WHO, and the
World Bank added three community-focused components to the mix—family planning, food
production, and female education—creating a program called GOBI/FFF.25
Integrated Management of Child- hood Illness (IMCI) is a package of simple, affordable,
and effective interventions for major childhood illnesses and undernutrition that was first developed
by UNICEF and WHO in 1995.26 The term “integrated” has several layers of meaning. 27 One
aspect of integration is an emphasis on the interrelatedness of chil- dren’s health conditions. A child
with malaria is more vulnerable to diarrhea. A child with vitamin A deficiency is more vulnerable to
death from measles. Clinicians working under an IMCI framework complete a series of med- ical
assessments on each sick child that allows for diagnosis of underlying conditions in addi- tion to the
primary illness. Integration also emphasizes families and communities work- ing together with the
staff in various levels of healthcare facilities to care for sick children.
IMCI aims to improve family and commu- nity health practices as well as the case man- agement
skills of healthcare staff. To advance this goal, IMCI provides home healthcare guidelines for
families with young children and evidence-based decision charts for clinicians to use when
assessing children and treating common illnesses. 28 For example, the family of a child with
diarrhea should know how to prepare oral rehydration therapy correctly and know what symptoms
require the child to be taken to the local clinic or hospital. The local clinic should support
community health edu- cation programs, provide care for advanced cases of dehydration, and make
referrals for hospital-based treatment, if necessary. In places where malaria is common, parents
should know how to use bednets to prevent mosquito bites and how to recognize fevers and other
symptoms of malaria. The local clinic should support those community health education efforts,
treat cases of malaria that do occur, and make referrals for advanced treat- ment when it is needed.
IMCI clinical guide- lines, which focus on management of serious childhood diseases at healthcare
facilities, are often paired with Integrated Community Case Management (iCCM) guidelines
that provide community health workers with algo- rithms for treating uncomplicated childhood
infections in homes.29
Each of these historic international child health programs contributed to significant improvements in
global child health metrics, but infant and child health statistics show that there is still a great deal of
work to be done. In order to ensure that as many children as pos- sible have a healthy start in life, it
is import- ant to further improve access to safe drinking water and nutritional foods, educate parents
about infectious disease prevention, promote breastfeeding, increase access to essential medications
and immunizations, and imple- ment other important public health measures. As of 2015, The
 Partnership for Maternal, Newborn & Child Health, which was launched in 2005, had more than 725
partner groups representing a diversity of sectors. 30 The min- istries of health and collaborating
agencies in low- and middle-income countries have expanded access to antibiotics, clean water,
antimalarial medications, and other tools for preventing and treating pneumonia, diarrhea, malaria,
and other potentially fatal infectious diseases in urban and rural areas within their own borders. Gavi
and other organizations have expanded access to vaccines that pro- tect against measles and other
life-threatening infections. UNICEF and numerous other mul- tinational groups have promoted
breastfeed- ing, distributed micronutrients to children, supported agricultural development, and
taken other actions to prevent infant and child malnutrition. Other United Nations agencies, partner
governments, clinical professional associations, nongovernmental organizations, private sector
companies, academic institutes, foundations and other donors, and count- less others are working at
the local, national, regional, and global levels to reduce infant and child mortality and promote health
and well-being in the early years.

18.4 Promoting Early Childhood development

Global child health in the 21st century is about helping babies and children thrive rather than
merely investing in keeping kids alive.31 Access to nutrition, health services, and social inter- action
with parents and other caregivers in the first months and years of life is critical not only for health
but for preparing young children for success in school and, later on, for healthy and productive
adulthood.32 Economic evaluations show that a diversity of health and nutritional, environmental,
educational, social, and eco- nomic interventions for young children and their families yield long-
term benefits not only for those individuals but also for their families, communities, and nations.33

Early childhood development (ECD) interventions target the physical, cognitive,

emotional, and social development of infants and children.34 The ECD process begins
during the first 1000 days, the time period encompass- ing the approximately one thousand
days from conception through the second birthday. 35 Adequate maternal access to
micronutrients and calories during pregnancy has a benefi- cial impact on fetal
development, and assisted delivery helps reduce the risk of brain damage from birth
trauma. During the first 2 years after birth, cognitive development, language acquisition,
motor skills, and socio-emotional development are facilitated by psychosocial stimulation
from parents and other caregiv- ers that promotes mental development; by nutritious food
that allows for health, growth, physical activity, and brain development; and by a clean
and safe environment that protects children from infectious diseases and vio- lence. 36
ECD continues through the preschool years as children gain the self-regulation and
learning skills necessary for success in a pri- mary school classroom. 37 One of the SDGs
aims to “ensure that all girls and boys have access to quality early childhood development,
care, and pre-primary education, so that they are ready for primary education” (SDG 4.2).5
Achieving this goal will require cooperation across the health, education, social service,
and economic development sectors.38

18.5 Children with special needs

A disability is not defined merely as a physical, cognitive, sensory, or other impairment (or a
combination of impairments). A disability is also a function of the social context and envi-
ronment in which a person with an impair- ment lives, learns, and works. Consider the example of
hearing loss. Some children who grow up Deaf are part of a vibrant community with a shared
language (a local form of sign language) and culture, especially if they are born into a Deaf family.
 (The use of the capital- ized term Deaf is used to indicate Deaf culture and identity.) For these
individuals, deafness is not considered to be a disability.39 But some people who grow up deaf or
hard of hearing never have the opportunity to learn a language, attend school, or be fully involved
in the lives of their families and communities. In that environment, being deaf is a disability
because it causes activity limitations and participation restrictions. Many children with various
types of special needs have difficulty accessing health and educational services, especially when
they live in low- and middle-income countries. Those barriers can have negative consequences
that persist for a lifetime.40
Children with special needs have the healthiest life trajectories when they are able to access
interventions early in life.41 For exam- ple, babies with cleft lip or cleft palate, which occurs when
the upper lip or the roof of the mouth is unclosed, may require surgery to be able to suck
properly and receive adequate nutrition. Children born with cerebral palsy and other mobility
disabilities can develop their motor skills to their highest potential when they have physical
therapy and the use of braces, crutches, and walkers at an early age. Children with developmental
disabilities may benefit from various types of physical, occu- pational, communication, and other
therapies early in life.42 Unfortunately, many parents do not have the resources or ability to have
their children start therapy at an early age, do not know what therapy to provide at home for their
children, and are not able to help their children with special needs access education.43 Increasing
access to support services, rehabil- itation, and assistive technologies by children with special
needs is both a public health pri- ority and a human rights issue.44

18.6 Health Promotion for Older Children

Most of the attention on health in pediatric populations is devoted to under-5 children because
the youngest age groups have the highest mortality rates. Although the mortality rate for older
children and adolescents is low, health education interventions during these age periods can be
valuable for keeping older children safe and also for preparing them for active and healthy
adulthood.45 Many of the health interventions for school-aged children are delivered at primary
schools.46 For exam- ple, one of the major contributors to reduced health status in middle
childhood and early adolescence is iron deficiency anemia, which is often caused by a combination
of rapid growth, inadequate dietary intake of iron, and malaria and hookworm infections. School-
based feeding and deworming programs for primary school children are effective in improving
school attendance, child health and development, and learning. 47 School health programs also
provide health and hygiene education and support for activities related to infection prevention,
nutrition, physical fitness, mental health and well-being, injury prevention and safety awareness,
medical and dental care, and healthy relationships and bul- lying prevention.48

Initiatives to support the rights of chil- dren also contribute to protecting their health and
enabling them to flourish. In 1989, the General Assembly of the United Nations adopted the
Convention on the Rights of the Child, which declares that the rights of the child include an
adequate standard of living, freedom from all forms of exploitation, pro- tection from all forms of
violence, access to education and appropriate information, the right to be heard, and the right to rest,
lei- sure, and play.49 Acknowledging the right of every child in the world to these protections is a
start, but this recognition must be acted on to be meaningful. Millions of children are still hungry,
abused, exposed to war and other forms of violence, unable to attend school, and otherwise being
denied their human rights.50 Girls are especially vulnerable to abuse and neglect. When a family has
limited resources, girls may face discrimination within the family due to preferential treatment of
sons. Daugh- ters may not be allowed to attend school and may be forced into early marriage. 51 In
1995, the United Nations adopted the Beijing Decla- ration that affirms several strategic objectives
 for promoting the rights of the “girl-child,” including eliminating educational discrimi- nation, the
exploitation of child laborers, and violence against children. Although some improvements have
been achieved, such as increasing school enrollment, significant inequalities between boys and girls
remain in many regions of the world. Those inequalities can have significant adverse health effects
for girls and young women.52

18.7 Health Promotion for adolescents

Adolescence is a time characterized by rapid physical, sexual, neurological, psy- chological,
and social development.53 This developmental stage may begin at around 10 years of age
(especially forgirls) and extend until around 19 years of age (especially for boys).54 As children
age into the adolescent stage, the proportion of deaths attributable to infections decreases as the
proportion of deaths from injuries increases and adoles- cent females begin to experience the risks
associated with pregnancy (FIGURE 18–11).9 The distribution of years lived with disabil- ity
(YLDs) attributable to various condi- tions shifts from younger children having a substantial burden
of disability from infec- tions, iron deficiency anemia, and asthma to adolescents having a high
burden from depression, anxiety, back pain, and head- aches (FIGURE 18–12).55 In some regions,
the rate of teen pregnancy is high due to lim- ited access to reproductive health services and to
other cultural and economic factors (FIGURE 18–13). Maternal mortality is a sig- nificant
contributor to deaths among young women in many of the places where teen pregnancy is
common.56
Adolescent health interventions focus on the immediate needs of youth and also on set- ting
the foundation necessary for those young people to become healthy adults. 57 The goal is to address
risk factors and to identify and pro- mote protective factors that will prevent health problems
emerging later on.58 The highest- impact health interventions for adolescents include programs for
mental health (includ- ing prevention of suicide, alcohol abuse, and drug abuse), injury prevention
(including prevention of violence), and reproductive health (including access to tools for preventing
pregnancy, HIV, and other sexually transmit- ted infections), as well as interventions that promote
nutritious diets, physical activity, tobacco-free living and other aspects of healthy adult lifestyles.59
Addressing broader concerns, such as youth unemployment, limited access to advanced education
and vocational train- ing, and unhealthy and violent environments, also promotes improved physical,
mental, and social health among adolescents.60