Reducing Child Mortality

Despite global interconnectedness, child health priorities continue to reflect local politics, resources, and needs. The state of health of any community must be defined by the incidence of illness and by data from studies that show the changes that occur with time and in response to programs of prevention, case finding, therapy, and surveillance. To ensure that the needs of children and adults across the globe were not obscured by local needs, in 2000 the international community established 8 Millennium Development Goals (MDGs) to be achieved by 2015 (www.countdown2015mnch.org). Although all 8 MDGs impact child well-being, MDG 4 (“Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate”) is exclusively focused on children. Globally, there has been a 23% reduction in under-5 mortality since 1990 (from 93 to 72 deaths per 1,000 live births), with a 40% reduction in developed countries (10 to 6) but only a 21% reduction in the least developed countries (180 to 142). In 62 countries progress was inadequate to meet the goals and 27 countries (including most of those in sub-Saharan Africa) made no progress or declined between 1990 and 2006. There were nearly 13 million under-5 deaths in 1990; 2006 marked the 1st year that there were fewer than 10 million deaths (9.7 million) with a further decrease to 9.0 million in 2007 and 8.8 million in 2008. However, overall progress has not been on target to reach the goal (Fig. 1-1).

Figure 1-1 Under-5 mortality rate per 1,000 live births, 1990, 2000, and 2006. CIS, Commonwealth of Independent States (formerly the USSR).

(From United Nations: The millennium development goals report 2008, New York, 2008, United Nations, p 20.)

In the late 19th century in the USA, 200 of every 1,000 children born alive died before the age of 1 yr of conditions such as diarrhea, pneumonia, measles, diphtheria, and whooping cough. In developing countries today, the leading causes of death remains diarrhea, pneumonia, malaria, and measles with much of the reductions in mortality that have occurred resulting from effective vaccine programs, oral rehydration therapy, early diagnosis and treatment of pneumonia, and, treated mosquito nets.

Neonatal (<1 mo) death contributes substantially to the under-5 mortality rate, growing in proportion as the under-5 death rate decreases. Globally, the neonatal mortality rate of 28 per 1,000 live births represents 62% of the infant mortality rate of 45 per 1,000 live births and 43% of the under-5 death rate of 72. The proportion of neonatal deaths in industrialized countries is higher (60% of infant deaths and 50% of under-5 mortality) than in the least developed countries (49% of infant deaths and 31% of under-5 deaths). In populations with the highest child mortality rates, however, just over 20% of all child deaths occurred in the neonatal period, but in countries with mortality rates <35/1,000 live births, >50% of child deaths were in neonates.

Across the globe, there are significant variations in infant mortality rates by nation, by region, by economic status, and by level of industrial development, the categorizations employed by the World Bank and the United Nations (Table 1-1). Most of the decline in infant mortality in the USA and other industrialized countries since 1970 is attributable to a decrease in the birthweight-specific infant mortality rate related to neonatal intensive care, not to the prevention of low-birthweight births (Chapter 87). The majority of deaths of infants younger than 1 yr of age occur in the 1st 28 days of life, most of these in the 1st 7 days; moreover, a large proportion of the deaths in the 1st 7 days occur on the 1st day. An increasing number of severely ill infants born at very low birthweight survive the neonatal period, however, and die later in infancy of neonatal disease, its sequelae, or its complications (Tables 1-2 through 1-4).

Causes of death vary by developmental status of the nation. In the USA, the 3 leading causes of death among infants were congenital anomalies, disorders related to gestation and low birthweight, and sudden infant death (Table 1-5). By contrast, in developing countries, the majority of infant deaths result from infectious diseases; even in the neonatal period, 24% of deaths are caused by severe infections and 7% by tetanus. In developing countries, 29% of neonatal deaths are due to birth asphyxia and 24% due to complications of prematurity.

In the majority of countries, the most robust predictor of infant mortality is a poor level of maternal education (and therefore another of the MDG addresses the need for universal access to primary schooling for girls). Other maternal risk characteristics, such as unmarried status, adolescence, and high parity, correlate with increased risk of postneonatal mortality and morbidity and low birthweight.

Health Among Postinfancy Children

A profound improvement in child health within industrialized nations occurred in the 20th century with the introduction of antibacterial disinfectants, antibiotic agents, and vaccines. Efforts to control infectious diseases were complemented by better understanding of nutrition. In the USA, Canada, and parts of Europe, new and continuing discoveries in these areas led to establishment of public well child clinics for low-income families. Although the timing of control of infectious disease was uneven around the globe, this focus on control was accompanied by significant decreases in morbidity and mortality in all countries. The smallpox eradication program of the 1970s resulted in the global eradication of smallpox in 1977. The introduction in the 1970s of the Expanded Program of Immunizations (universal vaccination against polio, diphtheria, measles, tuberculosis, tetanus, and pertussis) by the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) has resulted in an estimated annual reduction of 1 to 2 million deaths per year globally. Recognizing the importance of prevention of infectious diseases to the health of children, several countries among the 50 currently ranked by the World Bank as among the poorest nations (per capita income <$750/yr) have invested heavily in infectious disease control through the development of internal vaccine production capability. As diarrheal diseases continued through the mid-1970s to account for ≈25% of infant and childhood deaths in the nonindustrialized countries (∼4 million deaths per year at that time), attention turned to the development and utilization of oral resuscitation fluids to sustain children through potentially life-threatening episodes of acute diarrheal diseases. Oral rehydration solutions are largely credited with the current reduction of diarrheal deaths annually to 1.5 million.

In the later 20th century, with improved control of infectious diseases (including the elimination of polio in the Western hemisphere) through both prevention and treatment, pediatric medicine in industrialized nations increasingly turned its attention to a broad spectrum of conditions. These included both potentially lethal conditions and temporarily or permanently handicapping conditions; among these disorders were leukemia, cystic fibrosis, diseases of the newborn infant, congenital heart disease, mental retardation, genetic defects, rheumatic diseases, renal diseases, and metabolic and endocrine disorders. Thus, in industrialized nations, the end of the 20th century and 1st decade of the 21st century have been marked by accelerated understanding of new approaches to the management of many disorders as a consequence of advances in molecular biology, genetics, and immunology.

Increasing attention has also been given to behavioral and social aspects of child health, ranging from re-examination of child-rearing practices to creation of major programs aimed at prevention and management of abuse and neglect of infants and children. Developmental psychologists, child psychiatrists, neuroscientists, sociologists, anthropologists, ethnologists, and others have brought us new insights into human potential, including new views of the importance of the environmental circumstances during pregnancy, surrounding birth, and in the early years of child rearing. The later 20th century witnessed the beginning of nearly universal acceptance by pediatric professional societies of attention to normal development, child rearing, and psychosocial disorders across the continents. In the last decade, irrespective of level of industrialization, nations have developed programs addressing not only causes of mortality and physical morbidity (such as infectious diseases and protein-calorie malnutrition), but also factors leading to decreased cognition and thwarted psychosocial development, including punitive child-rearing practices, child labor, undernutrition, war, and poor schooling. Obesity is recognized as a major health risk not only in industrialized nations, but increasingly in transitional countries. Progress at the turn of the 21st century in unraveling the human genome offers for the 1st time the realization that significant genetic screening, individualized pharmacotherapy, and genetic manipulation will be a part of routine pediatric treatment and prevention practices in the future. The prevention implications of the genome project give rise to the possibility of reducing costs for the care of illness but also increase concerns about privacy issues (Chapter 3).

Although local famines and disasters, and regional and national wars have periodically disrupted the general trend for global improvement in child health indices, it was not until the advent of the AIDS epidemic in the later 20th century that the 1st substantial global erosion of progress in child health outcomes occurred. This erosion has resulted in ever-widening gaps between childhood health indices in sub-Saharan Africa compared to the rest of the world. From 1990 to 2002, life expectancy in sub-Saharan Africa decreased from 50 yr to 46 yr; although, as of 2008, it had returned to 52 yrs. Increasing rates of tuberculosis and continued problems with pandemics such as cholera further challenge many of these nations. Strains of drug-resistant malaria are also a major concern in isolated areas around the world, but 90% of malarial deaths (the majority among children) are occurring in sub-Saharan Africa. Diseases once confined to limited geographic niches, including West Nile virus, and diseases previously uncommon among humans, such as the avian flu virus, increased awareness of the interconnectedness of health around the world. Formerly perceived as a problem of industrialized nations, motor vehicle crashes are now a major cause of mortality in developing countries as well.

Enormous disparities exist in childhood mortality rates across the globe (see Table 1-1). Among the ∼8.7 million childhood deaths occurring worldwide, ≈50% occur in sub-Saharan Africa, home to <10% of the world’s population. Fifty percent of the world’s childhood deaths are occurring in 6 nations; 90% of childhood deaths are occurring in only 42 of the world’s 192 nations. In 2008, the USA had an under-5 mortality rate of 8/1,000 live births. Forty-two nations had under-5 mortality rates lower than that of the USA, with Singapore, Finland, Luxembourg, Iceland, and Sweden having the lowest rates at 3/1,000. The comparable child mortality rate in sub-Saharan Africa was 144/1,000 live births. As of 2008, Afghanistan has the highest under-5 mortality rate of 257/1,000 live births, followed by Angola at 220/1,000 live births and Chad at 209/1,000 live births. In 1990 Afghanistan and Angola had an under-5 mortality rate of 260/1,000 live births, showing minimal improvement over 2 decades. Causes of under-5 mortality differ markedly between developed and developing nations. In developing countries, 66% of all deaths resulted from infectious and parasitic diseases. Among the 42 countries having 90% of childhood deaths, diarrheal disease accounted for 22% of deaths, pneumonia 21%, malaria 9%, AIDS 3%, and measles 1%. Neonatal causes contributed to 33%. The contribution for AIDS varies greatly by country, being responsible for a substantial proportion of deaths in some countries and negligible amounts in others. Likewise, there is substantial co-occurrence of infections; a child may die with HIV, malaria, measles, and pneumonia. Infectious diseases are still responsible for much of the mortality in developing countries. In the USA, pneumonia (and influenza) accounted for only 2% of under-5 deaths, with only negligible contributions from diarrhea and malaria. Unintentional injury is the most common cause of death among U.S. children ages 1-5 yr, accounting for about 33% of deaths, followed by congenital anomalies (11%), malignant neoplasms (8%), and homicides (7%). Other causes accounted for <5% of total mortality within this age group (see Table 1-5). Although unintentional injuries in developing countries are proportionately less important causes of mortality than in developed countries, their absolute rates and their contributions to morbidity are substantially greater.

Morbidities Among Children

It is important to examine morbidities as well as mortality. Adequately addressing special health care needs is important in all countries both to minimize loss of life and to maximize the potential of each individual.

In the USA, ≈70% of all pediatric hospital bed days are for chronic illnesses; 80% of pediatric health expenditures are for 20% of children. In 2006, about 13.9% of U.S. children were reported to have special health care needs; 21.8 percent of households with children had ≥1 child with a special health care need (Chapter 39). Significantly more poor children and minority children have special health care needs. Although there are multiple chronic conditions and the prevalence of these disorders vary by population, 2 of these morbidities—obesity and asthma—have a substantial and increasing presence worldwide and are associated with substantial health consequences and costs. In the USA, ∼25% of children and adolescents are overweight, representing a 2.3- to 3.3-fold increase over the past 25 yr. Similar rates have been reported from Australia and multiple countries in Europe, Egypt, Chile, Peru, and Mexico (Chapter 44).

Also increasing in prevalence among industrialized nations and in middle- and low-income nations with substantial urbanization are rates of asthma. In the mid-1990s, the USA reported an annual prevalence rate of wheezing of 57.8/1,000 among children ages 0-4 yr and 74.4/1,000 among youth ages 5-15 yr, approximately 2-fold higher than comparable prevalence rates in 1980. In 2007, the Centers for Disease Control and Prevention (CDC) estimated that 9% of U.S. children have asthma, including 19.2% of Puerto Rican and 12.7% of non-Hispanic black children. The International Study of Asthma and Allergies in Childhood has conducted a systematic review of asthma prevalence, with compelling evidence for a substantial global burden of childhood asthma, although rates vary substantially between and within countries. The highest annual prevalence rates are in the United Kingdom, Australia, New Zealand, and Ireland, with the lowest rates in Eastern European countries, Indonesia, China, Taiwan, India, and Ethiopia (Chapter 138).

Chronic cognitive morbidities represent another substantial problem. Although different diagnostic criteria have been applied, attention-deficit/hyperactivity disorder (ADHD) has been identified in 5-12% of children in countries across the globe. Rates exceeding 10% have been reported in the USA, New Zealand, Australia, Spain, Italy, Colombia, and Great Britain. Variations in cultural tolerance and/or differences in screening approaches or tools may account for some of the differences in prevalence of the disorder by country, but genetic and gene-environmental interactions may also play a role. Despite variations in rate, the condition is universal. Beyond the personal and familial stress caused by the disorder, costs to the educational system are considerable. It is estimated that in 2010 the U.S. drug treatment costs for ADHD will exceed $4 billion. In developing countries without resources for special education, these children are unlikely to fulfill their academic potential (Chapter 30).

Mental retardation affects ≈1-3% of children in the USA, with ∼80% of these children having mild retardation. Rates are severalfold higher among very low birthweight infants, although data from European cerebral palsy (CP) registries has revealed a significant decrease in the prevalence of CP in very low birthweight infants, from 60.6 per 1,000 live births in 1980 to 39.5 per 1,000 live births in 1996. In the USA, there is substantial variation in rates of mild retardation by socioeconomic status (9-fold higher in the lowest compared to the highest socioeconomic stratum) but relatively equivalent rates of severe retardation. A similar income-related distribution is found in other countries, including some of the most impoverished countries such as Bangladesh. Lower overall rates have been reported in some countries, including countries ranging from Saudi Arabia to Sweden to China; the difference is primarily in the prevalence of mild retardation (Chapter 33).

The prevalence of post-traumatic stress disorder (PTSD) varies considerably around the globe, but in children with substantial exposure to violence, the rates may be very high. After the attacks on the World Trade Center towers and the Pentagon in 2001, 33% of U.S. children had experienced 1 or more symptoms of PTSD. One half of Palestinian children experience at least 1 significant lifetime trauma and >33% (66% of those experiencing trauma) meet the criteria of PTSD. Natural disasters such as the tsunami of 2004 and the Haitian and Chilean earthquakes and Pakistani floods of 2010; war, including those in Afghanistan, Sudan, and Iraq; and urban violence all leave their indelible marks on the minds of children.

Children in Poverty

Family income is central to the health and well-being of children. Children living in poor families, especially those located in poor communities, are much more likely than children living in upper- or middle-class families to experience material deprivation and poor health, die during childhood, score lower on standardized tests, be retained in a grade or drop out of school, have out-of-wedlock births, experience violent crime, end up as poor adults, and suffer other undesirable outcomes. In 2008, 20.7% of U.S. children <18 yr (21% of those less than 6 yr) lived in poverty (defined as income <$21,756/yr for a family of 4), a rate among the highest of developed countries. Seven percent lived in extreme poverty. The poverty rates are higher for children than adults and are highest for infants and toddlers. Children who are poor have higher than average rates of death and illness from almost all causes (exceptions being suicide and motor vehicle crashes, which are most common among white, non-poor children). Many factors associated with poverty are responsible for these illnesses; crowding, poor hygiene and health care, poor diet, environmental pollution, poor education, and stress.

Similar poverty-linked disparities may exist in countries with very high infant mortality rates (sub-Saharan Africa). In the low-income developing countries, the rate of infant mortality among the poorest quintile of the population is more than twice that of the wealthiest quintile (Fig. 1-2).

Figure 1-2 Poor children across South-Eastern Asia are much more likely to die before age 5 than their wealthier peers.

(From World Health Organization: World health statistics 2007, Geneva, 2007, World Health Organization, p 74; and United Nations Development Programme: Human Development Report 2007/08: fighting climate change: human solidarity in a divided world, New York, 2007, United Nations Development Programme, p 255.)

Poverty and economic loss diminish the capacity of parents to be supportive, consistent, and involved with their children. Clinicians at all times but especially in the context of a national or global recession need to be especially alert to the development and behavior of children whose parents have lost their jobs or who live in permanent poverty. Fathers who become unemployed frequently develop psychosomatic symptoms, and their children often develop similar symptoms. Young children who grew up in the Great Depression in the USA and whose parents were subject to acute poverty suffered more than older children, especially if the older ones were able to take on responsibilities for helping the family economically. Such responsibilities during adolescence seem to give purpose and direction to an adolescent’s life. The younger children, faced with parental depression and unable to do anything to help, suffered a higher frequency of illness and a diminished capacity to lead productive lives even as adults.

Pediatricians and other child health workers have a responsibility both to mitigate the effects of poverty on their patients and to contribute to efforts to reduce the number of children living in poverty. Clinicians should ask parents about their economic resources, adverse changes in their financial situation, and the family’s attempts to cope. Encouraging concrete methods of coping, suggesting ways to reduce stressful social circumstances while increasing social networks that are supportive, and referring patients and their families to appropriate welfare, job training, and family agencies can significantly improve the health and functioning of children at risk when their families live in poverty. In many cases, special services, especially social services, need to be added to the traditional medical services; outreach is required to find and encourage parents to use health services and bring their children into the health care system. Pediatricians also have the responsibility to contribute to and advocate for safety net services for impoverished children within and outside the boundaries of their own country. An increasing number of programs are available to help children of greatest need worldwide, such as Project Smile, CARE, Project Hope, and Doctors without Borders.

Children of Immigrants and Racial Minority Groups Including U.S. Native Americans

Eleven percent of the U.S. population is foreign-born; 1 of every 5 children lives in an immigrant family. The USA is experiencing a wave of immigration larger than that occurring in the early 20th century. There has been an increase in immigration from China, India, Southeast Asia, Mexico, the Dominican Republic, and the former Soviet Union nations. Until the mid-20th century, emigrants to the USA were primarily white and from Europe. Such individuals now represent only about 10% of immigrants; the remainder are overwhelmingly of color and from throughout the world. Although immigrants in the USA have faced discrimination and oppression throughout history, the potential for such discrimination is compounded by the racial differences represented in the current immigrant pool. In the USA, about 240,000 children legally immigrate each year, and an estimated 50,000/yr enter the country illegally, although these numbers have been declining in the wake of the 2008 recession. Immigrants comprise >15% of the population in >50 countries, including many Western European countries.

The immigrant population constitutes a substantial proportion of the low-wage labor market. Immigrants represent 14% of all U.S. workers but 20% of low-wage workers. Immigrants are twice as likely as U.S.–born citizens to earn less than minimum wage. The poverty rate of children in immigrant families is 50% greater than in U.S.–born families, with 50% of immigrant children compared to 33% of children in U.S.–born families being below the 200% poverty level. Contributing to the lack of access to higher salaried jobs is the lack of proficiency in English (≈66% of immigrants) and the lack of education (40% have not completed high school). In the past decade, about 9 million immigrants attained permanent residency status. There may be 850,000-1,000,000 illegal immigrant children.

Families of different origins obviously bring different health problems and different cultural backgrounds, which influence health practices and use of medical care. To provide appropriate services, clinicians need to understand these influences (Chapter 4). For example, the high prevalence of hepatitis among women from Southeast Asia makes use of hepatitis B vaccine essential for their newborns. Children from Southeast Asia and South America have growth patterns that are generally below the norms established for children of Western European origin, as well as high rates of hepatitis, parasitic diseases, and nutritional deficiencies and high degrees of psychosocial stress. Foreign-born children may surpass American-born children in some health outcomes, but their health deteriorates as they become acculturated (Chapter 4).

Refugee children who escape from war or political violence and whose families have been subjected to extreme stress represent a subset of immigrant children who have faced severe trauma. These children have a particularly high incidence of mental and behavioral problems (Chapter 23).

“Linguistically isolated households,” in which no one older than 14 yr of age speaks English, often present significant obstacles to providing quality health care to children because of difficulties in understanding and communicating basic concerns and instructions, avoiding compromising privacy and confidentiality interests, and obtaining informed consent (Chapter 4).

The USA is home to multiple minority populations, including the 2 largest groups, Latinos and African-Americans. The nonwhite minority groups will constitute >50% of the U.S. population by 2050 (Chapter 4). Nonwhite children in the USA disproportionately experience adverse child health outcomes (see Tables 1-2 through 1-4). Infants that are born to African-American mothers experience low birthweight and infant mortality rates twice those with white mothers (Chapter 87). Rates of these 2 adverse health outcomes are also substantially higher among some groups of Hispanic infants and children, although there is great variation by country of origin. The rates are particularly high among those of Puerto Rican descent (≈1.5 times the rates for white infants). In 2006, the overall infant mortality rate was 6.7/1,000 live births, whereas that for non-Hispanic African-America infants was 13.6; for Native Americans, 8.1; and for Puerto Ricans, 8.3. Mexicans, Asians, Pacific Islanders, Central and South Americans, and Cubans were below the national average. Latino, Native American, and African-American children are substantially more likely to live in poverty than are white children.

There are ≈2.5 million Native Americans (4.1 million in combination with other races/ethnicities) and 558 federally recognized tribes. With 840,000 children (1.4 million in combination), the Native American population has a much higher proportion of children (34%) than does the remainder of the U.S. population (26%). About 60% of Native Americans live in urban areas, not on or near native lands. Like their minority immigrant counterparts, they have faced social and economic discrimination. The unemployment and poverty levels of Native Americans are, respectively, 3-fold and 4-fold that of the white population, and far fewer Native Americans graduate from high school or go to college. The rate of low birthweight among Native Americans is more than the white rate but less than the black rate. The neonatal and the postneonatal mortality rates are higher for Native Americans living in urban areas than for urban white Americans. Deaths in the 1st yr of life due to sudden infant death syndrome, pneumonia, and influenza are higher than the average in the USA, whereas deaths due to congenital anomalies, respiratory distress syndrome, and disorders relating to short gestation and low birthweight are similar.

Unintended injury deaths among Native Americans occur at twice the rate for other U.S. populations; deaths due to malignant neoplasms are lower. During adolescence and young adulthood, suicide and homicide are the 2nd and 3rd causes of death in this population and occur at about twice the rates of the rest of the population. There may be significant underreporting of deaths of Native American children.

As many as 75% of Native American children have recurrent otitis media and high rates of hearing loss, resulting in learning problems. Tuberculosis and gastroenteritis, formerly much more common among Native Americans, now occur at about the national average. Psychosocial problems are more prevalent in these populations than in the general population: depression, alcoholism, drug abuse, out-of-wedlock teenage pregnancy, school failure and dropout, and child abuse and neglect.

Most other nations have indigenous populations who are subjected to discrimination, social and economic sanctions, and/or physical maltreatment and who demonstrate the poorest child health outcomes. An estimated 300 million indigenous persons live in 70 countries (50% in Asia) and speak ≈4,000 languages. Such children endure lower vaccination rates, lower school entry and higher dropout rates, higher rates of poverty, and lower access to justice. Indigenous children in Latin America account for 66% of the deaths of children younger than age 2 yr.

In the USA, existing programs for meeting child health problems are not available to all families in need, with gaps between eligibility for public support and parents’ ability to pay for services. Needed services for immigrants are often either nonexistent or fragmented among programs, agencies, or policies. Programs are often poorly coordinated, and the data collection is inadequate.

Children of Migrant Workers

Families facing economic, social, or political hardship have been forced to leave their land and homes in search of better opportunities; such migrations are often within a country or between neighboring countries. Both industrialized and developing countries experience these migrations.

In the USA, there are an estimated 3-5 million migrant and seasonal farm workers and their families. The eastern migration is primarily from Florida, whereas the western migration comes from Texas, other border states, and Mexico. Many children travel with their parents and experience poor housing, frequent moves, and a socioeconomic system controlled by a crew boss who arranges the jobs, provides transportation, and often, together with the farm owners, provides food, alcohol, and drugs under a “company store” system that leaves migrant families with little money or in debt. Children often go without schooling; medical care is usually limited.

The medical problems of children of migrant farm workers are similar to those of children of homeless families: increased frequency of infections (including HIV), trauma, poor nutrition, poor dental care, low immunization rates, exposures to animals and toxic chemicals, anemia, and developmental delays.

Among the most substantial migrant populations in the world is China’s “floating population,” an estimated 100 million (almost 10% of China’s population) of rural to urban migrants. The rapidly growing urban versus rural income gradient and a relaxation of restrictions on movement in the country has fueled this influx of rural residents who arrive in China’s urban areas without health, education, or employment benefits for themselves or their children. Similar patterns are seen in many countries in Asia, Africa, and South America. In most of these countries there are few legal or social programs to aid the families or their children, spawning massive squatter settlements without provisions for water, sanitation, education, or basic health needs. Government policies vary worldwide, but in some instances their response to such communities is to bulldoze the settlements and imprison or deport the residents.

Homeless Children

Families with children are the fastest growing segment of the homeless population in the USA. Children make up over 35% of the homeless population, over 40% of whom are under age 5 yr, with an estimated 100,000 children living in shelters on a given night and about 500,000 homeless each year. Many homeless are not in shelters (living in the street or with extended families), and thus these figures are low estimates. The population of homeless children has been increasing as a consequence of more families with children living in poverty or near poverty, fewer available affordable dwellings for these families, decreasing public assistance programs for the non-elderly poor, and the rising prevalence of substance abuse.

Homeless children have an increased frequency of illness, including intestinal infections, anemia, neurologic disorders, seizures, behavioral disorders, mental illness, and dental problems, as well as increased frequency of trauma and substance abuse. Homeless children are admitted to U.S. hospitals at a much higher rate than the national average. They have higher school failure rates, and the likelihood of their being victims of abuse and neglect is much higher. In 1 study, 50% of such children were found to have psychosocial problems, such as developmental delays, severe depression, or learning disorders. The increased frequency of maternal psychosocial problems, especially depression, in homeless households has a significant untoward impact on the mental and physical health of these children. Because families tend to break apart under the strain of poverty and homelessness, many homeless children end up in foster care. If their families remain intact, frequent moves make it very difficult for them to receive continuity of medical care.

Homelessness exists worldwide. There are an estimated 3 million people in the 15 countries of the European Union who do not have a permanent home while in Canada there are 200,000-300,000 homeless. In some nations in Latin America, Asia, and Africa, the distinction between rural-to-urban migrants and homelessness is blurred.

Provision of adequate housing, job retraining for the parents, and mental health and social services are necessary to prevent homelessness from occurring. Physicians can have an important role in motivating society to adopt the social policies that will prevent homelessness from occurring by educating policymakers that these homeless children are at greater risk of becoming burdens both to themselves and to society if their special health needs are not met.

Runaway and Thrown-Away Children

The number of runaway and thrown-away children and youths in the USA is estimated at about 500,000; several hundred thousand of these children have no secure and safe place to stay. Teenagers make up most of both groups. The usual definition of a runaway is a youth younger than 18 yr who is gone for at least 1 night from his or her home without parental permission. Most runaways leave home only once, stay overnight with friends, and have no contact with the police or other agencies. This group is no different from their “healthy” peers in psychologic status. A smaller but unknown number become multiple or permanent “runners” and are significantly different from the one-time runners.

Thrown-aways include children told directly to leave the household, children who have been away from home and are not allowed to return, abandoned or deserted children, and children who run away but whose caretakers make no effort to recover them or do not appear to care if they return. The same constellation of causes common to many of the other special-risk groups is characteristic of permanent runaways, including environmental problems (family dysfunction, abuse, poverty) and personal problems of the young person (poor impulse control, psychopathology, substance abuse, or school failure). Thrown-aways experience more violence and conflicts in their families.

In the USA, it is a minority of runaway youths who become homeless street people. These youths have a high frequency of problem behaviors, with 75% engaging in some type of criminal activity and 50% engaging in prostitution. A majority of permanent runaways have serious mental problems; more than 33% are the product of families who engage in repeated physical and sexual abuse (Chapter 37). These children also have a high frequency of medical problems, including hepatitis, sexually transmitted infections, and drug abuse. Although runaways often distrust most social agencies, they will come to and use medical services. Medical care may become the point of re-entry into mainstream society and the path to needed services. U.S. parents who seek a physician’s advice about a runaway child should be asked about the child’s history of running away, the presence of family dysfunction, and personal aspects of the child’s development. If the youth contacts the physician, the latter should examine the youth and assess his or her health status, as well as willingness to return home. If it is not feasible for the youth to return home, foster care, a group home, or an independent living arrangement should be sought by referral to a social worker or a social agency. Although legal considerations involved in the treatment of homeless minor adolescents may be significant, most states, through their “Good Samaritan” laws and definitions of emancipated minors, authorize treatment of homeless youths. Legal barriers should not be used as an excuse to refuse medical care to runaway or thrown-away youths.

The issue of runaway youths is very complex in many developing nations, where in many instances the youth may be orphaned and/or leaving situations of forced sex or other abusive situations. It is estimated that there are tens of millions of such youth worldwide. Natural disasters such as the 2010 earthquake devastating Haiti also contribute to growing numbers of orphaned children. In 2007, there were an estimated 11-15 million HIV orphans in Africa; this number is estimated to grow to as high as 20 million by 2010. With school attendance <50% in many parts of sub-Saharan Africa, children who are orphaned are 17% less likely to attend school. Humanitarian and international organizations have begun to focus on this very vulnerable group of youths across the globe. Rates are often uncertain, and in many countries, these children have not even been recognized as an at-risk group, so great is the social chaos and so massive are the unmet needs.

Children Directly Affected By War (Chapter 36.2)

Since the end of the Second World War, there have been ∼250 major wars (defined as armed combat with over 1,000 casualties), the majority of which have been civil wars. Many of these conflicts have lasted over a decade; Angola has been engaged in civil war for nearly 3 decades. Sixteen of the world’s poorest 20 countries have endured a civil war in the past 15 yr. In modern wars, 70-80% of casualties are among women and children. Direct mortality and morbidity to children account for only a portion of war’s destructive impact on children. In 1996 the United Nations commissioned a report addressing the full consequences of war on children entitled “Promotion and Protection of the Rights of Children: Impact of Armed Conflict on Children” including (1) the disruption of basic educational and child health pediatric care and services; (2) hardships endured as a result of refugee status; (3) the abuse of the 250,000 to 300,000 children under age 18 yr who are soldiers; and (4) the impact on children when 1 or both parents are deployed to serve.

Inherent Strengths in Vulnerable Children and Interventions

By age 20-30 yr, many children in the USA and other developed countries who were at special risk will have made moderate successes of their lives. Teenage mothers and children who were born prematurely or in poverty demonstrate that, by this age, the majority have made the transition to stable marriages and jobs and are accepted by their communities as responsible citizens. As the numbers of risk factors increases for an individual, however, the odds for a successful adulthood decline.

Certain biologic characteristics are associated with success, such as being born with an accepting temperament. Avoidance of additional social risks is even more important. Premature infants or preadolescent boys with conduct disorders and poor reading skills, who must also face a broken family, poverty, frequent moves, and family violence, are at much greater risk than children with only 1 of these risks. Perhaps most important are the protective buffers that have been found to enhance children’s resilience because these can be aided by an effective health care system and community. Children generally do better if they can gain social support, either from family members or from a nonjudgmental adult outside the family, especially an older mentor or peer. Providers of medical services should develop ways to “prescribe” supportive “other” persons for children who are at risk. Promotion of self-esteem and self-efficacy is a central factor in protection against risks. It is essential to promote competence in some area of these children’s lives. Prediction of the consequences of risk is never 100% accurate. However, the confidence that, even without aid, many such children will achieve a good outcome by age 30 yr does not justify ignoring or withholding services from them in early life.

A team is needed because it is rare for 1 individual to be able to provide the multiple services needed for high-risk children. Successful programs are characterized by at least 1 caring person who can make personal contact with these children and their families. Most successful programs are relatively small (or are large programs divided into small units) and nonbureaucratic but are intensive, comprehensive, and flexible. They work not only with the individual, but also with the family, school, community, and at broader societal levels. Generally, the earlier the programs are started, in terms of the age of the children involved, the better is the chance of success. It is also important for services to be continued over a long period.

The Challenge to Pediatricians

Concerns about the aforementioned problems of children throughout the world have generated 3 sets of goals. The 1st set includes that all families have access to adequate perinatal, preschool, and family-planning services; that international and national governmental activities be effectively coordinated at the global, regional, national, and local levels; that services be so organized that they reach populations at special risk; that there be no insurmountable or inequitable financial barriers to adequate care; that the health care of children have continuity from prenatal through adolescent age periods; and that every family ultimately have access to all necessary services, including developmental, dental, genetic, and mental health services. A 2nd set of goals addresses the need for reducing unintended injuries and environmental risks, for meeting nutritional needs, and for health education aimed at fostering health-promoting lifestyles. A 3rd set of goals covers the need for research in biomedical and behavioral science, in fundamentals of bioscience and human biology, and in the particular problems of mothers and children.

The unfinished business in the quest for physical, mental, and social health in the community is illustrated by the disparities with which deaths due to disease, injuries, and violence are distributed among white, black, and Hispanic children in the USA and between and within nations. Homicide is a major cause of adolescent deaths and has increased in rate among the very young, in whom the increase may, in part, represent the more accurate identification of child abuse (Chapter 37). Among adolescents, homicide may reflect unresolved social tensions, substance abuse (cocaine, crack), and an unhealthy preoccupation with violence in our society (Part III and Chapters 36, 107, and 108).

Health Services for At-Risk Populations

Adverse health outcomes are not evenly distributed among all children, but are concentrated in certain high-risk populations. At-risk populations may require additional, targeted, or special programs designed to be effective with unique populations. All nations, regardless of wealth and level of industrialization, have subgroups of children at particular risk, requiring additional services.

In the USA, the largest vulnerable group is children living in poverty, representing about 14% of U.S. children. Substantial proportions of children in other industrialized countries are also living in poverty. The approach to addressing the needs of this group in the USA has been the establishment of a targeted insurance program, Medicaid, which became law in 1965 as a jointly funded cooperative venture between the federal and state governments to assist states in the provision of adequate medical care to eligible needy persons. The federal statute identifies >25 different eligibility categories for which federal funds are available. These statutory categories can be classified into 5 broad coverage groups: children, pregnant women, adults in families with dependent children, individuals with disabilities, and individuals ≥65 yr old. Pediatric care in the USA is highly dependent on Medicaid; however, only a relatively small proportion of the Medicaid funds actually go to child health, with the remainder serving older adults. Following broad national guidelines, each state establishes its own eligibility standards; determines the type, amount, duration, and scope of services; sets the rate of payment for services; and administers its own program. Although Medicaid has made great strides in enrolling low-income children, significant numbers of children remain uninsured. From 1988 to 1998, the proportion of children insured through Medicaid increased from 15.6% to 19.8%, but the percentage of children without health insurance increased from 13.1% to 15.4%. Minority children were disproportionately among those without insurance. The Balanced Budget Act of 1997 created a new children’s health insurance program called the State Children’s Health Insurance Program (SCHIP). This program gave each state permission to offer health insurance for children, up to age 19 yr, who are not already insured. SCHIP is a state-administered program and each state sets its own guidelines regarding eligibility and services. There is great variation by state, but in many states, the SCHIP program has begun to reduce racial inequities in access to health care for children. In 2009, the percent of children without insurance had decreased to 9%.

Many industrialized nations have adapted different “safety net” systems to assure adequate coverage of all youth. Many of these programs provide health insurance for all children, regardless of income, hoping to avoid problems with children losing insurance coverage and access to health care due to changes in eligibility by providing a single form of insurance that all providers accept. The response of developing countries to the issue of universal access to care for children has been uneven, with some providing no safety net, but many having limited universal or safety net services.

To address the special needs of Native Americans in the USA, the Indian Health Service, established in 1954, has been the responsibility of the Public Health Service, but the 1975 Indian Self-Determination Act gave tribes the option of managing Native American health services in their communities. The Indian Health Service is managed through local administrative units, and some tribes contract outside the Indian Health Service for health care. Much of the emphasis is on adult services: treatment for alcoholism, nutrition and dietetic counseling, and public health nursing services. There are also >40 urban programs for Native Americans, with an emphasis on increasing access of this population to existing health services, providing special social services, and developing self-help groups. In an effort to accommodate traditional Western medical, psychologic, and social services to the Native American cultures, such programs include the “Talking Circle,” the “Sweat Lodge,” and other interventions based on Native American culture (Chapter 4). The efficacy of any of these programs, especially those to prevent and treat the sociopsychologic problems particular to Native Americans, has not been determined.

Recognizing the health needs of migrants in the USA, the U.S. Public Health Service initiated in 1964 the Migrant Health Program to provide funds for local groups to organize medical care for migrant families. Many migrant health projects that were initially staffed by part-time providers and were open for only part of the year have been transformed into community health care centers that provide services not only for migrants but also for other local residents. In 2001, the ≈400 Migrant Health Centers served >650,000 migrant and seasonal farm workers; >85% were people of color. Health services for migrant farm workers often need to be organized separately from existing primary care programs because the families are migratory. Special record-keeping systems that link the health care provided during winter months in the south with the care provided during the migratory season in the north are difficult to maintain in ordinary group practices or individual physicians’ offices. Outreach programs that take medical care to the often remote farm sites are necessary, and specially organized Head Start, early education, and remedial education programs should also be provided. Approaches in other countries have also focused on business initiatives for migrant populations to enable them to overcome the cycle of financial dependency on their migratory lifestyle.

The USA has spent >$12 billion through the 1987 McKinney-Vento Act to provide emergency food, shelter, and health care; to finance help for young runaways; to aid homeless people in making their way back into the housing market; and to place homeless children in school. Mobile vans, with a team consisting of a physician, nurse, social worker, and welfare worker, have been shown to provide effective comprehensive care, ensure delivery of immunizations, link the children to school health services, and bring the children and their families into a stable relationship with the conventional medical system. Special record-keeping systems have been introduced to enhance continuity and to provide a record of care once the family has moved to a permanent location. Because of the high frequency of developmental delays in this group, linkage of preschool homeless children to Head Start programs is an especially important service. The Runaway Youth Act, Title III of the Juvenile Justice and Delinquency Prevention Act of 1974 (Public Law 93-414) and its amended version (Public Law 95-509) have supported shelters and provide a toll-free 24 hr telephone number (1-800-621-4000) for youths who wish to contact their parents or request help after having run away.

In Belgium, Finland, the Netherlands, Portugal, and Spain, the right to housing has been incorporated into the national constitutions. The Finnish government has devised a multifaceted response to the problem, including house building, social welfare and health care services, and the obligation to provide a home of minimum standards for every homeless person. The number of homeless in Finland has been reduced by 50%.

Evaluation of Health Care

The shaping of health care systems to meet the needs of children and their families requires accurate statistical data and difficult decisions in setting priorities. Along with growing concerns about the design and cost of health care systems and the ability to distribute health services equitably has come increasing concern about the quality of health care and about its efficiency and effectiveness. There are large local and regional variations among similar populations of children in the rates of use of procedures and technology and of hospital admissions. These variations require continuing evaluation and explanation in terms of the actual impact of medical and surgical services on health status and the outcome of illness.

The Institute of Medicine (IOM) issued a report, “Crossing the Quality Chasm: A New Health System for the 21st Century” in 2001. This report, challenging American physicians to renew efforts to focus not just on access and cost, but also on quality of care, has been furthered in several pediatric initiatives, including but not limited to: specific initiatives for monitoring child health outlined in the IOM report “Children’s Health, the Nation’s Wealth”; challenge/demonstration grants funded by the Robert Wood Johnson Foundation; and the National Initiative for Children’s Healthcare Quality. Importantly, each of these initiatives is calling for the establishment of measurable standards for assessment of quality of care and for the establishment of routine plans for periodic reassessment thereof. Efforts have been initiated at some medical centers to establish evidence-based clinical pathways for disorders (such as asthma) where there exists sound evidence to advise these guidelines. Pediatricians have developed tools to evaluate the content and delivery of pediatric preventive “anticipatory guidance,” the cornerstone of modern pediatrics (Chapter 5).

Consistent with the increased focus on quality and lifelong learning, the Residency Review and Redesign in Pediatrics (R3P) project involving a broad-based pediatric constituency led by the American Board of Pediatrics, was undertaken to ensure that pediatric residency training meets the health care and well-being needs of children in the 21st century. The R3P and the follow-on program, the Initiative for Innovation in Pediatric Education (IIPE), are calling for a transformation of residency training that focuses on continuous evaluation, adaptation to the differing and changing needs of children, and the recognition that continued training throughout a pediatrician’s professional career will be necessary if the field of pediatrics is to best meet the needs of children. Increased attention is also being focused on the importance of providing pediatricians with the skills to communicate effectively with parents and patients and understanding the responsibilities of professionalism. These efforts are having an impact, with evidence that 66% of children are receiving good or excellent preventive care with no disparities according to race or income level. The increased focus on quality improvement in pediatric practice is reflected in the pediatric residency training competency requirements of practice-based learning and improvement and system-based practice.