The child

The child’s world will be affected by gender, genes, physical health, temperament and development. The impact of the social environment varies markedly with age:

Although the ‘two biological parent family’ remains the norm, there are many variations in family structure. In the UK, the family structure has changed markedly over the last 30 years (Fig. 1.2).

Single-parent households – One in four children now live in a single-parent household. Disadvantages of single parenthood include a higher level of unemployment, poor housing and financial hardship (Table 1.1). These social adversities may affect parenting resources, e.g. vigilance about safety, adequacy of nutrition, take-up of preventive services, such as immunisation and regular screening, and ability to cope with an acutely sick child at home.

Reconstituted families – The increase in the number of parents who change partners and the accompanying rise in reconstituted families (1 in 10 children live in a stepfamily) mean that children are having to cope with a range of new and complex parental and sibling relationships. This may result in emotional, behavioural and social difficulties.

Looked after children – Approximately 3% of children under 16 years old in the UK live away from their family home. At any one time in England, over 60 000 children are cared for by Local Authorities. These ‘looked after children’ are known to have worse outcomes in terms of physical health, mental health, education and employment.

Asylum seekers – These are often placed in temporary housing and moved repeatedly into areas unfamiliar to them. In addition to the uncertainty as to whether or not they will be allowed to stay in the country, they face additional problems as a result of communication difficulties, poverty, fragmentation of families and racism. Many have lost family members and are uncertain about the safety of friends and family.

Parental employment – With many parents in employment, many young children are with child-minders or at preschool nurseries. Parents are receiving conflicting opinions on the long-term consequences of caring for their young children at home in contrast to nursery care. Also, increasing attention is being paid to the quality of day-care facilities in terms of supervision of the children and improving the opportunities they provide for social interaction and learning.

Socioeconomic status

Socioeconomic status is a key determinant of health and well-being of children. It is estimated that 2.8 million children in the UK are living in poverty (below 60% of the national median income after adjustment for housing costs). The proportion of children in poverty in different countries is shown in Figure 1.3. Health issues in the UK in which prevalence rates are increased by poverty include:

• low birthweight infants

• injuries

• hospital admissions

• asthma

• behavioural problems

• special educational needs

• child abuse.

Low socioeconomic status is often associated with multiple disadvantages, e.g. food of inadequate quantity or poor nutritional value, substandard housing or homelessness, lack of ‘good enough’ parenting, parental education and health, and poor access to healthcare and educational facilities.

There are marked differences in living experiences between ethnic groups: 50% of Afro-Caribbean children live in single-parent households compared with 15% of white children and less than 10% of those from the Indian subcontinent. In 1992, in England and Wales, 12% of births were to mothers born outside the UK; in 2008 it was nearly 24%.

Cohesive communities and amicable neighbourhoods are positive influences on children. Racial tension and other social adversities, such as gang violence and drugs, will adversely affect the emotional and social development of children, as well as their physical health. Parental concern about safety may create tensions in balancing their children’s freedom with overprotection and restriction of their lifestyles. The physical environment itself, through pollution, safe areas for play and quality of housing and public facilities, will affect children’s health.

In general, there is an inverse relationship between a country’s gross national product and income distribution and the quality of its children’s health.

The lower the gross national income:

However, even in countries with a high gross national product, many children live in financially deprived circumstances.

The dramatic reduction in childhood mortality in England over the last century is shown in Figure 1.4. It is primarily from improvements in living conditions such as improved sanitation and housing, and access to food and water. These have dramatically reduced fatalities from infectious disease. More recent contributions to this reduction have been increased availability and uptake of immunisation and major medical improvements in perinatal and infant care.

In all countries difficult choices need to be made about the allocation of scarce resources. Should a developing country provide very expensive drugs and care for the small number of children with malignant disease or allocate its resources to preventive programmes for many children? In developed countries, difficult decisions also have to be faced in deciding the affordability of very expensive procedures, such as heart or liver transplantation, or neonatal intensive care for extremely premature infants and certain drugs, such as the genetically engineered enzyme replacement therapy for Gaucher disease or cytokine modulators (‘biologics’) and other immunotherapies. The public are becoming more engaged in these debates.

Where deaths occur

Not surprisingly, the mortality for infants and children living in poor countries is much higher than for those in rich countries. The lethal combination of poverty, HIV/AIDS and armed conflict underlies the very high under-5 mortality in some countries. In addition, many poor countries have warm, humid climates where tropical diseases such as malaria occur. However, even in these countries, much of the excess disease burden is due to illnesses such as respiratory infections and diarrhoea that occur at a much greater frequency and severity than in developed countries.

Although only about 48% of the world’s estimated 629 million under-5s live in sub-Saharan Africa and South Asia, 93% of child deaths occur in these two regions (Fig. 1.7). The difference in resources available is reflected in the difference in the number of healthcare professionals in different parts of the world. This is shown in diagrammatic form in Figure 1.8. Whereas the USA spends over $6000/person/year on health, the annual expenditure is only $25/person in the 49 lowest income countries. Put another way, the annual health budget available to the 1.2 billion people living in these countries is equivalent to that for the 6.5 million living in Arizona!

Over half of all child deaths occur in just five countries, which have high mortality rates and large populations: India, Nigeria, Democratic Republic of Congo (DRC), Pakistan and China. Nine countries have an under-5 years mortality rate of ≥180/1000 live births (Sierra Leone, Afghanistan, Chad, Equatorial Guinea, Guinea-Bissau, Mali, Burkina Faso, Nigeria, Burundi). This means that a child’s chance of dying before age 5 years is 30-fold greater in these countries than in developed countries, where the under-5 years mortality rate is 6/1000 live births. The impact of poverty and limited health facilities on children is demonstrated by Case History 1.1.

Case History

1.1 Burns to the face

This girl in West Africa sustained facial burns (Fig. 1.9). She fell into the open kitchen fire when she had a seizure. Although her epilepsy had initially responded well to phenobarbital, regular supplies were unavailable. Difficulty in finding affordable transport from the village to the health clinic delayed presentation by 4 days, by which time there was secondary infection and increased risk of cataract from conjunctival injury.

This simple example highlights the influence of environment on children’s health. Her illness was readily treatable, her injuries were preventable with a fireguard, delayed treatment resulted in complications and only basic medical care was available at the clinic.

Reducing child mortality

The international community has taken many steps to improve child health in poor countries. Some are listed in Box 1.4.

The launch of the Integrated Management of Childhood Illness (IMCI) in 1992 was a major advance (Fig. 1.10). It recognised that an integrated management approach to childhood illness is required, including nutrition and preventative care in families and communities. In health facilities, sick children are triaged according to the presence of specific danger signs and management is planned according to algorithms which can be followed by non-medical staff.

The major advance in global child health has been in the adoption of the Millennium Development Goals (MDGs), which has served as a major focus for the international community’s commitment to reduce child mortality (Fig. 1.11). There are specific targets for each goal. For MDG 4 it is to reduce child mortality in children <5 years by two-thirds, between the years 2000 and 2015. Contributions are also made by MDGs to improve maternal health and reduce mortality from malaria by insecticide-treated bednets and appropriate anti-malarial drugs and from HIV and TB.

Some of the specific health measures targeted in maternal and child health are shown in Figure 1.12, together with the overall success in implementing them.

The health measures include:

The aim is for 100% coverage.

Progress in reducing under-5-year-old mortality is being made (Fig. 1.13), although in many of the poorest countries it is slow and patchy, and considerable effort will be required to meet the MDG 4 target.