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# Child Healthcare: Childhood mortality

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Child Healthcare addresses all the common and important clinical problems in children, including:immunisation history and examination growth and nutrition acute and chronic infections parasites skin conditions difficulties in the home and society.

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### Child Healthcare: Childhood mortality

1. 1. 15 Childhood mortality Under-5 deaths are often used as a measure of Objectives the number of childhood deaths. When you have completed this unit you NOTE The WHO defines a child as a person under should be able to: the age of 18 years. Ideally all deaths under the • Calculate the under-5 mortality rate. age of 18 should be recorded as childhood • Understand the importance of deaths. However, this is rarely done as teenagers knowing local mortality rates. are usually not cared for by paediatric services. • Manage a mortality meeting. Many paediatric services only care for children up • List common causes of under-5 to the age of 13 (the common age of puberty). mortality. • Identify important modifiable factors. 15-2 What is a mortality rate for children? This is the number of children who die expressed as a proportion of all the childrenINTRODUCTION who could possibly die. For example, if there are 1000 liveborn children and 10 die, the mortality rate for these children is 10 per 1000.15-1 How are deaths during childhoodcounted? It is more useful to know the mortality rate than only the number of children who die.The most common way of recording the Therefore, it is not good enough to simplynumber of deaths during childhood is to know how many children died. Mortalitycount the number of children who die rates allow you to compare deaths betweenbefore the age of 5 years, therefore children different-sized groups of children.who are born alive but die before their fifthbirthday will be counted as under-5 deaths 15-3 What is the under-5 mortality rate?but children who die on or after their fifthbirthday will not be included. However, The number of children who die under thethere are limitations to this method as it is age of 5 years is usually expressed as a rate perimportant not to forget older children. 1000). Therefore, the under-5 mortality rate is defined as the number of children who die under the age of 5 years per 1000 live born infants. The under-5 mortality rate indicates the
2. 2. 238 CHILDHOOD MOR TALITYprobability that a live born child will not survive 15-5 What is an annual mortality rate?to the age of 5 years. The under-5 mortality rate Usually the infant and under-5 mortality ratesis one of the basic health indicators. are calculated for a calendar year. This is called the annual mortality rate. Sometimes the The under-5 mortality rate is the number of mortality rate is expressed over a longer period children who are born alive but die under the age of time, e.g. over 10 years. It is less accurate to of 5 years per 1000 liveborn infants. calculate mortality rates over periods shorter than one year.15-4 How can under-5 deaths be grouped? 15-6 Should the mortality rates beUnder-5 deaths are usually divided into age calculated for a special area?groups: Yes. Mortality rate is usually calculated for aNeonatal mortality includes all live born given health district (or region). For example,infants who die in the first 28 days of life. to determine the under-5 mortality rate for aOften neonatal deaths are further divided into health district, all under-5 deaths in each partearly neonatal deaths (deaths in the first 7 of that service (each clinic and hospital) mustdays of life) and late neonatal deaths (deaths be added together. The rate is then expressedbetween 8 and 28 days of life). The neonatal per 1000 live births in that district. Sometimesmortality rate is, therefore, the number of live the mortality rate is calculated for a wholeborn infants who die in the first 28 days of life province or country by combining the resultsper 1000 live born infants. of many districts. This is much better than simply calculating The neonatal mortality rate is the number of the mortality rate of a single hospital. Due to infants who are born alive but die in their first 28 differing patterns of referral, hospital deaths days of life per 1000 live born infants. do not necessarily reflect all deaths in the districts which drain to that hospital. For example, deaths at home or at clinics are notInfant mortality includes all the children who included. Therefore, mortality rates are bestdie before the age of 1 year (i.e. before reaching expressed for a health district in 1 year.their first birthday). Therefore the infantmortality rate is the number of children whodie under 1 year per 1000 infant born that year. It is best to calculate the under-5 mortality rate for a health district rather than only for a single The infant mortality rate is the number of hospital. infants who die before the age of 1 year per 1000 liveborn infants. 15-7 Are mortality rates the same for all health districts? NOTE Sometimes the infant mortality rate is No. Mortality rates often differ markedly divided into the neonatal mortality rate and between health districts. Usually the rates are the post neonatal mortality rate (the number of infants who die between 1 month and 12 higher for poor districts than wealthy districts. months per 1000 infants born that year). The child Similarly, rates are higher in developing mortality rate is the number of children aged 1 to (poorly resourced) than in industrialised 4 who die per 1000 live births. The 5–18 mortality (well resourced) countries. Therefore, a single rate includes all the children dying from 5 up to mortality rate for the whole nation is only of but not including 18 years. limited value.All the childhood mortality rates are expressedper 1000 liveborn infants.
3. 3. CHILDHOOD MOR TALITY 23915-8 Do mortality rates remain the same? are poor. Often both poor socioeconomic conditions and inadequate access to goodNo. Mortality rates may also differ between quality health services occur together. It is,different time periods. In most countries therefore, not surprising that the mortalitymortality rates have fallen over the past years. rates for children vary widely betweenWith the AIDS epidemic in Southern Africa, different districts and countries. The districtinfants and under-5 mortality rates are rising. with a high rate may have a specific healthTherefore, mortality rates allow you to problem (e.g. malaria) or a problem with thecompare different groups of children, either in health service (e.g. low immunisation rate).different places (districts, regions, provincesor countries) at the same time or in the sameplace at different times (months or years). The under-5 mortality rate reflects both the socioeconomic conditions and quality of health care provided. Mortality rates in the same place often vary over time. 15-11 What is the under-5 mortality rate in well resourced countries?15-9 Why is it important to know the infantand under-5 mortality rates? In well resourced (wealthy) countries or well resourced communities in poor countries theBecause they are one of the best ways of under-5 mortality rate is usually below 10.measuring the wellbeing of children. An This reflects a high standard of child health,improvement in mortality rates for a health nutrition and home conditions as well as adistrict from one year to the next is a good good health care service.way of showing that the wellbeing of children NOTEThe neonatal mortality rate and infantin that district is improving. An increase in mortality rate in industrialised countries is usuallythe mortality rates indicates that the wellbeing below 5/1000 and 7/1000 respectively.is deteriorating. A high mortality rate drawsattention to that district where there is 15-12 What is the under-5 mortality rate inobviously a problem. under resourced countries? In under resourced (poor) countries or under The under-5 mortality rate is one of the best resourced communities in wealthy countries methods of assessing the wellbeing of children. the under-5 mortality rate is usually higher than 80. Every effort must be made to reduce NOTE The 4th Millennium Developmental Goal set the under-5 mortality rate in poor countries by the United Nations is to reduce the under-5 so that it approaches the rate in well resourced mortality rate between 2000 and 2015 by a third. countries. Note the enormous difference in rates between wealthy and poor countries.15-10 What determines the infant andunder-5 mortality rates? Every effort must be made to reduce the under-5These mortality rates depends on both: mortality rate in poor countries.• The health, nutrition and home environment of children NOTE It is estimated that more than 10 million• The quality of health care that is available children die worldwide each year before their to children fifth birthday! Four million of these children dieThe mortality rate will increase if either the in their first month of life. The average worldwidehealth, nutrition and home environment of under-5 mortality rate is about 80/1000 but some very poor countries have an under-5 mortalitychildren is poor or the health care service rate above 250/1000!
4. 4. 240 CHILDHOOD MOR TALITY15-13 What is the under-5 mortality rate in health of young children in the country. SouthSouth Africa? Africa has a higher infant mortality rate than other countries with a similar income (e.g.This is not accurately known because the Mexico and Brazil). Therefore, South Africacollection of mortality data is not good in all has the financial resources to lower the infantregions as many childhood deaths are not mortality rate. It is important that a countryreported. However, the under-5 mortality uses its resources wisely and develops therate in South Africa is estimated to be about health service and improves living conditions70/1000. In other words, for every 1000 infants for all.that are born alive in South Africa, 70 willdie before their fifth birthday. The under-5 Furthermore, about 45 out of every 60 under-5mortality rate in South Africa is more like that deaths occur during the first year of life (i.e.of an under resourced than a wealthy country. 75%). Children under 1 year are, therefore, at greater risk of dying than are older children. The under-5 mortality rate in South Africa is NOTE The neonatal mortality rate in South Africa is estimated to be about 20 per 1000. Therefore, estimated at about 70/1000. about a third of all under-5 deaths occur in the first month of life, especially the first week of lifeThe under-5 mortality rate varies between when most neonatal deaths occur.urban (town and city) and rural (country) areasand between different regions of the country. 15-15 What do under-5 mortality rates tellWealthy communities in urban areas have an us?under-5 mortality rate similar to well resourcedcountries while poor, rural areas have a rate • How well a district, region, province orsimilar to under resourced countries. nation is caring for their children • Which districts, regions or provinces have NOTE The under-5 mortality rates between the greatest need for better child care provinces in South Africa vary from 40/1000 • It allows for comparison of mortality rates in the Western Cape to 80/1000 in the Eastern Cape. Similarly the under-5 rate for urban areas is between different areas or countries with a 40/1000 while the rate in rural areas is 70/1000. similar income. In other words, how well we are using our income to improve the15-14 What is the infant mortality rate in health of children.South Africa? • It helps identify areas or age groups where the causes of childhood death need urgentThe infant mortality rate in South Africa is investigation.estimated to be about 55 per 1000. Therefore,out of every 1000 infants born alive in SouthAfrica, 55 will die before reaching the age of COLLECTING INFORMATION12 months. This can be compared to an infantmortality rate of less than 10/1000 in developed ON UNDER-5 DEATHScountries and 20/1000 or more in developing(under resourced) countries. South Africatherefore has an infant mortality rate similar to 15-16 Should childhood deaths be notified?that seen in most under resourced countries. Yes. All deaths are notifiable in most countries, including South Africa. The child’s age, gender and cause of death should be stated South Africa has an infant mortality rate typical on the death notification form. Unfortunately of a developing country. the given cause of death is often unknown, incorrect or not helpful. For example, if a childThe high infant mortality rate in South Africa with severe malnutrition due to poverty diesindicates that there are problems with the
5. 5. CHILDHOOD MOR TALITY 241of pneumonia, it is of little help if the cause It is essential to identify the common causes ofof death is listed as pneumonia when the real under-5 mortality in each country, as they areunderlying reason was the low socioeconomicstatus of the family (i.e. poverty). Similarly, important in planning health care interventions.deaths due to AIDS are often recorded asgastroenteritis or tuberculosis. MORTALITY REVIEWThe list of common causes of death on officialpublications is, therefore, often misleading. 15-19 What is a mortality review? The cause of death given on many death notices This is an in-depth investigation and is often incorrect or misleading. discussion about each child death. The mortality review is usually done at specialIn well resourced countries with accurate mortality meetings. These are regular meetingrecords of all births and deaths, it is far easier of staff where every childhood death in thatto determine mortality rates and the important service is reviewed. This includes all childrencauses of death. who die in a hospital ward, outpatient or casualty department, and hospital or15-17 How should the causes of childhood peripheral clinics. Ideally all children whodeaths be accurately identified? die at home within the service region should also be included. Deaths due to both medicalThe fully history, detailed examination and and surgical conditions must be discussed.any special investigations must be recorded This is the best way of obtaining an accurateand reviewed (discussed) before deciding on assessment of each death.the most likely cause of death. Collecting thisinformation is best done as soon as possibleafter the child’s death while the probable cause The cause of death is best decided after discussionof death should be recorded after it has been at a mortality meeting.discussed and reviewed. 15-20 What are the aims of the mortality All the infant’s case details must be collected and review? recorded as soon as possible after the death. The main aims of a mortality review are to: • Obtain data on the number of deaths and15-18 Why is it important to know the calculate the mortality rates.common causes of under-5 deaths? • Identify the main cause of death as well asKnowing the under-5 mortality rate is of contributing causes.limited value if you do not know why the • Identify any modifiable factors.children are dying, because the common • Decide whether the child received goodcauses of death during childhood vary greatly management.from one country to another. • Allow all the staff involved with child care to contribute to the discussion.The common causes of death need to be • Discuss ways that both causes can beknown before interventions can be planned to avoided and modifiable factors corrected.lower the mortality rate. It is very important • Use the discussion to teach. Gettingthat we learn why children die. This is done at the staff to identify the clinical anda mortality review. management problems is a very effective way of learning.
6. 6. 242 CHILDHOOD MOR TALITY• Providing feedback on changes in the 9. Decisions about actions to be taken must frequency of causes and modifiable factors, be documented, and progress must be i.e. Are we making a difference? reviewed at the beginning of the next mortality meeting. The main aims of mortality reviews are to identify problems and find answers. Discussions in a mortality meeting must be confidential and carried out in a constructive andAn important part of the mortality review is non-threatening manner.the mortality meeting. Mortality meetingsshould be well organised and well managed. Well organised mortality meetings are one of the best ways of improving the standard of15-21 How should a mortality meeting be health care of children. Mortality meetingsmanaged? are also a very effective way of teaching. They help staff to identify and solve problems and1. A responsible person must be identified provide a wonderful learning opportunity. to arrange the meeting. This is usually a They reduce the number of children who die. doctor working in the paediatric service.2. Regular meetings are held once or twice a month depending on the number of deaths. Mortality meetings reduce the number of3. A suitable time and venue is needed. Often children who die. lunch times or late afternoons are best.4. All staff involved with child care 15-22 What information is needed for each should be invited (nurses, doctors and child who dies? administrators). Staff must understand that mortality meetings are very important. 1. Full name, hospital or clinic number,5. A brief summary of each death, giving gender (sex), age (date of birth) and date relevant information, must be prepared of death. before each mortality meeting. 2. Full clinical history including past history,6. Anything discussed in the meeting must record of immunisation, review of the be viewed as confidential. Summary sheets growth chart in the Road-to-Health Card, should be destroyed after the meeting. family history and home conditions.7. The meeting should discussed what 3. Results of a full examination together ‘we’ did incorrectly and how ‘we’ could with an assessment of the growth and do better in future. The meeting must nutritional status. never become a ‘witch hunt’. Any 4. Any special investigations (e.g. blood and disciplinary action must be handled with urine tests, X-rays). the person involved privately outside All the information must be summarised the meeting and never in front of other before the meeting so that a brief summary staff. Without a spirit of mutual support can be presented. This is often handed out on and trust, important details of the child’s an information sheet or presented with an management may be withheld. A team overhead projector. It is boring and wastes approach is needed to solve problems of time if information has to be looked for in the patient management. patient’s records during the meeting.8. All decisions (causes and modifiable factors) made must be recorded on the A register of all admissions and deaths must mortality sheets (death data capture be kept in each service area (e.g. ward) so sheets) at the time of the meeting and not that no deaths are missed and the number afterwards when important details may be of admissions are known. Basic information forgotten. in the ward or clinic register must include
7. 7. CHILDHOOD MOR TALITY 243each patient’s name, folder number, age, sex available, the most acceptable method of careand weight. All wards should keep a monthly should be obtained from a current textbook,death register which records all deaths in that journal article or expert on that condition. Bymonth. Often each death is given a unique asking questions at mortality meetings, bettercode (number). ways of preventing, diagnosing and managing childhood problems are often identified. This is one of the great benefits of these meetings. A brief clinical summary must be prepared before Modifiable factors must always be looked for the mortality meeting for each child who has died. and recorded at the mortality meeting. By identifying errors in management and15-23 How is the cause of death decided? correcting these errors, the lives of childrenThis is one of the most important parts of the in future can be saved. This is one of the mainmortality meeting. All the possible causes must aims of mortality meetings.be considered before agreement is reachedon the main cause of death. This is often only Identifying and correcting errors in managementagreed upon after some discussion. If the causeof death is not certain, then the probable cause can save the lives of other children.must be used. The cause of death, therefore, isdecided by everyone at the meeting. It is very important to praise good manage- ment, even if the child died. A positive attitude and willingness to compliment the It is important to decide on the most likely cause staff for good care helps to encourage active of death. participation and lessen the fear of criticism.15-24 How is the cause of death recorded? 15-26 What is a modifiable factor?For each child, the main cause of death must A modifiable (avoidable) factor is a missedbe identified. This is the most likely factor that opportunity for good care or an examplelead to the death of the child. Sometimes it of substandard care which probably lead tois not easy to decide which is the main cause the child’s death. No measles immunisationand which are contributing causes. Any other would be a missed opportunity in a 2-year-contributing causes should also be recorded. If old child who died of measles, while failure topossible, an ICD 10 code should be allocated to give adequate rehydration at a clinic would bethe main as well as other contributing causes. substandard care in a child who died of acute diarrhoea.An example would be measles as themain cause with bacterial pneumonia andmalnutrition as contributing causes. Modifiable factors include all missedIt is important to have a formal document opportunities for good care and any substandard(death data capture sheet) on which all the care which probably resulted in the death.relevant information as well as the causes andmodifiable factors can be entered and coded. Identifying modifiable factors is an important step in planning health care strategy and15-25 How should you decide whether the correcting problems which lead to poor caremanagement of a child was correct? and deaths. It is important to decide whether each death is probably avoidable or not. TheIf possible, standard national protocols of care identification of modifiable factors enablesshould be used. The management which was problem solving.given can then be compared to the approvedmanagement. If a national protocol is not
8. 8. 244 CHILDHOOD MOR TALITY • Septicaemia It is important to decide whether a death could • AIDS probably have been avoided. • Severe malnutrition • Tuberculosis15-27 How can modifiable factors be NOTE This data is from the Child Health Careclassified? Problem Identification Programme (Child PIP).Modifiable factors can be divided into:• Modifiable factors related to the family Infections are the most common cause of under-5 or caregiver. Examples include not taking mortality in South Africa. children for immunisation, delay in taking an ill child to clinic, poor nutrition, NOTE The most common cause of death in the not recognising that a child was ill, 5–18 year age group in South Africa is trauma neglect and abuse. (e.g. motor vehicle accidents and violence).• Modifiable factors associated with the clinical staff. Examples include poor clinical 15-29 How will the AIDS epidemic affect assessment, giving the incorrect treatment, the common causes of death? delay in referral, inadequate notes and not AIDS is becoming a much more common seeing a child when asked to do so. cause of death both in children and adults.• Modifiable factors related to the Many of these children will eventually die administration. Examples include of other infections such as pneumonia, lack of facilities, equipment or staff, diarrhoea, septicaemia and tuberculosis. Even lack of training, inadequate transport, if a child is not HIV-infected, death of one or poor communication, lack of policy or both parents will increase their risk of dying medications, and no laboratory service. under the age of 5 years. Therefore, the AIDS epidemic is expected to increase the under- Modifiable factors may be related to the 5 mortality rate, and especially the infant caregiver, clinical staff or administration. mortality rate, in South Africa and many other developing countries. NOTE Any event, act or omission contributing to the death or to substandard care should be regarded as a modifiable factors. The spread of AIDS will increase the under-5 mortality rate in South Africa.A comprehensive (full) list of commonmodifiable factors should be drawn up andreferred to when each death is discussed. It 15-30 Why is it important to determine theis helpful if each modifiable factor is given HIV status of each child that dies?a specific code as this makes the analysis of An assessment of the HIV status of eachmodifiable factors much easier. under-5 deaths should be made. Otherwise children who have died with AIDS may be misclassified. Often the HIV status of childrenCAUSES OF UNDER 5 who die is not known. As a result, the role of HIV infection is missed.DEATHS Clinical signs of HIV infection must always be looked for and documented. If possible the15-28 What are the common causes of child’s HIV and immunological status shouldunder-5 deaths in South African hospitals? also be determined.• Lower respiratory tract infection Children with definite or probable HIV• Diarrhoeal disease infection can be classified into:
9. 9. CHILDHOOD MOR TALITY 245• Definite HIV infection with both clinical 15-33 How is the data analysed? signs of HIV infection and positive HIV Previously, the information was counted and status analysed by hand, using paper information• Children with probable HIV infection who records. have clinical signs of HIV infection but an unknown HIV status (i.e. blood test not Today most analyses are done by computer. This done) is faster and more accurate. It is also possible to show the findings as graphs or tables. The HIV status of all children who die must be All the information recorded onto the assessed whenever possible. mortality data capture forms at the mortality meetings has to be transferred onto a15-31 How important is malnutrition as a computer-based record. This can be donecause of death? after each meeting or the information can be entered in batches.Malnutrition is an important main orcontributing cause of childhood death in most 15-34 What results are obtained from thepoor countries. Therefore it is important to analysis?determine the growth and nutritional statusof all children seen at a clinic, admitted to a • Details of the basic information, e.g.hospital, as well as all children who die. number of infants born alive each year and total hospital admissions. Admissions can be divided into age groups and by The nutritional status of all children who die nutritional status (e.g. below the 3rd centile must be recorded. for weight). • Number of deaths and mortality rates • Causes of death and modifiable factorsTHE ANALYSIS OF • Tables and graphs can be printed giving monthly or annual information on theMORTALITY DATA number of deaths, mortality rates, causes of death and modifiable factors. • Children can be grouped by age and site of15-32 What data are needed to analyse death.childhood deaths? • Data from more than one site or region canTwo sets of information are needed to analyse be combined.mortality data:• Baseline population data. For calculating 15-35 What should be done with the results infant and under-5 mortality rates, the of the analysis? number if liveborn infants each year It is extremely important that the results in that service or region is needed. For of the analysis be made available to all hospital mortality data, the total number who are interested, especially the staff and of admission are needed. All deaths must administration. The results must be used to be counted. This hospital data should be improve the care of children. recorded in the ward admission books. Without this information, mortality rates 15-36 What is a mortality report? cannot be calculated.• The causes of death and modiﬁable factors. This is usually an annual report prepared from This information should be recorded on the the monthly results of the mortality meetings. forms completed at the mortality meetings. The mortality report gives a summary of the results and also draws conclusions from
10. 10. 246 CHILDHOOD MOR TALITYthe results. It is of little value to collect and Figure 15.1 shows the data collection sheet foranalyse mortality data throughout the year childhood deaths from ChildPIP.without interpreting what the results mean.The mortality report should also suggest waysthat the results can be used to plan methods of WAYS OF AVOIDING THEreducing the mortality rate. The feedback loopbetween collecting mortality data, analysing COMMON CAUSES OFthe data and then using the data to improve UNDER 5 DEATHScare is very important. A mortality report must summarise mortality 15-39 What steps can be taken to reduce data and suggest ways to reduce mortality. the under-5 mortality rate? • Improve the general health, nutrition andAt a report-back meeting all the staff must be home environment of children. This can begiven the findings of the mortality report. An achieved by reducing poverty.annual mortality report should be prepared for • Improve the access and quality of careeach health district. Theses should be used to provided by the health system.produce reports for each province and for thewhole nation. 15-40 How can under-5 mortality data be used to improve the quality of care in a15-37 What ongoing assessments are health system?needed? By reviewing the data in hospitals and clinics,Regular assessments are needed to measure it is possible to decrease the under-5 mortalitywhether there are improvements in mortality and improve the care of children. The problemrates and whether causes and modifiable of a high under-5 mortality rate cannot befactors are being addressed. Only with ongoing addressed until the common causes of deathassessments can the impact of mortality and modifiable factors are fully understood.reports be judged. It is very important toidentify and correct causes of death that are All health facilities should conduct regularnot becoming less frequent and modifiablefactors that are not being corrected. mortality reviews as this can reduce the under-5 morality rate.15-38 What is the Child Health CareProblem Identification Programme? 15-41 What should be done to address specific causes of under-5 deaths?The Child Health Care Problem IdentificationProgramme (ChildPIP) is an important and Once the cause of each death has beeninnovative computer-based system to collect, established, it is important to look activelyanalyse and report on childhood mortality for any modifiable factors. It is of little valuedata. It was developed in South Africa and is to know the cause of death if nothing is donemodelled on the highly successful Perinatal to prevent similar deaths due to that cause inProblem Identification Programme (PPIP). future.The aim of ChildPIP is to determine themortality rates, causes of death and modifiable 15-42 What should be done once thefactors which may prevent childhood deaths. modifiable factors have been identifiedThis should improve the quality of care that within a region?children receive in the health service. A meeting of all role-players must be called to report and discuss the findings. It is