Paediatrics
Child mortality: Egypt improves, Iraq declines

A recently released report by Save the Children highlights progress, or lack of it, with child mortality in the Middle East and around the world. Middle East Health reports.

While the statistics of child mortality around the world are shocking – some 28,000 children under the age of five die every day – it appears some progress is being made.

In the Middle East, Egypt has made the most progress since 1990 – and Iraq the least – in saving the lives of children under five, according to the eighth annual State of the World's Mothers Report issued 5 May by Save the Children, a United States-based global independent humanitarian organisation.

The report includes the first-ever Child Survival Progress Rankings of 60 developing countries, which together account for 94% of all child deaths worldwide. The rankings indicate which countries are succeeding and which are failing to save the lives of children under the age of five.

According to the report, Iraq's child mortality rate has increased by a staggering 150% since 1990. Some 122,000 Iraqi children died in 2005 before reaching their fifth birthday. More than half of these deaths were among newborn babies in the first month of life. On the positive side, Egypt has achieved an impressive 68% decline in child deaths in the past 15 years.

Investments in health services for mothers and children have helped improve care for pregnant women, made childbirth safer and increased the use of family planning services. As a result, thousands of children's lives have been saved. Twenty of the 60 countries in the Child Survival Progress Rankings have either made no progress in reducing deaths among children under age 5, or their mortality rates have increased since 1990. Iraq, Botswana, Zimbabwe and Swaziland emerge as the countries that are regressing the most.

In each of these countries, under-5 mortality rates have increased in the past 15 years. In Iraq and Botswana, rates have more than doubled. “More than 10 million children under age five still die each year.

That's almost 28,000 a day – almost all in developing countries,” said Save the Children president and CEO Charles MacCormack, in issuing the report. “The interventions that can save these lives, such as vaccines, oral rehydration therapy and insecticide- treated mosquito nets are not expensive. Yet, sadly, many mothers and children lack access to these lifesaving measures,” he said.

“Every mother is concerned for the welfare of her child," said Save the Children spokesperson Jamie Lee Curtis. “Few mothers in this country [the United States] realise how frequently children under 5 die in the developing world,” said the actress, herself a mother of two. “Nine out of 10 mothers, for example, in sub-Saharan Africa are likely to lose a child during their lifetime.

It doesn't have to be this way. We can prevent this tragedy by ensuring that we do as much to protect mothers and children in poor countries as we do in rich countries,” stressed Curtis. The report also includes Save the Children's eighth annual Mothers' Index, which identifies the best and worst countries to be a mother and child-based on a comprehensive look at child and maternal well-being in 140 countries. More countries are included in this year's Index than in any previous year.

Sweden, Iceland and Norway top the rankings this year. The United States places 26th, tied with Hungary, while Niger ranks last.

Key findings:

- The three biggest killers of children under five worldwide are newborn disorders, pneumonia and diarrhoea. By using existing interventions, the report notes, we can save more than six million of the 10.1 million children who die every year from easily preventable or treatable causes.

- Child and maternal death rates are highest in the poorest, most disadvantaged places. According to the report, nearly all under-five and maternal deaths (99%) occur in developing countries in settings of poverty, where children are most vulnerable to diseases and malnutrition. The highest rates are in Africa and South Asia.

- Most child deaths occur in just 10 countries, many with large populations (such as China and India) and others with very high child mortality rates (such as Afghanistan, Angola and Democratic Republic of the Congo).

- AIDS remains one of the underlying causes affecting child mortality trends, particularly in sub-Saharan Africa. Other key factors behind spiking child mortality rates, as in the case of Iraq and Afghanistan, are the effects of armed conflict and social instability.

- Among developing countries, Malawi, Bangladesh, Nepal, Tanzania and Madagascar are making great strides in child survival despite limited financial resources. These countries have invested in better health care for mothers, better nutrition for children, and lifesaving healthcare services to prevent and treat deadly diseases, proving that political will and social commitment matter more than national wealth when it comes to saving the lives of children. Malawi, the report noted, has a per capita gross national income (GNI) of only US$650, but it achieved a remarkable 43% decline in under-five mortality between 1990- 2005 by directing more resources toward basic health care, offering better salaries and training for health workers, and widely distributing insecticidetreated bed nets to prevent malaria. The report also credits Nepal – despite having a GNI of only $1,530 and being mired in conflict – for having reduced its underfive death rate by almost half in the past 15 years. The report highlights increasing immunisation coverage and vitamin A supplementation among young children as key to this success.

- Children's deaths in the industrialised world are most likely the result of injury suffered in traffic accidents, intentional harm, drowning, falling, fire and poisoning.

Recommendations

To save the lives of children under five Save the Children recommends that countries:

- Ensure the well-being of mothers. Three key interventions that help both mothers and children to survive and thrive are nutrition, skilled care during childbirth and access to voluntary contraception.

- Invest in basic, low-cost solutions to save children's lives. The most dangerous threats to children's survival can be fought with relatively simple and inexpensive solutions. Breastfeeding provides nutrition and improves immunity to often lifethreatening illnesses common to infants. Immunisations protect children from measles and other diseases. Oral rehydration therapy can save a child from dying of dehydrating diarrhoea. Antibiotics treat pneumonia. Insecticide-treated mosquito nets help prevent malaria.

- Make health care available to the poorest and most vulnerable mothers and children. Childbirth can be made much safer if mothers and newborns receive care from trained health workers before, during and after delivery. In remote, hard-toreach communities, diarrhoea and many cases of pneumonia can be treated by training community-based health workers close to where children live.

- Increase funding and improve strategies to provide basic, effective, lifesaving services to those who need it most. Basic health systems and services in developing countries are grossly underfunded. To increase access to services, poor countries need new strategies such as community case management linked to local health facilities, and community education and mobilisation to encourage family members to adopt lifesaving homebased practices.

The report calls on governments to increase their political and financial support for proven solutions that save the lives of mothers, children and newborns.

“It only costs a few dollars to protect young children from conditions that disable or kill millions each year,” said MacCormack.

“With modest increases in funding, we can help countries reach the poorest with child survival and maternal health services.”

Damascus workshop moves to improve breastfeeeding in MENA

A four-day regional workshop initiated by WHO and UNICEF in May ended with agreement to significantly scale-up efforts to improve infant and young child feeding practices in the Middle East and North Africa. The workshop, held in Damascus, was convened to address growing concern among public health experts over falling rates of exclusive breastfeeding (EBF) and the relatively low proportion of Baby Friendly Hospitals (BFH) in the region.

Experts recommended the expansion of communitybased educational and awareness-building, improvements in the monitoring and assessment of EBF and complementary feeding (CF) rates, particularly in Sudan, Yemen, Djibouti and Egypt, building the capacity of health workers in these relevant areas and mainstreaming feeding interventions into major national health and development initiatives.

“Nutrition remains the weakest link in our region as far as child survival is concerned and there is a need to revitalise the Baby Friendly Hospital Initiative (BFHI) as well as to harmonise breastfeeding and complementary feeding practices,” said Dr Mahendra Seth, UNICEF health regional advisor.

Overall in the region, exclusive breastfeeding practices (EBP) for infants below six months of age are declining with a current overall rate of 32%. With the exceptions of Algeria, Oman, Sudan and Tunisia, most countries in the region have experienced falls in EBP rates or have failed to monitor breastfeeding rates.

“In impoverished areas, a child who is breastfed is almost three times more likely to survive infancy than a child who is not breastfed,” said UNICEF infant feeding officer Moazzem Hossain. “In an effort to give children the best possible start to life and to ensure the MDG Child Survival Goal is met, UNICEF and WHO are working with new mothers around the world to ensure that their babies are properly fed.”

While the average implementation of the Baby- Friendly Hospital Initiative (BFHI) in the region is below the global average, countries like Iran, Oman and Tunisia have set a formidable pace, with about 90% of their facilities being presently “Baby Friendly”. However, countries in the region face daunting challenges to the establishment of monitoring mechanisms that would ensure reliable data collection on Infant and Young child feeding.

“With an EBF rate of about 29% in Syria, together with our partners our future focus will be on expanding the Baby friendly Hospital initiative, reinforcing national expertise on complementary feeding and reactivating the national code for Breast Milk Substitutes,” added Mohamed Anis Salem, UNICEF Syria country office representative.

The workshop gathered representatives from Ministries of Health as well as WHO and UNICEF representatives from Algeria, Djibouti, Egypt, Iran, Iraq, Lebanon, Morocco, Oman, Sudan, Syria, Tunisia and Yemen.

The experts reviewed the status of infant feeding practices in the region and discussed more specifically key achievements and implementation challenges particularly in emergency situations.

- UNICEF's strategy for infant and young child feeding is based upon the Innocenti Declaration for the protection, promotion and support of breastfeeding, adopted in 1990, and subsequently endorsed by the World Health Assembly in the Global Strategy for Infant and Young Child Feeding (IYCF) May 2002 and UNICEF's executive board. Among the targets of the Declaration is the call to ensure that every facility providing maternity services fully practices all Ten Steps to Successful Breastfeeding set out in the joint WHO/UNICEF Baby-Friendly Hospital Initiative.

Watching kids brains grow

Recently published initial results from a US study that has been tracking brain development in some 500 children shows some interesting findings regarding behavioural, cognitive and motor skills development. Middle East Health reports.

Children appear to approach adult levels of performance on many basic cognitive and motor skills by age 11 or 12, according to a new study co-ordinated by the US-based National Institutes of Health (NIH).

The NIH Magnetic Resonance Imaging (MRI) Study of Normal Brain Development is tracking brain and behavioural development in about 500 healthy American children, from birth to age 18.

A report published online (18 May) by the Journal of the International Neuropsychological Society* contains the first glimpse of behavioural data – covering IQ, motor dexterity, language, computation, and social skills – collected from children ages 6 to 18.

The study “will provide researchers with a reference point for how the normal brain develops, so that they can better understand what goes wrong in children who have brain abnormalities caused by genetic disease, prenatal exposure to alcohol or drugs, or other factors”, said lead author Deborah Waber, PhD, an associate professor of Psychiatry at Children’s Hospital Boston and Harvard Medical School.

Some of the behavioural data validate trends seen in other studies; for example, they show that family income has an impact on a child's IQ and social behaviours. But the lack of evidence for dramatic cognitive growth during adolescence was a surprise.

The long-term goal of the study team is to link these behavioural data to MRI scans of the children's brains.

Together, the two data sets will allow researchers to view how the brain grows and reorganises itself throughout childhood, and to explore the meaning of the structural changes they see. “This study will provide a comprehensive database for clinicians and scientists alike,” said NIH director Elias Zerhouni, MD.

“A neurologist who notices something unusual in a child’s MRI could use the database to help determine if the anomaly is within the normal range of variation, or if it is cause for concern. A researcher studying an environmental toxin or genetic disease that affects brain development could use the database to help determine where and when development has strayed from its normal course.”

The study was launched in 1999 in a joint effort by the US-based National Institute of Neurological Disorders and Stroke (NINDS), the National Institute of Child Health and Human Development (NICHD), the National Institute on Drug Abuse (NIDA), and the National Institute of Mental Health (NIMH).

The NIH Blueprint for Neuroscience Research, an initiative that combines resources from those Institutes and other NIH components, recently provided additional funding so that the study team could collect brain scans by diffusion tensor imaging (DTI), a kind of MRI. While conventional MRI allows clinicians and researchers to visualise different parts of the brain, DTI allows them to see the networks of fibers that connect these parts.

To look into the normal developing brain, the investigators sought children from diverse geographic, socioeconomic and ethnic backgrounds.

They recruited children from six sites across the US: Children's Hospital in Boston; Children's Hospital Medical Center in Cincinnati; Children's Hospital in Philadelphia; University of California at Los Angeles; University of Texas, Houston; and Washington University, St. Louis.

They also shaped the demographics of the study group – in terms of family income and ethnicity – to resemble the demographics of the US population, based on census data from 2000. Finally, they used questionnaires to exclude children who had any signs or known risk of serious neurological or psychiatric disorders.

The Montreal Neurological Institute at McGill University in Quebec, Canada, is overseeing the imaging arm of the study and building the database of brain-behaviour information.

Observation

Though no child will be observed for the entire 18- year developmental span covered by the study, each one will be evaluated for several months to several years, depending on their age.

Children under age 6 at the time of recruitment are expected to go through dramatic, rapid developmental changes, and are being evaluated at short intervals. A total of 385 children have been recruited within the 6-18 age range, and are being evaluated at three time points -- at the beginning, middle and end of a four-year period.

The 18 May publication summarises the results of psychological tests conducted at the first time point. The tests measure a broad spectrum of abilities, from fine motor control, to social skills, to aspects of intelligence, such as the ability to explain verbal concepts or solve visual puzzles.

Income status

Children from low income families performed somewhat more poorly on IQ and achievement tests and displayed more behavioural problems compared to children from middle and higher income families.

They did not differ, however, on many other measures of basic cognitive functions, like memory and verbal fluency, or on most measures of social adjustment. A relatively larger percentage of low income children were excluded by the study's rigorous selection criteria, but the healthy low income children who did participate performed above published norms for their demographic. This suggests that in previous studies, general health disparities might have inflated the cognitive gap between low and high income children, Dr Waber said.

Gender differences

There were hints of muchcited differences in verbal and spatial ability between boys and girls, but these differences were not as sharp as those described in previous reports. In fact, there were no gender differences in verbal fluency.

There were also no differences in calculation ability, suggesting that boys and girls have an equal aptitude for math. Regardless of income or gender, children appeared to improve rapidly on many tasks between ages 6 and 10, with much less dramatic cognitive growth in adolescence.

This result fits with previous research suggesting that in adolescence, there is a shift toward integrating what one knows rather than learning new basic skills. Dr Waber cautioned, however, that these data provide "snapshots" of development in different children at different time points, rather than following each child over a series of time points.

“We don't know whether every child's performance slows during adolescence, or whether some children continue to improve, while others do not,” Dr Waber said. “It's also possible that our standard tests don't measure what really changes in adolescence. As we follow these children over time, we will have a better understanding of what's happening.”