Oxford Handbook of Paediatrics (2 edn)
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Child survival: world health
Worldwide, almost 9 million children aged <5yrs still die every year. Child mortality rates vary between world regions, and these differences are large and increasing. Some examples are:
1990. There were 180 deaths per 1000 live births in sub-Saharan Africa, but only 9 per 1000 in industrialized countries—a 20-fold difference.
1990–2000. This 20-fold gap increased to almost a 30-fold difference.
United Nations response
The United Nations set several development goals in September 2000, revised in September 2010:
Target: reduce by two-thirds, between 1990 and 2015, the mortality rate of children under 5yrs.
Since 1990
The number of children in developing countries who died before they reached the age of 5 dropped from 100 to 72 deaths per 1000 live births between 1990 and 2008.
The highest rates of child mortality continue to be found in sub-Saharan Africa, where, in 2008, one in seven children died before their fifth birthday.
Of the 67 countries defined as having high child mortality rates, only 10 are currently on track to meet the Millennium Development Goals target.
World health: childhood illness
Worldwide, half of the deaths in children aged <5yrs are due to:
pneumonia;
diarrhoea;
malaria;
measles.
Under-nutrition is a major factor contributing to these deaths. Two-thirds could be prevented by interventions already available and feasible today for implementation in low-income countries. In fact, we have the knowledge and instruments to reduce child mortality, but children continue to die because effective interventions are not reaching them. For example, Haemophilus influenzae type b vaccine coverage is universally low and, with few exceptions, insecticide-treated net coverage rates in malarial areas are well below 5%.
There are also clear indications in the developed world of health inequalities. Infant mortality rates show an excess associated with social deprivation and ethnic minorities.
The infant mortality rate in England and Wales of 4.7 deaths per 1000 live births in 2009 was the lowest ever recorded in England and Wales and has fallen by 64% since 1978 In sub-Saharan Africa the equivalent rate in children under 1yr was 81 deaths per 1000 live births, 39 in Asia and 19 in Latin America and the Caribbean. In the UK, the rate varies by socioeconomic status, being 69% higher in the ‘routine and manual’ group compared with the ‘managerial and professional group’.
In 2003, data showed also that:
Excess infant mortality also occurs in children of Asian parents—8.3 per 1000 live births born to mothers whose country of birth was Bangladesh, India, or Pakistan died.
Babies born to mothers whose country of birth was Pakistan had an infant mortality rate of 10.5 per 1000 live births.
The factors associated with excess infant mortality include low birth weight, ethnicity, poverty, maternal cigarette smoking, the delivery of health care, and consanguinity.
Taking children on holiday
Parents will often ask advice about taking their child on holiday. Here are some general guidelines to consider in well children. If a child has a chronic illness (e.g. diabetes, cystic fibrosis, CHD), consider whether they will require access to special health needs and provide details of a local expert. Your local specialist should be able to help.
Travel vaccinations
International travel with babies and children has the added dimension of considering the right immunizations long before you go:
Babies in the UK receive routine immunization (see 
p.728).
Exotic places usually means exotic diseases and therefore the need for immunization. Check with the National Travel Health Network and Centre (at 
www.nathnac.org/pro/index.htm), country by country, in the travel itinerary.
Babies under the age of 6mths and many immunosuppressed children cannot be given yellow fever injection.
Babies under the age of 2mths can take antimalarial tablets if the family need to travel to an area requiring prophylaxis. Just as important for very young travellers are the use of a cot mosquito net, and other measures to prevent mosquito and other insect bites.
Flying with babies
Most international travel will require an airline flight. Mothers will not be allowed to fly if they:
have given birth in the last 48hr;
had a Caesarean section in the last 10 days.
Families may choose to fly after the baby’s 6-wk check. Modern commercial aircraft maintain ambient air pressure equivalent to 8000 ft (2500m) or less, even during flight at altitudes above 13km (43,000 ft). Healthy babies should tolerate this ‘altitude’ well, although children with respiratory disease may need specialist consideration even if they do not usually require supplementary oxygen at home
Common medical problems encountered on holiday
Sunburn
Too much exposure is harmful
Protection prevents painful sunburn
Protection reduces the risk of skin cancer in later life
Some children are sensitive and will develop a rash
Keep infants out of direct sunlight especially in the middle of the day
Use high-protection, water-resistant sunscreen
Wear sun suits
If there is blistering or a rash seek medical advice ⚠
Cool the sunburnt area, but do not let the child get cold
Prickly heat
This fine, red rash with tiny pimples is centred around immature sweat glands. It can blister and be uncomfortable.
Diarrhoea
This can be serious in the very young if dehydration occurs (see p.90). Children returning from abroad should be investigated with stool samples for bacteria, viruses and parasites if the diarrhoea is severe enough to present to hospital or has been present for more than 7 days. This is because some pathogens that require treatment with antimicrobial agents are more common in those returning from abroad (Giardia lamblia, Shigella and some Salmonella). (See NICE guideline).1
Reference
Illness after international travel
review of travel itinerary;
exposure history;
duration of fever;
likely incubation period;
immunization state;
use or non-use of antimalarial chemoprophylaxis.
Incubation period
Determining an approximate incubation period is particularly helpful when you are trying to ‘rule-out’ possible causes of fever. It is also useful to consider causes according to key features. For example, is the fever:
Non-specific?
Associated with haemorrhage?
Associated with central nervous system involvement?
Associated with respiratory symptoms?
Associated with exposure to blood?
Associated with eosinophila?
The following subsection summarizes the likely causes by incubation period and key features. It can be used to guide your history. For example, if fever began more than 21 days after returning from international travel then dengue, rickettsial infections, and viral haemorrhagic fever (e.g. yellow fever, Lassa fever) are excluded, irrespective of the history of exposure. Once the travel exposure and likely duration of symptoms have been identified, your investigations could include:
Peripheral blood film for malaria.
FBC and differential WCC.
LFTs.
Urinalysis.
Culture of blood, stool, and urine.
CXR.
Specific serology based on the likely incubation period.
Causes of fever according to incubation period and key features
Fevers
with incubation period <14 days
Non-specific fever:
malaria (Plasmodium spp.)—tropics, subtropics, and temperate regions;
dengue (virus serotypes 1–4)—tropics, subtropics;
Rickettsial spotted fever—worldwide;
scrub virus—Asia, Australia;
leptospirosis—tropics;
Campylobacter, Salmonella, Shigella—developed or more commonly developing countries;
typhoid fever—developing countries;
East African trypanosomiasis—sub-Saharan East Africa.
Fever with haemorrhage:
meningococcaemia, leptospirosis, bacterial infection, malaria;
viral haemorrhagic fever.
Fever with CNS involvement:
meningococcal meningitis;
bacteria and viral meningitis and encephalitis;
malaria, typhoid, and typhus;
rabies—Africa, Asia, and Latin America;
arbovirus encephalitis: worldwide;
eosinophilic meningitis;
poliomyelitis;
East African trypanosomiasis.
Fever with respiratory findings:
influenza—widespread, seasonal;
legionellosis—widespread;
acute histoplasmosis—widespread;
acute coccidioidomycosis—Americas;
Q fever—worldwide.
Incubation period 14–55 days
Malaria.
Typhoid fever.
Hepatitis A: widespread.
Hepatitis E: widespread.
Acute schistosomias.
Amoebic liver abscess.
Leptospirosis.
HIV acute seroconversion.
East African trypanosomiasis.
Viral haemorrhagic fever.
Q fever.
Incubation period >55 days
Malaria
Tuberculosis: worldwide.
Hepatitis B and E: worldwide.
Visceral leishmaniasis: Africa, Asia, S. America, Mediterranean basin.
Lymphatic filariasis.
Schistosomiasis: tropics.
Amoebic liver abscess.
Further reading
United Nations millennium goals. Available at: http://www.un.org/millenniumgoals/pdf/MDG_FS_4_EN.pdf
UNICEF Statistics. Available at: http://www.unicef.org/sowc2011/pdfs/Table-1-Basic-Indicators_02092011.pdf
