Common mortality factors and co-factors in under-5 children

Under 5 children especially neonates are more at risk for diseases than adults. Globally, there are five common diseases which cause death in below 5 years age children especially in low income countries such as pneumonia, diarrhea, measles, malaria, malnutrition or combination of all or some of these illnesses (Arifeen et al. 2005, Gove et al. 1997, UNICEF 2008, UNICEF 2015, Weber et al. 1997). The major risk co- factors for infectious diseases are poverty, unhygienic living conditions, impure water, illiteracy and lack of quality health care (Zaidi et al. 2004).

Food insecurity, early and multiple pregnancies, low literacy rate among females, discrimination and lack of approach to proper health and nutritional facilities due to poverty and political set up are unusual co-factors which contribute towards child death (UNICEF 2008).

Infections such as diarrhea, pneumonia, tetanus and sepsis contribute up to 32% of deaths of newborn babies, 24% expiries are due to prematurity related problems, asphyxia and injuries during child birth and injuries contribute to about 29%. Low birth weight is another co-factor in neonatal deaths. Neonatal infections also contribute in neonatal deaths and common factors for neonatal infections are poor antenatal care, low- trained birth attendants, dirty delivery practices, low birth weight babies, poor control of infections, less use of exclusive breast- feeding and poor immunization against tetanus among mothers (Zaidi et al. 2004).

2.1.1. Pneumonia

Among acute respiratory infections, globally the single prominent cause of severe morbidity and mortality between neonates and children of less than five is pneumonia. Pneumonia caused about 920136 deaths in under-5 children worldwide in 2015and contributes about 16% of all child deaths globally. It causes illness in children and families anywhere but sub-Saharan Africa and South Asia are the major prevalent territories (WHO 2016a). The respiratory infections are

caused by viruses, bacteria and fungi. The most common bacterial organisms causing pneumonia in neonates and children are Streptococcus pneumoniae and Haemophilus influenzae (WHO 2005).

According to IMNCI guidelines, pneumonia is assessed and classified as severe pneumonia, pneumonia or no pneumonia. Pneumonia can be managed at community level with the support of properly trained community health facilitators. The best way to treat and reduce pneumonia at community level is by using standard antibiotics such as amoxicillin along with preventive measures. In this regard, important preventive measures are timely vaccination, exclusive breast-feeding and energy rich feed after the age of six months (WHO 2005).

2.1.2. Diarrhea

Diarrhea is defined as “the passage of three or more loose or liquid stools per day”. Diarrhea is considered as second major cause of mortality in under-5 years children. Diarrhea is a symptom of waterborne diseases produced by bacteria, viruses and parasites. The prime causative organisms are rotavirus and Escherichia coli. About 760000 children die per year due to diarrheal diseases (WHO 2015). Children under 2 years of age are mostly affected by diarrhea which most often leads to malnutrition. Diarrhea usually affects more to infants of less than 6 months age fed by cow milk and infant formulas (WHO 2005). The child having diarrhea must also be examined for dysentery by observing blood in stool (WHO 2008).

Malnutrition, unhygienic home environment, poor sanitation, open defecation, lack of vaccination and poor basic health facilities are major elements of danger for deaths due to diarrhea. All diarrheal diseases are preventable by exclusive breast feeding, healthy nutrition, timely vaccination, soap hand washing, safe water, improving sanitation, use of ORS and Zinc supplementation (UNICEF 2012).

2.1.3. Malaria

About more than one million causalities are occurred due to malaria every year thus contributing about 8% childhood deaths a year. Globally, deaths from malaria have reduced about 25 percent since 2000. In 2010, worldwide deaths due to malaria were about 655000 and about 86% of them were among the younger than 5 years old children (WHO 2011). In 2015, nearly 214 million malaria cases were reported and almost 438000 deaths occurred in 100 countries of

world. Most of these deaths are in less than five years age children especially in sub- Saharan Africa where burden of malarial disease is the highest in the world (WHO 2015)

Treated mosquito nets provide good protection against malaria in the regions of “intense transmission Plasmodium Falciparum” (Mushi et al. 2003). In sub-Saharan Africa, about 40%

deaths among below 5 years of age children are due to malaria disease along with pneumonia because of overlap of symptoms. As the symptoms of malaria and pneumonia overlap, so management based on IMNCI strategy includes provision of antibiotics and anti-malarial drugs together (Ukwaja et al. 2011).

2.1.4. Measles

This is the fourth common mortality cause in less than 5 years old children. Before the widespread use of vaccination against measles, there were about 2.6 million deaths yearly. In 1999, out of 10.5 million under-5 year old child deaths in developing countries about 8% were due to measles (WHO 2001). In 2005, worldwide 345000 people died of measles and among them 90% were children of less than 5 years. In 2007, the global burden of this highly contagious disease was 4% among younger than 5 years old children (UNICEF 2008). Despite the availability of safe and low cost vaccine, there were 114900 deaths in less than 5 year age children globally in 2014 (WHO 2016b). The major signs of measles are fever and body rash. 6 months to two years is the most vulnerable period for measles in children. The complications of measles are diarrhea, pneumonia, mouth ulcers, ear problem, eye infections and acute encephalitis. It’s a vaccine preventable disease (WHO 2005).

2.1.5. Malnutrition

Malnutrition or under – nutrition is a common element of illness and deaths in less than 5 years old children globally. In 2000, about 150 million children were malnourished and about to half of child deaths happen in the under developed and low income countries related to secondary effects of malnutrition (Hamer et al. 2004). Malnutrition has two components, protein energy malnutrition and lack of micronutrients. The major burden of malnutrition is in under develop countries specially South Asia and sub-Saharan Africa. Malnutrition is directly involved in about 300,000 deaths annually and causes about 150,000 casualties in below five babies indirectly in low income countries (Muller and Krawinkel 2005). In 2015, 93 million under-five children are

suffered from secondary effects of malnutrition and 45% of deaths in children are directly related to malnutrition (WHO 2015).

Child malnutrition is considered as major public health measure for assessing nutritional health situation in the community. Childhood malnutrition is a good indicator for assessing development regarding Millennium Development Goals (de Onis et al. 2004). Lack of breastfeeding, low quality food, lack of access to highly nutritious food and deficiency of zinc, vitamin A and iodine like micronutrients are common contributing factors to malnutrition.

Infections like diarrhea, pneumonia, measles and malaria also contribute to malnutrition. Early, exclusive and continued breast feeding along with complementary and micronutrients rich feeding after the age of 6 months can reduce the burden of under nutrition in children (UNICEF 2012).

2.1.6. Perinatal Deaths

Perinatal deaths contribute up to 37% in neonatal deaths globally. In developing countries share of peri-natal deaths is up to 18% in the child deaths occurring in less than five years old children(WHO 2005). In the year 2000, globally there were 6.3 million peri-natal deaths and 98% of these deaths were in developing countries. About 2 million peri-natal deaths occur during child birth. HIV/AIDS and other factors contribute up to 12% of under - 5 child deaths (Muller and Krawinkel 2005). There are many causes of peri-natal deaths such as infection of amniotic fluid, placental abruption, early rupture of membranes, congenital problems and infarcts in the placenta. Home deliveries also contribute towards peri-natal deaths (Naeye 1977).