Describe under-five mortality and the child survival interventions.

Measurement and Causes of Under-five Death

• The component rates, which should be defined precisely — neonatal mortality (deaths under 28 days per 1000 live births); post-neonatal (28 days to 1 year); infant mortality (under 1 year); and child mortality (1 to 4 years) per 1000 children in that age group
• The 1 to 4 year rate is particularly sensitive to malnutrition and the environment, and was historically used as an indirect nutritional indicator
• The changing composition as mortality falls is the key epidemiological point — as the infant mortality rate declines, the neonatal proportion rises
• The reason is that post-neonatal deaths, being caused chiefly by infection and the environment, are easier to prevent by immunisation, sanitation and oral rehydration; while neonatal deaths require skilled care at delivery and after
• Hence further reduction in India now depends chiefly on newborn care and on the quality of intrapartum services
• The major causes of under-five death — neonatal causes (prematurity, asphyxia, sepsis) which now form the largest group; pneumonia; diarrhoea; measles and other vaccine-preventable disease; malaria; congenital anomalies; and injuries
• Malnutrition is the underlying factor in a very large share of these deaths, though it is rarely the recorded cause — it increases both the risk of acquiring infection and the case fatality once acquired
• This is the important concept of malnutrition as an associated rather than a direct cause, and it means that mortality statistics by cause systematically understate the contribution of nutrition
• The social determinants — maternal education, which is among the strongest predictors; poverty; birth order and spacing; maternal age; sex of the child, with excess female mortality in parts of India; water and sanitation; and access to care

Child Survival Interventions

• The child survival interventions are remembered as GOBI-FFF, which was the original selective primary health care package:
• G — growth monitoring, with promotion; O — oral rehydration; B — breastfeeding; I — immunisation; and the three Fs, family planning, female education and food supplementation
• The interventions grouped by the death they prevent gives a more useful answer:
• For neonatal deaths — skilled attendance at birth, essential newborn care, resuscitation, kangaroo mother care, home-based newborn care visits, and management of sepsis
• For pneumonia — early recognition by counting the respiratory rate and looking for chest indrawing; prompt oral amoxicillin; pentavalent (Hib) and pneumococcal vaccination; reduction of indoor air pollution by clean cooking fuel; exclusive breastfeeding; and zinc and adequate nutrition
• The respiratory rate thresholds are worth memorising — 60 or more per minute under 2 months; 50 or more from 2 to 12 months; and 40 or more from 12 months to 5 years
• For diarrhoea — ORS and zinc for 14 days; continued feeding; rotavirus vaccine; safe water, sanitation and handwashing; and exclusive breastfeeding
• For vaccine-preventable disease — full immunisation coverage
• For malnutrition — infant and young child feeding, growth monitoring, supplementary feeding, vitamin A, and management of severe acute malnutrition
• The point worth making is that pneumonia and diarrhoea together still kill a large number of Indian children, and both are treatable with cheap, widely available remedies — amoxicillin, ORS and zinc
• The failure is therefore one of recognition and access, not of medical knowledge, and that is why community-level case management by trained workers has such large effects
• The INDIAN programmes and strategies — IMNCI, considered separately; the universal immunization programme; home-based newborn and young child care; the intensified diarrhoea control fortnight; SAANS, for pneumonia awareness and management; rashtriya BAL swasthya karyakram (RBSK), which screens children for the 4 Ds — defects at birth, deficiencies, diseases and developmental delay including disability — and provides free treatment including surgery through District Early Intervention Centres; and the ICDS
• The under-five clinic concept — a clinic providing care in illness, preventive care (immunisation and growth monitoring), nutritional surveillance, and health education under one roof, so that a child brought for one purpose receives all four
• That principle — using every contact for every purpose — is the organising idea of child health services, and is why a child attending with a cough should leave with their immunisation checked and their weight plotted
• The sustainable development goal target is to reduce under-five mortality to 25 and neonatal mortality to 12 per 1000 live births
• India has made substantial progress on both, with the neonatal rate falling more slowly than the post-neonatal, which is the pattern the epidemiology predicts
• Pneumonia and diarrhoea are treated with cheap remedies, so the failure is recognition and access rather than knowledge
• Use every contact for every purpose, so a child seen for cough leaves with immunisation checked and weight plotted
• Count the respiratory rate to diagnose pneumonia, with thresholds of sixty, fifty and forty by age band
• Chest indrawing indicates severe pneumonia and the need for referral rather than oral treatment at home
• The neonatal share rises as infant mortality falls, since post-neonatal deaths are the easier ones to prevent
• Further Indian reduction depends on newborn care, which follows directly from that shift in composition
• Malnutrition is an associated rather than direct cause, so cause-of-death statistics understate its contribution
• The one to four year rate is nutrition-sensitive, and was historically used as an indirect nutritional indicator
• Maternal education is among the strongest predictors of child survival, ahead of most health service variables
• Excess female mortality persists in parts of India, which is a social rather than biological finding
• RBSK screens for the four Ds — defects, deficiencies, diseases and developmental delay
• District Early Intervention Centres provide treatment, which is what makes RBSK screening worthwhile rather than merely diagnostic
• Clean cooking fuel prevents pneumonia, which links the nutrition, energy and child health programmes together
• The under-five clinic combines four functions under one roof — curative, preventive, nutritional and educational
• SDG targets are twenty-five and twelve for under-five and neonatal mortality per thousand live births
• Give zinc for fourteen days with ORS, which reduces both the current episode and the next one
• Amoxicillin is the oral treatment for pneumonia, and is cheap, available and effective at community level
• Rotavirus vaccine is now in the schedule, addressing the commonest cause of severe infant diarrhoea
• GOBI-FFF was the selective package, and remains a useful way to recall the core child survival interventions
• Community case management has large effects, precisely because the binding constraint is access rather than knowledge
• Under-five mortality is a wellbeing indicator, responding to nutrition, infection, income and education together
• Birth order and spacing affect survival, which connects family planning directly to child mortality
• Congenital anomalies rise in proportion as infectious deaths fall, changing what child health services must offer
• Measles still causes preventable deaths where coverage has slipped, and its case fatality rises steeply with malnutrition
• Injuries and drowning matter after infancy, and are the neglected part of the under-five mortality picture
• SAANS addresses pneumonia awareness, since delay in recognising fast breathing is what kills
• Handwashing with soap prevents both pneumonia and diarrhoea, which is why it appears in every child survival list