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Sjolin, S. and Vahlquist, B. (Department of Paediatrics, University Hospital, Uppsala, Sweden). Child health in Sweden. Acta Paediatr Scand, 63: 485, 1974.—On the basis of relevant vital statistics, some characteristic features of the health of Swedish children during the last two centuries are presented and analysed with regard to probable causative factors. An attempt is also made to define in brief the child health problems of the future.

Diphtheria, Pertussis and Tetanus (DPT) are the vaccine preventable diseases of childhood. The published literatures and reports related to DPT immunization coverage are relatively more than DPT diseases. The striking reduction in deaths and in the incidence of these diseases has been closely associated with the introduction of specific vaccination program. Expanded Program on Immunization (EPI) is a priority program in the country. Nepal has been running country-wide immunization program since 1989. However, there is no doubt that the program has contributed significantly towards reduction of infants and child mortality. Effective and efficient surveillance system and strengthening the routine immunization against DPT are the key steps for elimination of DPT diseases. Key words: DPT, Diphtheria, Pertussis, Tetanus, Immunization, DPT Vaccine, surveillance, vaccine coverage, Nepal. doi: 10.3126/kumj.v6i4.1749 Kathmandu University Medical Journal (2008), Vol. 6, No. 4, Issue 24, 520-525

A detailed study of the growth and health of 215 children under 5 years in the village of Keneba (Gambia) during 1962-1963 was conducted. At the same time, outline information was collected in 3 adjacent villages--Jali, Manduar, and Kantongkunda. There were 99 live births during 1962-1963. It became obvious during the 1st year of the study that season exercised a marked effect on trends in body weight, and it became necessary to define the seasons. Data from children who died during the survey period were excluded. Of the 99 liveborn babies, 93 were measured within 3 days of birth. The data suggested that birth weights were on average lower during the wet than the dry months, but the differences between the quarter years were not statistically significantly. There was no indication that the weight gains in the 1st 6 months of small babies differed from those of large babies. The seasonal effect was slight during the early months of life but became obvious at later ages. Children born in the early part of the year gained very well until nearly the end of their 1st rainy season, when there was a short setback. Children born during the wet months grew well until the onset of the rains in the following year. Those born during the earlier part of the dry season received a marked check to growth soon after entering the wet months. Both season of birth and age dictated the average pattern of gain in weight during the 1st year of life. Until about 6 months of age, season made little difference to rates of gain in Keneba, but thereafter increments were about zero or slightly negative during the wet months with some catch up during the dry months. The Keneba babies grew much faster than American babies during the first 3 months of life, but much more slowly during the 2nd half of the 1st year. By the end of the 2nd year the average rate of growth in height had practically caught up with the American standard. The data confirmed the previous finding that, in general, the growth of children who die is not very different from that of children who survive, and that the events which precede death cause effects on body weight which are of relatively short duration.

Analysis of the causes of death in 1041 children in all Newcastle hospitals admitting children in the period 1960 to 1966 shows that genetically determined disease makes a major contribution, 42% in this series, to the total of mortality in childhood. The findings are very similar to a previous survey made in London.

An account is given of relief measures taken by Indian Government and voluntary agencies in a camp for Bangladesh refugees near Calcutta between June, 1971, and February, 1972. Data were collected by house-to-house survey in order to establish the total camp population, age structure, and mortality by age-group, approximately five months after the opening of the camp. Among a population of 170,000 in the camp, mortality was highest in the very young and lowest among adults. Total mortality in this group of refugees from the beginning of their migration to India in March/April, 1971, until their return to Bangladesh in February, 1972, is estimated at not less than 4000, most of them small children— many more than might normally have died even considering the high infant mortality of this population. A review of the records of all 2607 patients admitted to the main wards of the Save the Children Fund hospital between July, 1971, and February, 1972, indicated that most deaths in small children were due to intestinal infections precipitating and complicating protein-calorie malnutrition. It is suggested that the relative ineffectiveness of the relief effort in preventing this considerable child mortality was due to the failure to collect data about the prevalence of malnutrition and disease, and to ignorance of suitable methods of distribution of materials and services on a massive scale at low cost.

This article starts from the premise that there are good reasons as to why family planning and child health services should be closely related to each other in the end helping prolong the life of the infants promote optimum levels of growth and better the quality of par ental care. The points discussed in those terms are: 1) greater intervals between pregnancies reduces the chance of infant and child mortality 2) family planning helps better the quality of family life and the health of the existing children by keeping the number of children low and the intervals between them optimum 3) infant and child mortality reduction is a prerequisite in many underdeveloped countries for couples to adopt family planning 4) family planning education and services should be a part of school programs 5) large family size and overcrowding are associated with childrens diseases 6) children of large families are smaller in size 7) maternal care in large families is less adequate than that in smaller families 8) because of less maternal supervision accidents in childhood may be more in the large families. The authors feel that family planning and child care services should be brought together for the foregoing reasons. The ways of doing this may include special health programs for school children dissemination of family planning information in day care centers head start programs and diagnostic counseling and treatment centers for handicapped children etc.

Damage to somatic cells in bodies of cigarette smokers is not limited to the respiratory tract; absorption of harmful agents and their excretion in the urine has been demonstrated. During the past 30 years with the increase in cigarette smoking increases have occurred in the child mortality rate ascribed to congenital malformations and child leukemia rates in the U.S. Data gathered from a telephone survey of 2052 mothers out of 4790 from whom live births were reported in Seattle Washington during the study period. Further information was obtained from birth certificates for these infants. Patterns indicate that infant birth weight is associated with maternal smoking during pregnancy but not before conception. Increasing maternal smoking during pregnancy is associated with a large negative gradient in birth weight and also an apparent effect on sex ratio of live-born infants. The percentage of males decreased from over 53% to slightly over 49% depending on the number of cigaretts smoked. This effect is attributed to sexually unequal reproductive losses. Smoking may possibly contributed to birth defects childhood leukemia and bladder cancer. More efforts should be made to dissuade women from smoking during pregnancy.

Calling population the most important health problem in the world (with nutrition 2nd tuberculosis 3rd and malaria 4th) the role of infant and child mortality in fertility is examined. Excess of births over deaths is greatest in poor countries which are expected to increase 66% by the year 2000. Even if birthrates decline by 15 or 20/1000/year by the year 2000 world population would still reach 10 billion by the end of the 21st century. One of the strongest factors in this increase is the desire for surviving sons coupled with high infant and child mortality. In a study in the Punjab area of India it was found nearly 40% of live-born children die before their mothers reach age 45 53% of families have lost 2 or more children while 36% of high cast and 67% of low cast families have lost 3 or more and women age 45 or more averaged 7.5 live births with 4.7 surviving children. He recommends revising priorities to attack problems affecting large numbers of people in developing countries devoting more resources to common illnesses which hold people to low levels of productivity such as trachoma and make fertility control services an integral part of basic health care for all families regardless of socioeconomic status.(GR BBB: Dept. of Population Sciences)

Summary The maternity records of Vom Christian Hospital for the years 1963 to 1967 have been analyzed, and some of the results compared with those of a similar survey conducted at the same hospital 12 years ago. The stillbirth rate of babies of the Birom tribe has fluctuated over the five-year period, but has not fallen. It is 66·4 per thousand total single births. The death rate of Birom babies in the first week of life is 47·8 per thousand live single births, and has not improved over the five years. The perinatal mortality rate for Birom babies is 107 per thousand total single births. The neonatal mortality rate for Birom babies, based on records of the previous three deliveries only, is 83 per thousand live single births. The infant mortality rate for Birom children is 213 per thousand live births, while the overall “under five years childhood mortality rate” is 266·5 per thousand. This compares favourably with the figure of 490·5 obtained twelve years ago for the same tribe. The figure for overall fetal losses at all stages is 300 per thousand total births for both the Birom children and the children of the other 69 tribes represented in small numbers during the review period. The commonest causes of death in children under five years old are measles (31 per cent), respiratory infections (21 per cent), dysentery (11 per cent), and febrile convulsions (10 per cent). The average birthweight of single Birom babies born alive has increased slightly since the last survey, from 6 pounds ¼ ounce (2729 g.) to 6 pounds 4 ounces (2836 g.). The sex ratio of all babies in whom the sex was recorded is 111 male to 100 female. The incidence of twinning amongst the Birom mothers is 1 in 48, and is even higher amongst the other tribes attending the hospital (1 in 36). In this series as many second twin babies survived as first.

2 series of investigations into the incidence and degree of malarial infection in 551 African parturient women in Lagos an urban and semi urban area of Southern Nigeria and their newborn infants were carried out during 1948-50. The routine technique of the investigation consisted of taking blood slides from the peripheral circulation of the mother and her newborn within 6-24 hours of delivery. A blood slide was made from a deep layer of a piece of the maternal placenta excised near the center. The weight of all newborn infants was recorded and whenever possible the progress of the infants was followed up throughout the neonatal period. The weight of all newborn infants was recorded and whenever possible the progress of the infants was followed up throughout the neonatal period. The mean incidence of malarial parasitaemia (mainly due to Plasmodium falciparum) in the sample of 323 Africa parturient women was found to be 33% somewhat higher than the usual parasite rate of the adult indigenous population. The incidence of malarial infection of the placenta was 23.8%. There were no cases of congenital malaria in 332 babies born of these mothers. The mean weight at birth of 237 babies born of mothers whose placentae were noninfected was 145 mg higher than that of 73 babies born of mothers whose placentae were found to be infected. The difference was statistically significant. There was no apparent correlation between neonatal mortality and infection of the placenta. Periodic investigation of a sample of 138 African infants followed up from the age of about 1 month through the 1st year of life and through part of the 2nd year showed that the mean parasite rate due principally to P. falciparum increased from 2.2% during the 1st quarter year to 20% in the 2nd quarter to 60-70% during the 3rd and 4th quarters and to over 80% thereafter. The infection rate when calculated in relation to the known length of exposure to infection shows that an equally long exposure leads to different frequencies of infection in the various age groups of the sample of infants investigated and that in the age group 1-3 months the parasite rate was significantly lower than might have been expected. Periodic follow-up of the mean weight curves of infection and noninfected infants indicated that the curves of both groups showed a considerable flattening out at about 5 months of age and later and that the flattening out is more pronounced in the infected group than in the noninfected. Records of 3540 autopsies performed upon children in Lagos during the years 1933-50 revealed that acute malaria can be incriminated as the cause of death in 9% of infants in 14% of children aged 1-4 years in 9% of children aged 5-7 years in 4% of older children and in 2% of adolescents. The number of deaths due to direct effects of malaria in the Nigerian population under 15 years of age amount to 35000/annum.

Of the many causes of ill-health among children of the tropics malnutrition is undoubtedly the most important. Apart from its direct effects on health, malnutrition also exerts an indirect effect by diminishing resistance to infectious diseases. The infant and child mortality rates in tropical countries are high. In India, according to the latest census figures, while infants and children under the age of 5 years constitute 16.5% of the total population, deaths within this age group account for 40% of the total deaths in the country. Infant and toddler mortality rates in some of the tropical countries are shown in Table I. A curious reflection of such high mortality in infancy and childhood is that in contrast with the situation in Europe the average expectation of life in tropical countries is actually higher at the age of 5 years than at birth. These data indicate the magnitude of ill-health among infants and children in tropical countries.

An orientation of modern child care viewed in the light of the trend in Scandinavia and the Netherlands places the following concepts before us. Now that infant mortality has reached a level of twenty per thousand births, we have arrived at an important point in the development of child care. This fact forces us not only to form an impression of the past and present, but likewise to look to the near future. A relatively drastic reduction of child mortality is still possible, although it is less spectacular than in the past. The rates in the near future can be predicted. Now that serious illness and death in children have become a secondary problem– except for perinatal mortality, some acute diseases, some chronic illnesses and the problem of accidents–the essential task of child health care has become the active promotion of the health of the child in order to achieve an optimal development. The doctor, if he wishes to acquit himself properly of this task, should have some idea of socio‐biology and vital statistics, a knowledge of child development and experience in public health, of which maternal and child health is a part that is closely connected to other branches. More and more maternal and child health is integrated into public health. Continuity and coordination in maternal and child health should be assured from conception up to and including adolescence. The observation of growth and development of the individual child in its longitudinal trend from birth until adulthood is the ABC of modern child health. The new child health strives towards an optimal development of the child and thereby towards optimal conditions in family, school and society. The term “maternal and child health” expresses more clearly than “child hygiene” what social obstetrics and pediatrics attempt to achieve. The continuity which characterises the development of the child should be the basis for the organization of maternal and child health. The new orientation of child health adapts itself to modern conditions in a civilisation entering the atomic age. In their interdependence and their interrelationship research, evaluation of methods and organisation deserve to be adjusted towards this modern constellation which they have not yet sufficiently attained.

Investigations are being undertaken on interracial groups of pre-school children in South Africa to investigate the bearing of socio-economic, rural, urban, and other factors on the health pattern. To throw light on the subject, mortality rates of children under 5 were studied among different groups of Bantu and Caucasians. As expected, a rise in socio-economic status in the Bantu was associated with a fall in child mortality. The relatively small difference between Bantu rural and urban toddler mortality rates was disappointing, as it occurred in spite of the far better public health facilities in the urban centres. The mortality differential between Bantu and Caucasian children aged 1–4 is believed, as by other workers, to be a far more sensitive index of the public health situation than that of infant mortality; the rate at age 1–2 may even more closely portray the public health state. It is concluded that the benefits accruing from enlightened health education and modern hygienic practices will not be fully manifest until there is an improvement in the nutrition of this toddler group, and in the adverse effects of poverty, ignorance and disease.