Pediatric Primary Care

The health status of all children must be viewed with
a global lens. Whether considering pandemic infectious diseases or the global emigration of populations between continencs, the health of all children is
interconnected worldwide. Inequalities in the health srarus
of children globally and nationally are largely determined
by common biosocial faaors affecting health, which include
where they are born, live, are educated, their work, and their
age (World Health Organization [WHO], 2014a). The biosocial faaors also include the systems in place co address
health and illness in children and families.
The biosocial circumstances or social dererminanrs of
child health are shaped by economics, social policies, and
politics in each region and country. In order to impact
health outcomes, scaling up the efforts nationally and globally to build better health systems is required. Significant
progress has been made in reducing childhood morbidity
and mortality using this approach. The framework of the
United Nations Millennium Development Goals 2014
(United Nations, 2015) and the Healthy People 2020 (U.S.
Department of Health and Human Services [HHS] Office
of Disease Prevention and Health Promotion, 2015a) goals
ser the mark for improving child health status. Ir is for
societies to embrace and prioritize these goals on behalf of
This chapter presencs an overview of the global health
status of children, including the issue of global food insecurity, child health status in the United States and current
healrh inequalities, the progress toward achieving the Millennjum Development Goals and Healthy People 2020
targecs, the effect of health care reform in the United States
on access to care for children and adolescents, and the
important role pediatric health care providers have in advocating for polices that foster health equity and access co
quality health care services for all children and families. The
final section addresses rhe health frameworks and rools
available co pediatric health care providers to assess and
monicor che health and well-being of children from infancy
to young adulthood.
Global Health Status of Children
Thirty-five million children younger than 20 years old are
part of the international migration of populations across
continents (UNICEF, 2014). Emigrant children have
increased health and educational needs chat impact the
health and weU-being of communities; many of these communities have fragile health care sysrems. The United
Nations Convention on the Rights of Children (UNCRC)
charter was established 25 years ago and declares the
minimum entidements and freedoms for children globally,
including the righc t0 the best possible health (Uruted
Nations International Children’s Fund, 2009). Emigrant
children have the right co be protected under this charter
(Box 1-l ). Governments are advised to provide good quality
health care, clean wacer, nutritious foods, and clean environments so that children can stay healthy. The charcer is
founded on the principle of respect for the dignity and
worth of each individual, regardless of race, color, gender,
language, religion, opinions, origins, wealth, birth statuS, or
ability. The UNCRC continues co work on ensuring chat
all children have these basic human rights and freedoms.
Special emphasis is placed on the responsibility and strength
of families and the vital role of the international community
to protect and secure the rights of children, including access
to health care and primary health care services.
Health equity is the absence of unfair or remediable differences in health services and health outcomes among
populations (WHO, 2014b). Although the rate of child
mortality globally remains high, there have been significant
CHAPTER 1 Health Status of Children: Global and National Perspectives
The UNICEF conventions include 42 articles that are
summarized in the following list. They represent 1he worldwide
standards for the rights of children. The conventions apply to all
children younger than 18 years old. The best interests of
children must be a top priority in all actions concerning children.
• Every child has the right to:
• Life and best possible health
• Time for relaxation, play, and opportunities for a variety of
cultural and artistic activities
• A legally reglstered name and nationality
• Knowledge of and care by his or her parents, as far as
possible, and prompt efforts to restore the child-parent
relationship if they have been separated
• Protection from dangerous work
• Protectfon from use of dangerous drugs
• Protection from sale and social abuse, exploitation,
physical and sexual abuse, neglect and special care to
help them recover their health if they have experien~
such toxic life events
• No incarceration with adults and opportunftfes to maintain
contact wlth parents
• Care with respect for religfon, culture, and language if not
provided by the parents
• A full and decent life in conditions that promote dignity,
independence, and an active role ln the community, even
if disabled
• Access to reliable Information from mass media,
television, radio, (lewspapers, as well as protection from
information that might harm them
• Governments must do all that they can to fulfill the rights of
chlldren as listed above.
‘UNICEF stands lor the lull name Unltl!d Nations lnterria11onal Childl’eo’s
Emergency Fl.ind. In 1953. Its name was sho<tened 10 the United Nations
Cl’llloren’s Fund, However, 1118 original acronym was retained.
reductions in the rate over the past few decades. Since 1990,
child mortality in children younger than 5 years old has
decreased by 47% due co targeted policies to reduce childhood pneumonia, diarrhea, and malaria and also co reduce
the number of precerm births and perinatal complications.
Despite these efforts, 6.3 million children younger than 5
years old die each year worldwide (Wang cc al, 2014). To
reach the World Health Organization (WHO) tatget of
two-thirds reduction jo mortality for childten younger than
5 years old, more rapid progress is needed, particularly in
sub-Saharan Africa, where the highest rate of infant mortality occurs. Currently, sub–Saharan Africa and Southern Asia
account for 81% of the infant morrality globally (United
Nations, 2015).
Diarrhea and pneUJllonia remain the leading infectious
causes of childhood morbidity and mortality globally. The
highest proportion of deaths due to these two co?~itions is
in children younger than 2 years old; undernurrmon, suboptimum breastfeeding, and zinc deficiency contribute significantly co the mortality rate from these diseases. (Zinc
reduces the duration and severity of diarrhea and likelihood
of reinfections for 2 to 3 months. As a micronucrient, it js
essential for protein supplementation, cell growth, immune
function, and intestinal transport of water and electrolytes
[Khan and Sellen, 2015).) Rotavirus is the most c.ommon
cause of diarrhea globally and Streprococcu.r pnrumoni,u is
the leading cause of pneumonia (Walker et al, 2013). Both
of these are vaccine-preventable infectious diseases.
Successful vaccination programs have markedly reduced
the mortality caused by some infectious diseases, particularly measles and tetanus. Cambodia serves as a noteworthy
example. To reduce childhood mortality in children younger
than 5 years old, Cambodia targeted measles vaccination
due to the high mortaljty associated wjth the disease. Within
a decade, health workers were able to increase the rate of
measles immunization by 71 % in children younger than
1 year old (United Nations, 2015). To achieve complete
eradication of measles, WHO helped the Cambodian
national immunization program to idemify and reach
communities at high risk for low rates of immunizations.
A national immunization program also began providing
a booster dose of a measles-containing vaccine after
18 months old. The result was measles eradication in
Cambodia since 2012. Such sustained immunization programs by partnerships between communities, governments,
and international organizations can markedly improve
global child health status. However, emerging viral and
bacterial infectious diseases present complex challenges to
public health infrastructure and threaten the global progress
made on reducing childhood mortality (see Chapter 24).
The majority of the extremely poor live in five
countries-India, China, Nigeria, Bangladesh, and the
Democratic Republic of Congo. The risk of maternal death
from pregnancy-related complications and childbirth in
developing regions is 230 deaths per 100,000 births; this
rate is 14 times higher than jn developed countries (United
Nations, 2015).
Global Food Insecurity and Effect on
Children’s Health
Hunger and undernucrition are often referred to as food
insecurity. which is the condition that exists when populations do not have physical and economic access to sufficient,
safe, nutritious, and culturally acceptable food to meet
nutritional needs. Food insecurity occurs in impoverished
populations in devdoping countries and in industrialized
nations, particularly among migrant populations. Children
affected by migration and family separ.icion are at risk for
food insecurity and are vulnerable co further health consequences, including exposure to exploitation and child trafficking. Growing evidence on climate change indicarcs the
dramatic effect on food crops that lead to food distribution
issues, which is one of the primary contributors to food
insecurity (Fig. 1-1}.
Globally, undernutrition is an important determinant of
maternal and child health and accounts for 45% of all child
1 Pediatric Primary Care Foundations
Health effects
illness and death
Extreme weatherrelated health effects
Regiona: wuether
changes ~–, Co111amination
Air pollution-related
health effects
• Hea\waves .;· !”ransmission
dyflarn,cs Water- and food-borne
diseases • Extreme weather
• Temperature ,; Food
• Precipitaiion ·:.’I Migration Vector- and rodent-borne
………………. . Psychological effects
Malnutrition :····)–
measures ..
………..•.•. …••••….
• Figure 1-1 Health effects of climate change.
deaths in children younger than 5 years old (United Nations,
2015). Suboptimal breastfeeding remains a problem in
developed and developing nations. Children who are exclusively breastfed for the first 6 months of life are l 4 times
more likely to survive than non-breastfed infancs {United
Nations, 2015). Vitamin A and zinc deficiencies also contribuce co the disease burden in mortality for children
younger than 5 years old. In developing countries, 55
million women are stunted from undernucrition and lack
of micronuuiems, including iron, folic acid, vitamin A, and
zinc (Save the Children, 2015). Preventable nutritional deficiencies are a compelling case for further implementation
of che Millennium Developmenr Goals and increased
supporr for rnicronutrient supplementation for children in
devdoping regions.
United Nations Millennium Development
Goals: Project Goals
The Millennium Projecr, a global health project of research
and srudy co improve prospecrs for a better future for
humaniry, publishes a framework (Millennium Development Goals) annually to address the challenges, both local
and global, facing the world populations. Health and access
co health care in the context of social determinanrs are
covered in the document. Figures 1-2 and 1-3 and Box 1-2
illustrate the collaborative action .required among governments, international organizations, corporations, uttiversiries, and individuals and societies to address the issue of
health eqwry from a global perspective (The Millennium
Project, 2014).
One of the main goals of the Millennium Development
Goals framewo rk is co reduce infant mortality by ac lease
two-thirds by 2016 in 27 countries. Eight goals consist of
21 quantifiable targets measured by 60 health indicators
(see Fig. 1-3). They provide a framework for the international community to ensure socioeconomic development
reaches all children.
Progress on the Millennium
Development Goals
Significant progress has been made in many areas, including
reductions in child mortality and preterm birth. In 30
developing countries, progress toward achieving reductions
in child mortality has been faster than predicted due co
income, education, and secular shifts in living and work
environments (Wang et al, 2014). However, increased assistance in improving economic status and levels of ma.cernal
education is required to susrain the e£forr.
Since 1990, progress has been made by reducing world
poverry by half, access co clean drinking water has improved
for 2.3 billion people, chronic undernutririon in children
causing stunting has decreased by 40%, and 90% of children in developing regions are attending primary school
(United Nations, 2015). The achievements are the result of
the collaborations becween governments, international
communities, civil societies, and private corporations. To
make further sustained progress, expansion and acceleration
of the interventions by the WHO are required to target the
leading causes of death in the target councries.
The economic growth potential remains strong in
many of the developing regions, and partnerships between
CHAPTER 1 Health Status of Children: Global and National Perspectives
Sustainable development
and climate change
organized crime
Status of women
Peace and conflict
Education Health issues
and resources
Global foresight
and decision-making
convergence of IT
• Figure 1-2 Fifteen global challenges facing humanity. IT, Information technology.
[ .! ] Goal 1, Erad<ale “””‘me P™rty ood hm,ge,
[]] Goal 2, Aoh;.,,e uoh,ern•I prim,,y eduoalioo
[2] Goal 3• Promol& geode, equ,ltty ,ad empowe, womeo
[ I ] Go,i ,, Reducoohlld mortalily
[ f}i ] Go•I s, Imp””” m”””” health
[ I!] l Go,1 6c Combat HIV/AIDS, m,l,ri,, ,ad othe, di’88Ses
[ Jt- j Go,t Hosu,e em,i,oomoot,t ,u,taio,~ttty
[ mi:) ] Go,t e, o.,.~, • global p,rtoo,st,lp to, -~pmem
• Figure 1-3 List of eight MIiiennium Development Goals. AIDS,
Acquired immune deficiency syndrome; HIV. human immunodeficiency
Births before 37 weeks’ gestation can result in lifelong
disabilities, and children born preterm are at higher risk of death
during their first few days of life.
Race and Ethnicity
African American, non-Hispanic
American Indian or Alaska Native
Hispanic mothers
White, non-Hispanic mothers
Asian or Pacific Islander mothers
Preterm Birth Rate
11 .6%
The African American preterm birth rate is more than
1.5 times higher than that experienced by Asians or Pacific
HHS Office of Disease Prevention and Health Promotion: L.Hl infographic
gallery: matemal, infant, and child health (April 2014): pretemi births and Infant
deaths, (Website):
-health-indicators/LHl-lnfographic-Gallery#Apr-2014. Accessed August 13,
J Pediatric Primary Care Foundations
developing countries and nongovernmental organi’llltions
(NGOs) continue to provide significant sources of dcvclopmenral assistance. Official devdopment assistance is at the
highest level ever recorded by the United Nations agency
parmers (United Nations, 2015). Developing countries
require further debt relief, reduced trade ba.rrlers, improved
access to technologies for renewable energy production, and
enhanced prorecrion from and response ro environmenral
disasters to sustain current advances. Further, global political efforts are required to support achievement of the Millennium Development Goals beyond 2015 and a renewed
commitment to the furure health and weU-being of children
Health Stat us of Children
in the United States
Globalism will increasingly affect child health in the Uni red
Stares. The demographic mix of children and families cared
for by pediatric beaJch care providers in the United States
has become increasingly complex, with a greater number
of children living in poverty who are at increased risk for
chronic physical and menral health conditions and exposure
co intimate parmer violence (IPV), gun violence, and abuse
(American Academy of Pediatrics [AAP], 2014). Child
poverty rares in che United States remain higher chan in
other economically developed nations. One in five children
(out of 16.3 million) in the United Stares live in families
with incomes below che federal poverty level (FPL) (Annie
E. Casey Foundation, 2015). The rate of household poverty
is higher (one in three) for Latino and Afriaul American
Mosr concerning among the child healrh indicators is the
percentage of ovcrwcighr and obese children. Seventeen
percent of youth are “obese” as defined as a body mass index
(BMI) greater than rhe 95ch percentile for age on the BMl
age and gender-specific growth charts. For infants and children younger than 2 years old, the rate of obesity is 8.1 %
as determined by weight for recumbent length charts.
Alchougb races of obesity among children and youth remain
high, surveillance srudies show chat the rate of increase in
overweight and obesity has stabilized. The obesity rate
among 2- w 5-yea.r-olds showed a significant decrease of
5.5% between 2004 and 2013 (Ogden et al, 2014).
Obese and overweight children and youth are more at
risk for developing adult health problems, including heart
disease, rype 2 diabetes, stroke, and osceoanhriris. Poor
eating panerns are a major factor in the high race of obesity
among children and adolescents. Children’s diets have been
out of balance over the past two decades with too much
added sugar and sarura.ced fats, and limited fruits, vegetables, and whole grains. Of all the child health indicators,
overweight and obesity will significantly affect the cosc of
p roviding health care services in che United States in the
coming years. Chapter IO discusses childhood obesity, the
comorbidiries, and the related cost of health care.
Food Insecurity in Children
in the United States
Despite many government food assistance programs, nearly
one in five children in the United States lives in a foodinsecure household. Children who are food insecure are
more likely to have poorer general heakh, higher races of
hospicalizacion, increased incidence of overweight, aschma,
anemia, and experience behavioral problems. Factors other
chan income do impact whether a household is food
insecure. Maternal education, single-parent households,
intimate-parrner violence, and parental substance abuse also
contribute to food insecurity in households. Children living
in households where the mother is moderarely-ro-severely
depressed have a 50% to 80% increased risk of food insecurity (Gundersen and Ziliak, 2015).
Three-quarters of children spend some portion of the
preschool years being cared for outside of the home.
Depending on child care arr.angements, rhe care can contribute co or ameliorate the effects of food insecurity for
children. Young children who attend a preschool or child
care center have lower food insecurity, whereas children
cared for at home by an unrelated adult are at higher risk
for food insecurity (Gundersen and Ziliak, 2015). The
Supplemental Nurrirional Assistance Program (SNAP), rhe
Special Supplemenral Nutrition Program for Women,
Infants, and Children (WlC) and the School Breakfusr
Program (SBP) are federally funded programs wich the
purpose ro combat childhood hunger. In 2013, 11 .2 million
children participated in the SBP for a free or reduced price,
and WIC served 8.7 million women and children at a cost
of $6.45 billion (Gundersen and Ziliak, 2015). The.average
monthly WJC benefit for families is $43.