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why child health

• children and young people are still large proportion in whole population
• large disease burden in children
  • 60% of malaria deaths, 10% of TB cases
• children are very vulnerable not only to infectious diseases but also injuries of all causes
• neonate and other children groups are still neglected and lacking epidemiological data
• children are not little adults
• preterm birth, neonatal and childhood health affect long-term health and wealth in later adulthood
• children are future

children death

• 5.9 mil. < 5 y/o died in 2015
  • 16,000 children death everyday
  • most in sub-Sahara and SE Asia
• pneumonia, malaria, diarrhea, poverty...
• the top death cause < 5 y/o is pneumonia
• 47% of <5 y/o deaths are neonates

pneumonia

framework for pneumonia control

• WHO
  • protect
    • exclusive breastfeeding for 6 months
    • adequate nutrition
    • prevent LBW
      • smoking cessation, maternal health control, prevent of young marriages
    • reduce indoor air pollution
    • handwashing
  • prevent
    • vaccine - pertussis, pneumococcal and Hib
    • prevention of child HIV
    • cotrimoxazole prevention for HIV children
    • zinc supplementation for diarrheal children
  • treat
    • appropriate medical treatment

IMCI Integrated Management of Childhood Illness

Integrated Management of Childhood Illness (IMCI)

HIV in children

epidemiology

• 2.8 mil. amongst 38 mil. LHIV are children 0-19 y/o
• DRC in 2019
  • 333,778 LHIV
  • 14,546 pregnant PMTCT
  • 22,828 infants

transmission

• 95% mother to child transmission (MTCT)
  • intrauterin 6-7%
  • prepartum 19%
  • postnatal/breastfeeding 10%
  • 35% risk in total
  • risk factor of MTCT
    • high VL, low CD4, subtype C HIV 1, cracked nipples, prematurity, ...
• sexual abuse
• sex in adolescent
• blood transfusion
• cultural actions; scarification, circumcision, tattoos by unsteriled knives

clinical features

• no symptoms at birth
• no specific symptoms after birth:
  • chronic or recurrent diarrhea
  • pneumonia (PCP)
  • oral thrush
  • poor growth
  • recurrent severe infection
  • chronic parotitis
  • bacterial infections

diagnosis

• very difficult because of passive maternal antibody up to 18 months of age
• HIV DNA, HIV RNA, P24 antigen
• 2 positive virology test means definitive HIV infection
• 1 positive virology test means presumed HIV infection
• in the absence of virology test result, based on clinical conditions
• should be confirmed by antibody test after 18 months of age
• refer diagnostic algorithm in the handout

treatment

• all infants irrespective of WHO Stages or CD4
• first line:ABC/3TC+DTG

prophylaxis

• HIV positive mother not under ART at birth or mother HIV diagnosed after delivery are high risk of MTCT
• HIV positive mother under ART at birth, refer algorithm on the handout
• NVP for exposed infants
• options for infant feeding by HIV infected mother, refer the handout
  • cultures in such DRC make HIV infected mother difficult to choose exclusive formula feeding, because such mother usually lives with big family and HIV infected status would be secreted due to stigmatization
  • exclusive formula feeding criteria: AFASS

HIV-TB coinfection in children

• early HIV infection: TB presentation same as HIV negative children
• late HIV infection: disseminated TB
• older children with HIV: TB same as adult
• diagnosis same as HIV negative children
• treatment

injury, accident, disability in LMICs

epidemiology of injuries

• 5 mil. deaths (in all ages) due to injuries per year
  • 9% of global mortality
  • more than three major IDs with 3 mil. deaths
  • injuries are neglected more than infectious diseases
• proportions of injuries-caused deaths in 2012
  • road traffic 24%
  • falls 14%
  • suicide 16%
• children deaths in HICs
  • <1 y/o suffocation is the major
  • 1-4 y/o traffic accident, drowning, fall
  • 5-9 y/o traffic accident, drowning, burn

suffocation

• overlay by other person
• entrapment (wedging)
• strangulation of neck
• choking
• confinement like in fridge or laundry machine

burn

• 100,000 deaths <20 y/o per year
• girls are more suffered from burn than boys
  • possibly because girls tend to help cooking

drowning

• leading cause of children death in WPRO and South East Asian countries

poisoning

• seasoning, alcohol, fuel in kitchen
• medicine, drug

bite

• wild or strayed animal bites
• poisonous insect bites

road traffic accident

• deaths due to road traffic are increasing in LMICs contrary to HICs because of accelerated motorization without improvement of road conditions, traffic safety education and traffic legal system
• Haddon Matrix

violence

• child abuse
• human trafficking
• illegal organ trade
• sexual exploitation
• child labor
  • 158 mil. children 5-14 y/o
  • hazardous work; mines, chemical work,
• child soldier
• witch hunt

disability

• sharp decline of children deaths directly linked to increase of children in disabilities
• "impairment, disability, handicap" transformed into social model
  • disability is activity prevented by society
  • handicap is participation prevented by society
• vicious cycle of disability and poverty

neonatal health

• year to year decline rate of neonatal deaths is lesser than that of overall child death
  • another neglected health problem in LMICs

prescribing antimicrobials for children and pregnant women

children

• first line empiric antimicrobials for neonatal sepsis:
  • ampicillin and gentamycin
  • cefotaxim and gentamycin
  • ceftriaxone is not recommended because of risk of bilirubiuria
  • but in fact AMPC/GM or CTX/GM doesn't cover well neonatal sepsis pathogens now.... meropenem might be the best
• dose varies not depending on weight but also on age, especially in neonates and preterm babies, because of differences of absorption, distribution, metabolism and excretion

pregnancy

malaria in pregnancy

• risk for severe malaria
• maternal anemia
• spontaneous abortion/stillbirth
• premature birth/LBW
• treament
  • severe malaria in pregnancy - artesunate IV
  • uncomplicated falciparum malaria in pregnancy - ACT
• primaquine for vivax hypnozoite is contraindicated in pregnancy
  • should wait pregnancy termination
• chemoprophylaxis
  • doxycycline is contraindicated

TB in pregnancy

• treatment
  • first-line drugs cross placenta but seemingly not harmful
  • use same regimen as non-pregnant women, 2RHZE+4RH
    • but Z is not recommended in US