Preterm birth and pneumonia kill most children under five years in India

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The Hindu

Use of incubators, supported infections control and kangaroo care will go a long way in preventing deaths even if the baby is preterm. Photo: V. Ganesan

Of the 6.3 million deaths in children under the age of five years, nearly 44 per cent of deaths during 2000-2013 occurred during the neonatal period (0-27 days after birth). Preterm birth complications, pneumonia and intrapartum-related complications have been found to be the three main causes of death in children globally.

The results are published today (October 1) in the journal The Lancet. According to Li Liu from the Institute of International Programs and the first author of the paper, there will be 4.4 million deaths in children younger than five years even in 2030 if the present trend continues.

In 2013, India, Nigeria, Pakistan, the Democratic Republic of Congo and China together accounted for half of deaths in the world in children aged under five years, and 52.5 per cent of all neonatal deaths. In the case of India and Pakistan, the three leading causes were preterm birth complications, pneumonia and intrapartum-related complications, in that order. In the case of China, the order was different — intrapartum-related complications, preterm births complications and pneumonia were the three leading causes.

Globally, preterm birth complications caused 15 per cent (0.96 million) of child deaths in 2013. This was closely followed by pneumonia. While pneumonia caused only 0.14 million deaths in neonates, at 0.8 million, it was the second major cause of death across the world in children aged 1-59 months. The two periods together accounted for 0.93 million deaths caused by pneumonia in children aged under five years. As expected, diarrhoea killed more children after the neonatal period — 0.02 million during the neonatal period and nearly 0.59 million during the period 1-59 months.

Case management of pneumonia and diarrhoea can be easily implemented and large number of deaths can be prevented with minimum intervention at little cost. Use of antibiotics to treat pneumonia and timely oral rehydration therapy in the case of diarrhoea can prevent deaths in children under five years.

“Deaths due to pneumonia and diarrhoea can be reduced in India. The coverage [of antibiotics and oral rehydration therapy] is not wide enough in India ... it’s not sufficient,” Prof. Robert E. Black from the Johns Hopkins Bloomberg School of Public Health and the Corresponding author of the paper told this Correspondent. “Pneumonia [occurs] during and after neonatal period and diarrhoea [occurs] mainly after neonatal period.”

For pneumonia less than 30 per cent of children in India receive antibiotics, and over 600 million defecate in the open and have very poor access to clean drinking water resulting in most cases of diarrhoea.

“Compared to managing premature babies which involves sometimes months of intensive care, complex medical treatments and follow-ups, treatment for pneumonia (early diagnosis and three-day antibiotic treatment costing about Rs.25) and diarrhoea (oral rehydration therapy) are relatively straight forward and will save a lot more lives in the short term,” Dr Nicholas Furtado Attending Paediatrician, University of Illinois Hospital and Health Sciences System, Chicago said in an email to this Correspondent. Dr. Furtado was not involved in the study.

“In the long term, prevention of pneumonia by immunisation, acute diarrhoea by improving water supply and sanitation, and decreasing prematurity through quality care before, during and after birth would be the most important ways to decreased under five mortality rate,” Dr. Furtado noted.

Explaining why pneumonia cases are more common than diarrhoea, Dr. Furtado said: “During the neonatal period the lungs are immature and more prone to infection.”

Simple measures like exclusive breastfeeding for six months can further cut the number of diarrhoeal episodes and deaths in children. However, only about 46 per cent of children in India were exclusively breastfed for six months during 2005-2006.

It is to be noted that reduction in pneumonia, diarrhoea and measles during the period 2000-2013 has led to nearly 50 per cent decrease in deaths in children under five years.

Preterm births

India is one of the 10 countries with an estimated 100,000 to 250,000 preterm births in 2010. Preterm births cause about 50 per cent of neonatal mortality. “The causes of preterm births are not known. Conditions like high blood pressure in pregnant mothers and infections during pregnancy are some of the reasons. In a majority of cases no cause can be attributed. It’s hard to prevent preterm births,” said Prof. Black.

“Preterm birth complications will probably remain the leading cause of neonatal and under five deaths,” the paper notes.

But measures like supported infections control, kangaroo care (skin to skin contact of the baby with the mother to keep the baby warm) and use of incubators will go a long way in preventing deaths even when the baby is preterm. “We can’t prevent preterm births but can treat them and prevent most of the deaths,” Prof. Black said.

“In this analysis we didn’t include small for [gestational] age as a risk factor,” he said. Most small-for-gestational-age infants are born in India, Pakistan, Nigeria, and Bangladesh.

A July 2013 Comment piece in The Lancet notes: “In 2010, an estimated 32·4 million infants were born [at term but] small for gestational age in low- and middle-income countries (27 per cent of live births).”