Around the world, the death rate of children has been dropping dramatically. Where 1 in 11 children under 5 years old died in 1990, it was 1 in 27 children in 2020. The total number was 12.6 million in 1990 and 6 million in 2020, according to the World Health Organization.
But a new study in The Lancet Global Health points out an underlying tragedy among the childhood deaths that do occur today. Too many are coming after children have been treated and often discharged from hospitals.
For the study, a network of researchers called CHAIN (Childhood Acute Illness and Nutrition Network), most of them from 6 sub-Saharan African and south Asian countries, collected a massive amount of data on 3,101 hospitalized children aged 2 to 23 months hospitalized between 2016 and 2019. Most had conditions such as diarrhea, pneumonia or malaria. 350 of the children died within six months of hospitalization. They looked not just at the children's medical condition at the time of hospitalization but also talked to the families about their social and economic situations, and they found that while malnutrition is at the root of the post-hospitalization deaths, other family and health problems play a role.
Among the children studied, a little more than 10% died within six months of admission. Among the malnourished, the rate was more like 20%. That's "astronomically high," says Dr. Judd Walson, a professor of global health at the University of Washington and an author of the study.
Another disturbing point emerges from the research: More than half of those 350 children who died after discharge died at home rather than in a health facility.
Understanding those deaths suggests ways to prevent them. "We know how to reduce the mortality when children are brought to the hospitals," says Tahmeed Ahmed, executive director of the International Centre for Diarrhoeal Research in Bangladesh and another author of the study. "Now we're learning about the factors that predispose some of these children to die. We need to harness all this information and bundle it up into a package that can be used to make children survive and thrive."
Without such a new approach, the statistics about childhood death will remain grim, the authors say. "We really think that we're at a place where without a fundamental shift in strategy, we're not going to continue to see the massive reductions in childhood deaths that we've seen in the past decades," says Walson.
NPR talked to Ahmed and Walson about what the study showed, and what can be done about it. The study was funded by the Bill & Melinda Gates Foundation, a funder of NPR and this blog. Here are some of the key findings.
Malnutrition plays a critical role in raising risk of death
It's no surprise that malnourished children fared poorly. The study found that "wasting" or "severe wasting" factored large in whether a child would still be alive 6 months or more after a hospitalization. Infants and toddlers who came into the hospital somewhat malnourished were nearly 3 times more likely to be dead 6 months after discharge than those who were not malnourished. Those who were severely malnourished were nearly 6 times more likely to be dead.
To that end, one of the solutions proposed by the researchers is to focus on improving nutrition for children. That might prevent hospitalization in the first place; it certainly would help afterward.
The role of the mother must be addressed
The study also showed that to break the cycle of hospitalization and subsequent death, children's caregivers – mostly mothers – should be considered patients as well by the health-care team. "Maternal mental health measured in these mothers around the time of their child's sickness is a major part of the pathway to mortality," says Walson. "The markers were not things like being suicidal or having psychosis but lost pleasure in day-to-day activities. The stresses on a poor mother with a sick child are enormous."
Many of the mothers of the children who died were over-stressed as home. Says Ahmed, "In a country like Bangladesh, where I come from, mothers have many other things to do at home – household chores, taking care of the husband, taking care of other children in many circumstances. We see a lot of anxiety, and a lot of depressive symptoms." Mothers with incomes might have to choose between work – and thus food on the table – and taking a child to the hospital. "In order to take care of children with malnutrition, we also need to take care of the health and nutrition of women and mothers," says Ahmed.
In terms of addressing mental health needs of mothers, the researchers point to successful interventions now in place that could be expanded and make a big difference. Walson and Ahmed are both fans of the concept of friendship benches, where women elders who've had some training in mental health issues are available to talk to anyone who wants to come by. Walson has done work in Kenya with SMS texting among new moms. "These are not high-cost interventions," he says.
Pay more attention to the discharge process
"This concept that we treat with a one-and-done approach where a child comes into the hospital, gets successfully treated for pneumonia and you're done with it really fails to recognize that some of these children remain at elevated risk for a very long time," says Walson. But there are ways to address the risk, starting with the end of the hospital stay. "We should be thinking about guidelines to help direct discharge planning more systematically. In addition, many children leave the hospital either against medical advice or when they still have clinical signs of illness," says Walson. "There are many reasons for this. Some families are afraid of hospital bills that they may have to pay, and they flee in the middle of the night." Or they have other children at home that need care, and they just can't stick around.
Money makes a difference
Information, education and financial aid within the hospital setting can help. Financial aid especially – "actually giving money to individuals to try to help them navigate the poverty in which many of them live," Walson says – not for every child leaving the hospital, but for those in high risk groups because they were especially malnourished or their family circumstances were especially dire. "If your child was in a very high-risk group, a targeted cash transfer around the time of discharge might be enough to ensure that they can return for care if and when they're needed," Walson says.
Other ideas include having health care workers in the communities available to deal with post-hospitalization problems occur.
Nutrition and nutritional supplementation might prevent hospitalization in the first place; it certainly would help afterwards.
Mental health support for mothers would also make a big difference. Walson and Ahmed are both fans of the concept of friendship benches, where women elders are available to talk to anyone who wants to come by. Walson has done work in Kenya with SMS texting for new moms. "These are not high-cost interventions," he says.
The outlook for the future
"When we started this work people really wanted a magic bullet – proof that this drug works, or that vaccine works," says Walson. "Until we have that support for caregivers and families and the children themselves, we're unlikely to really make a meaningful impact on this mortality."
Walson sees positive signs. "The World Health Organization is moving in this direction very quickly, and the funding community is also now really embracing this." The research network that did the current study has already started clinical trials on nutritional supplements and targeted cash transfers.
What inspires the researchers to keep going
Asking impoverished families about their efforts to help a sick child, and counting children's deaths when they fail, isn't easy work. In Bangladesh, Tahmeed Ahmed has been trying to prevent malnutrition and keep children healthy for three decades. I asked him what keeps him going – why does he keep trying when the work that he's doing quantifies so much tragedy, and he told me this: "There is frustration --why should so many children suffer needlessly? But when I first started my career as a medical doctor in Dhaka, I used to take care of really malnourished children every day, hundreds of them. When they recovered, there was a smile on the face of the children and there was a smile on the face of the mother. And that still inspires me."
Joanne Silberner is a freelance journalist and former health policy correspondent for NPR. She has covered global health issues since the outbreak of HIV.
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