Bishnu Dutta Paudel
CHILD HEALTH AND PAEDIATRIC MEDICINE
Nepal is a small land-lacked country situated in between two big Asian super-powers China and India. This country is known as country of Himalayas because of highest mountain "Everest". This is a country where lord Buddha was born. Nepal is unique among the nations of the region. It was never colonized in past. Nepal is a member of SAARC. SAARC (South Asian Association for Regional Co-operation) is formal regional alliance of seven south Asian countries. Other six countries are India, Pakistan, Sri Lanka, Bangladesh, Bhutan and Maldives.
Nepal is a land of diversity with marked multi-Ethnic characteristics. By the seventh country the country had Sanskrit studies and arts and crafts. More especially, Nepalese arts and crafts reveal an established and rich tradition that is clearly indigenous.
The cast structure in the country is based on the Hindu Varna system. Manu is regarded as the founder of four cast Brahmin (Priest), Kshatriya (warrior), Vaishya (trader) and Shudra (untouchable). The highest ritual position is occupied by Brahmin and Kshatriya.
For Administrative purpose Nepal is divided into 14 zones 75 districts 4000 VDCs (Village Development Committees) and 34,000 wards. The Ilakas is an administrative service level located between the district and VDCs with 9 Ilakas per district. Politically Nepali has multiparty democracy with Monarchy according to now constitution which was promulgated on 9th Nov. 1990. There are two houses of parliament an upper house consisting 50 members and house of representatives with 205 members.
Democratic Government commitment in children welfare is proved by the ratification by HMG (His Majesty Government) of convention of the rights of this child on 19th August 1990. Government has accepted the international marketing code on breast milk substitutes. This as been adopted since 1st Jan. 1991. The promulgation of the new constitution of the kingdom in Nov. 1990 which contains clauses of special benefit to children including right to citizenship, Equality, Education including in the mother tongue, a right against exploitation and special protection for the disadvantages, such as disabled children and orphans is positive step. Like wise the signing of summit declaration and plan of action, committing Nepal to provide children a special focus in the national agenda and a national programme of action for children and development of the 1990s has been finalized by the national planning commission.
Even though Nepal is only Hindu Kingdom of world where about 90% population is Hindu other religious people like Buddhist (5%). Muslims (2.7%), Christians, Jains are living with Hindus as like Brothers and sisters. there is no racial war.
The population of Nepal is approximately 20 millions with very high population growth rate i.e. 2.1%, Male Female ratio is 51:49. Among them 42% are under 14 age group.
The primary Geo-physical division in the country is between its three distinct belts the mountains in the north, which border the Tibetan Plateau; the hills in the middle and the narrow plain bolt of the tarai to the south. Ethnic and linguistic divisions tend to follow the same division, with the north dominated by tibeto-burman speaking and largely Buddhist group, the middle hills with a concentration of Nepali speaking Hindu group and the south with the Indo-Aryan Hindu groups, Largely characterized by Malthali and Bhojpuri speaking people.
Economically Nepal is one of the poor countries of the world. It's GNP per capita is 180$. Majority of Nepalese are under poverty line. About 35% people are literate. Between 1952 to 1986, male literacy rate increased from 9.5% to 51.8% while female from 0.7% to 18%.
The health status of Nepalese are not so good including the children. Life expectancy for males is 55.38 an for female 52.6 at birth.
One out of seven children die on their first day of life in every thousand birth in Nepal. About 70,000 children die each year. Under five mortality is about 128. Infant mortality rate (IMR) was previously 186 in 1960 and 107 in 1991. At present IMR is 102 per thousand live-birth. IMR is higher in rural areas than in urban areas (115 Vs 78-80). In certain remote areas it is as high as 230.
Through different levels health care is delivered to people of Nepal including children
Sub-Health Post ----- Health Post ----- Primary Health Center ------District Hospital ----- Zonal Hospital ----- regional Hospital ----- Central Hospital.
Sub-Health Post and Health Post are managed by paramedical. There are no Doctors in these Health care delivery centers. Primary Health center and district hospital are managed by general doctors. There are no paediatricians in these two institutions. From Zonal Hospital onwards paediatricians are available for service.
There is only one paediatirc hospital in Nepal in central level which act as tertiary referral center. Most of the paediatricians of the country are engaged to manage the only paediatric hospital which is situated in capital. Still this hospital is shortage of paediaticians. Because among two thousand doctors working in Nepal only about a dozen of them are degree holders in paediatric medicine and there are few more diploma holders in child health. Besides government institutes there are several NGOs (Non Governmental Organization ) and INGOs (International Non Governmental Organization) working in the field of health. Save The Children (UK, USA AND JAPAN), UNICEF, Family Planning association, Red Burnna, INF, BNMT are mainly working in the field of mother and child health.
THE COMMON CAUSES OF CHILDHOOD ILLNESS
In neo-natal period congenital abnormalities, prematurity, birth-injuries, neo-natal tetanus, low birth weight (LBW) etc. are common problems. It is estimated that about 49% death among infants takes in this vulnerable period.
Data of LBW are based on small samples in 1985, an estimate of 23.2% was made in four hospital. A later survey gave exactly the same figure aggregated but with marked differences noted between ethnic groups. It is possible that nutritional and other health feature of the mother of these ethnic groups would have an effect on the child. At the only maternity hospital of country which is located in Kathmandu the average birth weight is 2.77kg. over all a low birth weight rate of 20.7% is reported. 42.28% of LBW were found in Brahmins and Kshatry followed by 39.0% LBW in newer groups, 9.04% in Tibet Burman groups.
TETANUS:
Reported incidence of neo-natal and all form of tetanus is highest in far western tarai.
Tetanus remains a common and often fatal disease in our country specially of new born whose cord has been cut with unsterile instruments and treated with contaminated dressings. Several surveys have been conducted out to determined the incidence of neo-natal tetanus. A 1980 survey carried out in the tarai showed 15 neo-natal tetanus deaths per one thousand live birth in an area were there were 37 neo-natal deaths per thousand, neo-natal death attributable to tetanus therefore cause to 39% of the total neo-natal deaths.
DIARRHOEAL DISEASES:
In Nepal still diarrhoeal diseases is number one leading cause of death in children. About 45 thousand children a year die only due to diarrhoea. But due to increase in awareness in health sectors specially about oral rehydration solution (ORS) death due to diarrhoeal diseases is decreasing day by day. Even in those parts of country where packets not available people are making locally salt, sugar and water solution to prevent from dehydration. Through the community water supply and sanitation programme, our government , with the assistance of UNICEF, local and international organization is providing improved drinking water facilities and sanitation education all around the country which is helping to reduce diarrhoeal diseases. At present over 700 thousand people have access to safe drinking water.
ACUTE RESPIRATORY TRACT INFECTIONS (ARI)
ARI is second leading cause of death in children. Approximately 40 thousand children of under 5 die due to ARIs. Malnutrition, passive smoking, air pollution, domestic smoke pollution and working in carpets factories by mothers carrying their children contribute to high incidence of repetative respiratory tract infection. But nowadays ARI is decreasing. Even paramedical are trained to diagnose ARI by looking and counting respiration rate and managed b giving simple medication like paracetamol and course of antibiotic.
MALNUTRITION
The problem of malnutrition is serious in Nepal about 50% of the children of under 5 years age group are suffering from malnutrition. Malnourished children suffer from other problems also. So while managing malnourished children other problems are also tackled side by side.
IMMUNIZATION
The expanded Immunization division in the ministry of health is the main agency to provide immunization in all 75 districts of Nepal. Present government has given high priority to immunization. Previously immunization coverage was very poor. But infectious diseases: Tetanus, Tuberculosis, Diphtheria, Pertusis, Polio and measles. Good immunization coverage is a major factors for declining IMR in Nepal. Our government is planning to increase immunization coverage to 95% by the year 2000 AD.
TUBERCULOSIS (TB)
Young children are more vulnerable to TB in Nepal because of low socio-economic status, poor housing, over crowding poor nutritional status. By the age of 14 it is estimated that as many as 86% of children in urban Kathmandu will have been exposed to the tuberculosis bacillus. The lower rate of exposer are in the mountain area. National incidence rate of sputum positive case is 1.1/1000.
DIPHTHERIA AND PERTUSIS:
The significance of these diseases for child health is decreasing in Nepal probably due to increasing number of vaccination coverage. In 1983 estimates show an annual diphtheria incidence rate of 14.5 per 100,000 population an annual pertusis rate of 436 per 100,000.
In Kanti Hospital 7 cases of diphtheria were reported in 1983-84 and only one case in 1988-89.
ENCEPHALITIS:
Japanese Encephalitis was recognized in Nepal for the first time in 1978. The disease is mainly found in the tarai, where pigs and birds act as host. Japanese Encephalitis carries a high fatality rate. Over the period 1978-1984 of 2508 admission to hospital 886 patients died -- a fatality rate of 35.32%. Worst affected are school children and these over the age of 15 but a significant percentage 155 were in the 0-4 years age group. There are more cases among males than female and the disease reaches epidemic forms in alternate years. Seasonality is noted with a peak in cases between May to October with very few cases in the winter months. Although a vaccine is available it is rarely used.
KALA-AZAR
Most cases are reported from central and eastern tarai. Data obtained is from hospital records. the cases of 446 were reported in 1990. Among which 34 died. The disease mainly affected the children of 5-15 age group. Most of the patients were reported from Morang and Siraha districts.
WORM INFESTATIONS:
Worm infestation is quite common in Nepal. Almost all children suffer from one or other worm infestations. This makes the malnourished children health more malnourished.
ANAEMIA
There has been only one countrywide effort to document the status of Anaemia in Nepal, under taken in 1975 during the national nutritional status survey. The survey measured the haemoglobin levels of the children 6 to 72 months of age.
Following that attempt there have been some sporadic studies to document the anaemia status of children. The surkhet anaemia survey in 1981 found that 32.7% of children 0-4 years age group were suffering from anaemia of haemoglobin of less that 9 gm./dl. Hookworm is important cause of anaemia in Nepal.
MEASLES:
In well nourished children this viral infection is relatively mild but in malnourished children it could be fatal. Measles infection is associated with diarrhoea, TB and other problems. A 1983 estimate gave a rate of 567:1000 in Dhanusha and rate of 124:1000 was estimated in Kathmandu valley.
LEPROSY:
The leprosy mission conducted a survey in Lalitpur district which found a rate of now leprosy cases of 0.63:1000 school children.
POLIO
A survey by Lothenberg in 1983 in four districts found the polio attributable lameness prevalence rte of 2:1000 children aged 6-10 years. With better immunization it is hoped that this problems is now under control and could e eradicated by 2000 AD.
MALARIA
One of the causes of anaemia in new born is malaria in pregnancy. Following initial success in control the incidence rate rose steadily from some 26000 cases in 1992 peaking at 42000 in 1985, with DDT resistance strain of Anopheles mosquitoes and chloroquine resistance forms P. faleiparum. In the following four years the incidence of malaria fell to 23000 cases in 1989. This gives continuing cause of concern, especially in southern plains. Earlier success have been virtually nullified and malaria rates actually rose between 1983 to 1985 up to 102 positive cases per 100,1000 population.
MENINGITIS:
Meningitis causes mental impairment, permanent motor neuron damage and deafness. In Nepal children appears to be most affected member of population during epidemics which follow cyclic patterns. The disease is epidemic in Nepal, more common in winter months and primarily affecting children. Although a vaccine is available it is not widely used. An epidemic occurred in 1984-1985 with an over 10% of fatality rate. In more recent years the number is declining.
VIT. "A" DEFICIENCY:
Vit. A deficiency is a leading cause of blindness in Nepal. The nationwide surveys were conducted in 1980-81. No nationwide surveys have been conducted after 1981. The finding of survey confirmed Vit. A deficiency is a public health problem in Nepal. Children suffering from Vit. A deficiency present from night blindness to total blindness. Besides vision Vit A deficiency affects other system of the body like reproductory system, defense system, skeletal system etc.
IODINE DEFICIENCY:
Iodine deficiency is also a public health problem in Nepal. There have been repeated spot survey though no nationwide surveys have been conducted. According to information gathered from these surveys it has become clear that if Iodinized food and Iodine infection is provided to vulnerable population these problem will go down for example mean gaitre prevalence has reduce from 57.6% to 39.7%. Likewise prevalence rate of cretinism reduced from 2.8% to 0.4%. So that since 1973 our government has implemented a salt iodinazation programme.
CHILD DISABILITY:
Different form of child disabilities are found in our country, deafness, blindness, paralyses, mental impairment are examples of them. There are multiple factors for these disabilities. Like Iodine deficiency causing creatinism, deafness and muteness. Vit A deficiency if not properly managed results into blindness. LBW leading to impaired mental function. Paralyses due to polio. Physical disabilities due to accidents. Now a days there are different centers working for disable child and life for them have become convenient that past.
CHILD LABOR (WORKING CHILDREN)
No detail research have been conducted in this field. But 1981 census showed that about 50% of child population in the age group at 10 to 14 were economically active. These working children are engaged in different sectors from rural to urban areas. About 80% are engaged in agricultural and related activities in countryside. Other 20% are engaged in different factories, restaurant, hotels, like porters and servants in hoses. However the children act prohibits to employ children below the age of 14. A sample survey conducted in Nepal in 1990 revealed that 19% of total work force involved in carpet industries in Katmandu district were done by children of below 14 years. Likewise children of below 16 (14-16) constitutes 33.11% of total work force. After this report publication and other media of communication highlight the situation the government has taken strong steps so the number of working children in carpet factories have gone down.
WOMAN HEALTH IN RELATION TO CHILD HEALTH
The health of child is directly related to that of its mothers. Child health of Nepalese women is usually affected by the factors like child bearing at too young age, having children too close together, too many pregnancies, a heavy household work, smoking and inadequate food distribution. Even though legally girls are eligible for marries only after 16 years about 22% girls in Nepal are married before they reach 13 and 50% are married before they reach legal age. It is estimated that at least 70% of pregnant women are at risk of nutritional anaemia.
BREAST FEEDING
Breast feeding is quite common in Nepal. However duration and frequency is variable. Sometimes mother due to lack of knowledge do not add extra diet even after the age when breast feeding a long is not sufficient. In urban and semi-urban areas as a result of increasing numbers of mothers involving in out door activities, influence from advertisement in TV, radio and other media about artificial milk, breast feeding is declining to some extent compare to rural areas. Because the sanitation is not proper and due to poor hygiene the bottle fed babies suffer more attack of diarhoea than breast fed babies. Some time which become deadly also.
CHILD EDUCATION:
Education as a whole is very important to change the status of health including the children. Therefore primary education is one of the top priorities in our country. Government is keen to increase quality of primary education, increase equitable access to schooling, strengthen the management of the formal and non formal education delivery system.
Government while passing this year budget on Oct. 15th has decided to give breakfast allowance to these 200,000 primary school children in these districts where primary education is very low.
CONCLUSION:
Even though health status of children is not very good in Nepal. If some of young graduate who are interested to work in the field of paediatric are given opportunity to specialize in this field and given suitable environment and co-operation to work from Government and public then the present status can definitely improve. There should be combined dedication from politicians, bureaucratese, technicians and by general public for the sake of children welfare.
REFERENCES:
*Children and woman of Nepal, situation analysis, UNICEF 1992.
*National Planning Commission 1992, Nepal children and development
*The quest for Health, Dr. Henag Dixit 1995
*Children of Nepal, UNICEF, 1994
*The progress of Nations, 1994 UNICEF *Division of diarrhoeal an acute respiratory disease control, Interim report 1994.
