PRIMARY CARE PAEDIATRICS (Social and Preventive Paediatrics)

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PRIMARY CARE PAEDIATRICS (Social and
Preventive Paediatrics)

• Dr Adegoke, SA
• Lecturer/ Consultant,
• Dept of Paediatrics/ Child Health,
• OAU/ OAUTHC, Ile-Ife.

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Outline

• Introduction
• Health problems of Nigerian children
• Determinants of health diseases in children
• PHC Historical perspectives
• PHC Definition, components, relevance,
  challenges solutions
• Childhood survival strategies
• Preventive paediatrics
• Conclusion

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Introduction

• Most African countries are still in the 1st phase
  of national development, i.e. fertility and
  mortality rates are high, cf. with developed
  nations.
• 2nd phase High fertility and low mortality
• 3rd phase Low fertility and low mortality
• Children in developing nations constitute about
  45 of the entire population.
• Greater burden of deaths in most Africa countries
  occur in children. (70 vs. 5 of total deaths in
  developing and developed countries)

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introduction

• Globally, more than 10 million children die each
  year
• gt90 of them occur in developing countries.
• 50 occur in 6 countries (India, Nigeria, China,
  Pakistan, DR Congo, Ethiopia).
• gt70 are caused by preventable diseases.

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Introduction Primary care Paediatrics.

• Refers to preventive aspects of Paediatrics
• An integral part of Child health
• It focuses on wellness of children rather than
  treating childhood illnesses
• Researches have shown that Preventive
  paediatrics hold the key to childhood survival in
  developing nations, where modern medical
  infrastructures and enabling conditions are not
  usually available.

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Health problems of Nigerian children

• Undernutrition and infections are the two leading
  health problems in African children
• Malnutrition (Under nutrition) account for 40 of
  childhood morbidities, either singly or in
  combination with other diseases.
• Prevalence of stunting 45.5, wasting 17,
  underweight 29.
• Infections
• Malaria 25
• Diarrhoea 25
• RTI 25
• Other infections (HIV, TB, Measles)

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Other paediatric problems

• Neonatal problems Birth asphyxia, Jaundice and
  Kernicterus, infections including tetanus, LBW
  (Preterm, SGA)
• Haematological problems SCA, G6PD def, etc
• Childhood injuries Gradually becoming a
  significant cause of childhood deaths
• Malignancies Burkitt Lymphoma, Leukaemia, etc
• Renal conditions

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Childhood mortality in Nigeria

• Neonatal mortality rate Number of deaths of
  newborn (first 28 days of life) per 1000 live
  births. NMR 47/ 1000 live births
• Infant mortality rate Number of deaths of
  infants (lt12 months) per 1000 live births.
  IMR 107/ 1000 live births
• U5MR Number of U5 deaths per 1000 live births
  U5MR 189/ 1000 live births.
• Perinatal mortality rate Number of deaths in the
  first week of life and stillbirths per 1000 total
  births. PMR 87/ 1000 births

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Nigeria and some other countries
Country NMR IMR U5MR PSA GNI (dollar)
Sweden 2 3 3 95 46060
UK 3 5 6 98 42740
USA 4 7 8 92 46040
SA 17 57 59 88 5760
Nigeria 47 107 189 63 930
Afghanistan 60 144 257 61 250
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Relevance of the vital statistics

• PMR Is a reliable index of
• 1. Status of women and their health
• 2. Quality of antenatal, natal and neonatal
  care
• IMR and U5MR are indicators of national health
  (they reflect nutritional health, immunization,
  food security, clean and safe water of a nation).
• What are the other indices of national
  development? MMR, Life expectancy, Literacy rate,
  GDP/ GNP, PQLI

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Determinants of health diseases in children

• Hereditary genetic make-up of individual
• Environment Physical, biological, chemical
• Life style Nutrition, exercise/ sedentary
  lifestyle, personal habits etc.
• Socioeconomic conditions

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SOCIAL, ECONOMIC, POLITICAL AND CULTURAL
FACTORS.

• 1. Poverty 70 of Nigerian are poor (spend gt 40
  of income on food or earn lt 1 dollar/ day).
• GDP and GNP are low
• 2. Ignorance Literacy level is low (36 vs. 98)
• 3. Beliefs Eating of meats may lead to stealing
  etc
• 4. Culture/ traditional practices FGM, polygamy,
  male sex preference etc
• 5. Poor political will

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• 6. Ethno-religious or political conflicts and war
• 7. Inadequate resources low health budget (WHO
  recommends 15, Nigeria gives lt5 of her total
  budget.
• 8. Lack of basic amenities safe water, food
  security hygiene, proper sanitation, good
  transportation
• 9. Unequal distribution of resources 80
  resources vs. 20 population
• 10. Corruption The bane of every sector.

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Primary Health Care- history

• WHO/ UNICEF international conference was held at
  Alma Ata in USSR in September 1978
• There, the aim and objectives of PHC (to bring
  health care closer to the populace) were
  highlighted and endorsed by the participating
  nations.
• PHC was identified as the key to attaining the
  basic or essential health for all.
• The declaration made at the end of that
  conference is known as Declaration of Alma Ata.

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PHC Definition, components, relevance,
challenges and solution.

• Defined as
• An essential health care
• Based on practical, scientifically sound and
  socially acceptable methods and technology
• Made universally accessible to individuals and
  families in the community
• Through their full participation and
• - At a cost that the community and country can
  afford to maintain at every stage of their devpt.
  

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Principles of PHC

• A successful PHC is based on
• 1. Equitable distribution of resources Since
  health is a fundamental right of every
  individual, health services should be provided
  for all.
• 2. Manpower development Training and retraining
  of health staff
• 3. Community involvement/ participation Involve
  community members e.g. TBA, Village health
  workers
• 4. Appropriate technology Methods in keeping
  with the local culture e.g. ORSS
• 5. Intersectoral collaboration Involve other
  sectors

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Components of PHC

• 1. Health education
• To improve awareness on prevailing health
  problems and methods of preventing them so as
  to change health behaviour of people
• 2. Provision of food proper nutrition
• To ensure food security in terms of
  quality, quantity, balanced nutrition and
  nourishment

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• Provision of safe water and basic sanitation
• Ensure adequate quality Free from biologic
  chemical contaminants
• b. Quantity 20 - 40L/ person/ day
• c. Makes environment unsuitable for vectors of
  infections
• d. Reduces contamination of water, food and soil.

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Immunization....

• 4. IMMUNIZATION means of acquiring specific
  immunity to microorganism.
• Immunity Bodys ability to resist disease
• Could be Artificial or Natural immunity
• NATURAL Transfer of antibodies through the
  placental or breast milk (passive), or transfer
  of antigen following an infective illness
  (active).
• NB Antibodies that are acquired naturally decay
  some months after birth (e.g. Malaria antibodies
  by about 6 months)
• Immunity following exposure to infection may be
  life long (e.g. Immunity following measles).

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• ARTIFICIAL - Process of inducing immunity
  artificially, either actively or Passively
• Passive immunization Giving of antibody (e.g.
  ATS, hepatitis immunoglobulins, etc)
• Active immunization Giving of antigens
  artificially, known as VACCINATION.
• Vaccines may consist of
• (a) Whole organism either killed or
  attenuated
• (b) Part of the organism
• (c) Modified portion of the organism e.g.
  toxins

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Burden of Vaccine Preventable Diseases (VPD)

• Worldwide, about 3 million children die of VPD,
  annually (measles 2m, tetanus 0.8m, pertusis
  0.6m, TB 0.4- 0.5m, polio 0.2m)
• Another 3 million children are disabled yearly as
  a result of VPD globally (Cripple, deaf, blind,
  MR etc)
• In Nigeria, 20 35 of U5M are due to VPD

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Immunization schedules in Nigeria

• EPI Launched in 1979
• a. Targeted at 6 killer diseases, giving in the
  first 2 years of life.
• b. Had poor start and was revised in 1984
• c. Thereafter, coverage improved to about 80 in
  1990.
• NPI replaced EPI in August 1997.
• (a) Re-engineer the existing policy so as to
  improve the dwindling coverage
• (b) Target some other diseases (Hep, YF)
• NID was introduced in 1996 to complement the
  routine immunization in polio eradication. Was
  modified in 2006 to include Vit A and Measles
  vaccination.

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Types of vaccines Life, killed, toxoid

• BCG- Live vaccine
• Polio Oral form (Sabin) is a live vaccine, while
  IM form (Salk) is a killed vaccine.
• Hepatitis Live vaccine
• Diphtheria and Tetanus Toxoid
• Pertusis Killed form
• Measles Live
• Yellow fever Live

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Special considerations

• Preterm should be fully immunized, but its
  usually commenced when about 2.5kg or about 2
  months old.
• HIV (Exposed or infected) / AIDS should have all
  the routine immunization some others, but with
  caution when giving live vaccines-
• Sickle cell anaemic and others with asplenia
  Pneumococcal Conjugate Vaccine (PCV) Hib
  vaccines
• Hepatitis vaccines to babies born to hepatitis
  seropositive mothers within 72 hours of delivery.
• Some important vaccines not routinely given in
  Nigeria MMR, PCV Hib vaccine (2,4,6,12-15 mo),
  rotavirus vaccine etc.

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Contraindications to immunization

• Concurrent moderate to severe illness
• Previous anaphylactic reaction to the vaccine
• Local sepsis of intended injection site
• Severely immunocompromised should not be given
  live vaccines
• COMPLICATIONS
• Pertusis encephalopathy
• Risk of infection
• Injection abscess or cellulitis
• Fever
• Pain and irritability

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• 5. Maternal and Child health (Women and children
  are the most vulnerable groups in the society).
• a. Includes family planning.
• b. Child care Well child clinic visits, Growth
  monitoring, IMCI
• c. Mother care ANC, Safe labour delivery
  services, PNC.

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• 6. Supply of essential drugs
• Antimalarials, ORSS, antibiotics, haematinics etc
• 7. Treatment of common illnesses and injuries
• a. Achievable with the use of essential drugs
• b. Encourage early treatment of diseases
• c. Reduces severity/ complications

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• 8. Prevention and control of locally endemic
  diseases (e.g. Malaria, diarrhoea, pneumonia
  etc.)
• Others
• Mental health
• Dental heath

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Problems of PHC

• Corruption
• Lack of personnel
• Lack of supervision
• Not readily affordable
• Health facilities are not easily accessible
• Sustainability
• Ignorance/ Illiteracy
• Cultural factors Taboos, beliefs

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Strengthening PHC

• Proper funding
• Separate budget for PHC
• Private partnership
• International/ NGO support
• Proper supervision and evaluation
• Personnel performance enhancement
• Proper recruitment
• Motivation
• Training and re-training

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Contd

• Proper community involvement
• To include funding management
• Intersectoral collaboration
• Strengthening referral system

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Childhood survival strategies (gobifffeeth)

• These are low-cost strategies adopted by UNICEF
  to reduce childhood mortalities. They include
• Growth Monitoring
• Oral Rehydration Therapy
• Breastfeeding
• Immunization
• Female education
• Food supplementation
• Family Planning
• Environmental protection and sanitation
• Essential drug supply
• Treatment of common diseases
• Health education

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Preventive Paediatrics

• There are three main levels of disease
  prevention.
• 1. PRIMARY PREVENTION Aim at preventing disease
  from occurring. It is subdivided into
• a. General prevention Growth monitoring,
  Breastfeeding, Female education, Health
  education, Personal environmental hygiene,
  provision of safe water, premarital counselling
• b. Specific prevention Immunization against a
  disease, Iodine/ Iron/ Vitamin A supplementation,
  drug prophylaxis etc.
• 2. SECONDARY PREVENTION Make prompt diagnosis
  and treatment

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• 3. TERTIARY PREVENTION
• a. Limitation of disabilities i.e. ameliorate or
  arrest physical/ mental disabilities from the
  illness Physiotherapy, Psychotherapy, use of
  prosthesis etc.
• b. Rehabilitation Use of hearing aid, speech
  therapy, special education for deaf, blind,
  mentally retarded etc.

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Conclusion

• Preventable diseases account for a large
  proportion of childhood morbidities and deaths in
  developing nations.
• Primary care paediatrics therefore involves
• 1. Identifying childhood preventable diseases
• 2. Understanding the underline socio-economic
  factors associated with childhood diseases
• 3. Describing cost-effective and highly
  efficacious strategies (PHC CSS)
• 4. Using the classical levels of disease
  prevention

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Assignment

• Discuss the roles of the following in
  childhood survival
• Growth monitoring
• Female education
• Immunization
• Family planning
• Breastfeeding

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• THANKS