Diseases of Children in the
Subtropics and Tropics


This book is licensed under a Creative Commons Attribution 3.0 License

Diseases of Children in the
Subtropics and Tropics
Paget Stanfield
Martin Brueton
Michael Chan
Michael Parkin
Tony Waterston
Copyright © 2008 Paget Stanfield

For any questions about this text, please email:
The Global Text Project is funded by the Jacobs Foundation, Zurich, Switzerland

This book is licensed under a Creative Commons Attribution 3.0 License

This edition was scanned and converted to text using Optical Character Recognition. We are in the process of
converting this edition into the Global Text Project standard format. When this is complete, a new edition will be
posted on the Global Text Project website and will be available in a variety of formats upon request.
This is the fourth edition of this book that was last published in 1991.

Diseases of Children in Subtropics and Tropics

2

A Global Text

Foreword

Paediatrics is often thought of as following two main
routes. One is that of ultratechnology and evernarrower specialization. The other is recognition of
child health in a community context, related to family
circumstances (especially the health and welfare of
mothers) and influenced by the environment, social
stresses, economic limitations, cultural attitudes and
practices, and policy decisions and priorities based on
the political system.
Neither is right, but rather a balance is needed.
Thus, preventive programmes, such as immunization,
depend on refined technology to produce appropriate
vaccines and devise workable equipment for effective
'cold-chains'. Curative paediatrics, especially simplified methods in appropriate technology, has to be
underpinned by science - both by necessity and to
achieve acceptance by orthodox members of the Establishment. Examples include the work of gastroenterologists on the intestinal 'sodium pump' and how this
can be 'primed' and made more effective by glucose.
In this way, essential scientific credence has been
given to the seemingly simple methods of oral rehydration, using prepared ORS packets or home-made mixtures of sugar and salt or dilute rice (or other staple)
gruels.
However, as always, it can be difficult to persuade
physicians, including paediatricians, to acquire a community perspective, understanding and, still more, a
truly active role. This is often in part because of their
training which frequently remains predominantly
clinical - 'we teach what we have been taught'. However, things are changing in some more enlightened
training establishments, and the trend is certainly
indicated in this Fourth Edition.
Sound clinical work, as in a hospital environment, is

vital and will always remain a major need. This

approach alone cannot begin to touch the major issues
of child health. Some of these may be beyond the scope
of the paediatrician or of medical science. Nevertheless,
an awareness of the need for an advocacy role has to be
cultivated. In this way, advice and guidance may begin
to move those in power towards policies which can
improve community child health.
The 'complete' paediatrician anywhere, but especially in less technically developed countries, often in
tropical regions, needs to be much more than a
blinkered 'vertical' /'horizontal' expert. Rather, there
is a need for 'lateral' thinking, training and action. This
implies realization of the wide range of factors needing
consideration in child health work and also recognization of the value of a dove-tailed curative-preventive approach, as part of a team including paediatrIClanS, nurses, community health workers and
(importantly) parents, particularly mothers, in the
community itself.
The present edition of Diseases of Children in the Subtropics and Tropics moves in this direction and will most
certainly be valuable not only as a clinical reference
text. My hope is that it will also persuade its readers that
a paediatrician should not only be clinically sound, but
also able to recognize the wider community issues
involved in the causation of problems and the need for
imaginative interdisciplinary programes to improve the
outlook for life and health of mothers and children in the
Third World.
D.B. Jelliffe, MD, FRCP.
Professor of Public Health and Pediatrics,
Director, International Health Program,
School of Public Health,

University of California,
Los Angeles, USA


Preface

The fourth edition of this book incorporates significant
advances in technical knowledge and also takes into
account the widening role of paediatricians in the health
care of children in developing countries. As in earlier
editions, it seeks to provide paediatricians with an upto-date review of the diseases of children encountered in
the tropics, together with their diagnosis and treatment,
with particular reference to the practical management
of difficult problems facing the busy doctor. Technically
there have been spectacular advances since the last
edition, for example oral rehydration and drugs for the
treatment of schistosomiasis, neonatal septicaemia and
malignant diseases in childhood. There have also been
setbacks, such as increasing drug resistance in malaria
and leprosy. The mechanisms of many nutritional,
genetic and metabolic disturbances have been
considerably clarified and means of early detection of
disease and the identification of risk to health factors
have been developed even though many need yet to be
adequately applied.
The vital relationship of the health of the mother to
the well-being of the child has become a major concern
in developing countries since the last edition was
published. A new section has been added to focus on
practical care for pregnant women, the management of

labour and delivery, the care of the newborn infant, and
the organization of perinatal care.
Doctors are becoming increasingly aware of the
limitations of a largely hospital and curative based
medical education in preparing practitioners to play a
leading part in child health. This edition is intended to
prepare its readers for the task of improving the health
care of children in the developing world.
The environment remains the major determinant of
child health. The balance of influence changes in favour
of the child wherever there is stability, education,
economic growth, more equitable distribution of
resources and a political will to improve the health of
mothers and children. In contrast, national and international economic constraints and political conflicts

have profoundly damaging effects on child health, both
through diminished government budgets available for
services and through decreased parental employment
and income. Likewise, the grim consequences of
natural and man-made disasters have highlighted the
vulnerability of mothers and children, for example,
among refugees.
Increasingly efficient and penetrating communication is also having its effects throughout the world. The
shrinking globe has exposed traditional ways of life to
the stimulus, advantages and distortions of other
cultures. Extended family units, which have buffered
the mother and child from severe physical and social
deprivation, are tending to break up. There is a steady
migration of people from country into city and agriculture to industry while urban unemployment continues
to increase. The impact of modern, ecologically

inappropriate advertising has adversely influenced
many child-rearing practices such as breast-feeding, as
well as the prescribing of drugs.
Alongside these potentially harmful developments
there has been emerging a world-wide emphasis on the
extension of primary health care to the community.
This has been accompanied by a growing sense of the
importance of local participation in the provision of
community-based health care. There has been a new
recognition of the enhanced role of community selected
health volunteers, including trained indigenous healers
and health attendants, not only in effecting changes of
attitudes and behaviour towards health but also in
gathering information about the incidence and causes
of ill health within a community.
Those concerned with paediatrics need to become
vigorous advocates of child health services and of
legislation which favours mothers and children. This
requires persistent education, persuasion and, in
political terms, lobbying of those in control of
budgetary priorities and national policy. New skills in
communication and teaching methods are required.
The complete paediatrician needs to know about


Vlll

Preface

critical pathway analysis, discreet education and

persuasive presentation as well as about the murmurs of
mitral stenosis and the clinical picture of malaria.
Against this background the present edition sets out
to achieve a difficult but essential blend. Each section
attempts to find a balance between clinical and applied
paediatrics; between curative and preventive medical
care; between disease in the individual child and in the
community; between maternal and child health,
acknowledging that mother and child are biologically
and psychologically an inseparable dyad throughout the
reproductive life of the one and the prenatal, neonatal
and early pre-school life of the other. A balance has to
be struck between the assembly of information and
instruction needed by the paediatrician in the reference
centres of excellence and the study and practice of
management at the level of primary care.
The book therefore aims to be a readable specialized
reference source appropriate to the care of children in
well-equipped hospitals. In addition, it describes
explicitly the presentation and management of childhood disease problems in a way relevant to the practice
of primary and preventive health care of the children in
their communities. Furthermore, the perspectives of
this edition are intended not only for those dealing with
the practice and problems of child health now but also
for medical students who will be the practitioners and
leaders of health care in the future. It is very important
that we share our hopes and ideals with those to whom
they will become realities. The present publication is
therefore geared to the training of medical students as
well as offering a resource for general practitioners,


primary health centre doctors, paediatricians and those
responsible for the planning and administration of
maternal and child health services in the developing
world.
The sudden and unexpected death of Michael
Parkin, as this edition has gone to press, is a grievous
loss to us all. It has been a great privilege to have
worked with him as a member of our team in editing
and writing parts of this edition. In spite of his many
commitments he joined us gladly and his contribution
to its production has been substantial. Michael was
dedicated to family life in the North East of England,
where he was known and loved by many parents and
children. Sheila, Michael's wife, shared his commitments to the well-being of children throughout the
world. She would join us in the hope that this book will
enable many to appreciate and share Michael's care for
mothers and children and the ways in which he
practised this care. In his wide travels he made it clear,
as he writes in his introduction, that the principles and
practice he learned and taught in Newcastle were relevant to all parts of the world. It was characteristic of
Michael that he introduced the section on growth and
development with a verse from the Bible. Weare grateful that he was able to complete this task.

Paget Stanfield
Michael Chan
Martin Brueton
Tony Waterston

1991



Acknowledgements

The editors acknowledge with thanks a number of colleagues and publishing houses who have contributed figures,
tables and photographs which have helped to illustrate the text. The origins of these contributions are
acknowledged individually as they appear in the book and we sincerely hope that no omissions have occurred.
It has been a privilege to work with such a ready, willing and patient team of contributors whose experience and
knowledge are broadening and deepening the care of mothers and children throughout the world.
The editors would also like to thank Paul Price and the editorial staff at Edward Arnold for all their support,
encouragement and advice.
In all, we hope readers of this book will benefit as much from its study as we have from its production.


Contents

Foreword
Preface
Acknowledgements
Contributors

Section 1
1
2
3
4

5
6
7


Maternal and Child Health

111
V

Vll

X111

Tony Waterston

Introduction Torry Waterston and Paget Stanfield
Cultural aspects of common childhood diseases Valerian Kimati
Primary health care FJ Bennett
Delivering the services
Hospital and clinic WEK Loening
Case studies in primary health care
Zimbabwe: the children's supplementary feeding programme
David Sanders
Brazil: oral rehydration therapy MA de Souza
China: primary health care Victor W Sidel and Ruth Sidel
Bangladesh: primary health care in the rural community
Zafrullah Chowdhury
Management in primary health care John P Ranken
Immunization Paget Stanfield
Maternal health Kusum P Shah
Working with traditional midwives Gill Tremlett
Breast-feeding: protection, support and promotion
Michael C Latham

Community diagnosis Michel Pechevis
The doctor as teacher Tony Waterston
Parents and children in hospital Janet Goodall

Section 2 Maternal, Prenatal, Perinatal and Neonatal Care
Michael Chan
1
2

Introduction Michael Chan
Maternal Health
Maternal care Olive Frost

1

3
14
26
38
38
56
56
60
62
65
70
78
88
94
95

103
114
120

129
131
136
136


xii

Contents

3
4

5

6

Maternallactation Dorothy A. Jackson) MW Woolridge)
Stella Imong andJD Baum
Prenatal health Michael Chan
Prenatal infections Michael Chan
Perinatal health
Obstetric problems and perinatal mortality David Goodall
Perinatal infections Michael Chan
Neonatal health
Neonatal care Michael Chan

Feeding the neonate Indira Narayanan
Low-birth-weight infants Michael Chan
Neonatal jaundice Michael Chan
Convulsions in the newborn Michael Chan
Bleeding in the newborn Michael Chan
Neonatal infections Michael Chan
Organization of perinatal care SK Bhargava) S RamJi and
I Bhargava

Section 3 Growth and Dev.elopment
and Paget Stanfield
1
2

3
4

5

6

7

8

153
158
163
175
175

180
186
186
195
208
221
228
229
233
241

Michael Parkin

Introduction Michael Parkin
Physical growth
Growth in childhood AS Paynter and Michael Parkin
Making growth monitoring more effective Gill Tremlett
Short stature Michael Parkin
Puberty and its disorders Michael Parkin
Development
Child development P Morrell
Disability in childhood P Zinkin
Nutrition
Nutritional need of healthy infants RG Whitehead and AA Paul
Protein-energy malnutrition V Reddy
Prevention of protein-energy malnutrition MGM Rowland
Specific vitamin deficiencies V Reddy with WH Lamb
Mineral and trace element nutritional disorders Peter J Aggett
Nutrition rehabilitation MA Church
Behaviour

Emotional development AD Nikapota and HG Egdell
Mental health problems HG Egdell and AD Nikapota with
K Minde and S Musisi
Delinquency K Minde and S Musisi
Deprivation
Social deprivation SN Chaudhuri
Child abuse and neglect within the family Nigel Speight
Genetics of tropical diseases J Burn and AJ Clarke

251

253
254
254
270
275
281
286
286
311
324
324
335
358
367
379
387
391
391
398

419
422
422
426
430


Contents

Section 4
1
2
3
4
5
6
7
8
9
10
11
12
13

10
11
12
13
14
15

16

Paget Stanfield

Introduction Paget Stanfield
Infections and the immune system Badrul Alam Chowdhury
and Ranjit Kumar Chandra
Diarrhoeal diseases William AM Cutting
Common childhood infections Nimrod Bwibo
Tuberculosis DH Shennan and MA Kibel
Leprosy M Elizabeth Duncan
Foreword SG Browne
Bacterial, spirochaetal, chlamydial and rickettsial infections
David Mabey
Viral infections Patrick Goubau) Jan Desmyter and Roger Eeckels
Mycotic infections RJ Hay
Helminthiasis John Vince
Dracunculiasis H Taelman
Schistosomiasis HA Wilkins
Malaria Tan Chongsuphajaisiddhi
Other vector-borne parasitic infections
Trypanosomiasis H Taelman
Leishmaniasis Phillipe Lepage
Filariasis H Taelman
Filariasis in children in Asia JW Mak

Section 5
1
2
3

4
5
6
7
8
9

Infectious Diseases

Diseases of the Systems

Martin Brueton

History-taking and examination Wong Hock Boon
Diseases of the respiratory system JK G Webb
Diseases of the gastro-intestinal tract Martin Brueton
Diseases of the central nervous system Suresh Rao Aroor
Cardiovascular diseases F Jaiyesimi
Disorders of the kidney and urinary tract Yap Hui Kim
Endocrine and metabolic disorders Wong Hock Boon
Haematological disorders C Chintu
Immunological disorders Badrul Alam Chowdhury and RanJit
Kumar Chandra
Diseases of the skin AN Okoro
Neoplastic diseases CLM Olweny
Paediatric surgery SD Adeyemi
Diseases of the ear, nose and throat Christopher Holborow
Orthopaedic disorders RL Huckstep
Diseases of the eye DD Murray McGavin
Accidents and poisoning Nimrod Bwibo

Snake bites Martin Brueton
Arthropod-produced diseases A Miller

445
447
449
455
496
519
553
553
577
600
624
633
649
650
657
675
675
682
686
691

697
699
706
725
741
762

784
806
822
839
847
873
888
902
910
926
940
954
957

XlII


xiv

Contents

Section 6
1
2
3
4
5
6
7


Practical Aids

Tony Waterston

Introduction Tony Waterston
The appropriate use of drugs Nigel Speight
Appropriate use of the laboratory Andrew Hughes
Appropriate technology for health Katherine Elliott
Child care in refugee situations john Seaman
Practical procedures Cj Clements
Appropriate imaging techniques PES Palmer

Index

965
967
968
974
985
993
1001
1019

1025


Contributors

SD Adeyemi, MB BS(Lagos), FRCS(C), FMCS,
FWACS, CSCPS.

Associate Professor and Consultant Paediatric
Surgeon, Department of Surgery, College of Medicine, and Lagos University Teaching Hospital,
Lagos, Nigeria.
Peter J Aggett, MSc, MB ChB, FRCP,
DCH(Eng.).
Senior Lecturer In Child Health and Nutrition,
Department of Child Health, University of
Aberdeen, UK.
Suresh Rao Aroor, MB BS, DCH, MD, DM.
Associate Professor of Paediatric Neurology,
National Institute of Mental Health and Neurosciences, Bangalore, India.
JD Baum, MA, MSc, MD, FRCP.
Professor of Child Health, Department of Child
Health, University of Bristol, Royal Hospital for
Sick Children, Bristol, UK.
FJ Bennett, MB ChB, DPH, FFCM.
Formerly Director, Department of Community
Health, African Medical and Research Foundation,
Nairobi, Kenya.

SG Browne, MD, FRCP, FRCS, FKC, CMG,
OBE.
Formerly International Consultant in Leprosy;
Director of the Leprosy Study Centre, and Medical
Consultant to the Leprosy Mission, London, UK.
Martin Brueton, MD, MSc, FRCP, DCH.
Reader in Child Health, Department of Child
Health, Westminster Children's Hospital, London,
UK.
J Burn, B Med Sci(Hon), MB, FRCP.

Consultant Clinical Geneticist and Clinical
Lecturer, Department of Human Genetics, U niversity of Newcastle upon Tyne, UK.
Nimrod Bwibo, MB ChB, MPH, FAAP, MRCP.
Deputy Vice-Chancellor and
Professor of
Paediatrics, College of Health Sciences, University
of Nairobi, Kenyatta National Hospital, Kenya.
Michael Chan, MD, FRCP, FRACP.
Senior
Lecturer,
Department
of Tropical
Paediatrics and International Child Health and
Honorary Consultant Paediatrician, Liverpool
School of Tropical Medicine, UK.

I Bhargava, MB BS, MS, DSc, FlAP, FAMS.
Formerly Deputy Director General, Ministry of
Health and Family Welfare, Government of India,
New Delhi, India.

Ranjit Kumar Chandra, MD, FRCP(C), PhD,
DSc(Hon), DPhil(Hon).
Professor of Paediatric Research and Medicine,
Director of Immunology, Memorial University of
Newfoundland, Newfoundland, Canada.

SK Bhargava, MB BS, DCH, MD, FlAP.
Consultant Paediatrician, Gouri Hospital, New
Delhi and formerly Professor and Head of Department of Paediatrics, Safdarjung Hospital, New

Delhi, India.

SN Chaudhuri, MB BS(Rgn), MD(AIIMS).
Director, Child In Need Institute, Vill. Daulatpur,
PO Pailan, Via-Joka, 24 Parganas South, 743512,
West Bengal, India.


XVI

Contributors

C Chintu, MD, LMCC, FRCP(C), DABP.
Professor of Paediatrics and Child Health, Consultant Haematologist and Oncologist, University
Teaching Hospital, Lusaka, Zambia.
Tan Chongsuphajaisiddhi, MD, PhD, DTM & H.
Dean, Faculty of Tropical Medicine, Mahidol
University, Bangkok, Thailand.
Badrul Alam Chowdhury, MD, PhD.
Resident, Department of Internal Medicine, Wayne
State University School of Medicine, Detroit,
Michigan, USA.
Zafrullah Chowdhury, MB BS.
Projects Coordinator, Gonoshasthaya Kendra
(Peoples' Health Centre), PO Nayarhat; via
Dhamrai, Dhaka, Bangladesh.
MA Church, MB B Chir, FFCM, DTPH.
Medical Advisor, Scottish Health Education Group,
Health Education Centre, Edinburgh, UK.
AJ Clarke, BSc, MD, MRCP.

Senior Lecturer in Medical Genetics, University
Hospital of Wales, Cardiff, UK.
CJ Clements, MSc, MB BS, MFPHM(NZ),
MCCM, DCH, Dip Obst.
Medical Officer, Expanded Programme on
Immunization, WHO, Geneva, Switzerland.

Research Worker, Department of Bacteriology,
Edinburgh University Medical School, Edinburgh,
UK.

Roger EeckeIs, MD, Dip Trop Med.
Professor of Paediatrics, University of Leuven,
Belgium.
HG Egdell, MB ChB, FRCP, FRC Psych, DPM.
Clinical Lecturer, Department of Psychiatry,
University of Liverpool, UK.
Katherine Elliott, MRCS, LRCP, FFCM.
Formerly Director of Appropriate Health Resources
and Technology Action Group (AHRTAG), 1
London Bridge Street, London SEl 9SG, UK.
Olive Frost, MB ChB, MSc, MFCM, FRCOG.
Consultant in Public Health Medicine, Clinical
Lecturer, Department of Paediatrics and Child
Health, University of Liverpool and Honorary
Senior
Lecturer,
Department
of Tropical
Paediatrics, Liverpool School of Tropical Medicine,

UK.
David Goodall, MB BS, MRCS, LRCP,
MRCOG.
Consultant in Gynaecology and Obstetrics, Queens
Park Hospital, Blackburn and Honorary Senior
Lecturer, Department of Tropical Paediatrics,
Liverpool School of Tropical Medicine, UK.

William AM Cutting, MB ChB, FRCPE, DCH, Janet Goodall, FRCPEd, DCH, DObst RCOG.
DObst RCOG.
Formerly Consultant Paediatrician, City General
Senior Lecturer and Honorary Consultant Hospital, Stoke on Trent, UK.
Paediatrician, Department of Child Life and
Health, University of Edinburgh, UK.
Patrick Goubau, MD, Dip Trop Med.
Senior Registrar, Department of Virology, U niverJan Desmyter, PhD, MD, Dip Trop Med.
sity Hospital, Leuven and Lecturer, Institute of
Professor of Microbiology and Epidemiology, Tropical Medicine, Antwerp, Belgium.
University Hospital and Rega Institute for Medical
Research, University of Leuven, Belgium.
RJ Hay, DM, FRCP, MRCPath.
Professor of Cutaneous Medicine, Department of
MA de Souza, PhD.
Dermatology , United Medical and Dental Schools of
Professor of Community Medicine, Department of Guy's and St Thomas' Hospitals, University of
Community Health, Federal University of Ceara, London, UK.
Brazil.

M Elizabeth Duncan, MD(Hons), FRCSE,
FRCOG.

Consultant to the WHO, Ethiopia and Associate

Christopher Holborow, OBE, TD, MD, FRCS,
FRCSEd.
Consultant ENT Surgeon, Westminster Hospital,
London, UK.


Contributors

RL Huckstep, CMG, FTS, MA, MD(Cantab.),
Hon.MD(NSW), FRCS, FRCSE, FRACS.
Professor and Head, Department of Traumatic and
Orthopaedic Surgery and Chairman of the School of
Surgery, University of New South Wales, Prince of
Wales Hospital, Sydney, Australia.
Andrew Hughes, MA, BM BCh, MRCP,
MRCPath.
Consultant Haematologist, Harold Wood Hospital,
Romford, UK.

XVll

WEK Loening, MB ChB, FCP(Paed.).
Professor of Maternal and Child Health, Department of Paediatrics and Child Health, University of
Natal, Durban, South Africa.
David Mabey, MA, BM BCh, MRCP, MSc.
Senior Lecturer, Department of Clinical Sciences,
London School of Hygiene and Tropical Medicine
and Honorary Consultant Physician, Hospital for

Tropical Diseases, London, UK.

JW Mak, MB BS, MD, MPH, MRCPath, DAP &
E.
Stella Imong, MD, MRCP.
Head, Malaria and Filariasis Research Division,
Clinical Lecturer in Paediatrics, Department of
Institute for Medical Research, Kuala Lumpur,
Child Health, University of Leicester, UK.
Malaysia.
Dorothy A Jackson, D Phil.
Research Fellow in Child Health, Department of
Child Health, University of Bristol, Royal Hospital
for Sick Children, Bristol, UK.
F Jaiyesimi, MB BS(Ibadan), FRCP(Lond.),
DCH, FMCPaed, FWACP.
Professor of Paediatrics, University of Ibadan and
Consultant Paediatrician and Paediatric Cardiologist, University College Hospital, Ibadan,
Nigeria.
MA Kibel, FRCP(Edin), DCH(Lond.).
Professor of Child Health, Department of
Paediatrics and Child Health, University of Cape
Town, South Africa.
Valerian P Kimati, MB ChB, FRCPE,
FRCP(Glasg.), MRCPI, DCH.
Chief of Health, UNICEF, Lagos, Nigeria.
WH Lamb, MB BS, MD, MRCP.
Consultant Paediatrician, Bishop Auckland General
Hospital, Durham, UK.
Michael C Latham, OBE, MB, FFCM, MPH,

DTM&H.
Professor of International Nutrition and Director,
Program of International Nutrition, Cornell
University, New York, USA.
Philippe Lepage, MD.
Head,
Department of Paediatrics,
Hospitalier de Kigali, Kigali, Rwanda.

Centre

DD Murray McGavin, MD, FRCSEd, FCOphth,
DCH.
Associate Senior Lecturer, Department of Preventative Ophthalmology, Institute of Ophthalmology,
London, UK.
A Miller, PhD, MS, BS.
Formerly Associate Professor of Medical Entomology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana,
USA.
K Minde, MD, FRCP(C).
Chairman of the Division of Child Psychiatry,
McGill University, Director of Psychiatry,
Montreal Children's Hospital and Professor of
Psychiatry and Pediatrics, McGill University,
Montreal, Canada.
P Morrell, MB ChB, MRCP.
Consultant
Paediatrician,
South
Hospital, Cleveland, UK.


Cleveland

S Musisi, MB ChB, FRCP(C).
Consultant Psychiatrist, York Central Hospital,
Ontario, Canada.
Indira Narayanan, MD, MNAMS.
Formerly Head of Department of Neonatology and
Senior Consultant in Paediatrics, Shri Mool Chand
Kharaiti Ram Hospital, New Delhi, India.
AD Nikapota, MB BS(Ceylon), DPM(Lon), MRC
Psych(UK).
Consultant Child and Adolescent Psychiatrist,


XVlll

Contributors

Brixton Child Guidance Unit and Senior Lecturer,
Institute of Psychiatry, London, UK.
AN Okoro, MB ChB, MRCP, FRCP.
Consultant Dermatologist, University of Nigeria
Teaching Hospital, Enugu, Nigeria.
eLM Olweny, MB ChB, MMed, MD, FRACP.
Professor, University of Manitoba, and CoDirector, WHO Collaborating Centre for Quality of
Life in Cancer Care, St. Boniface General Hospital,
Manitoba, Canada.
PES Palmer, MD, FRCP, FRCR.
Emeritus Professor of Radiology, University of
California, Sacramento, California, USA.

Michael Parkin, MD, FRCP.
Formerly Professor of Clinical Paediatrics, Department of Child Health, Royal Victoria Infirmary,
Newcastle upon Tyne, UK.
AA Paul BSc.
Scientist, MRC Dunn Nutrition Unit, University of
Cambridge, UK.
AS Paynter, MB BS(Madras), MRCP, DCH.
Consultant Paediatrician, Community Child
Health, West Cumberland Hospital, Cumbria, UK.
Michel Pechevis, MD.
Consultant Paediatrician and Head, Training
Department, Centre Internationale de L'Enfance,
Paris, France.

David Sanders, MB ChB, MRCP, DCH, DTPH.
Associate Professor and Consultant Paediatrician,
Department of Community Medicine, University of
Zimbabwe, Harare, Zimbabwe.
John Seaman, MB BS, DCH.
Senior Overseas Medical Officer,
Children Fund, London, UK.

Save

The

Kusum P Shah, BSc, MD, DGO.
Formerly Associate Professor of Obstetrics and
Gynaecology, Grant Medical College, Bombay,
India.

DH Shennan, MD, DPH, DCH, DTCD.
Tuberculosis Officer, Department of Health, Ciskei,
South Africa.
Ruth Sidel, PhD.
Professor of Sociology, Hunter College,
University of New York, USA.

City

Victor W Sidel, MD.
Professor of Social Medicine, Montifiore Centre,
Albert Einstein College of Medicine, New York,
USA.
Nigel Speight, MB BChir, DCH, FRCP.
Consultant Paediatrician, Dryburn Hospital,
Durham, UK.

S Ramji, MB BS, MD.
Associate Professor, Department of Paediatrics,
Maulana Azad Medical College, New Delhi, India.

Paget Stanfield, MD, FRCP, FRCPS, DCH.
Director, Department of Community Health,
African Medical and Research Foundation,
Nairobi, Kenya.

John P Ranken, BA, MIPM, LHA.
Senior Lecturer, Tropical Child Health Unit, Institute of Child Health, University of London, UK.

H Taelman, MD, Dip Trop Med.

Head, Department of Internal Medicine, Centre
Hospitalier de Kigali, Kigali, Rwanda.

V Reddy, MD, DCH, FlAP.
Director, National Institute of Nutrition, Indian
Council of Medical Research, Hyderabad, India.

Gill Tremlett, B Nurse, MSc.
Nurse, midwife and health visitor, London, UK.

MGM Rowland, MB BS, FRCP(UK), MCFM,
DCH, DTM&H.
Consultant Epidemiologist, East Anglian Regional
Health Authority, Cambridge, UK.

John Vince, MD, FRCP.
Specialist Medical Officer in Paediatrics, Port
Moresby Hospital and Honorary Lecturer in Child
Health, University of Papua New Guinea.


Contributors

XIX

Tony Waterston, MD, MRCP, DCH, DRCOG.
Consultant Paediatrician, Community Child
Health, Newcastle General Hospital, Newcastle
upon Tyne, UK.


Wong Hock Boon, MB BS, FRCP(Lond.),
FRCP(Ed), FRACP, FRCP, DCH, PJG, PPA.
Senior Fellow and Emeritus Professor, Department
of Paediatrics, National University of Singapore,
Singapore.

J KG Webb,

OBE, MA, BM BCh, FRCP.
Emeritus Professor, University of Newcastle upon
Tyne, UK.

MW Woolridge, PhD.
Research Fellow in Child Health, Department of
Child Health, University of Bristol, Royal Hospital
for Sick Children, Bristol, UK.

RG Whitehead, MA, PhD, FI BioI, Hon. MRCP.
Director, MRC Dunn Nutrition Unit, University of
Cambridge, UK.

Yap Hui Kim, MB BS, MMed(Paed.).
Associate Professor and Head, Department of
Paediatrics, Division of Paediatric Nephrology,
Immunology and Urology, National University
Hospital, Singapore.

HA Wilkins, MA, MB BChir, DTM&H, DObst
RCOG.
Director, Medical Research Council Laboratories,

Fajara, The Gambia.

P Zinkin, MB ChB, FRCP, DCH.
Senior Lecturer, Department of International Child
Health, Institute of Child Health, London, UK.



SECTION I

Maternal and Child Health
Tony Waterston



CHAPTER 1

Introduction
Tony Waterston and Paget Stanfield

The world situation
Causes of high mortality and morbidity
Socio-economic background
Effect of development on the environment
Health service delivery

Primary health care
The role of traditional medicine
Women and children in primary health care
Children's rights

The role of doctors in primary health care
References

There must be very few doctors working with children
in the closing years of the twentieth century who do not
accept two cardinal statements about child health: first,
that children cannot be considered apart from their
family and society; and second, that doctors treating
sick children in hospital have a wider responsibility
for those outside who fail to reach their wards. It has
taken time for these messages to penetrate into medical
education, and to a wider public, through the efforts of
prescient thinkers in developing and developed countries. The concepts of integrated health care, of health
promotion, of a group approach in addition to individual care, and of the political content of health are
now widely accepted and have been well-publicized
both by the vy orld Health Organization and by
UNICEF in its annual reports on The State of the World's
Children.
It might with logic be asked, why have a section on
mother and child health in a textbook on children's
diseases? To answer this question, we need first to
define health. Many doctors find the World Health
Organization definition (a sense of complete physical,
mental and social well-being) tendentious and illusory;
such a state is unlikely to be achieved in most parts of
the world, even if it is the ideal, and progress towards
such a state is impossible to measure. However,
measurement of health is essential if we are to use the
more positive term health promotion in addition to the
rather negative 'disease prevention'. Indices are now

available to measure health. 1 This section is entitled
'maternal and child health' because the health of the

mother is intimately bound up with that of the child,
and because similar approaches are needed in the
delivery of paediatric and obstetric care. But perhaps in
the future, family health will become the more correct
term. Its use would not only encourage the inclusion of
fathers, but also of grandparents, uncles and aunts.
Fathers are essential to families and the recent spate of
publications on fatherhood 2,3 is a sign of the times. The
fact that in many families, the father is absent or contributes little to child care does not negate this - there is a
trend towards more paternal involvement and we hope
that paediatricians will encourage this. Children need
fathers too.
However, the above concepts have tended to suffer
from excessive rhetoric and require illumination by
detailed examples; they also require the application of a
scientific approach. Health workers should not assume
that public participation in health is an easy aim to
achieve, nor that prevention in the community can
succeed without special skills and long effort. In this
section of the book we hope to provide the evidence for
the effectiveness of the Primary Health Care approach
(further defined on p. 26ff.) by giving the reader access
to the basic sciences of preventive medicine: epidemiology, anthropology, psychology and sociology among
others. A good grasp of politics is also needed but
perhaps, like medicine, politics is more of an art than a
science. The political content of medicine has long been
recognized: it was Virchow who stated in the nineteenth

century, 'Politics is nothing more than medicine on a
grand scale' .


4

Introduction

The world situation

which exists in many low-resource countries and which
is further discussed below.
It is now well-known that the most common causes of
death in these countries are malnutrition, infectious
diseases and (for mothers and children) childbirth. It
should be remembered, however, that child morbidity
and disability also form an increasing burden, particularly in situations where medical services prevent
child deaths but do not combat their causes. Some of
these conditions (for which accurate figures are rarely
available) are outlined in Table 1.1.1. The burden
these conditions present to the community is enormous, yet they are highly amenable to prevention. If
preventable, why not prevented?

Globally, the annual death toll of mothers and children
is still appalling and despite improved delivery of health
care there is little light on the horizon because of
the overall socio-economic depression affecting most
developing countries. Experience in Western Europe
has shown that health inputs alone contribute little to
mortality reduction - improved nutrition and hygiene

are more important factors. However, health measures
which are appropriately targeted and which are integrated with initiatives from other sectors are effective,
as some very poor countries have shown (see Fig.

1.1.1).
Improved care has barely touched the 'gap' area
between the last antenatal visit and the first postnatal
contact. Upwards of 80 per cent of women in developing countries deliver at home, attended by older female
family members or traditional midwives. Both mother
and child pass this perilous time hidden and effectively
out of reach from any health facility. The recent unveiling of the magnitude of neonatal tetanus mortality by
dint of retrospective surveys has emphasized the high
and, for the most part, unrecorded maternal and perinatal mortality and morbidity rates in these countries.
Figures 1.1.2-1.1.7 illustrate the problems. In most
developing countries children make up 50 per cent of
the population and this proportion is not decreasing.
The world figures for death rates and causes of death at
different ages are shown, as well as comparisons
from high, middle and low-mortality countries. It is
important to remember that there are differences
within, as well as between, developing countries and
this is illustrated by an example from Asia (Fig. 1.1.6).
Such disparities are the result of the 'dual economy'
en
..c::
1:::

:0
Q)
~

0
0

;?
Q:;

a.
~
ctS

Q)

>-

300
250
200

..,,....,

.,.',
""

"',

150

".

Ii)


I

8
en
..c::

1ii
Q)

100
50

'."

E

()

0
0
0

120

Q:;

100

.'.-0


140

,..-

Sudan

a.

en

(ij
Q)
>-

Ii)

........ • Turkey

.............

.• Jordan

'0

::Q

Middle and low mortality

..........


~

.

'.'.,

Most of the diseases of developing countries are
poverty-associated rather than purely tropical diseases
and the spectrum is very similar to that seen in Europe
in the nineteenth century, as shown in Table 1.1.2.
There remains a close association between economic
status and child deaths as illustrated by Fig. 1.1.8
comparing economic development and infant mortality. Poverty contributes to child deaths for

1:::

~a Bangladesh

"

Socio-economic background

:.0
Q)

~
' ... ... ...
".


The multiple origins of child and maternal deaths are
now well understood. Detailed analysis of causes will be
found under the various disease sections but we will
examine more closely here two of the fundamental factors: the socio-economic background, and the
structure of medical services.

en
..c::

High mortality

......

Causes of high mortality and morbidity

.,

1ii
Q)

...........

.~

80

........

~


.... 1.......
~I Philippines

,,',,

:-...

60

I

8
en
..c::

.... ...

Guyana

............

40
20

._

.• Panama
- . Costa Rica

'0


1960

1980 1988

::Q
E

()

0

1960

Fig. 1.1.1 Mortality reduction among children under five in some developing countries. (Reproduced from State of the World's
Children 1990, by permission of the Oxford University Press.)


Causes of high mortality and morbidity
0.3 Million
(3%)

1131 Million
(25.5%)

Annual infant deaths
(0 - 11 months)
10.7 million
0.1 Million


World population
4432 million
18 Million
(15%)

(2%)

Annual child deaths
(1 - 4 years)
4.5 million

Annual births
121 million
Key

D

Developing world's share

Table 1.1.1

5

'WIi:i:Mit::1 Developed countries share

Causes of child morbidity and disability

Disease

Disability


Recurrent diarrhoea

Malnutrition; time off school

Malnutrition

Mental and physical stunting;
infections; blindness

Measles

Malnutrition; blindness; cancrum
oris

Whooping cough

Mental retardation; respiratory
impairment

Polio

Paralysis and deformity

Tuberculosis

Respiratory impairment; chronic
bone disease; mental retardation;
deafness


Malaria

Anaemia

Helminth infections;
hookworm; ascaris

Anaemia; mental and physical
stunting

Bilharzia

Liver disease; renal disease

Trachoma; vitamin
deficiencies

Blindness

Neonatal jaundice;
birth asphyxia

Deafness, cerebral palsy

Accidents

Physical handicap

Fig. 1.1.2


The
developing
world's share of population,
births
and
deaths
(1983).
(Reproduced from State of the
World's Children 1984, by
permission of the Oxford University Press.)

various reasons, some of which are listed in Table
1.1.3. It is always worth asking the fundamental
question 'Why?' when a child is admitted to hospital
with a problem. Werner has shown the value of this
approach well (see Fig. 1.1.9).
'Development' has a harmful effect on particular
sectors of the population within low resource countries
as a result of the so-called 'dual economy'. This
phenomenon is also recognized within industrialized
countries for the same reasons. In the very highmortality countries this disparity is less noticeable,
since the population is almost entirely rural and dependent on subsistence. Urbanization is occurring less
rapidly in these countries and everyone remains poor.
However, in the medium-mortality countries poverty is
more and more an urban phenomenon. The rural
population suffers relative poverty but, except when
affected by drought or war, are able to live at subsistence level. It is the drift to the cities, the result of
national and international development, which leads to
the dual economy whereby a relatively well-off elite is
dependent for its servicing on the poverty-stricken

masses living in the slums and shanty towns. Table
1.1.4 illustrates the degree of urbanization in developing countries. To some extent, urbanization is
encouraged by patterns of agricultural development
which favour capital-intensive cash crops such as


6

Introduction
Age
90

1

The
United
Kingdom

Tanzania

I

I

I

I

I


I

I

I

I

I

8

6

4

2

0

0

2

4

6

8


I

I

I

I

I

10 12 14 16 18

Percentage of the population

Fig. 1.1.3 Population
developing countries.

age

structure

in

developed

and

tobacco, cotton, tea and coffee and, more recently,
exotic fruit and vegetables intended for the luxury
markets of the richer countries. For those moving to the

cities, the only work to be found in the informal sector is
in ministering to the needs of, or robbing, the well-

Table 1.1.2

off - which includes food marketing, personal services
and petty crime. The environment in which such
families are forced to rear their children in the periurban and inner-city ghettos is appalling, with inadequate housing, poor sewage and water supplies, limited
health services and an absolute dependence on the cash
sector for food and resources. It is hardly surprising that
in these circumstances there is a shift to bottle-feeding
(copying the habits of the well-off), weaning diets are
inadequate, malnutrition and diarrhoea are rife, and
families break up as the mother and often older children
are forced to work - yet no appropriate child -care
facilities are available. It is the exception for urban
'development' funds to trickle down to the inhabitants
of the inner-city or periurban slums. 4
This picture of gloom is hardly lightened when we
look at the overall relationship between spending on
health and on other sectors of the economy. World
Bank figures show that the 43 countries with the highest
infant mortality rates (over 100 deaths per 1000
livebirths) are currently spending three times as much
on defence as on health. Yet at the same time, aid from
industrialized countries has fallen from 0.51 per cent of
their combined GNP in 1960 to 0.37 per cent in 1982.
During this period (see Fig. 1.1.10) arms spending has
increased world-wide and we now have a situation
where the more developed countries spend 20 times as

much on the military as on development assistance,
while developing countries spend twice as much on
arms as on the health of their children. In a significant
number of countries, war (either internally or
externally mediated) is a major cause of death of
children.
These grim statistics illustrate the interdependence of
health and development and show that political factors
lie at the root of the major health problems affecting
mothers and children. Only a redistribution of national
resources, both within countries and between rich and
poor countries will begin to affect the balance in

Death rates (per million) in 1848/54 and 1971 in England and Wales

Conditions attributable to micro-organisms (communicable)
Airborne diseases
Water- and food-borne diseases
Other conditions
Total
Conditions not attributable to micro-organisms
All diseases

1848/54

1971

Percentage of reduction
attributable to each category


7259
3562
2144
12965
8891
21 856

619
35
60
714
4070
5384

40
21
13
74
26
100

Reproduced with permission from Sanders, D. The Strugglejor Health, 1985, Macmillan.


Causes

of high mortality and morbidity

7


Annual number of infant deaths in thousands
India (27.6)
China (9.3)
Bangladesh (5.0)
Nigeria (4.7)
Indonesia (4.4)
Pakistan (4.3)
Brazil (2.9)
Ethiopia (2.1)
Vietnam (2.0)
Turkey (1.8)
Iran (1.7)
Egypt(1.6)
Afghanistan (1.4)
Mexico (1.4)
Zaire(1.3)

East Asia 10% * Latin America 8%
More developed
regions 3%
Africa 24%

Burma(1.3)
South Africa (1.0)
Algeria (1.0)
Sudan (1.0)

Percentage of total infant deaths (1975 - 1980)
Note: * East Asia excludes Japan


Philippines (0.9)

Note: Figures in parentheses are the percentages of the world total

Countries with the greatest number of infant deaths (1975-1980). (Reproduced from State of the World's Children
1984, with permission from the Oxford University Press.)

Fig. 1.1.4

Table 1.1.3

favour of the disadvantaged. The countries which have
attempted this have achieved a measure of success, as
outlined below.

Poverty and child death

Underlying factor

Cause of death

Poor land; urbanization and
migrant labour; low income;
low parental education

Malnutrition

Overcrowding; lack of
water/latrines; lack of
appropriate health services


Infectious diseases

Maternal malnutrition; lack of
health services; low parental
education

Maternal/neonatal deaths

Effect of development on the environment

Table 1.1.4 Proportion of urban population and projected
increase in 109 developing countries (1980-2000)

Proportion urban
population (%)

1980
No. (%)
countries

2000
No. (%)
countries

0-25
26-50
51-75
Over 75


41 (37)
38 (35)
22 (20)
8 (7)

19
32
42
16

(17)
(29)
(38)
(15)

Reproduced from Ebrahim GJ, Social and Community Paediatrics in
Developing Countries, 1985, Macmillan.

'Development' affects health not only through urbanization but by its effect on the land. Population pressure
and the lack of national energy policies leads to a
shrinking of forested land as trees are cut down for
firewood. This not only makes the women's tasks heavy
(for who collects wood but the women ?) but also causes
soil erosion and makes the land less productive. Land
policies which encourage the production of cash crops
by commercial farmers cause malnutrition in at least
three ways: less food is grown for local consumption;
small farmers stop producing and become labourers, so
entering the cash sector (but farm workers are often
very poorly paid); and the land requires expe~sive

fertilizer to grow crops to international standards, with
consequent diversion of scarce foreign exchange. There
are many complex interrelationships between agriculture and health which merit deeper study by
thoughtful paediatricians.


a

Introduction
5000

4000
c::

0

~

"S

§- 3000
Q.

0

a

0
0


a

Q5
en

Q.

2000

.s::::.

co
Q)

0

1000

o

EI
(rural)

(Bolivia)

suburban

Key:

1;~imMNI All causes


c=J Immaturity

~ Nutritional deficiencies

-sc::

Health service delivery

~ over 301

~201 - 300
§ 101 - 200
~

~ 51-100

~

en

21 - 50

$Q. under20

81

::I

0:


Fig. 1.1.5 Mortality in children
under five years of age from all
causes
and
from
nutritional
deficiency and immaturity. (Reproduced
with
permission
from
Sanders, D. The Struggle for Health,
1985. Macmillan.)

IMR (infant deaths per 1000 livebirths)

Fig.1.1.6 Income and infant mortality, New Delhi (1969-74).
(Reproduced from State of the World's Children 1984, with permission from the Oxford University Press.)

Landowner
Owner worker
Agricultural labourer

43
Deaths per 1000 livebirths

Fig. 1.1.7 Occupation of household head and child death rate
Matlab, Bangladesh (1 974-7). (Reproduced from State of th~
World's Children 1984, with permission from the Oxford University Press.)


Any discussion on methods of prevention must take into
account the past role of the health services in its effect
(or lack of it) on the pattern of disease in children.
Writers such as Cicely Williams, Morley, Illich and
McKeown have analysed the over emphasis of these
services on disease, on the curative approach and on
high-technology medicine practised in large hospitals,
to the detriment of health, prevention and communitybased medicine. Two memorable statistics tell us that
the cost of one bed in a major teaching hospital in Africa
would pay for the upkeep of a rural health centre, while
250 such centres could be built for the same price as that
large hospital. The historical evolution of curative care
for the individual has made this situation inevitable.
Doctors are trained to treat sick people, ill people
desperately want help, and the well-off are better at
finding help than the poor. Criticisms of this situation are less helpful than attempted solutions, and it is
essential to remember that adequate curative services
provided appropriately at primary, secondary and
sometimes tertiary level are a necessary part of any
primary health care programme.


Causes of high mortality and morbidity

9

12820

Cci


%~.

Key:

MM~mM Per capita GNP 1981 ($)

~

f:~t}d IMR (infant deaths per 1000 livebirths) * figures for 1980.

Economic development and infant mortality. (Reproduced from State of the World's Children 1984, with permission
from the Oxford University Press.)

Fig.1.1.8

A further constraint in the health sector in addition to
the maldistribution of services is the professional
attitude of many medical personnel which again
Werner illustrates well (Fig. 1.1.11).
Health workers in the past were taught not to disclose
information to patients as this might cause anxiety and
confusion and would not be understood. Sanders
considers5 that doctors deliberately withheld health
knowledge in order to retain their control over the
health care system. Whatever the reason, the fact is that
doctors have tended to play little part in effective health
education or promotion. Since they set an example and
teach many of the other cadres in the service, this deficiency is soon replicated throughout the system; hence
the importance of improving training as a way of
improving the system (see pp. 114-28).

A third factor in the health services which more
positively contributes to ill health is iatrogenesis, or
medically-induced sickness. Two areas where this is
particularly obvious are bottle-feeding and the misuse
of potent drugs. The reasons for harm are not positive
intent but the increasing technological orientation of

the system, as well as the intervention of the commercial
sector in health. Doctors have been passive partners in
this process, perhaps failing to recognize its side-effects.
Thus, the swing to artificial feeding is influenced by
hospital practices (e.g. separation of mother and baby
after birth) and by commercial promotion of breastmilk substitutes (see p. 100). Drug misuse is accelerated
by opportunist sales tactics, by excessive medical
prescribing, by a demand for injections (at first doctor.;.
induced), and by the lack of government controls over
the sale of potent drugs on the open market. A single
example illustrates the tragedies which may result from
the unrestricted commercial sale of drugs in poor
countries:
As the boat drew into the shore we heard a strange sound from
the bank. A woman was crying. We found her with a dead
baby in her arms and a collection of medicine bottles beside
her. She had spent all her money on these expensive drugs.
She could not understand why they had not saved her baby.
This Bangladeshi woman had never been told what was
obvious to the doctor who found her. The baby had become
severely dehydrated from diarrhoea. Her death could have